Medicare and SNF Presented by Lizeth Flores, RHIT Health Information Management Consultant Anderson Health Information Systems, Inc Front Porch April 27 & 29, 2010

Coverage Requirements For a beneficiary to be covered in a SNF under Medicare Part A, he or she must: Have a 3 day qualifying hospital stay: Have received inpatient hospital care for at least three consecutive days, (3 midnight rule) including the date of admission but not the date of discharge;  Be admitted to the SNF within a specified time period (generally, within 30 days) of that hospital discharge;

Coverage Requirements continued….  Need post-hospital extended care services for a condition that was treated during the qualifying hospital stay or for a condition that arose while he or she was in the SNF for treatment of a condition which was previously treated during the qualifying hospital stay;  Have a physician or other qualified practitioner certify that he or she requires skilled services on a daily basis that, as a practical matter, can only be provided in a SNF on an inpatient basis;

Coverage Requirements continued…. Require skilled nursing or rehabilitation services which means that services are ordered by a physician, require the skills of technical or professional personnel, and are furnished directly by, or under the supervision of, such personnel; Be admitted to a Medicare-certified SNF; and  Require services that are reasonable and necessary for the diagnosis or treatment of his or her condition (i.e., are consistent with the nature and severity of the individual’s illness or impairment, the individual’s particular medical needs, and accepted standards of medical practice).

Skilled Services Require the skills of qualified technical or professional health personnel such as registered nurses, licensed practical (vocational) nurses, physical therapists, occupational therapists, and speech- language pathologists or audiologists; and Must be provided directly by or under the general supervision of these skilled nursing or skilled rehabilitation personnel to assure the safety of the patient and to achieve the medically desired result. Must be furnished based on a physician’s order

How can I determine if a service is considered “Skilled” If the inherent complexity of a service prescribed for a patient is such that it can be performed safely and/or effectively only by or under the general supervision of skilled nursing or skilled rehabilitation personnel, the service is a skilled service; For Example: the administration of intravenous feedings and intramuscular injections; the insertion of suprapubic catheters; and ultrasound, shortwave, and microwave therapy treatments.

Rehab Services When rehabilitation services are the primary services, the key issue is whether the skills of a therapist are needed. The deciding factor is not the patient’s potential for recovery, but whether the services needed require the skills of a therapist or whether they can be provided by non-skilled personnel.

Examples of Non-Skilled Services General maintenance care of colostomy and ileostomy; Routine services to maintain satisfactory functioning of indwelling bladder catheters (this would include emptying and cleaning containers and clamping the tubing); Changes of dressings for uninfected post-operative or chronic conditions; Prophylactic and palliative skin care, including bathing and application of creams, or treatment of minor skin problems; Routine care of the incontinent patient, including use of diapers and protective sheets;

“Midnight Rule” excerpted from chapter 3 of the Benefit Policy Manual at olicy/bp102c03.pdf olicy/bp102c03.pdf BPM, CHAPTER Counting Inpatient Days (Rev. 1, ) A , A , A , HO-217.3, HO , SNF The number of days of care charged to a beneficiary for inpatient hospital or skilled nursing facility (SNF) care services is always in units of full days. A day begins at midnight and ends 24 hours later. The midnight-to-midnight method is to be used in counting days of care for Medicare reporting purposes even if the hospital or SNF uses a different definition of day for statistical or other purposes.

“Midnight Rule” Excerpted from Medicare Claims processing manual chapter 6 section 30 - Billing SNF PPS Services (Rev. 1472, Issued: , Effective: , Implementation: ) The day on which the patient began a leave of absence is treated as a day of discharge, and is not counted as an inpatient day unless the patient returns to the facility by midnight of the same day. The day the patient returns to the hospital or SNF from a leave of absence is treated as a day of admission and is counted as an inpatient day if the patient is present at midnight of that day.

Supporting Documentation Paints a picture of the Resident’s condition and services provided Provides legal, historical account of services Incomplete documentation may lead to denial of payment, and/or questions as to the quality of care provided Professional responsibility Legal requirement Record resident’s care Communication tool for the IDT

Provide evidence of level of care If resident is receiving therapy services Nursing documentation must describe resident’s level of activity with nursing staff, participation in therapy and reflect nursing activities that support rehab statements and goals

Vulnerabilities Incomplete documentation (charting omissions) Unsigned physician orders Inaccurate documentation of indirect nursing services as this is not part of MDS information and can only be supported by nursing documentation

Checklist Physician’s orders for services (signed and dated) Documentation of services rendered for dates of service billed Documentation to support medical necessity for services billed

Certification The initial certification is completed on or prior to admission for Medicare coverage. Within 72 hours of admission; On the day the physician visits the resident and writes the first progress note; On the Inter-facility Transfer form as an alternative to completing the initial certification. The facility is responsible for obtaining timely and complete certification / re-certifications. Re-certifications are due on or before the 14th day of admission, and every 30 days after that until coverage ends

Authentication Medicare requires a legible identity for services provided / ordered. Signatures must be legible and include first and last name Signatures must be obtained prior to billing services to Medicare NO STAMPS

Discussion Who verifies qualifying stay? Who determines skilled services? Who identifies the principal diagnosis? What forms are you currently using to communicate services and care being provided? How is the record monitored for documentation compliance? Who tracks completion of the Certifications?

TRIPLE √ Current Process Participants Forms used Most common issues

ICD-9-CM Coding

Coding Guidelines for Post Acute Care Per ICD-9-CM Official Guidelines for Coding and Reporting, aftercare codes are generally first to explain the specific reason for the encounter (admission) Certain aftercare code categories need a secondary dx code to describe the resolving condition or sequelae For others (V codes) the condition is inherent in code title

MYTH The FI / MAC will not accept V-codes as principal diagnosis - is an INCORRECT statement. Truth: Medicare requires that the Principal DX be reported according to Official ICD-9-CM guidelines for coding and reporting, as required by HIPAA including any applicable guidelines regarding the use of V-Codes

MYTH In order to truly support the relationship between SNF services and the qualifying stay I must code the hospital diagnosis Truth: The skilled services are covered as long as they are related to the condition treated at the hospital Example: Though the SNF does not perform joint replacements it does provide rehabilitative services during the recovery period.

Types of codes used in LTC Aftercare – used when the initial treatment of a disease or injury has been performed and the patient still requires continued care to heal or recover. Late Effects – a late effect is a residual condition that remains and requires medical evaluation, rehab treatments and/or nursing care after the initial illness or injury.

Types of codes used in LTC History of – (Hx) – history codes are acceptable on any Medical record regardless of reason for admission/encounter. A history code is distinct from a “status” code in that history codes indicate that the patient no longer has the condition and “status” codes indicated a present state. There are two types of history V- codes, personal and family.

Sequencing The order in which codes are listed is called sequencing. The coder should make every effort to record the codes in a logical sequence that is descriptive of the resident’s condition.

Coding for Rehabilitative Services Category V57 does not indicate that rehab services were provided, only that the resident was admitted for this purpose Use only one code from Category V57 for an admission If the resident is admitted for multiple therapies, use V57.89

V57 Care Involving Rehab Code also the condition requiring the rehab, such as: –Residuals –Late effects –Aftercare –Symptoms

ICD-9-CM Official Guidelines for Coding & Reporting Latest Revision October 1, 2009 Codes revised twice per year April and October April codes will come out only if significant or important and can not wait until October

What is your current practice? Discussion of current coding methodologies for your facility Review of available sample face sheets

SNF Prospective Payment System Clinical characteristics Limitations in activities of daily living ADLs Types of services received

PPS & The MDS 108 data fields of MDS 2.0 used to classify the resident into a RUG-III category that determines the payment level for the resident MDS contains information about the resident’s nursing needs, ADL impairments, cognitive status, behavioral problems and medical diagnoses. Data must be accurate, consistent and supported by the medical record documentation.

RUG – III Classification Calculated from the MDS assessment data 7 broad categories in descending level of acuity Assessment schedules defined by regulation i.e. 5 day, 14 day etc.

Assessment Reference Date Determines elements of care to be captured for reimbursement Example: A. Ultra High Intensity Criteria In the last 7 days (section P1b [a,b,c]): 720 minutes or more (total) of therapy per week AND At least two disciplines, 1 for at least 5 days, AND 2nd for at least 3 days

Discussion Points

Advanced Beneficiary Notice

SNFABN 2002 CMS released the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) This form consolidated the five Denial Letters into one alternative

Providing the notice…… If the SNF provides the beneficiary either SNFABN (CMS-10055) or a Denial Letter at the initiation, reduction or termination of Medicare Part A benefits, the provider has met its obligation to inform the beneficiary of his/her potential liability for payment related standard claim appeal rights. Issuing Notice to Medicare Non- Coverage (CMS-10123) only notifies of rights to expedited review of a service termination but does not fulfill obligation to advise of potential liability for payment.

CMS Informs of right to expedited review of a service termination Must be issued upon termination of all Medicare part A services for “coverage reasons” not exhaustion of benefit covered days. If after issuing CMS 10123, the SNF expects resident to remain in the facility on a non- covered stay CMS or a Denial Letter must be issued to inform of potential liability for the non-covered stay.

Survey Protocol Let’s review Attachment 2

When and What to issue…….. On Admission: Beneficiary had qualifying hospital stay but does NOT meet daily skilled care requirement – Issue SNFABN CMS or Denial Letter Beneficiary did not have 3 day qualifying stay – Issue SNF NEMB or Other Type of notice (CMS 20014) – voluntary

When and What to issue…….. Part A ending because daily skilled services no longer required Beneficiary will remain in the facility under custodial Care Beneficiary not receiving therapy or other part B benefits Issue CMS and for part A & B only 1 st and SNFABN CMS or Denial Letter 2 nd

When and What to issue…….. Part A benefits ending because daily skilled services no longer required and resident will not remain at the facility Issue CMS Part A benefits ending because beneficiary has exhausted 100 days of coverage SNF NEMB or other type of notice CMS (voluntary)

When and What to issue…….. Part B: No part A coverage – continued stay at SNF short term PT under part B– therapy cap not met Issue-CMS & (for Part A&B only) ABN (CMS R131) Part B only No part A coverage – continued stay at SNF - short term PT under part B – PT / SLP cap has been met - Issue CMS R131 (voluntary)

When and What to issue…….. Part B: No part A coverage – continued stay – Receiving OT & PT – PT services end or discontinued- PT /SLP cap not met Issue – CMS st & CMS R131 2 nd

Q & A

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