Compliance Issues under Medicare Prospective Payment for Nursing Facilities Presented by: Patricia J. Boyer NHA, RN BDO / Heritage Healthcare Group
Anyplace where there is no PPS
Risk Areas Physician Certification / Recertifications MDS Accuracy & Completion Medical Necessity Physician approval of the Plan of Care Consolidated Billing
Per CMS HM 12, 220.2 For Part A claims, a physician must certify the patient s need for skilled nursing or rehab services on a daily basis
Physician Certifications Required Upon admission (72 hours*) No later than day 14 Every 30 days thereafter *Subject to interpretation of your FI
MDS Accuracy & Completion RAI System Setting the ARD Supportive documentation Signing and transmission of the assessment MDS Hot Spots
RAI / MDS / RUGs III Hot Spots Section E Section G Section P
MDS Hot Spots Section E (Mood and Behavior Patterns) Call as you see it Not require depression diagnosis Require supportive documentation
MDS Hot Spots Section G (Physical Functioning and Structural Problems) Capture 24 hours Late loss ADL emphasis
MDS Hot Spots Section P (Special Treatments and Procedures) PT, OT, ST days / minutes Respiratory Therapy Restorative Nursing
Skilled Therapy Services Medical Necessity Necessity of treatment Supportive diagnosis Goals do not exceed prior level of function Change of condition documentation Documentation
Physician Approval of the Plan of Care Skilled therapy certification physician approval of the plan of care Clarification orders
Part A Covered Services To Be Billed By SNF PT, OT, and Speech Therapy Lab/X-rays, EKGs Medications/I.V. s TPN and supplies Enteral solutions and supplies Dressings Prosthetic devices (i.e. ostomy, colostomy, urologicals, tracheotomy)
Services To Be Billed By SNF Orthotics, braces, etc. Medical supplies (e.g. airbeds) Certain ambulance services Psychological services by a social worker Incident to physician services Hyperbaric oxygen therapy
Resident Status and SNF Responsibility for Services and Billing SNF s responsibility ends when: The beneficiary is admitted as an inpatient to a Medicare-participating hospital or critical access hospital or as a resident to another SNF Receives services from a Medicare-participating home health agency under a plan of care or; Beneficiary out past midnight.
Resident Status and Responsibility For Billing The SNF must bill all services provided to a Part A resident except for the following: Outpatient hospital services that are not furnished pursuant to the SNF s required resident assessment or comprehensive care plan and are excluded by CMS The resident is discharged (or otherwise departs) from the SNF and is not readmitted before midnight
Services NOT Billed by SNFs Under Part A Hospice services for terminal care Home dialysis supplies and equipment selfcare home dialysis support services, and institutional dialysis services and supplies Erythropoietin for certain dialysis patients
BBA Refinement Act PM AB-00-18 Effective date April 1, 2000 Excludes the following: Chemotherapy Radioisotope treatment Customized prosthetics
Incident To Physicians Services Services provided in a physician s office performed by someone other than the physician or other excluded provider e.g. nurse practitioner or physician s assistant including: Lab X-ray EKG Therapy
Billing UB-92s Corresponding MDSs Completed Submitted Supporting therapy treatment logs Invoices for ancillary services
Medicare UB-92 Triple Check Team meeting monthly BOM Date of service Verify UB-92 data MDS Coordinator/DON ARD List Validation Report MDS acceptance by State Rehab Coordinator Section P logs match Signed physician order for therapy
BDO/HERITAGE