Widespread Targeted Review Results – IA – FI - Skilled Nursing Facility (SNF) Claims Billed With a RUG-III Code of RUBXX
Part A Medical Review has recently completed the 4th quarter widespread targeted prepay review of skilled nursing facility (SNF), type of bill 21X. The topic code for this review is 5TSAQ. This code selected claims with a RUG-III code of RUBXX, ending in 02, 03, 04, for length of stay greater than 30 days, and excluding diagnosis codes of 430-438, processed between October 1, 2007, and December 31, 2007. An educational article providing the results of a previous review was posted on the “What’s New” page of the Cahaba web site on May 2, 2007. The results of the current widespread review are summarized below:
Providers included in review: 10
Claims reviewed: 12
Claims denied/downcoded: 12
Charges reviewed: $98,110
Charges denied/downcoded: $49,914
Error rate: 51%*
*Error rate is based on the charges denied divided by the charges reviewed
The major denial reason was 53512 – “The documentation does not support the level of service at the billed RUG-III category. The service will be paid at a reduced RUG-III category at a lower rate.”
The goal of therapy is for a patient to return to their highest level of function that is realistically attainable and within the context of their disability. However, the skills of a therapist may not necessarily be required on a daily basis in the skilled setting to attain this goal. On an ongoing basis, therapy, nursing, and other staff must determine if the patient’s functional impairments continue to be at a level of complexity that require the daily skills of a therapist. It must also be determined whether the patient could safely and effectively participate with the facility’s trained staff in a maintenance and/or restorative nursing program, or receive therapy services in a less-intensive setting, such as outpatient or home health.
When the skills of a therapist are required on a daily basis, the documentation in the medical record should include specific descriptions of the patient’s ongoing functional impairments using objective tests and measurements to clearly identify their deficits. Goals should be specific, realistic, and individualized. Each day, the skilled therapy services should be documented. At a minimum, therapy should do a weekly progress note. The progress note should be more than just a status report, and should reflect how the therapy intervention impacted the patient. The progress note should also include problems or difficulties encountered by the patient that impacted progress, specialized techniques that were utilized, status in relation to goal achievement and discharge, education provided to the patient, family, and/or staff, and any modifications made to the plan of care.
To support a patient’s unstable condition, documentation must indicate signs and symptoms and abnormal assessment results that are different from the patient’s baseline. To require the skilled setting, these changes in medical status would most likely require physician notification, physician orders, and nursing intervention. Simply monitoring a patient day after day, when their condition does not require intervention, is often an indication that observation and assessment at the skilled level is not medically necessary.
As a result of this review, Part A Medical Review will continue a targeted pre-pay review of all SNF facilities billing these RUG codes. Also, providers identified through data analysis as driving this aberrancy may warrant provider-specific medical review.
Page last updated: March 26, 2008
