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In a previous article, we covered the basics of ethical and effective documentation practices to use in the long-term care setting. We learned that documentation can not only make the difference between saving or sacrificing you and your license, but also can make a positive impact on resident outcomes. With the basics in mind, we will explore the keys to successful skilled documentation. Why is that so important? Medicare reviewers do not ever physically see the resident; the key to their decision to pay the claim or not is in the medical record. Every entry in the medical record needs to build the case that the resident is being provided services and care that meet the definition of skilled services, that the services are so inherently complex they can only be provided by or under the supervision of professional or technical personnel. In addition, the nature of the service and the skills required for safe and effective delivery are the deciding factors.
When the Patient-Driven Payment Model (PDPM) implements this October 1 in the fee-for-service Medicare Part A Skilled Nursing Facility Prospective Payment System (SNF PPS), concurrent therapy, group therapy, and even restorative nursing will once again take on a renewed importance as tools for achieving a resident’s clinical goals, says Joel VanEaton, BSN, RN, RAC-MT, vice president of compliance and regulatory affairs for Broad River Rehab in Asheville, NC.
“However, you may run into trouble if SNFs or therapists simply dictate, ‘We will do X amount of concurrent and group therapy,’” suggests VanEaton. “PDPM is intended to be a reimbursement system that elevates the resident’s voice by ensuring that resident care decisions appropriately reflect each resident’s actual care needs.”
Nurse assessment coordinators (NACs) won’t be able to take much of a breather following the October 1, 2019, implementation of the new Patient-Driven Payment Model (PDPM) case-mix classification system for the fee-for-service Medicare Part A Skilled Nursing Facility Prospective Payment System (SNF PPS). NACs will have exactly one year to get comfortable with PDPM before their interdisciplinary team has to begin submitting data for 59.5 new Standardized Patient Assessment Data Elements (SPADEs) across the PPS admission and PPS discharge assessments that will be required under the data submission threshold requirement for the Skilled Nursing Facility Quality Reporting Program (SNF QRP). This includes four SPADEs that will be used to calculate and check the logic of two new MDS-based SNF QRP quality measures (QMs) involving the Transfer of Health Information IMPACT Act domain.
One of the few breaks NACs received in the Fiscal Year (FY) 2020 SNF PPS Final Rule is that CMS has put off plans to expand the SNF QRP to all SNF residents regardless of payer source. Here are the highlights NACs need to know about.
Background: The Centers for Medicare & Medicaid Services (CMS) periodically updates the lists of Healthcare Common Procedure Coding System (HCPCS) codes that are excluded from the consolidated billing (CB) provision of the SNF Prospective Payment System (PPS). Services excluded from SNF PPS and CB may be paid to providers, other than SNFs, for beneficiaries, even when in a SNF stay. Services not appearing on the exclusion lists submitted on claims to Medicare Administrative Contractors (MACs), including Durable Medical Equipment MACs (DME MACs), will not be paid by Medicare to any providers other than a SNF. For non-therapy services, SNF CB applies only when the services are furnished to a SNF resident during a covered Part A stay; however, SNF CB applies to physical and occupational therapies and speech-language pathology services whenever they are furnished to a SNF resident, regardless of whether Part A covers the stay. In order to assure proper payment in all settings, Medicare systems must edit for services provided to SNF beneficiaries both included and excluded from SNF CB.
The CPT codes 29580, 29581, and 29584 addressed in this CR are incorrectly categorized. This CR will provide instruction to correctly categorize 29580, 29581, and 29584 on the SNF CB files.
Nursing Home Strategy Part 1 – Strengthening Oversight
The Centers for Medicare and Medicaid Services (CMS) posted the 5th episode of the CMS: Beyond the Policy podcast which focuses on the first of the CMS’s 5-pronged strategy on strengthening oversight in nursing homes. This podcast features CMS Administrator Seema Verma, Dr. Kate Goodrich, CMS Chief Medical Officer and Director of our Center for Clinical Standards and Quality and Matt Hittle, Senior Adviser for Administrator Seema Verma discussing CMS’s efforts regarding nursing home oversight.
Change tables, MDS mockups, and data specifications.
The Significant Change in Status Assessment (SCSA) may be considered an “old dog” in the assessment world, but we will need to learn new tricks under the Patient-Driven Payment Model (PDPM). While the SCSA is an OBRA assessment, historically it could count as a PPS assessment, and could therefore affect payment when completed during a resident’s Medicare stay. Under PDPM, that is no longer the case. The newly-introduced Interim Payment Assessment (IPA) will be the only assessment, beyond the 5-day, that will be able change a resident’s Medicare rate. While this assessment seems to have similarities to the SCSA, nurse assessment coordinators (NACs) must understand the key differences for criteria, scheduling, timing, and payment and survey implications to ensure success under PDPM.
In the current RUG-IV case-mix classification system used in the Medicare Part A Skilled Nursing Facility Prospective Payment System (SNF PPS), the activities-of-daily living (ADL) score derived from MDS section G (Functional Status) factors into the calculation of every case-mix group. Effective October 1, that all changes. While section G will still be important for care planning and some quality measures (QMs), section GG (Functional Abilities and Goals) will take over on the payment front, providing functional scores that will be used in case-mix classification for three of the five case-mix-adjusted payment components under the new Patient-Driven Payment Model (PDPM): physical therapy (PT), occupational therapy (OT), and nursing.
The Centers for Medicare & Medicaid Services (CMS) issued a final rule [CMS-1718-F] for Fiscal Year (FY) 2020 Medicare payment rates and quality programs for skilled nursing facilities (SNFs). This final rule is part of the agency’s continuing efforts to strengthen the Medicare program by better aligning payment rates for these facilities with the costs of providing care and increasing transparency so that patients are able to make informed choices. The final rule [CMS-1718-F] can be downloaded from the Federal Register at: https://www.federalregister.gov/documents/2019/08/07/2019-16485/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities.
This fact sheet discusses three major provisions of the final rule:
· SNF payment policy under the SNF Prospective Payment System (PPS)
· SNF Value-Based Purchasing Program (VBP)
· SNF Quality Reporting Program (QRP).
This final rule includes policies that continue to move forward agency commitments to shift Medicare payments from volume to value, with the continued implementation of the SNF VBP and SNF QRP to improve program interoperability, operational quality and safety.
During this call, learn about your Skilled Nursing Facility (SNF) Value-Based Purchasing (VBP) Program Performance Score Report. CMS experts present a high level summary of the program and highlight the payment year 1 results (FY 2019 program year).
A question and answer session follows the presentation; however attendees may email questions in advance to SNFVBP@rti.org with "SNF VBP Aug 27 NPC" in the subject line. These questions may be addressed during the call or used for other materials following the call.
Videos and post-training materials (includes answers to knowledge checks and interactive sessions) from the May 2019 Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Provider Training held in Kansas City, MO, on May 7 and 8, 2019, are now available.
Please note: Post-training materials include answers to knowledge checks and interactive sessions. Additionally, Section GG presentation has been updated to include links to videos shown during the training.
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