News, Payment/economy, Skilled Nursing Facility

Pre-pay audits target J5 providers in IA, KS, MO, NE and national

J5 Jurisdiction providers are being targeted for prepayment, service specific, complex medical reviews of Inpatient SNF services conducted by Wisconsin Physician Services Government Health Administrators (WPS GHA), a Medicare Administrative Contractor (MAC) for the Centers for Medicare & Medicaid Services (CMS).

J5 Jurisdiction includes skilled nursing facilities (SNF) that submit claims from Iowa, Kansas, Missouri, Nebraska, and other national providers. Though WPS GAH is also the CMS MAC for the J8 Jurisdiction, the American Health Care Association (AHCA) has confirmed that this new audit announcement only applies to J5 Jurisdiction providers.

The WPS GAH explains that these audits will use data analysis to determine services at risk for potential errors; once a high risk billing practice has been identified for a specific service, a prepayment edit will be implemented to identify potential errors or incorrect billing. WPS GAH’s news announcement states that: “A prepay edit will be initiated with reason code 51SNF for J5 claims with dates of service on or after April 1, 2017, meeting the following criteria:

  • Original inpatient claims
  • Type of bill – 21X
  • Containing ultra-high rehabilitation RUGs”

Providers will be notified of selected claims via the normal Additional Document Request (ADR) letter. The news update states further that “documentation to support the dates of service billed may include, but is not limited to:

  • Hospital Documentation to include:
    • Hospital discharge summaries
    • Transfer forms
    • Medication administration records
  • Documentation to support each of the HIPPS code(s) billed, including notes related to each of the assessment reference date(s) (ARD)
  • Minimum Data Set (MDS) Documentation to include:
    • A hardcopy version of each MDS related to the billing period being reviewed
    • Documentation to support each of the look back periods requested and documentation to support each of the look back periods which may fall outside of the billing period (The lookback or observation period is the 7, 14 or 30-day period prior to and ending on the ARD date)
  • Physician Documentation to include:
    • Physician Certifications and Re-certifications for skilled care
      • Including physician signature and date
      • Re-certifications must include the need for continued skilled care
  • Physician orders, including admission orders
  • Physician progress notes
  • Physician History and Physical
  • Nursing Documentation to include:
    • Nursing notes and admission assessment
    • Patient care plans
    • Vital sign records
    • Medication & IV administration records
    • Any nursing treatment sheets such as:
      • Skin care/wound care treatment sheets
      • Respiratory treatments and O2 therapy records
  • Rehabilitation Documentation to include:
    • Initial therapy evaluations and re-evaluations:
      • Objective and measurable prior level of function and current level of function to support functional decline
    • Rehabilitation therapy notes including progress notes
    • Treatment records, grids or logs
    • Actual therapy minutes provided
  • All other documentation supporting the beneficiaries need for and delivery of the skilled services being provided in the SNF
  • Advance Beneficiary Notice (if applicable)”