Top 3 Tips to Avoid Your Medicare Part A Claim Being Denied

Now that the first year of the PDPM payment system is behind us, CMS and its contractors have a lot of PDPM data to study for trends.  That said, CMS Medicare auditing contractors will be looking to reject claims but under PDPM, the stakes are much higher.  Under PDPM, with typically only 1 PPS assessment with one HIPPS code for payment, the ENTIRE claim or stay may now be denied whereas, under RUGIV only portions of the stay associated with multiple RUG payment periods were typically denied. Physician Certifications have been a particular area of interest before PDPM and will continue to be going forward.  Here are some tips to ensure your Physician Certifications meet regulatory requirements:

  1. Ensure all written areas are Legible
    1. If any part of the MD certification is illegible, it will be denied. Use typed Physician Certifications. 
    2. For physician signatures, keep a facility signature log and include with any medical record request.  
  2. If using a certification form, ensure it meets regulatory requirements and avoid blanks areas.

While there is no required specific format for physician certifications/recertifications, they must, at minimum, contain certain information according to the Medicare Benefit Policy Manual Chapter 8, Section 40.  

An acceptable certification statement must state the following information:

  • The individual needs skilled nursing care or other skilled rehabilitation services.
  • Such services are required on a daily basis.
  • Such services can only practically be provided in a SNF on an inpatient basis.
  • Such services are for an ongoing condition for which the individual received inpatient care in a hospital; and 
  • A dated signature of the certifying physician or nurse practitioner.

An acceptable recertification statement must contain the following information: 

  • The reasons for the continued need for post hospital SNF care.
  • The estimated time or length of stay the individual will need to remain in the SNF;
  • Plans for home care or discharge disposition when skilled care ends.
  • If the reason for continued need for skilled services is a condition that arose after admission to the SNF (and while being treated for an ongoing condition for which the individual received inpatient care in a hospital) this must be indicated; and
  • A dated signature of the recertifying physician or nurse practitioner.

 3. Avoid Late Signatures.

If your Physician Certification has a late signature, include a written explanation to explain why the signature was late.

About Lance Leifert