MDS Language Impacts CAHs

Transcription

1 MDS Language Impacts CAHs April 2014 Kerry Dunning, MHA, MSH, CPAR, RAC-CT Sr VP, Long Term Care Division GPS Healthcare Consultants

2 Objectives To Sufficiently Understand: Medicare intent for documentation Medicare definitions CAH responsibilities in complying with Medicare required paperwork Update to the Medicare Manual or SNFs as a result of the Jimmo vs. Sebelius Settlement Agreement 2) 2

3 Swing Bed Medicare benefits allow a patient to remain in a Swing Bed as long as he/she continues to meet all criteria and has benefit days available Once the patient no longer meets criteria, Medicare will not reimburse for the services What needs to be documented? 3

4 Jimmo vs. Sebelius Intended to clarify that when skilled nursing or skilled therapy services are required in order to provide care that is reasonable and necessary to prevent or slow further deterioration Medicare skilled coverage cannot be denied based on the absence of potential for improvement or restoration Conversely, coverage in this context would not be available when the beneficiary s care needs can be met safely and effectively through the use of nonskilled personnel The Agreement does not modify, contract, or expand the existing eligibility requirements for receiving Medicare coverage 4

5 Documentation Even though appropriate documentation is not an element of the definition of a skilled service, appropriate documentation serves as the means by which a provider would be able to confirm that skilled care is needed and received. 5

6 Three Qualifying Midnights Medicare beneficiaries must receive acute care as a hospital or CAH inpatient for a medically necessary stay of at least three consecutive calendar days to qualify for coverage of SNFlevel services. 6

7 Regulatory Critical Access Hospitals, Statutory Citation, 2254A, Chapter 2, State Operations Manual (updated 9/27/13) The Conditions of Participation (CoPs) for Critical Access Hospitals are found in the Code of Federal Regulations at 42 CFR Part 485 subpart F Compliance with the specific CAH SNF requirements specified by 42 CFR (d) must be met for swing beds 7

8 Residents rights Be in Compliance with 42 CFR (d)(1-9) Admission, transfer, and discharge rights Resident behavior and facility practices Patient activities (with exceptions for director of services) Social services Comprehensive assessment, comprehensive care plan, and discharge planning (with some exceptions) Specialized rehabilitative services Dental services Nutrition

9 RAI Manual The Resident Assessment Instrument (RAI) helps facility staff to gather definitive information on a resident s strengths and needs, which must be addressed in an individualized care plan It also assists staff to evaluate goal achievement and revise care plans accordingly by enabling the facility to track changes in the resident s status Interdisciplinary use of the RAI promotes emphasis on quality of care and quality of life Provides resource for increased clarity of documentation 9

10 Where do YOU Begin? 10

11 Most Common Use of SBs Need was for physical and occupational therapy for orthopedic patients Patients needing strengthening following their hospital stay Patients requiring wound care Patients getting intravenous antibiotics were also common among the swing bed population. 11

12 Admission Guidelines Milliman Care McKesson InterQual for Subacute Medicare Fiscal Intermediary Manual, Part 3, Chapter 2 BUT Plan of Care establishes need for skilled services AND documentation should be closely linked to POC Must project team approach to care 12

13 Other Documentation: Labs, X-Rays, MRIs, CAT scans or supporting diagnostic reports Diagnosis supporting rehabilitation, skilled services or therapies Discharge summaries from the qualifying hospital stay Evaluations, treatment plans, or POCs signed by a physician 13

14 Colorado Rural Health Center Manual for CAHs Forms Certification/Recertification Patient Tracking Form Patient Transfer to CAH Swing Bed Assessment Swing Bed Care Plan Swing Bed Team Meeting Care Plan Update Swing Bed Patient Activity Plan 14

15 Swing Bed Requirements CMS clarified that CAHs are required to complete a resident assessment and a comprehensive care plan for each Swing Bed patient Documenting: significantly high probability that complications would arise without skilled supervision of the treatment plan by a licensed nurse (and therapist) 15

16 Start with Assessment Use of Nasal Cannula Use of a cannula or the need for respiratory therapy services does not alone qualify a patient for skilled care Must be daily documentation of the patient s progress and/or complications Need for skilled management should be reevaluated at least once weekly Precise delivery of oxygen concentration, e.g., titration of O2 for Ventimasks. Oxygen delivery by nasal cannula is usually not eligible for RT visits. 16

17 RAI Manual: Nebulizers Respiratory therapy services include coughing, deep breathing, heated nebulizers, aerosol treatments, assessing breath sounds and mechanical ventilation, etc., which must be provided by a respiratory therapist or trained respiratory nurse Does not include hand-held medication dispensers Not a skilled service if patient can selfmedicate 17

18 Dehydration: At least 2... Resident takes in less than the recommended 1,500 ml of fluids daily (water or liquids in beverages and water in foods with high fluid content, such as gelatin and soups). The recommended intake level has been changed from 2,500 ml to 1,500 ml to reflect current practice standards. Resident has one or more potential clinical signs (indicators) of dehydration, including but not limited to dry mucous membranes, poor skin turgor, cracked lips, thirst, sunken eyes, dark urine, new onset or increased confusion, fever, or abnormal laboratory values (e.g., elevated hemoglobin and hematocrit, potassium chloride, sodium, albumin, blood urea nitrogen, or urine specific gravity). Resident s fluid loss exceeds the amount of fluids he or she takes in (e.g., loss from vomiting, fever, diarrhea that exceeds fluid replacement). 18

19 Wound Care Wound Care (including decubitus ulcers) care alone rarely requires a SNF setting A physician must order wound care The patient must require extensive wound care (e.g., packing, debridement, and/or irrigation) that cannot be accomplished by the patient, caregiver, or home health services Treatment of extensive decubitus ulcers or other widespread skin disorder Skilled observation and assessment of a wound must be documented daily and should reflect any changes in wound status to support the medical necessity for continued observation 19

20 Endotracheal Suctioning Deep tracheal suctioning must be required at least every 4 hours Suctioning daily or PRN less frequently than every 4 hours is not considered skilled Requires clear documentation that the patient is being suctioned at least every 4 hours 20

21 Urinary Catheters The presence of a stable indwelling or suprapubic catheter, the need for routine intermittent straight catheterization, catheter replacement or routine catheter irrigation does not quality a patient for SNF placement unless other skilled needs exist 21

22 Intermittent Catheterization Sterile insertion and removal of a catheter through the urethra for bladder drainage Do not include one time catheterization for urine specimen during look back period as intermittent catheterization 22

23 Isolation Only when the resident requires strict isolation or quarantine alone in a separate room because of active infection (i.e., symptomatic and/or have a positive test and are in the contagious stage) with a communicable disease, in an attempt to prevent spread of illness Do not code isolation if primarily consists of body/fluid precautions, because these types of precautions apply to everyone 23

24 Shortness of Breath SOB with exertion SOB when sitting at rest SOB when lying flat 24

25 Therapy The deciding factor in determining whether rehabilitation services are skilled is not the patient s potential for recovery, but whether the services require the skills of a therapist or non-skilled personnel What needs to be documented? Clear documentation of the patient's rehabilitative and restorative functional potential Documentation of the treatment plan, PT goals (including the approximate dates the goals will be met), as well as the anticipated length of treatment and discharge plan 25

26 Physical Therapy PT must relate to the restoration of lost function; e.g., gait, transfer, or stair training or bed mobility Unless a gait disturbance is present the following are not considered skilled PT: Progressive ambulation Repetitive exercises to improve ambulation and maintain strength and endurance, and Assisted walking of 100 feet or more 26

27 RAI Manual and Weight Bearing: Episodes of full staff performance are considered to be weight-bearing assistance When every episode is full staff performance, this is total dependence When there are three or more episodes of a combination of full staff performance and weight-bearing assistance Code extensive assistance When there are three or more episodes of a combination of full staff performance, weight-bearing assistance, and non-weight-bearing assistance Code limited assistance 27

28 RAI Manual: Rehab Potential Possible underlying problems that may affect function: Delirium Acute episode of chronic condition Change in cognitive status Mood decline Behavioral symptoms Use of physical restraints Pneumonia Fall Hip fracture Recent hospitalization Fluctuating ADLs Nutritional problems Pain Dizziness Communication issues Vision problems Abnormal Lab values (electrolytes, blood sugar, etc.) 28

29 RAI and ADLs Bed Mobility how a resident moves to and from lying position, turns side to side and positions body while in be or alternative sleeping furniture Transfer how resident moves between surfaces including to or from bed, chair, wheelchair, and standing position BUT excludes transfer to bath/toilet 29

30 Therapy Log Requires skilled services on a daily basis Shows length of service, thus allowing for necessity, duration and quantity documentation 30

31 Required Paperwork Physician Certification Admission Orders Practical Matter Notice of Medicare Non Coverage (NOMNC) 31

32 Regulatory Federal Public Law 42 CFR Part 485 Subpart F: [Conditions of Participation: Critical Access Hospitals (CAHs)] Section deals with the Conditions of Participation for Critical Access Hospitals. Section identifies special requirements for CAH providers of long term care services Public Law 42 CFR Part 409, Subpart C, Section ; and 42 CFR Part 409, Subpart D, Subpart D: (Includes requirements for coverage of post hospital SNF Care) Medicare State Operations Manual, Appendix W: Survey Protocol, Regulations and Interpretive Guidelines for Critical Access Hospitals (CAHs) and Swing Beds in CAHs. 32

33 Regulatory Comprehensive Assessment: Medicare State Operations Manual, Interpretive Guidelines for Long term Care Facilities Appendix PP 483.2(b)(2) Medicare Benefit Policy Manual: Section 20.1, Chapter 8 Medicare Claims Processing Manual: Physicians/Non physician Practitioners: Chapter 12, Section B Medicare Claims Processing Manual: SNF Inpatient Part A Billing: Chapter 6, Section 10.2, Medicare Benefit Policy Manual: Chapter 9, Sections and CMS Swing Bed Fact Sheet: Updated November 2010 Each state has its own unique state requirements. Refer to your state s website for the most current information 33

34 Contacts Lisa Pando, LTC Consultant Tammi DeSimone, LTC Consultant Kerry Dunning, Sr. VP LTC Division