To bill under traditional fee-for-service Medicare Part A, skilled nursing facilities (SNFs) must obtain appropriate, timely physician certifications and recertifications of posthospital inpatient extended-care services. The physician cert/recert policy did not change with the implementation of the Patient-Driven Payment Model (PDPM) on October 1, 2019.
However, the Centers for Medicare & Medicaid Services (CMS) did adjust the instructions in the Medicare Online Manual System to explain when providers need to obtain a new physician certification vs. when they should continue using the existing cert/recert to account for the interrupted stay policy that was implemented in conjunction with PDPM. This adjustment brought to light the fact that some SNFs may be counting calendar days instead of Medicare days to determine when certs/recerts are due—a practice that is incorrect CMS officials tell the American Association of Nurse Assessment Coordination (AANAC).
“The regulations at 42 CFR 424.20(d) state that the first recertification is required no later than ‘the 14th day of post-hospital SNF care.’ This would have the schedule track with the days of the stay (i.e., covered days) rather than calendar days,” explain officials. Note: Review the physician cert/recert section of the Code of Federal Regulations in the box at the end of this article.
“This also tracks with previous statements we have made comparing the recertification timeline with the variable per-diem schedule, and interrupted stays have similar impacts on both, as noted in response to FAQ 13.21,” say officials. Here is the FAQ excerpted from Patient-Driven Payment Model: Frequently Asked Questions (FAQs):
13.21: How Does the Interrupted Stay Policy Affect Medicare Physician Certification?
The existing requirements governing level-of-care certification and recertification timeframes are tied to a beneficiary’s SNF admission. If a beneficiary is discharged from the SNF (or from the covered Part A stay) and then resumes covered SNF care within the interruption window, the subsequent resumption would not be considered a new admission and, thus, would not trigger a new certification/recertification schedule.
Consider the following scenario:
A resident in a Part A SNF stay receives their first physician recertification on day 9 of their stay. The resident leaves the SNF and is admitted to the acute-care hospital on day 38. They return to the same SNF to receive a Part A skilled level of care on day 40, meeting the requirements for an interrupted stay.
That day 40 from the initial Medicare payment schedule resets to day 38 (the first noncovered day, which in this scenario is the day of discharge) on the updated Medicare schedule because those noncovered days are skipped over. Payment, covered by the existing PPS 5-day unless the facility chooses to complete an Interim Payment Assessment (IPA), resumes on the new day 38 upon readmission/return because it is a continuation of the previous stay, and the variable per-diem adjustment schedule resumes on the new day 38 as well.
Question: This resident’s second recertification was due on day 39 of the original Medicare schedule but was missed because they were out of the facility. Is the second recertification, which must be completed no later than 30 days after the first recertification, due by the new day 39 of the updated Medicare schedule, i.e., the day after the resident’s return? Are the noncovered days skipped over for the recertification just like they are for payment and the variable per-diem adjustment schedule?
Answer: “The recertification would be due no later than day 39 of the revised Medicare schedule, which would be when the patient returns from the interrupted stay,” state CMS officials.
Question: If this same resident left the facility on day 38 and returned to a Part A skilled level of care in the same SNF on day 42, the resident would be admitted as a new admission with a new PPS 5-day required, according to the interrupted stay policy. Medicare payment and the variable per-diem adjustment schedule would restart at day 1. Would a new initial certification be due “at the time of admission, or as soon thereafter as is reasonable and practicable”?
Answer: Yes, a new initial certification would be needed, say officials. If that Part A resident’s absence exceeds the three-day interruption window, “then their return to that SNF is considered a new admission, and that would also restart the cert/recert schedule,” they explain. “If there is a new admission, there is a new variable per-diem schedule and a new cert/recert schedule to go with it.”
Note: “The interruption window begins on the first noncovered day following a Part A-covered SNF stay and ends at 12:00 a.m. on the third consecutive noncovered day. The first noncovered day may be different depending on if the patient leaves the facility or simply leaves Part A coverage,” according to section 120.2, Interrupted Stay Policy, in chapter 6, “SNF Inpatient Part A Billing and SNF Consolidated Billing,” of the Medicare Claims Processing Manual.
The bottom line for certs/recerts and interrupted stays is:
If the variable per-diem adjustment schedule picks up from the first noncovered day (because the resident’s stay meets the criteria for an interrupted stay and is a continuation of the previous stay), so does the cert/recert schedule.
If the variable per-diem adjustment schedule restarts on day 1 because the resident’s stay does not meet the requirements for an interrupted stay, so does the cert/recert schedule.
The fact that timing requirements for the physician cert/recert schedule follow covered Medicare days instead of calendar days makes sense, says Carol Hill, MSN, RN, RAC-MT, DNS-MT, QCP-MT, CPC, president of Hill Educational Services in Warrior, AL. “A Medicare day is a Medicare day. If you can’t bill for the day, then how could it be included in the cert/recert schedule? The same rules about skipping noncovered days that apply to the Medicare payment schedule and the variable per-diem adjustment schedule also apply to the cert/recert schedule.”
Here are some other steps to take to be sure certs/recerts are done correctly:
Be careful counting the due date of the first recertification
Another common timing issue is not including day 1 (the day of admission) in the count toward the due date of the first recertification, notes Hill. “That first recertification must be completed by the 14th day of the Part A stay. It can be completed earlier, but no later than day 14. Unfortunately, sometimes staff members who are in charge of obtaining certs/recerts don’t include day 1 in their count of the first 14 days. Consequently, they think they are getting that first recertification signed on day 14 when they are really on day 15—and the recertification is late.”
Using a form? Fill it out completely
While it’s not required, many providers use a cert/recert form so that all of the necessary components of the cert/recert are in one piece of documentation, says Hill. “However, it’s fairly common for cert/recert forms to be incomplete. Although all of the right questions are on the form, they may not all be answered. It’s not a valid cert/recert if you don’t have each of the required components.”
Make sure the docs date when they sign
Whether a physician or a physician extender (i.e., nurse practitioner, clinical nurse specialist, or physician assistant) meets the criteria to sign certs/recerts for the SNF, they need to understand the importance of dating when they sign, stresses Hill. “You can’t date it for them, just like you can’t sign it for them. They need to sign and date the cert/recert themselves. You can complete other sections of the cert/recert for them, but the signature and the date need to be done by that physician or physician extender.”
Include certs/recerts in your triple check
Section 6.3, Medical Review of Certification and Recertification of Residents in SNFs, in chapter 6, “Medicare Contractor Medical Review Guidelines for Specific Services,” of the Medicare Program Integrity Manual states:
The Medicare conditions of payment require a physician certification and (when specified) recertification for SNF services. … Contractors shall deny claims for failure to comply with the certification or re-certification content requirements in 42 CFR 424.20 and not for the failure to use a separate certification form or particular format.
Given that noncompliance with the cert/recert content requirements means an automatic payment denial, providers should review certs/recerts as part of the triple-check process, says Hill. “As you go through all of the PDPM items to make sure they are in order as part of a triple check, don’t forget to look at those certs/recerts as well. Getting back to the basics in this way can help you avoid costly mistakes.”
Educate staff who are responsible for certs/recerts
The types of simple mistakes staff members often make indicate a need for training, suggests Hill. “From a payment perspective, there is so much riding on accurate, timely certs/recerts. How much education have you provided to this staff member? What resources and references have you given them to ensure they know who can sign, when they can sign, and what information must be included? Your certs/recerts need to be able to stand up in the event you are audited.”
In addition to 42 CFR 424.29, sources of information about physician cert/recert requirements include the following:
Section 40, Certification and Recertification by Physicians for Extended-Care Services, in chapter 4, “Physician Certification and Recertification of Services,” of the Medicare General Information, Eligibility, and Entitlement Manual, includes six key subparts:
o 40.1 - Who May Sign the Certification or Recertification for Extended-Care Services,
o 40.2 - Certification for Extended-Care Services,
o 40.3 - Recertifications for Extended-Care Services,
o 40.4 - Timing of Recertifications for Extended-Care Services,
o 40.5 - Delayed Certifications and Recertifications for Extended-Care Service, and
o 40.6 - Disposition of Certification and Recertifications for Extended-Care Services.
Section 40, Physician Certification and Recertification of Extended-Care Services, in chapter 8 of the Medicare Benefit Policy Manual, includes information about the difference between a direct and indirect employment relationship and how that impacts who can sign certs/recerts.
Section 6.3, Medical Review of Certification and Recertification of Residents in SNFs, in chapter 6, “Medicare Contractor Medical Review Guidelines for Specific Services,” in the Medicare Program Integrity Manual, reviews when MACs should deny Part A claims for not complying with cert/recert content requirements.
MLN Matters article SE1428 discusses common mistakes providers make related to certs/recerts, according to Comprehensive Error Rate Testing.
Section 6.5, SNF PPS Eligibility Criteria, in chapter 6 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual summarizes key requirements, including spelling out the upper PDPM groups that can be used to validate the resident’s need for skilled care.
What the Code of Federal Regulations Says About Certs/Recerts
§424.20, Requirements for posthospital SNF care.
Medicare Part A pays for posthospital SNF care furnished by an SNF, or a hospital or CAH with a swing-bed approval, only if the certification and recertification for services are consistent with the content of paragraph (a) or (c) of this section, as appropriate.
(a)Content of certification—
1) General requirements.Posthospital SNF care is or was required because—
i. The individual needs or needed on a daily basis skilled nursing care (furnished directly by or requiring the supervision of skilled nursing personnel) or other skilled rehabilitation services that, as a practical matter, can only be provided in an SNF or a swing-bed hospital on an inpatient basis, and the SNF care is or was needed for a condition for which the individual received inpatient care in a participating hospital or a qualified hospital, as defined in §409.3 of this chapter, or for a new condition that arose while the individual was receiving care in the SNF or swing-bed hospital for a condition for which he or she received inpatient care in a participating or qualified hospital; or
ii. The individual has been correctly assigned one of the case-mix classifiers that CMS designates as representing the required level of care, as provided in §409.30 of this chapter.
2) Special requirement for certifications performed prior to July 1, 2002: A swing-bed hospital with more than 49 beds (but fewer than 100) that does not transfer a swing-bed patient to a SNF within 5 days of the availability date.Transfer of the extended care patient to the SNF is not medically appropriate.
(b)Timing of certification—
1) General rule.The certification must be obtained at the time of admission or as soon thereafter as is reasonable and practicable.
2) Special rules for certain swing-bed hospitals.For swing-bed hospitals with more than 49 beds that are approved after March 31, 1988, the extended care patient's physician has 5 days (excluding weekends and holidays) beginning on the availability date as defined in §413.114(b), to certify that the transfer of the extended care patient is not medically appropriate.
(c)Content of recertifications.
1) The reasons for the continued need for posthospital SNF care:
2) The estimated time the individual will need to remain in the SNF;
3) Plans for home care, if any; and
4) If appropriate, the fact that continued services are needed for a condition that arose after admission to the SNF and while the individual was still under treatment for the condition for which he or she had received inpatient hospital services.
(d)Timing of recertifications.
1) The first recertification is required no later than the 14th day of posthospital SNF care.
2) Subsequent recertifications are required at least every 30 days after the first recertification.
(e)Signature.Certification and recertification statements may be signed by—
1) The physician responsible for the case or, with his or her authorization, by a physician on the SNF staff or a physician who is available in case of an emergency and has knowledge of the case; or
2) A physician extender (that is, a nurse practitioner, a clinical nurse specialist, or a physician assistant as those terms are defined in section 1861(aa)(5) of the Act) who does not have a direct or indirect employment relationship with the facility but who is working in collaboration with a physician.
For purposes of this section—
A) Collaboration means a process whereby a physician extender works with a doctor of medicine or osteopathy to deliver health care services.
B) The services are delivered within the scope of the physician extender's professional expertise, with medical direction and appropriate supervision as provided for in guidelines jointly developed by the physician extender and the physician or other mechanisms defined by Federal regulations and the law of the State in which the services are performed.
(ii)Types of employment relationships.
(A) Direct employment relationship.A direct employment relationship with the facility is one in which the physician extender meets the common law definition of the facility's “employee,” as specified in §§404.1005, 404.1007, and 404.1009 of title 20 of the regulations. When a physician extender meets this definition with respect to an entity other than the facility itself, and that entity has an agreement with the facility for the provision of nursing services under §409.21 of this subchapter, the facility is considered to have an indirect employment relationship with the physician extender.
(B) Indirect employment relationship.
(1) When a physician extender meets the definition of a direct employment relationship in paragraph (e)(2)(ii)(A) of this section with respect to an entity other than the facility itself, and that entity has an agreement with the facility for the provision of nursing services under §409.21 of this subchapter, the facility is considered to have an indirect employment relationship with the physician extender.
(2) An indirect employment relationship does not exist if the agreement between the entity and the facility involves only the performance of delegated physician tasks under §483.30(e) of this chapter.
(f)Recertification requirement fulfilled by utilization review. A SNF may substitute utilization review of extended stay cases for the second and subsequent recertifications, if it includes this procedure in its utilization review plan.
(g)Description of procedures.The SNF must have available on file a written description that specifies the certification and recertification time schedule and indicates whether utilization review is used as an alternative to the second and subsequent recertifications.
Source: 42 CFR 424.20.
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