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Blog: CMS 5-Claim Reviews – Lessons Learned

CMS kicked off their 5-claim SNF audits June 5th, 2023.  Audits are PDPM claim focused, dating back to October 2019 with the exclusion of claims containing COVID-19 diagnosis. 

Denials have been predominately technical in nature while downcoding has been a result of missing documentation to support items claimed in the MDS.  There have been upcodes of items missed with a reimbursement pick up; however, these are still counted as errors in the error rate.    

Find below our top 5 lessons learned following CMS’ final determinations:    


  • Invalid SNF Certifications 
  • Lack of Qualifying Hospital Stay 
  • Missing MDS Assessments in the National Repository 


  • Unsupported Hospital IV Fluid Capture  
  • NTA Component Capture Missing Physician Authentication or Documented SNF Management  


Auditing against the claim UB04 is essential for validation of technical components and to ensure information from a prior stay has not routinely pulled over to the current claim.

  • Check if the hospital stay date span is correctly reflected, validated as a qualifying stay, and supported by comprehensive hospital records.
  • Verify the accuracy of the admit-to-skilled date.
  • Confirm the accuracy of the Assessment Reference Date, HIPPS code, and primary diagnosis and confirm that they are consistent with the MDS.
  • Comprehensively capture end-of-month assessments.

MDS and billing accuracy matter.

  • Upcodes have been issued to capture conditions not identified by provider. Such upcodes, while beneficial from a reimbursement perspective, contribute to the provider’s error rate.
  • The reviewer will look for documentation to support the qualifying hospital stay reflected on the UB04, so the stay documented must be correct.
  • MDS assessments will be validated in the national repository.
  • Diagnoses documented as active in Section I will be reviewed for physician authentication and active SNF management during the look-back period. Reviewing for accuracy is especially important for repeat admissions to prevent prior diagnoses that may no longer be active from pulling to this section.

Consider the importance of the physician query during the look-back period. This is significant for validation of PDPM component qualifiers at risk for exclusion.

  • Review nutritional assessments classifying a resident as malnourished or at risk for malnutrition.
  • Check BMI assessments qualifying a resident as morbidly obese.

Medicare Administrative Contractors manage error rates differently.

  • Some MACs calculate error rates by claim count and financial impact; others base it on claim count only.
  • The error rate threshold for advancement to prepay probe review varies among MACs.

The Point Is: IDT knowledge base of PDPM along with a strong triple check process in collaboration with billing is paramount to success. Our QRM Medical Review team continues to successfully navigate our clients through an efficient and expedited process of gathering required information, identifying areas of risk and ensuring presentation of complete packets for optimal outcomes. Click here to learn more about QRM’s Medical Review services. 

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