Issue 2005-10, October 2005

SNF Policy and Procedure Reminders  

The Medical Review Department continues to identify claim and documentation issues. The problems involved are as follows:

• Changes (corrections) made to the paper copy of the Minimum Data Set (MDS)
• Dates and signatures on the MDS
• Failure to send in MDS and/or medical records for the “observation period”
• Billing data that does not match information on the MDS

MDS Corrections

Corrections to the MDS should be made like any other medical documentation correction. If a change is made to information previously recorded on a medical record ( including the MDS) the original author must:

• be the person to make the correction
• draw a single line through the incorrect date
• date and initial the error
• make the appropriate changes above the old data.

If these steps are not followed accordingly, the record will be considered “inappropriately altered.” Claims that are inappropriately altered may be denied and subject to investigation.

( Please refer to MNU article 2005-8 “Correction vs. Alteration.”)

MDS Dates and Signatures

When submitting an MDS for review:

• Be sure all corrections are made appropriately
• Send in a copy of the original (hard-copy) versions used (the signed one)

Remember: Medicare requires a legible identity and credentials for services ordered and provided.

Section R2a of the MDS requires the signature of a registered nurse (RN). The RN should include her name along with her credentials. Remember, the RN is attesting to completion of the MDS, not the accuracy of the portions that were completed by other health care professionals.

Section R2b of the MDS requires the actual date that the MDS was completed, reviewed and signed. The date must meet MDS 2.0 guidelines for the timing of the MDS.

The MDS 2.0 user guide requires the MDS to be completed, signed and dated, within 14 days after the assessment reference date (ARD). If for some reason the MDS cannot be signed on the date it is completed, it is appropriate to use the actual date that it is signed. It is strongly recommended that the staff document the reason for the discrepancy in the clinical record. Back dating R2b on the computer generated MDS, to the date the handwritten copy was completed and/or signed, is not acceptable.

(See Chapter 3, Resident Assessment Instrument (RAI) Manual, Version 2.0 December 2002 Revisions)

Helpful Hint: When the MDS was not signed…

• If a record is requested for review or an appeal, and the MDS(s) is missing the original RN assessment coordinators’ signature and/or completion date, it is recommended that the provider attach documentation stating why the signature/date was missing.

The current RN Assessment Coordinator should sign and/or date section R2b., and document why there is a discrepancy. With any case of a late signature on the MDS, it is recommended that the provider document on their facility letterhead the reason for the late signature. This should be made a part of their clinical record. Include this documentation from the record when submitting records, as needed.

The Importance of “The Look-Back Period” Information:

All records submitted by skilled nursing facilities (SNFs) for review should include information for “the look-back period.”

The look-back period includes information for 30 days prior to each assessment reference date applicable to the billing period (dates of service) on each claim requested.

Often times, this material is not submitted for review, which may result in the denial code 56938 (missing information). These records are used to:

• Assess beneficiary prior level of function
• Validate the RUGS category billed for each assessment
• Support the need for services billed in the claim
• Demonstrate progress made by the patient attending therapy.

Look-back period information should also be submitted for claims that are sent for appeals and CERT (Comprehensive Error Rate Testing).

Reminder : The date of the Initial Therapy Evaluation forms or Hospital Discharge summaries do not always fall into window of time encompassing “the look-back period.” However, this information is specifically asked for on each SNF ADR or Letter of Request, and should always be submitted for review.

Correlating the MDS and the Claim

Many SNF billing denials (Denial Code 56918) and RTP (Return to Provider-Reason Code 50095) are occurring due to improper documentation of the service date. It is important to remember that the service dates and modifiers on each claim must correlate with the corresponding MDS sections A3 (ARD) and AA8b (reason for assessment).