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Ask the Experts: Certification and Recertification
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Question: Do you understand certification and recertification?

Answer: There is no form that I know of, that holds as much power over payment/claims approval as the Certification and Recertification (referred to hereafter as cert/recert). Most persons do not understand that unlike most other forms or claim issues, this form whether incorrectly completed or not, cannot be appealed. In my opinion, this is your “Golden Ticket.”

I like to believe that a lack of understanding regarding the significance of the cert/recert is the reason why it so often is not given the level of importance it deserves. Frequently, I have and continue to see, the cert/recert assigned to staff for completion with little to no training and no oversight/review, which lends it to being incorrectly completed.

Still not convinced of the cert/recert importance? From 2012-2014 the percentage rate of improper payments to SNF almost doubled all stemming from failure to obtain cert/recert from physicians or NPP’s. Don’t be confused, “failure to obtain” can not only mean a lack there of, but also incorrectly completed. With all the power this one form holds, there is no specific format or procedure for the cert/recert, but it must contain specific content within the Certification Statement, Recertification Statements and timeframes must be adhered to for each.

The Certification Statement must include that the individual requires skilled nursing (furnished directly by or requiring supervision of skilled nursing personnel) or skilled rehabilitation services on a daily basis in a SNF or swing-bed hospital as an inpatient. Important to note: services must be related to an ongoing condition which the individual received inpatient care in the hospital. An example of this: admit to a hospital for CVA then transfer to SNF for Aftercare of CVA. This statement must be signed and dated by the certifying physician or NPP at the time of admission or as soon it is reasonable or practicable. This signature and date must appear in the same ink/writing – you cannot date this form for them, this has been a reason for denial.

The first Recertification statement is required no later than day 14 of their SNF stay (start counting day of Admission). The reason(s) for continued need for post hospital SNF care: be very descriptive and inclusive. Give as much info as possible in case parts of the skilled are denied. Example: PT Services: 719.7 difficulty walking and 728.87 muscle weakness D/T 438.22 Hemiplegia affect non-dominant side R/T CVA. OT: 728.87 muscle weakness and 781.3 lack of coordination D/T 438.22 Hemiplegia non-dominant side R/T CVA. Nursing: 250.00 DMII.

Other requirements include; estimated time and the individual will need to remain in the SNF, indicate if a condition arose after admission to the SNF. That is a reason for continued needed services (while being treated for ongoing condition they received inpatient care at the hospital), home care plans- if any, signature and date of the recertifying physician or NNP.

October 26, 2015
By Richter

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