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MDS item I0020B (ICD Code/Resident’s Primary Medical Condition) sets a Medicare Part A resident’s default primary diagnosis clinical category for determining case-mix classification in the physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) payment components of the Patient-Driven Payment Model (PDPM). However, a major surgery in the resident’s immediately preceding inpatient hospital stay that is coded in MDS items J2100 – J5000 can push the resident into a surgical category that takes precedence over the default category, resulting in a higher-paying case-mix group.
Planning for time off over the holidays often takes coordination across the entire interdisciplinary team (IDT) to ensure processes and systems continue to operate smoothly while key players are missing. The nurse assessment coordinator (NAC) must ensure MDS assessments are in place, skilled Medicare decisions are being made appropriately, significant changes or the need for an Interim Payment Assessment are identified, determinations of whether a resident meets the criteria of an interrupted stay occur, and the list can go on and on. With some pre-planning, though, the NAC can have a stress-free holiday—at least from work-related stress.
Here are some strategies NACs can use to achieve time off.
1. Share the knowledge.
Often, the NAC will find him- or herself the only nurse in the facility who knows how to open an MDS assessment, request a Medicare physician certification or recertification, or even locate the RAI User’s Manual. This is not a good strategy for success.
The SNF consolidated billing file reflects new codes that have been developed for 2020. In addition, the file reflects additions to categories of services excluded from consolidated billing.
The annual update file below contains the complete list of HCPCS codes that are excluded from SNF CB for claims submitted to Part A MACs for payment. Minor Surgery and Part B therapy inclusions are also included with this file.
The Patient-Driven Payment Model (PDPM) under the Skilled Nursing Facility Prospective Payment System (SNF PPS) pushes providers to implement value-driven care, which gives added significance to the Skilled Nursing Facility Quality Reporting Program (SNF QRP) quality measures (QMs), says Maureen McCarthy, BS, RN, RAC-MTA, RAC-MT, DNS-MT, QCP-MT, president/CEO of Celtic Consulting in Torrington, CT.
“The SNF QRP QMs are now the report card for PDPM,” she explains. “The Centers for Medicare & Medicaid Services (CMS) has made it clear that the agency will be watching quality of care throughout PDPM implementation. If your care model changes and your quality goes down, you are likely to be audited. Nurse assessment coordinators (NACs) and any other interdisciplinary team (IDT) members who complete the MDS need to be mindful as to how that MDS data will impact not only payment but also quality, especially as more QMs continue to be added to the program.”
The nurse assessment coordinator (NAC) often handles the entire Medicare program in the facility, from managing the PPS schedule to leading the skilled coverage decision. With PDPM in full swing, a lot seems to have changed, but some things have not.
“The implementation of the Patient-Driven Payment Model (PDPM) changed the payment system used for traditional Part A residents,” says Suzy Harvey, RN-BC, RAC-CT, managing consultant at BKD in Springfield, MO. “It did not change the coverage policies for skilled services.”
Key requirements that remain in place—and that NACs need to know about—include the following:
jRAVEN (version 1.7.2) is now available for download which contains the following updates:
The Centers for Medicare & Medicaid Services (CMS) is announcing updates and initiatives aligning with the CMS strategic initiative to Ensure Safety and Quality in Nursing Homes. These updates and initiatives include:
• Phase 3 Interpretive Guidance: CMS will be releasing updated Interpretive Guidance and training for the Requirements for Participation for Long-Term Care (LTC) Facilities. However, this guidance will not be released by the November 28, 2019 implementation date of the regulations. We will be releasing the guidance in the second quarter of calendar year 2020, along with information on training and implementing related changes to The Long Term Care Survey Process (LTCSP). While the regulations will be effective, our ability to survey for compliance with these requirements will be limited until the Interpretive Guidance is released.
• Medicare and Medicaid Programs; Revision of Requirements for Long-Term Care Facilities: Arbitration Agreements: On July 18, 2019, the Department of Health and Human Services (HHS) published a final rule establishing requirements related to the use of binding arbitration agreements. This final rule amends the requirements that Long-Term Care (LTC) facilities must meet to participate with Medicare and Medicaid.
• Actions to Improve Infection Prevention and Control in LTC Facilities: CMS has created a nursing home antibiotic stewardship program training; updated the Nursing Home Infection Control Worksheet as a self-assessment tool for facilities; and is reminding facilities of available infection control resources.
• Release of Toolkit 3, “Guide to Improving Nursing Home Employee Satisfaction”: CMS has created a toolkit that helps facilities improve employee satisfaction.
Collaboration. It is one of the key terms used to describe data collection for section GG, Functional Abilities and Goals. Collaboration among clinicians, to identify usual, and baseline conditions—these are also important terms used throughout section GG. But in a profession that is used to coding section G, Activities of Daily Living (ADLs), and calculating the Rule of 3, the process of determining usual performance for section GG holds some challenges. Does the data collected and documentation actually support how we are coding section GG? Let’s take a look at a case study of Mrs. Georgia Geoffrey and how the clinicians determined usual performance for some of the key GG tasks on her 5-Day assessment.
Mrs. Georgia Geoffrey admitted to Happy Valley Nursing Facility following a knee replacement due to osteoarthritis. The wheelchair transport van wheeled her into the nursing home, and the nurse aide assigned to her alerted the nurse of her arrival and propelled her down the hall to her room.
A surprising number of nurse assessment coordinators (NACs) still don’t monitor the Final Validation Reports that the QIES ASAP MDS submission system automatically generates when each batch of MDS records is submitted, says Carol Maher, RN-BC, RAC-MTA, RAC-MT, CPC, director of education for Hansen, Hunter & Co. PC in Vancouver, WA.
“When I go into facilities to work on a problem and ask MDS coordinators if they received any error messages or warnings on the Final Validation Reports for the MDSs in question, they often don’t know what I’m talking about,” notes Maher. “Some NACs have never even seen the Final Validation Reports because another staff member does the MDS transmissions on their computer.”
These NACs are missing out on a critical step in the MDS submissions process, stresses Maher. “Reviewing every Final Validation Report allows the NAC to make sure that all of the MDSs were accepted into the federal database and to follow up on any fatal error or warning messages. While some software systems can show whether an MDS was accepted or rejected, they often don’t show warning messages—and each warning message is very important, giving you the information needed to determine if something should be modified or changed in that MDS.”
The LTCSP Procedure Guide provides instruction on the procedural and software steps necessary for completing the Long-term Care Survey Process. Surveyors use the Procedure Guide for all standard surveys of SNFs and NFs, whether freestanding, distinct parts, or dually participating. The LTCSP steps are organized into seven parts: 1) offsite preparation; 2) facility entrance; 3) initial pool process; 4) sample selection; 5) investigation; 6) ongoing and other survey activities; and 7) potential citations. Below is a broad overview of the key onsite parts of the LTCSP (parts 3 – 7).
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