CAH SWING BED BILLING, CODING AND Lisa Pando, Sr. Consultant GPS Healthcare Consultants
Learning Objectives: 1. Review Medical Necessity documentation specific to swing bed patients 2. Reasons to use the MDS as the underpinning for documentation and coding 3. Oversight of claims and self-audit opportunities 4.Review of current RAC and other audits
WHY DO WE NEED APPROPRIATE?
The importance of appropriate, accurate and complete documentation of clinical services provided to swing-bed patients cannot be overemphasized
Documentation is important to validate the care rendered to the resident. Documentation is important to support reimbursement for the services rendered Documentation is the main source of evidence that usually determines the outcome of the inquiry Attorneys use documentation to make the facility and the caregivers appear to be negligent. Documentation is the Facility and caregiver s best protection.
Establish a timeline of care beginning at admission Paint a picture If it is not documented... Project a team approach to care (i.e. nursing can document how a therapy patient is improving/not improving in ambulation during the evening) 6
Medical Necessity Documentation Tips Answer the following in your documentation: Why should you be involved? What did you do? Did you say that? What was the patient s response to your actions? If the patient s response was not positive, what did you do about it?
Medical Necessity Documentation Tips Chart to support the skilled care provided Must be detailed and specific-justifies Medicare reimbursement Needs to be Daily (per Medicare regulations) Recommend every shift Not charting by exception If Rehab is the primary skill, nursing must document patient participation, tolerance and progress in therapy
Medical Necessity Documentation Tips For exceptional documentation, remember to include: Who Performing, supervising and referring practitioners What (and how many) Services and quantities of services performed Where Place of service When Date of service Why Medical necessity and diagnosis
Example: Medical Necessity Documentation Tips Lisa continues to require PT and OT for strengthening and balance. Ambulates to bathroom with 2 person extensive assist and becomes SOB with exertion. Uses the toilet with staff oversight and transfers with limited assist into bed.
The CAH is substantially in compliance with the following SNF requirements contained in subpart B of part 483 of this chapter: Comprehensive assessment, comprehensive care plan, and discharge planning ( 483.20(b), (k), and (l) of this chapter, except that the CAH is not required to use the resident assessment instrument (RAI) specified by the State that is required under 483.20(b), or to comply with the requirements for frequency, scope, and number of assessments prescribed in 413.343(b) of this chapter). SOM Appendix W; C-0360; 485.645(d) SNF Services
THREE KEY ELEMENTS COMPREHENSIVE ASSESSMENT COMPREHENSIVE CARE PLAN DISCHARGE PLANNING 12
The facility must conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each resident s functional capacity. State Operations Manual Appendix W - Survey Protocol, Regulations and Interpretive Guidelines for Critical Access Hospitals (CAHs) and Swing-Beds in CAHs
(b) Comprehensive assessment. (1) Resident assessment instrument A facility must make a comprehensive assessment of a resident s needs The assessment must include at least the following: (i) Identification and demographic information
(ii) Customary routine (iii) Cognitive patterns (iv) Communication (v) Vision (vi) Mood and behavior patterns (vii) Psychosocial well-being (viii) Physical functioning and structural problems
(ix) Continence (x) Disease diagnoses and health condition. (xi) Dental and nutritional status (xii) Skin condition (xiii) Activity pursuit (xiv) Medication. (xv) Special treatments and procedures (xvi) Discharge potential
(xvii) Documentation of summary information regarding the additional assessment performed through the resident assessment protocols (xviii) Documentation of participation in assessment State Operations Manual Appendix W - Survey Protocol, Regulations and Interpretive Guidelines for Critical Access Hospitals (CAHs) and Swing-Beds in CAHs
The assessment process must include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts.
Minimum Data Set (MDS) definition: A core set of screening, clinical and functional status elements including common definitions and coding categories, which forms the foundation of a comprehensive assessment..rai Manual; Chapter 1; page 6
The MDS should be used as a guideline for Swing Bed documentation. The actual MDS does not have to be completed but rather the components used as a documentation template.
CAH-based Swing Beds are costreimbursed No MDS Assessment is required for Medicare billing Exempt from SNF PPS Consolidated Billing provisions
Patient must have prior qualifying inpatient hospital stay of at least 3 days Qualifying stay does not count time in outpatient status (observation) Can be more than one hospital, but must be at least 3 consecutive days This is reported with occurrence span code 70 in FL 35-36 Reference IOM 100-02, Chapter 8, Section 2
30 Day Transfer Requirement Skilled care must start within 30 days of qualifying stay Medically predictable and appropriate delayed admissions Readmissions to same or other facility Returned to skilled care within days 1-30 No new qualifying stay Days 31-60 Reference IOM 100-02, Chapter 8, Sections 20.2.1 and 20.2.2
Swing Beds Part A Only No Part B benefit in Swing Beds Switch to hospital provider number Type of bill = 12x Billable inpatient Part B services http://www.cms.gov/manuals/downloads/clm 1 04c04.pdf (Section 240)
Although there are items excluded from a PPS swing bed program (i.e., CT scan), all charges while the patient is in a CAH s swing bed should be included on the swing bed claim, regardless of the reason for the service, the findings, or whether additional services were required. Social Security Act 1888(e)(7), 1883(b)(3), 42 CFR 413.114, MLN Matters SE0606
If your MAC provides conflicting information they are basing it on the Balanced Budget Act of 1997 which required swing beds to be incorporated into the SNF PPS beginning July 1, 2002. Those rural facilities must use the MDS and bill services under RUG.
Swing Bed Bill Types 180 Non-Covered Stay 181 Admit to Discharge claim 182 Interim first claim (status 30) 183 Interim subsequent claims (status 30) 184 Interim last claim Patient status would be discharged/expired 12X Ancillary hospital claim Part A benefits exhaust Non-skilled level of care
Revenue Code Examples: Room & Board -0120 Pharmacy -0250 Lab/Chemistry -0301 Physical Therapy-0420 -- Physical Therapy Eval-0424 Supplies -0270 Reference: 100-04, Chapter 6, Section 20
All CAH swing bed SNF-level care bills are submitted and processed with a "z" in the third position of the provider number.
Don t forget about these requirements: Physician Certification/Re-certification MSP-Medicare Secondary Payer Consent to Treat/Bill CMS R-193-Important Message from Medicare NOMNC-CMS 10123-Notice of Medicare Noncoverage
Swing Bed Medicare Advantage (MA) Claims Swing Bed (SB) providers must submit covered claims with condition code 04 (in FL 18-28, information only bill) for beneficiaries enrolled in MA plans and receiving skilled care in order to take benefit days from beneficiary and/or update beneficiary s benefit period in the Common Working File (CWF) IOM, Chapter 6, Section 90-90.2 and CR 5653
Billing for Leave of Absence (LOA) Away at Midnight Beneficiary is on a Leave of Absence (LOA) Benefit Day is NOT Taken 30-day transfer requirements Discharge bill if patient doesn t return Date of discharge is date the individual actually left facility
LOA Claim Coding: Occurrence Span Code 74 Non-covered days in FL 39-41 with value code 81 Revenue code 018X with no charges Do NOT include LOA days in 12X revenue code line
Benefits Exhaust, No-Pay and Demand Bills IOM, 100-04, Chapter 6, Section 40.8 40.9 Full Benefits Exhaust Claims no benefit days remain for the billing period (statement covers from/through dates) Partial Benefits Exhaust Claims only one or some days are available for the billing period (statement covers from/through dates) Must be submitted monthly by calendar month
Benefits Exhaust Claims Use appropriate covered type of bill (FL 4)(181, 182, 183, 184) Note: Do not use bill types 180 (Swing Beds) Bill all days and charges as covered- Covered/Coinsurance Days Occurrence Span Code 70 (FL35-37)with the qualifying hospital stay dates Value Code 09 or 11 (FL 39-41), as applicable to coinsurance days with dollar amount Occurrence code 22 (date active care ended) Patient status = 30 (still a patient)
No-Payment Claims Claims for patients no longer at a skilled level of care Two options Patient dropped to non-skilled care within the month, needs denial for other insurance Patient previously dropped to non-skilled care
No-Payment Claims-180 TOB Denial Notice Type of Bill 180 (no-payment bill) Statement covers from-through dates depend on billing frequency Days and charges all entered as non-covered Condition code 21 (billing for denial) Occurrence Span Code 74 with applicable dates Patient status code as appropriate
No-Payment Claims-180 TOB Demand Bills TOB 180 Patient in certified bed Days and charges submitted as non-covered Condition code 20 (demand bill) Occurrence Span Code 74 & applicable dates Patient status code as appropriate
If expedited review has taken place, include appropriate Condition Code on both denial claims and demand claims C3 partial approval C4 admission denied C7 extended authorization
Common Demand/ No Pay Errors No submission of no-pay claims after 100 days used No ABN submitted No documentation that beneficiary/family wants demand bill submitted Incorrect usage of condition code 20 and 21 Billing ancillary services prior to demand bill processed Claim submitted after expedited review with no condition codes C3, C4 or C7
Recovery Audit Contractor The Recovery Audit Program s mission is to reduce Medicare improper payments through the efficient detection and collection of overpayments, the identification of underpayments and the implementation of actions that will prevent future improper payments.
The purpose of this contract will be to support the Centers for Medicare & Medicaid Services (CMS) in completing this mission. The identification of underpayments and overpayments and the recoupment of overpayments will occur for claims paid under the Medicare program for services for which payment is made under part A or B of title XVIII of the Social Security Act. The CMS expects that Recovery Auditors review all claim types to assist the Agency in lowering the error rate and in identifying improper payments that have the greatest impact on the Trust Fund. Statement of Work for the Recovery Audit Program
OIG has focused its efforts on identifying and offering recommendations to reduce improper payments, prevent and deter fraud, and foster economical payment policies. Future planning efforts for FY 2016 and beyond will include: additional oversight of hospice care, including oversight of certification surveys and hospice-worker licensure requirements; oversight of Skilled Nursing Facilities (SNF) compliance with patient admission requirements; and evaluation of CMS s Fraud Prevention System 45
CERT-Comprehensive Error Rate Testing ZPICs-Zone Program Integrity Contractor MAC-Medicare Administrative Contractor(FI) GAO-Government Accountability Office
QUESTIONS
CMS LINKS http://www.cms.gov/outreach-andeducation/medicarelearning- NetworkMLN/MLNProducts/downloads/CritAccessHospfctsht.pdf http://www.cms.gov/outreach-andeducation/medicarelearning- NetworkMLN/MLNProducts/downloads/SwingBedFactsheet.pdf http://www.cms.gov/outreach-andeducation/medicarelearning- NetworkMLN/MLNProducts/downloads/RuralChart.pdf http://www.cms.gov/outreach-andeducation/medicare-learning- NetworkMLN/MLNProducts/downloads/CritAccessHospfctsht.pdf
REFERENCES Medicare Benefit Policy Manual, CMS IOM Publication 100-02, Chapters 1,6,8 and 10 Medicare Claims Processing Manual, CMS Publication 100-04, Chapters 1,3,4 and 15; IOM, 100-04, Chapter 1; Section 50.2; Chapter 6. SOM Appendix W
CAH RESOURCES CMS CAH Webpage - http://cms.gov/medicare/providerenrollmentandcertification/certificationandcomplianc/c A Hs.html State Operation Manual Chapter Two - http://cms.gov/regulationsandguidance/guidance/manuals/downloads/ s om107c02.pdf
GPS HEALTHCARE CONSULTANTS Lisa Pando, RN, BA, CCRN, CLNC, C-DONA, RAC-CT, AHIMA Approved ICD-10 Trainer Senior Consultant Lisa.pando@gpshealthcon.com 321-544-8819 Kerry Dunning, MHA, MSH, CPAR, RAC-CT Chief Senior Services Officer Kerry.dunning@gpshealthcon.com 904-923-7229