Description
Documentation will be reviewed to determine if the Skilled Nursing Facility stay meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary.
Affected Code(s)
TOB 21X
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1814(a)(2)- Conditions of and Limitations on Payment for Services
4. 42 CFR §405.929- Post-Payment Review
5. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
6. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
7. 42 CFR §405.986- Good Cause for Reopening
8. 42 CFR §409.30- Basic Requirements
9. 42 CFR §409.31- Level of care requirement
10. 42 CFR §409.32- Criteria for skilled services and the need for skilled services
11. 42 CFR §409.33- Examples of skilled nursing and rehabilitation services
12. 42 CFR §409.34- Criteria for “daily basis”
13. 42 CFR §409.35- Criteria for “practical matter”
14. 42 CFR §409.36- Effect of discharge from posthospital SNF care
15. 42 CFR §411.15(p)- Services furnished to SNF residents
16. 42 CFR §413.337- Methodology for calculating the prospective payment rates
17. 42 CFR §413.343- Resident Assessment data
18. 42 CFR §424.5(a)(6) – Basic conditions
19. 42 CFR §424.11(b)- Obtaining the certification and recertification statements
20. 42 CFR §424.20- Requirements for posthospital SNF care
21. 42 CFR §483.20- Resident assessment
22. Medicare General Information, Eligibility and Entitlement Manual, Chapter 4- Physician Certification and Recertification of Services, §40- Certification and Recertification by Physicians for Extended Care Services
23. Medicare Benefit Policy Manual, Chapter 8- Coverage of Extended Care (SNF) Services Under Hospital Insurance, §20- Prior Hospitalization and Transfer Requirements, §30- Skilled Nursing Facility Level of Care- General, §40- Physician Certification and Recertification for Extended Care Services
24. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §220.1.3- Certification and Recertification of Need for Treatment and Therapy Plans of Care
25. Medicare Claims Processing Manual, Chapter 6- SNF Inpatient Part A Billing and SNF Consolidated Billing, §30- Billing SNF PPS Services; §120- Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM)
26. Medicare Claims Processing Manual, Chapter 25- Completing and Processing the Form CMS-1450 Data Set
27. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
28. Medicare Program Integrity Manual, Chapter 6- Medicare Contractor Medical Review Guidelines for Specific Services, §6.1- Medical Review of Skilled Nursing Facility Prospective Payment System (SNF PPS) Claims; §6.1.4- Medical Review Process; §6.3 Medical Review of Certification and Recertification of Residents in SNFs
29. MDS 3.0 RAI Manual, October 2019 (on or before 09/30/2023)
30. MDS 3.0 RAI Manual, version 1.18.11 v5, October 2023 (on or after 10/01/2023)
31. CMS.gov Minimum Data Set (MDS) 3.0 Technical Information: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIMDS30TechnicalInformation
32. ICD-10-CM Official Guidelines for Coding and Reporting