Skilled Nursing Facility Medicare Basics

Transcription

1 Judy Wilhide Brandt, RN, BA, RAC-MT, QCP, CPC, DNS-CT www. Skilled Nursing Facility Medicare Basics January 2018 NC & VA Helpful Resources:. Resources judywilhide.com (c) 1

2 How does resident receive Medicare? Must confirm coverage rules for each Original Medicare A State dueleligible program MA Plan Is Medicare secondary? ACO/Bundled Payment/other Medicare Health Plan SNF Medicare Options Part A Hospital Part B Outpatient services Medicare Health Plans Medicare Advantage Plans (Part C) Home Health Demonstration /Pilot Programs SNF Hospice judywilhide.com (c) 2

3 MA Plan Medicare pays a fixed amount for care each month to MA Plan insurance company. Each can charge different out-of-pocket costs and have different rules for how to get services and HOW TO GET PAID Different payment requirements RUGs Levels Pre-Auth In Network Physician Certification Qualifying Hospital Stay Benefit Period Technical Requirements judywilhide.com (c) 3

4 3 Day Qualifying Stay Required for Original Medicare Must be consecutive Must be an inpatient ER, outpatient midnights do not count Hospice Revocation in Hospital If hospice resident receives general inpatient care for 3 days And elects to revoke hospice Stay will still qualify the beneficiary for SNF services Although hospice hospital LOC judywilhide.com (c) 4

5 SNF 100 Day Benefit Period (after qualifying hospital stay) May use up to 100 days per benefit period if level of care requirement met If part of a benefit period used and skilled need rearises within 30 days from last SNF day, may resume same benefit period with access to remaining days If SNF need arises between 31 & 60 days from last SNF day, may only access remaining days upon completion of another 3 day qualifying stay in hospital If SNF need arises after 60 day wellness, may access new 100 day benefit period with 3 day hospital stay 60 Day Wellness Period 60 consecutive days in which resident is not in a certified bed receiving at least a SNF level of care Medicare and/or Medicaid certified bed in NF or higher (hospital) judywilhide.com (c) 5

6 Wellness Period Scenarios In certified bed Receiving SNF LOC In certified bed Not receiving SNF LOC Not in certified bed Receiving SNF LOC Not a wellness day A wellness Day A wellness day Examples: Receiving qualifying tube feeding in a certified SNF bed after exhaustion of 100 days Goes to hospital for 3 day qualifying stay 6 months later for hip fracture No benefit days available Receiving qualifying tube feeding in a certified SNF bed after exhaustion of 100 days Goes home to receive care for tube feeding, then to qualifying hospital stay 6 months later for hip fracture 100 day benefit period available Receiving 5 days a week therapy in a certified SNF bed after exhaustion of 100 days Wellness period not generating until therapy drops below 5xweek After 60 day wellness and 3 day qualifying hospital stay: New 100 day benefit period Must verify eligibility with on-line system and your own investigation judywilhide.com (c) 6

7 30 day transfer requirements 1 Must be admitted to certified bed within 30 days of qualifying hospital stay If resident is admitted meeting SNF criteria, but Medicare is secondary, Medicare day 1 can be >30 days from discharge. 2 If cut from Medicare with benefit days remaining, may access the rest of the current benefit period if skilled need rearises within 30 days of last Medicare day. Medical Appropriateness Exception May begin Part A stay > 30 days after hospital d/c when the patient s condition makes it medically inappropriate to begin SNF stay immediately after hospital discharge. Must be medically predictable at hospital discharge that SNF care will be required within a predeterminable time period. Physician must document estimated time period and reason for delay judywilhide.com (c) 7

8 SNF & Hospice Benefit May access both simultaneously As long as reason for SNF services is totally unrelated to reason for Hospice services MD Cert Requirements Initial Cert SNF services are required on an inpatient basis because of the resident s need for skilled nursing or rehabilitation care on a continuing basis for the condition(s) for which s/he was receiving inpatient hospital services prior to his/her transfer to the SNF. Subsequent Continued need for extended care services, Estimated period of time required for skilled care Any plans for home care, Need for SNF care is for a condition related to hospital stay or which arose during the SNF stay No requirement for a certain form judywilhide.com (c) 8

9 Physician Certification of Need for Skilled Care MD, PA, NP may sign Medicare certification of need for skilled care If discharged and readmitted, re-start certification schedule Delayed certs honored when isolated oversight /lapse with explanation Faxed signatures accepted May only bill if written certification present Required Timetable: Initial Certification: On admission or as soon thereafter as practical. First Recertification: On or before day 14 of the stay. Subsequent Recertifications: Not more than 30 days from date of last certification. judywilhide.com (c) 9

10 If all blocks are not filled out or checked, it is not a valid certification The claim will be denied upon medical review Is order Admit to skilled care required? No There is no requirement for this order Palmetto will deny if they don t see this order Yes judywilhide.com (c) 10

11 The great Palmetto Insanity Palmetto for a long time has been denying SNF claims because there is no order to admit to skilled care. They cite Fed Reg title when denying. The Qualified Independent Contractor (QIC) at the second level of appeal will overturn Palmettos 1 st two denials Physician services. A physician must personally approve in writing a recommendation that an individual be admitted to a facility. Each resident must remain under the care of a physician. Palmetto is clearly insane. But, it is prudent to write Admit to Skilled Care for all Part A residents. It s not worth the fight. judywilhide.com (c) 11

12 Skilled Level of Care Requirements Skilled Rehab Skilled Rehab & Nursing Skilled Nursing Care in a SNF is covered if all of the following four factors are met: 1. Requires skilled nursing services or rehab for any condition For which the patient received inpatient hospital services or That arose while receiving care in a SNF for a condition for which he received inpatient hospital services Nursing/Rehab services are considered skilled when they are so inherently complex that they can be safely and effectively performed only by, or under the supervision of an RN/LPN or Therapist/Assistant judywilhide.com (c) 12

13 Care in a SNF is covered if all of the following four factors are met: 2. The patient requires these skilled services on a daily basis 5 days a week rehab 7 days a week nursing 3. As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF May have short LOA during Part A stay for brief period of time Skilled rehabilitative therapy must be required 5 calendar days a week to meet SNF criteria. Therapy that is purposefully spread out over five days just to make it look like the five day a week criteria is met will be prohibited. Su Mo Tu We Th Fr Sa OT ST OT ST OT judywilhide.com (c) 13

14 Care in a SNF is covered if all of the following four factors are met: 4. The services delivered are reasonable and necessary for the treatment of a patient s illness or injury, are consistent with the nature and severity of illness or injury, particular medical needs, and accepted standards of medical practice. Presumption of Coverage When Admitted directly from hospital And RUG on PPS 5 day in top 52 RUGs Then Stay deemed covered through ARD of PPS 5 Day If no presumption, chart must show clear skilled need Rehab + Ext Rehab Extensive Services Special Care High Special Care Low Clinically Complex After presumption timeframe, RUG does not indicate SNF criteria met judywilhide.com (c) 14

15 Skilled Services Defined Skilled nursing/rehab: Require skills of qualified health personnel such as RN, LPN(LVN), PT, OT, SLP, COTA, PTA due to the nature of the service and Must be provided directly by or under the general supervision of these skilled nursing/rehab personnel to assure the safety of the patient and to achieve the medically desired result. Skilled care may be necessary to improve current condition, to maintain current condition, or prevent or slow further deterioration of the patient s condition Principles for Determining Whether a Service is Skilled While a particular medical condition is a valid factor in deciding if skilled services are needed, a patient s diagnosis or prognosis should never be the sole factor in deciding that a service is skilled. Are skilled nurses/therapists providing the service because it is beyond the scope of unskilled (CNA/Rehab Tech) staff? judywilhide.com (c) 15

16 Therefore the patient s medical record must document as appropriate: H&P exam, (including the response or changes in behavior to previously administered skilled services); Skilled services provided; Patient s response to the skilled services provided during the current visit; Plan for future care based on the rationale of prior results. Detailed rationale that explains the need for the skilled service in light of the patient s overall medical condition and experiences; Complexity of the service to be performed; Any other pertinent characteristics of the beneficiary. Medical record documentation must be accurate, and avoid vague or subjective descriptions of the patient s care that would not be sufficient to indicate the need for skilled care. For example, the following terminology does not sufficiently describe the reaction of the patient to his/her skilled care: Patient tolerated treatment well Continue with POC Patient remains stable judywilhide.com (c) 16

17 Record should contain: Objective documented measurements of: physical outcomes of treatment should be provided and/or a clear description of the changed behaviors due to education programs So that all concerned can follow the results of the provided services Specific Examples of Some Skilled Nursing or Skilled Rehabilitation Services Management and Evaluation of a Patient Care Plan Constitutes skilled services when they require the involvement of skilled personnel to Meet medical needs, Promote recovery, and Ensure medical safety. Clinical record must clearly establish that there was a likely potential for serious complications without skilled management judywilhide.com (c) 17

18 Principles for Determining Whether a Service is Skilled EXAMPLE: An 81-year-old woman who is aphasic and confused, has hemiplegia, CHF, A-fib, post CVA, is incontinent, has a Stage 1 PrU, and is unable to communicate and make her needs known. Even though no specific service provided is skilled, the patient s condition requires daily skilled nursing involvement to manage a plan for the total care needed, to observe the patient s progress, and to evaluate the need for changes in the treatment plan. The medical condition of the patient must be described and documented to support the goals for the patient and the need for skilled nursing services. Mgt/Eval of Care Plan Example from BPM: Pt is recovering from pneumonia, lethargic, disoriented, has residual chest congestion, is confined to bed as a result of his debilitated condition, and requires restraints at times. MD orders frequent changes in position, coughing, and deep breathing. While the residual chest congestion alone would not represent a high risk factor, the patient s immobility and confusion represent complicating factors which, when coupled with the chest congestion, could create high probability of a relapse. judywilhide.com (c) 18

19 Observation & Assessment Pt with CHF may require continuous close observation to detect signs of decompensation, abnormal fluid balance, or adverse effects resulting from medication(s) that serve as indicators for adjusting therapeutic measures. Documentation must describe the skilled services that require the involvement of nursing personnel to promote the patient s recovery and medical safety in view of the patient s overall condition, to maintain current condition, or to prevent or slow further deterioration. Observation & Assessment If patient did not develop a further acute episode or complication, the skilled observation services still are covered so long as there was a reasonable probability for such a complication or further acute episode. Reasonable probability = likely possibility Information from the patient's medical record must document that there is a reasonable potential for a future complication or acute episode sufficient to justify the need for continued skilled observation and assessment. judywilhide.com (c) 19

20 Observation & Assessment: When it s not skilled Must be a reasonable potential that skilled observation/assessment will result in changes to the treatment of the patient It s not reasonable and necessary where these characteristics are part of a longstanding pattern of the patient's waxing and waning condition which by themselves do not require skilled services and there is no attempt to change the treatment to resolve them. Teaching and Training Activities Teaching and training activities, which require skilled nursing or skilled rehabilitation personnel to teach a patient how to manage their treatment regimen, would constitute skilled services. Documentation must thoroughly describe all efforts that have been made to educate the patient/caregiver, and their responses to the training. judywilhide.com (c) 20

21 IM or IV injections or feedings Tube feeding at least 26 % calories/501 cc per day Naso-pharyngeal and tracheotomy aspiration Insertion, sterile irrigation, and replacement of suprapubic catheters MD Rx Heat treatments as part of active treatment Treatment of decubitus ulcers, Stage 3 or worse, or a widespread skin disorder Application of dressings with prescription medications and aseptic techniques Rehabilitation nursing procedures Direct skilled nursing services Initial phases of oxygen therapy Early post op colostomy care in present of complications Services that are NOT skilled: Routine care of: Oral meds, eye drops, ointments, oxygen Colostomy/ileostomy Indwelling catheter/incontinence Plaster casts/braces ADL assist/exercises Minor skin issues/turning/repositioning Dressings for uninfected post op/chronic/palliative skin problems judywilhide.com (c) 21

22 Skilled therapy services must meet all of the following conditions: Directly and specifically related to an active written treatment plan based on initial evaluation by qualified therapist after admission to the SNF and prior to the start of therapy services in the SNF that is approved by the physician after any needed consultation with the qualified therapist. EXAMPLE: A patient with Parkinson s disease may require the services of a PT to determine the type of exercises that are required to maintain his present level of function. The initial evaluation of the patient s needs, the designing of a maintenance program which is appropriate to the capacity and tolerance of the patient and the treatment objectives of the physician, the instruction of the patient or supportive personnel (e.g., aides or nursing personnel) in the carrying out of the program, would constitute skilled physical therapy and must be documented in the medical record judywilhide.com (c) 22

23 It s not the condition, it s what we are doing about it that determines need for skilled care. Would the person be safe in a lower level of care, without RN/Therapist Oversight? Review: There must be documentation of medical instability or the probability of change in the resident s condition. Evidence of risks/potential complications requiring careful supervision. Evidence skilled licensed personnel are assessing/supervising care. judywilhide.com (c) 23

24 Medical Review: Many different payers may ask for the clinical record to verify the HIPPS on the claim. Monitor MAC website for information and guidance on Original Part A medical review Pepperresources.org judywilhide.com (c) 24

25 Targeted Probe and Education (TPE) Palmetto The CMS has seen positive results during pilot testing in hospitals and home health, using TPE strategy, the key elements of which include: Replace all current medical record reviews in the MAC s Improper Payment Reduction Strategy(IPRS) with up to three rounds of a prepayment Targeted Probe & Educate process. If high denial rates continue after three rounds, the MAC shall refer for additional action, which may include: Extrapolation Referral to the Zone Program Integrity Contractor (ZPIC) or Unified Program Integrity Contractor (UPIC) Referral to the RAC 100% pre-pay review, etc. CR /15/17 judywilhide.com (c) 25

26 TPE Process TPE: Continued The MAC, rather than CMS, will select the topics for review (based on existing data analysis procedures) The MAC can target the strategy on the providers most likely to be submitting non-compliant claims, rather than reviewing 100% of the providers Limit the sample for each probe round to a minimum of twenty (20) and a maximum of forty (40)claims Policy: The MACs shall conduct all medical record review following the TPE strategy. Automated reviews and prior authorization directed by CMS are outside of the TPE strategy. judywilhide.com (c) 26

27 TPE: Continued The MAC shall have the discretion to define provider/supplier compliance, which may vary based on the item/service reviewed. NOTE: It is the intent of the education that the focus will be on improving specific issues without allowing other problems to develop and provide opportunities for the provider/supplier to be able to have questions answered. After each round of claim reviews, the MAC shall conduct a 1:1 educational intervention with the provider/supplier that reinforces compliant parameters and reiterates issues identified in the round, to avoid any shifts from the non-compliant factors. TPE: Continued The MACs shall conduct 1:1, intra-probe educational intervention when easily curable errors are identified, even if the probe round is not completed. The MACs shall request and accept new documentation from providers/suppliers hen easily curable errors are identified at a y time during the current round of probe reviews. judywilhide.com (c) 27

28 Targeted Probe and Educate (TPE) Process Palmetto GBA will identify areas with the greatest risk of inappropriate program payment. RU and RV Palmetto GBA selects providers for the TPE process based on the following: Analysis of billing data indicating aberrancies that may suggest questionable billing practices or On targeted review and is transitioned to the TPE process based on error rate results or On service specific review error rate results Palmetto GBA will mail a letter to those who have been selected for TPE review. The letter will outline the reason for selection, and will provide an overview of the TPE process and contact information. judywilhide.com (c) 28

29 Targeted Probe and Educate (TPE) Process TPE consists of up to three rounds of review with claims sample selected (pre or post payment) for each round Subsequent rounds will begin days after individual provider education is completed. Discontinuation of review may occur if appropriate improvement and compliance is achieved during the review process. An Additional Document Request (ADR) will be generated for each claim selected For pre-pay reviews, Palmetto GBA has 30 days from the date the documentation is received to review the documentation, and make a payment decision For post-pay reviews, Palmetto GBA has 60 days from the date the documentation is received to review the documentation, and make a payment decision Targeted Probe and Educate (TPE) Process Note: Non-response denials count as an error when calculating the error rate. Palmetto GBA recommends using eservices, our secure online web portal to submit documentation in response to medical review ADRs and when/if additional documentation is requested throughhout the review process. Prior to the conclusion of each round, the medical reviewer will call all providers with moderate to high error rate to discuss the summary of the errors found. At the conclusion of each round, a letter with the review results will be mailed. The letter will include the number of claims reviewed, the number of claims allowed in full, and the number of claims denied in full or in part. When high denial rates continue after three rounds of TPE, Palmetto GBA will send a referral to CMS for additional action. judywilhide.com (c) 29

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32 Medical Review Update Jan 24, 2018 Providers in areas serviced by Livanta QIO have gotten requests for 10 records to verify the NOMNC was correctly issued. No CMS announcement beforehand When providers called the number on the request, they were told this was a new project from CMS Questions/Discussion judywilhide.com (c) 32

33 We frequently update our articles to reflect the latest changes and updates to Medicare, and strongly recommend you visit this article at link below to confirm you have the latest version Palmetto GBA, LLC Published Date:12/04/2017 Printed Date: 1/22/2018 URL: open Ask the Contractor Teleconference (ACT) - Medical Review Targeted Probe & Educate (TPE) Process, November 29, 2017 Facilitator: Wendy Weary Speakers: Kim Hinson, Director, Jason Rhodes and Medical Review Team Participants were welcomed to the Medical Review Targeted Probe & Educate (TPE) Process Ask the Contractor Teleconference (ACT). The purpose of ACT is intended to open the communication channels between the provider community and Palmetto GBA. We believe this is an excellent forum to encourage dialogue between our providers and Palmetto GBA. Prior to the call, an announcement was sent out via listserv and posted on the website. Wendy Weary, POE provided a summary of the Targeted Probe & Educate (TPE) Process ( 0Part%20A~Medical%20Review~Targeted%20Probe%20and%20Educate~ASNPH36180?open). Listed below are the questions and answers addressed by the Medical Review Team. Question: I know we need to give one single contact person s name and number. However, when we receive the education call to review the findings; we will have multiple people that want to be on that phone call, such as CFO, Case Management Director and the Appeal Coordinator, plus. Is there a way you can contact that one person and coordinate a date and time when we could allow others to fit in on that education information? Answer: Yes, that will be the TPE process. The Medical Reviewer conducting the reviews for your particular provider number will reach out to the TPE Provider Contact (/ palmetto/providers.nsf/docscat/providers~jm%20part%20a~medical%20review~targeted%20probe%20and%20educate~at6fuk6386?open) that we are given and schedule that call. The reviewer will reach out to you so that you can coordinate with your internal staff. Ideally, the call should be scheduled within the next few days. Question: Can you tell me how the determination will be made on whether these will be pre or post-pay reviews? Answer: Typically, the TPE Process will be done mostly as pre-payment reviews. There will be a rare occurrence where a post-pay model is better fittings perhaps with labs, etc. The normal Additional Documentation Request (ADR) process with claim suspension and ADR letter will occur. We notify the provider if they are selected for either the pre-pay or post-pay. Question: Can you give us some examples of billing aberrations that may trigger probe? Answer: We analyze data to identify services that have a high payment error probability and/or present the greatest risk. These services may be identified via previous review activity conducted by the MAC, the CERT contractor, the OIG and other CMS contractors. Once the services are identified, additional data analysis includes (but is not limited to) establishing a baseline to identify unusual trends such as provider s rank against peers and changes in utilization over time. Question: When do you expect the first round of probe letters to go out? Answer: Initial TPE notification letters have already been mailed. As new providers and topics are identified, additional notifications will be mailed. We have sent ADRs and responses are currently in review for several topics. Question: What is the appeal process for any denials? Answer: The appeal process will not change. Historically Medical Review has conducted both provider and service specific review and the appeal process was the same then as it will be now. The TPE Process will move the Medical Review focus to provider specific editing only, and will provide more focus on education by including the 1:1 education program. Medical Review will still follow the probe process as outlined in IOM, but will now allow up to three rounds of the probes if needed and will provide one-on-one education at end of each of those rounds. If you have a review determination during one of those rounds that results in a claim denial, we encourage you to review the medical records you submitted, and if you disagree with that determination - you should follow the normal appeal process. Question: Two of our facilities have received the Notice of Review letters. Of the 20 to 40 reviews that will be done, will we receive one letter for each of those two facilities or will this be one letter at a time, similar to the ADR process for prepayment review? Answer: Upfront each provider will receive a notification letter indicating that they have been chosen and what the rationale is. In addition, when you bill your claim you will receive your normal ADR letter of request that identifies the claim has been selected for a prepay probe. The initial round letter does not detail that information for a prepay probe, but will for a post pay probe. For prepay probes, providers should still monitor for your ADR letters and Part A providers can still review in Direct Data Entry (DDE) for the claims in the S B6001 the location for prepay probes. To ensure you receive this very important information (initial notification letter and ADR letters), this is a good time to make sure your address information is correct with provider enrollment. A Medical Review Decision and Education Letter will be generated for each specific claim review resulting in a denial. Additionally, at the conclusion of the review for all claims in the sample, you will receive one-on-one education with a clinician via teleconference. After the one-on one education has been completed, you will receive a packet in the mail that aggregates the reviews for all claims in the sample, provides claims specific information and gives the top denials in order in which they were in part of the sampling. You will know which area to focus on first and we provide the steps to make sure you can avoid those errors in the future. If you have two facilities chosen for TPE; these are two independent samples and will not be combined together. They will be two organizations or two sites with separate reviews. If one is compliant and one is not compliant, then Provider A will not be subject to further review but Provider B will. Question: Could you review the process again for how a provider notifies you of the appropriate contact for the education component?

34 Answer: When you respond to the ADR include the contact information in the cover letter. The same reviewer is reviewing that entire set of records and he or she will become accustom to who that contact person is. Please make sure to include the contact name(s) and a correct phone number. We are experiencing some trouble getting in touch with and finding the appropriate person, so that will be greatly appreciated. Question: Is there a particular color to the TPE envelope or is it just a white normal Palmetto GBA envelope? Answer: You will receive the white normal Palmetto GBA envelope. Question: The education component would be provided for those providers who have moderate to higher error rate; does that means that those with a moderate to high error rate will automatically go on to another round? Answer: Let s clarify that we will be providing education to any provider that has any denials. If you have 40 samples and one claim is denied, we will be reaching out to provide education about why that one claim was denied. But just because you had education given, does not mean that you will automatically progress to the next round. Our due diligence is to help you understand why that claim was denied and how to prevent that in future. Question: With the new TPE process, if a round of ADRs is completed and we appeal the denials; will we still receive ADRs on that same service to be reviewed or will you hold off until you ve exhausted the appeal? Answer: If Medical Review has collected the 20 to 40 claim samples for the probe round and there have been some denials that you disagree with, you should follow the normal appeals process. At the end of that probe, we will evaluate the information that we have on hand and make a determination on whether we advance to that next round or not. Medical Review would not be aware of outstanding appeals and those would not be considered for that determination at that time. It doesn t mean you shouldn t appeal, it just means that all of the appeals would have to be resolved for us to consider that during our valuation of that particular probe. That is not a variance from the normal Medical Review process. If appeals are complete at the time we re evaluating data, we take that into account. But if they re still outstanding, that information is not available to consider. Question: If we have not yet received a letter related to TPE, does that mean we re not going to get a letter? How does that process flow - if we haven't heard yet, it doesn't necessarily mean that we won't hear? Answer: That is correct. Much like every other organization we try to stage to make sure that we re not over-burdening providers and receiving too much documentation all at one time. Providers are notified of our medical review strategy focus so there will be ample time if you prepare for any audit that may come your way. Question: Do individual letters for each NPI go to the individual office or to the corporate office? Answer: The letters are based on PTAN and the provider address registered with Provider Enrollment. Each provider sets their organization s provider enrollment information separately for their address choice. If the address on file is the individual practice, the letter will go there. If it s listed as the corporate headquarters, it will go there. Question: Do you have criteria for sampling 20 or 40 for a particular provider? How would you determine that 20 is enough and to stop at this point? Answer: We take many things into account when deciding what sample size to use, the type of service and overall protection of the Medicare Trust Fund. Part of what s included would be your billing practice or billing volume. If you are a small provider submitting 15 claims a month, Palmetto GBA is not going to require 40 claims from you as that would be burdensome to your organization. The provider s billing pattern will be taken into consideration in determining the number of claims per round to substantiate a review. We do not have a timeline to stop the ADRs; we will keep going until we reach between 20 or 40 depending on which level is set for that particular provider. Question: Is there a time limit on this round for the TPE process if our agency hasn't heard anything as of yet, within a month, two months? Answer: Please understand that when we refer to a round, it s not like we re starting today and all providers we put in at the end of the day we expect to be done by this other date. What we mean each provider is going to be treated independently. The first draw of claims to be reviewed that is pulled from them is round one. The rounds are specific to the provider not specific to the program. Question: Are the doctors required to participate in the TPE education or is it voluntarily done or provide? Answer: That would be an organizational decision as to whomever you would like to participate and that s why we re asking for the point of contact so they may coordinate within your practice. We re happy to have the physicians included in the education and recommend including those that can help make the necessary changes. Question: How do you differentiate the ADR letters that are part of the TPE versus just a normal prepay ADR letter request? How we can identify if the ADR letters are related to TPE or not? Answer: As of 10/01/17 all ADRs are for the Targeted Probe and Educate Process and we are not sending any other Palmetto GBA Medical Review ADRs at this time. We re only focused on TPE. Question: How is this different from the audits that the Zone Program Integrity Contractors (ZPIC)? Answer: From Palmetto GBA, you will receive an ADR request that is specific to Palmetto GBA. It will indicate the claim was selected for TPE and it will have in the body of the ADR letter where you should send the medical records to. The Zone Program Integrity Contractors (ZPIC) has a separate contract with CMS and their own focus problem list. You will receive a similar ADR because Palmetto GBA actually develops those letters on behalf of the ZPIC. The ZPIC ADR letter will instruct you to send the medical records to the ZPIC. If you're involved in the TPE process, you may or may not receive a request from the ZPIC. If you do receive a ZPIC ADR you should send the records just like you normally would to that contractor. Question: My organization is currently undergoing the TPE process and so far we've had 24 requests. Are we to expect up to 40 at this point because they keep trickling in? Answer: Without knowing the case specific to the organization it is difficult to say the exact number you should be looking for. However, you should expect up to 40.

35 AANAC.org I I 400 S. Colorado Blvd, Ste. 600, Denver, CO Copyright 2018, American Association of Post-Acute Care Nursing, d/b/a American Association of Nurse Assessment Coordination. All Rights Reserved. No. 1 Technical Requirements 3 consecutive calendar days (midnights) (count the day of admission, but not the day of discharge from acute in-patient hospital) Days in observation, ER, or non-acute swing bed use, are not counted If not admitted directly from acute in-patient hospital, may meet Thirty-Day Transfer Rule Resident has days remaining OR has achieved a 60-day wellness period No. 2 Validation of Skilled Level of Care *Must meet all 4 items below (see also Presumption of Coverage) Resident requires skilled nursing services or skilled rehabilitation services that are: Ordered by a physician Performed by or under the supervision of professional or technical personnel Rendered for a condition for which the resident received inpatient hospital services or a condition that arose while receiving care in a SNF for a condition for which the resident received inpatient hospital services Resident requires skilled services on a daily basis. Daily skilled is defined as: 7 days per week for skilled nursing services AND/OR 5 days per week for skilled therapy As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF Services delivered are reasonable and necessary for treatment of resident s illness or injury Disclaimer: AANAC has made every attempt to ensure the accuracy and reliability of the information provided. AANAC does not accept any responsibility or liability for the accuracy, content, and completeness of the information. Skilled Nursing Facilities are responsible to review and understand the Medicare benefit policy manual before making coverage decisions. For more information: Thirty-day Transfer Rule (Meets Any 1 to Qualify) Resident may utilize Medicare SNF benefits if admitted to the SNF within 30 days of a qualifying hospital stay (day of discharge from the hospital is NOT counted in the 30 days) Resident may utilize Medicare SNF benefits if readmits to a SNF within 30 days of the last covered skilled day (day of discharge is counted) Resident that ends skilled coverage without discharging from the SNF may utilize Medicare benefits if skilled care arose within 30 days of last covered skilled day Note: Must validate skilled level of care Presumption of Coverage May be Used Until the ARD of the 5-day MDS if: RUG IV classification on the 5-day achieves one of the top 52 of the 66 RUG levels AND Resident is admitted/readmitted directly to the SNF after a qualifying hospital stay OR Resident was on Medicare in the SNF, was re-hospitalized, and returned directly to the SNF Note: Must meet skilled level of care as of the day after the 5-day ARD Presumption of Coverage Does Not Apply When: Resident is admitted/readmitted under the thirty-day transfer rule The ARD of the 5-day is set late (e.g., greater than day 8) RUG IV classification on the 5-day achieves one the lowest 14 of the 66 RUG levels

36 Determining Skilled Nursing Services (Direct or Indirect) Key Highlights from the Medicare Benefit Policy Manual Chapter 8 direct skilled nursing services indirect skilled nursing services Some examples of direct skilled nursing services [include]: Intravenous or intramuscular injections and intravenous feeding; Enteral feeding that comprises at least 26 percent of daily calorie requirements and provides at least 501 milliliters of fluid per day; Naso-pharyngeal and tracheotomy aspiration; Insertion, sterile irrigation, and replacement of suprapubic catheters; Application of dressings involving prescription medications and aseptic techniques (see 30.5 for exception); Treatment of decubitus ulcers, of a severity rated at Stage 3 or worse, or a widespread skin disorder (see 30.5 for exception); Heat treatments which have been specifically ordered by a physician as part of active treatment and which require observation by skilled nursing personnel to evaluate the [resident s] progress adequately (see 30.5 for exception); Rehabilitation nursing procedures, including the related teaching and adaptive aspects of nursing, that are part of active treatment and require the presence of skilled nursing personnel; e.g., the institution and supervision of bowel and bladder training programs; Initial phases of a regimen involving administration of medical gases such as bronchodilator therapy; and Care of a colostomy during the early post-operative period in the presence of associated complications. The need for skilled nursing care during this period must be justified and documented in the [resident s] medical record. [ 30.3] The documentation in the medical record as a whole is essential for determination of indirect skilled nursing services and must illustrate the complexity of the unskilled services that are a necessary part of the medical treatment and which require the involvement of skilled nursing personnel to promote the [resident s] recovery and medical safety in view of the [resident s] overall condition. [ ] 1. Management and Evaluation of a [Resident] Care Plan The development, management, and evaluation of a [resident] care plan, based on the physician s orders and supporting documentation, constitute skilled nursing services when, in terms of the [resident s] physical or mental condition, these services require the involvement of skilled nursing personnel to meet the [resident s] medical needs, promote recovery, and ensure medical safety. 2. Observation and Assessment of [Resident s] Condition Observation and assessment are skilled services when the likelihood of change in a [resident s] condition requires skilled nursing or skilled rehabilitation personnel to identify and evaluate the [resident s] need for possible modification of treatment or initiation of additional medical procedures, until the [resident s] condition is essentially stabilized. 3. Teaching and Training Activities Teaching and training activities, which require skilled nursing or skilled rehabilitation personnel to teach a [resident] how to manage their treatment regimen, would constitute skilled services. Disclaimer: AANAC has made every attempt to ensure the accuracy and reliability of the information provided. AANAC does not accept any responsibility or liability for the accuracy, content, and completeness of the information. Skilled Nursing Facilities are responsible to review and understand the Medicare benefit policy manual before making coverage decisions. For more information: Downloads/bp102C08.pdf