The US Department of Health and Human Services, Medicare Learning Network (MLN) has published a document, Provider Compliance Tips for Skilled Nursing Facility (SNF) Inpatient Services, that clarifies the distinction between skilled services Medicare payments and custodial services (e.g., bathing, dressing and using the bathroom), which are not paid by Medicare. According to the Supplementary Appendices for the Medicare Fee-For-Service 2015 improper Payments Report, the improper payment rate for SNF inpatient services was 11 percent and the projected improper payment amount for SNF services during the 2015 report was $4 billion.
The MLN document asserts that the majority of improper payments for SNF services are due to insufficient documentation. SNFs are required to submit medical records to support the medical necessity of skilled services; including certification that the beneficiary needed daily skilled care, an authenticated plan of care, and the time (in minutes) for the therapy services provided. Further, claims for skilled coverage need to include sufficient documentation to enable a reviewer to determine: the beneficiary requires skilled services in order for the services to be furnished safely and effectively; the services are reasonable and necessary for the treatment of the resident’s illness or injury; the nature and severity of the individual’s illness or injury; and the individual’s particular medical needs and accepted standards of medical practice.
The documentation also must show that the series are appropriate in terms of duration and quantity, and that the services promote the documented therapeutic goals. Resident goals also must be routinely assessed and documented to provide a sufficient basis for determining Medicare coverage.