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July 27, 2016

Resource Utilization Group (RUG) Codes RUA, RUB and RUC: Complex Review – Ohio Documentation Findings

CGS is currently performing reviews of Ultra High Therapy RUG codes in Skilled Nursing Facilities (SNFs). During our reviews, we have identified two areas which present opportunities for documentation improvement: Co-treatment therapy minutes and Certification. Certification has also been identified as a leading cause of Comprehensive Error Rate Testing (CERT) denials for SNFs.

Co-treatment

Co-treatment in SNFs can be both beneficial for patients and assist in collaboration between therapies. It is important to remember documentation requirements for Medicare coverage of co-treatment therapy. Co-treatment is defined as two clinicians from different disciplines who treat one resident at the same time with different treatments. During this treatment, both therapy disciplines may code the treatment session in full.

The need for co-treatment should be documented clearly to prevent a claim denial or downcoded result. It should also be noted that the use of co-treatment should be limited per the Resident Assessment Instrument (RAI) manual.

Certification

Certification is required for a SNF covered stay. Since there is not a specific form, documentation of the physician’s certification may be included in forms utilized by the facility, notes, or records. The statement must be signed and dated by the physician upon admission. The admission order by a physician alone does not meet the certification requirements. There must be a separate, signed statement which indicates that the beneficiary requires skilled care on a daily basis.

If the Certification/Recertification is delayed, an explanation for the delay must be documented.

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