• SNF QRP Review and Correct Reports Now Available (4/19)

    By CMS - April 05, 2019

    The enhanced Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) review and correct reports are now available, on demand in the Certification and Survey Provider Enhanced Reporting (CASPER) application. In addition to enhanced sorting functionality, this report now includes patient level data and automated CSV file creation functionality that contains patient level results. Providers can access these reports by selecting the CASPER Reporting link on the “Welcome to the CMS QIES Systems for Providers” webpage.

    NOTE: You must log into the CMS Network using your CMSNet user ID and password in order to access the “Welcome to the CMS QIES Systems for Providers” webpage.

    In addition to the sorting enhancements and inclusion of resident level data, these reports:

    • Contain quality measure information at the facility level
    • Allow providers to obtain aggregate performance for the past four quarters (when data is available)
    • Include data submitted prior to the applicable quarterly data submission deadlines
    • Display whether the data correction period for a given CY quarter is “open” or “closed.
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  • Tips for a Successful ACO Partnership!

    By Christina Gardiner - March 06, 2019

    Creating successful partnerships with Medicare accountable care organizations (ACOs) can seem like a daunting task for many skilled nursing facilities (SNFs), but with the right tools and strategic approaches, these relationships can be the cornerstone to clinical, and operational, success. Below are a few tips to assist in ACO success.

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  • SNF QRP 3Q 2018 Help Desk Q+A Doc Includes 2 GG Coding Q&As (2/19)

    By CMS - February 19, 2019
    A new Question and Answer (Q+A) document is now available from the SNF Quality Reporting Program FAQs webpage. The Q+A document reflects frequently asked questions that were received by the SNF QRP Help Desk during the third quarter (July - September) of 2018. It includes information about the SNF QRP program, as well as two section GG coding questions (related to GG0170N and GG0170O).
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  • Section GG’s Role in PDPM: The Basics

    By Caralyn Davis, Staff Writer - February 06, 2019
    MDS section GG (Functional Abilities and Goals) will replace section G (Functional Status) as a key payment driver for fee-for-service Medicare Part A residents paid under the Skilled Nursing Facility Prospective Payment System (SNF PPS) when the Patient-Driven Payment Model (PDPM) implements on Oct. 1, 2019. Using items from section GG instead of section G “advances CMS’s goal of using more standardized assessment items across payment settings,” said officials with the Centers for Medicare & Medicaid Services during the Dec. 11, 2018, SNF PPS: PDPM National Provider Call (NPC).
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  • The Long, Long List of Potential Medicare/Medicaid Claims Auditors

    By Caralyn Davis, Staff Writer - January 23, 2019

    Audit and medical review are terms that understandably put a lot of nursing homes on edge. The newsmakers in the Medicare/Medicaid billing arena are the U.S. Department of Justice (DOJ) and the Office of Inspector General (OIG) at the U.S. Department of Health and Human Services (HHS), which lead some significant collaborative efforts.

     

    On the civil side, DOJ and the OIG regularly work with other agencies and law enforcement to coordinate False Claims Act (FCA) lawsuits, accruing more than $2.8 billion in FCA settlements and judgments just in fiscal year (FY) 2018 ending Sept. 30, 2018. It’s fairly common for nursing homes to be targeted in FCA lawsuits. For example, skilled nursing facilities (SNFs), their executives, and even their consultants paid more than $41 million to resolve FCA allegations in FY 2018, mostly related to rehabilitation therapy services that weren’t reasonable, necessary, and skilled, as well as for grossly substandard quality of care. In addition, there were several FY 2018 FCA cases tangentially involving nursing homes (e.g., a company facing FCA allegations related to paying nursing homes kickbacks).

     

    On the criminal side, the now 11 DOJ/OIG-led Medicare Strike Force teams based in high-fraud areas nationwide have charged more than 3,700 defendants who submitted over $14 billion in false Medicare billings since the program’s inception in 2007 under the interagency Health Care Fraud Prevention and Enforcement Action Team (HEAT). In June 2018, the Strike Forces led the nation’s largest-ever healthcare fraud enforcement action (aka Takedown Day), charging more than 600 doctors, nurses, and other licensed medical professionals in fraud cases worth more than $2 billion in false billings.

     

    The Strike Forces partner U.S. Attorney’s Offices, the FBI, and the OIG with other federal and local law enforcement agencies and state Medicaid Fraud Control Units. Using advanced data analysis techniques to find aberrant billing levels, suspicious billing patterns, and emerging schemes, the Strike Forces investigate and prosecute cases involving fraud, waste, and abuse in federal healthcare programs, including Medicare and Medicaid. Thus far, nursing homes haven’t been a significant target of the Strike Forces. In FY 2018, Strike Force teams brought only one case indirectly involving nursing homes.

     

    The Center for Program Integrity (CPI) runs point on healthcare fraud, waste, and abuse at the Centers for Medicare & Medicaid Services (CMS). These efforts start with a focus on improper billing and move all the way up to outright fraud and abuse, including working with the DOJ/OIG civil and criminal teams. Here are the key CMS contractors that could send nursing homes an additional documentation request (ADR) letter related to Medicare or Medicaid claims.

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  • Q&A: If a resident had a neck fracture with a hip replacement, would we code the aftercare for the joint replacement as the primary code?

    By Carol Maher, RN-BC, CPC, RAC-MT - January 23, 2019
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  • Q&A: A resident refuses to be weighed, and so I must dash KO200B (Current Weight). Are there exclusions to this QM trigger?

    By Jane Belt RN, MS, RAC-MT, RAC-CT, QCP - January 23, 2019
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  • Pathway to PDPM Readiness Tool

    By AANAC - January 09, 2019
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  • I0020B: Getting the PDPM Primary Clinical Category for PT, OT, and SLP

    By Caralyn Davis, Staff Writer - January 09, 2019
    The fiscal year (FY) 2019 skilled nursing facility prospective payment system (SNF PPS) final rule included now-inaccurate information related to how the default primary diagnosis clinical category will be determined for the physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) components of the patient-driven payment model (PDPM) that will implement on Oct. 1, 2019. The final rule cited MDS item I8000 (additional active diagnoses) as the source of the primary SNF diagnosis code that would drive the default primary clinical category, stating, “… PDPM would use ICD-10-CM diagnosis codes entered in the first line of section I8000 on the MDS assessment to assign residents to clinical categories for classification and payment purposes in three PDPM payment components (PT, OT, and SLP).”
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  • I8000 Helps Capture SLP and NTA Comorbidities Under PDPM

    By Caralyn Davis, Staff Writer - January 09, 2019

    Despite what appeared to be finalized in the fiscal year (FY) 2019 skilled nursing facility prospective payment system (SNF PPS) final rule, I8000 (additional active diagnoses) will not play any role in determining the primary diagnosis clinical category for the physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) components of the patient-driven payment model (PDPM) that will implement on Oct. 1, 2019. Instead, new item I0020B, in conjunction with relevant new surgical history items J2100 – J5000, will drive the primary clinical category for PT, OT, and SLP, said officials with the Centers for Medicare & Medicaid Services (CMS) during the Dec. 11 SNF PPS: PDPM National Provider Call. Note: Access the call slides, as well as a transcript and recording, here.

     

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  • Q&A: Are the PDPM rates still adjusted by a VBP adjustment factor and in cases where a provider fails to submit data required by the SNF QRP?

    By CMS - January 09, 2019
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  • Q&A: Why is PT and OT payment higher for case-mix groups with higher functional independence in some cases?

    By CMS - January 09, 2019
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  • Q&A: What are some notable differences between G and GG scoring methodologies?

    By CMS - January 09, 2019
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  • PDPM Switch Could be a Rough Road for Some SNFs

    By Caralyn Davis, Staff Writer - December 20, 2018

    On Oct. 1, 2019, the new Patient-Driven Payment Model (PDPM) will replace RUG-IV as the case-mix classification system for Part A beneficiaries under the Skilled Nursing Facility Prospective Payment System (SNF PPS). “There is no transition period between RUG-IV and PDPM, but rather a hard switch from one system to the other,” said officials with the Centers for Medicare & Medicaid Services (CMS) during the Dec. 11 SNF PPS: PDPM National Provider Call. “This is due to the immense potential for significant administrative burden, and the confusion that would arise from trying to run the RUG-IV and PDPM systems concurrently.” Note: Access the call slides, as well as a transcript and recording when available, here.

     

    The two most critical points that nurse assessment coordinators (NACs) need to know about this hard switch are:

     

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  • From SNF PPS Final Rule to Medicare Remit: How Much $ Will You Get?

    By Caralyn Davis, Staff Writer - December 18, 2018

    Due to how payments are calculated in the Medicare Part A Skilled Nursing Facility Prospective Payment System (SNF PPS), there’s always been a slight difference between the federal payment rate tables that are published annually in the SNF PPS rules and the adjusted rates that SNFs actually receive from their Medicare administrative contractors (MACs). The potential difference increased slightly in fiscal year (FY) 2018 with the launch of the Skilled Nursing Facility Quality Reporting Program (SNF QRP). However, financial discrepancies could be larger than ever now that the Skilled Nursing Facility Value-Based Purchasing (SNF VBP) program impacts SNF PPS payment effective with FY 2019, which began on Oct. 1, 2018.

     

    To avoid problems in such key areas as accounts receivable and budget forecasting, nurse assessment coordinators (NACs) and billing staff need to understand the basic rules for how SNF PPS payment rates are created and adjusted, especially now that SNF QRP and SNF VBP are in the mix. The key steps discussed below (and presented graphically in a flow chart at the end of this article) lead from:

     

    (1)   The unadjusted federal payment rates that the Centers for Medicare & Medicaid Services (CMS) publishes in the SNF PPS rules, to

    (2)   The adjusted rates that SNFs bill on Part A claims, to

    (3)   The Medicare remittance advices that MACs use to explain final claim adjudication and payment information.

     

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