Pre-Payment Review Results for Skilled Nursing Facilities for January to March 2025

Published 05/23/2025

Pre-Payment Review Results for Skilled Nursing Facilities (SNF) Probe and Educate (SPE) for January to March 2025

The Centers for Medicare & Medicaid Services (CMS) implemented the Jurisdiction J Part A (JJA) Skilled Nursing Facilities (SNF) Probe and Educate (SPE) process. The reviews with edit effectiveness are presented here for Alabama, Georgia and Tennessee.

Cumulative Results

Table 1. Cumulative Results.
Number of Providers with Edit Effectiveness Providers Compliant Completed/Removed After Probe Providers Non-Compliant Progressing to Subsequent Probe Providers Non-Compliant/Removed for Other Reason
37 18 19 0
Table 2. Cumulative Results.
Number of Claims with Edit Effectiveness Number of Claims Denied Overall Claim Denial Rate Total Dollars Reviewed Total Dollars Denied Overall Charge Denial Rate
184 57 31% $1,369,850.42 $210,048.05 15%

Probe One Findings

Table 3. Probe One Findings.
State Number of Providers with Edit Effectiveness Providers Compliant Completed/Removed After Probe Providers Non-Compliant Progressing to Subsequent Probe Providers Non-Compliant/Removed for Other Reason
Ala. 13 9 4 0
Ga. 3 2 1 0
Tenn. 21 7 14 0
Table 4. Probe One Findings.
State Number of Claims with Edit Effectiveness Number of Claims Denied Overall Claim Denial Rate Total Dollars Reviewed Total Dollars Denied Overall Charge Denial Rate
Ala. 65 22 34% $435,675.28 $79,087.25 18%
Ga. 15 4 27% $115,539.50 $9,377.54 8%
Tenn. 104 31 30% $818,635.64 $121,583.26 15%

Risk Category

The categories for SNFs are defined as:

Table 5. Risk Category.
Risk Category Error Rate
Minor 0–20%
Major 21–100%

Figure 1. Risk Category for Skilled Nursing Facilities (SNF SPE).

Pie chart showing 49% Minor and 51% Major.

Top Denial Reasons

Table 6. Top Denial Reasons.
Percent of Total Denials Denial Code Number of Occurrences
53% 5D501, 5H501 25
23% 5D504, 5H504 11
9% 5D505, 5H505 4
6% 5H507 3
4% 5D510 2

Denial Reasons and Recommendations

5D501/5H501 — Reason for Denial
The claim was fully or partially denied due to the documentation submitted does not support the level of service as shown on the claim. The Health Insurance Prospective Payment System (HIPPS) was recoded to reflect Minimum Data Set (MDS) changes supported by the documentation submitted.

How to Avoid This Denial
Ensure that all charges for accuracy/timeliness prior to submitting the final bill to Medicare. Check to ensure that all documentation submitted in response to the Additional Documentation Request (ADR) corresponds to the service(s) rendered and the dates of service(s) billed. 

Reference: CMS Internet Only Manual (IOM), Pub. 100-08, Medicare Program Integrity Manual, Chapter 6, Section 6.1.4 (C-D) (PDF).
 

5D504/5H504 — Reason for Denial
The claim was fully or partially denied due to the documentation submitted did not support that SNF services were medically reasonable and necessary for the treatment of the beneficiary's illness or injury.

How to Avoid This Denial

  • Documentation should support treatment of a condition for which the beneficiary was receiving inpatient hospital services or for a condition that arose while receiving care in a SNF for treatment of a condition for which the beneficiary was previously treated in the hospital
  • Submit all documentation to support the services billed and the medical necessity of those services. Services must be medically reasonable and necessary and supported by documentation. 
  • Submit a copy of the qualifying hospital stay transfer/discharge summary that relates to the services provided in the SNF
  • Submit a physician certification and subsequent recertifications of the need for continuing daily skilled SNF services
  • Submit the corresponding MDS for each Resource Utilization Groups (RUG) code billed. If more than one RUG code is billed, an MDS for each RUG code must be submitted for review. This may include all MDS from the start of care through the dates of service billed.
  • Submit all documentation used to complete each MDS. This includes the documentation to cover the look back periods for each MDS submitted. 
  • Submit dated physician’s orders for all services billed, including services provided during the look back period (s). Orders for services rendered during the look back period(s), written prior to the look back period, must be submitted with the documentation.
  • Include any separate forms used for documentation of medication, wound care, staging of wounds, therapy minutes, weights, vital signs, intake and output, enteral feedings, nutritional consults, percentage of meals consumed, bladder and bowel function with the submitted records.
  • Ensure any changes in condition or treatment that would warrant daily skilled care are documented and submitted for review. This documentation includes, but is not limited to, nurse’s notes, social worker notes, nutritional services, activity reports, progress notes, consultations, laboratory and X-ray reports, treatment plans. 
  • Documentation should include the beneficiary’s functional level and mental status, changes in treatment or medications, the skilled services provided in response to physician’s orders, and visits from the physician or other professional personnel
  • Documentation in the form of checklists must include documentation of the beneficiary’s response to the services rendered
  • Clinical documentation that furnishes a picture of the beneficiary’s care needs and response to treatment helps to establish the need for Part A services in a skilled nursing facility

References

5D505/5H505 — Reason for Denial
The claim was fully or partially denied due to the certification was not obtained timely, and no documentation of delayed certification submitted. 

How to Avoid This Denial

  • A certification or recertification statement must be signed by an attending physician or a physician on the staff of the SNF who has knowledge of the case or a nurse practitioner who does not have a direct or indirect employment relationship with the facility, but who is working in collaboration with the physician, or a clinical nurse specialist who does not have a direct or indirect employment relationship with the facility, but who is working in collaboration with the physician. Initial certifications must be obtained at the time of admission, or as soon thereafter as is reasonable and practicable.
  • The routine physician’s admission order is not a certification of the necessity for post-hospital extended care services for purposes of the Medicare program
  • When responding to a request for copies of medical records, submit the initial certification and/or subsequent recertifications related to the look back periods and the dates of service under review

References

5H507 — Reason for Denial
The claim was fully or partially denied due to a new MDS not being completed upon readmission to the SNF for readmission after 11:59 p.m. on the third consecutive non-covered day.

How to Avoid This Denial

  • Ensure that the MDS has been entered into the National Repository prior to submitting request for payment to Medicare
  • Check all bills for accuracy and ensure that the MDS clinical assessment includes data for all covered days associated with the billing period

References

5D510 — Reason for Denial
The claim was fully or partially denied due to there being insufficient documentation to support that there was a three-day inpatient qualifying stay prior to admission to the SNF, and no waiver is indicated.

How to Avoid This Denial
The three consecutive calendar day stay requirement can be met by stays totaling three consecutive days in one or more hospitals. In determining whether the requirement has been met, the day of admission, but not the day of discharge, is counted as a hospital inpatient day. In addition, the qualifying hospital stay must be medically necessary.

Reference: CMS IOM, Pub. 100-02, Medicare Benefit Policy Manual Chapter 8, Section 20.1 (PDF).
 

Education
Palmetto GBA offers providers selected for TPE an individualized education session to discuss each claim denial. This is an opportunity to learn how to identify and correct claim errors. A variety of education methods are offered such as webinar sessions, web-based presentations or teleconferences. Other education methods may also be available. Providers do not have to be selected for TPE to request education. If education is desired, please complete the Education Request Form (PDF).

Next Steps
Providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of TPE Probe 1 will advance to Probe 2, and providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of TPE Probe 2 will advance to Probe 3 of TPE after at least 45 days from completing the 1:1 post-probe education call date.


Was this article helpful?