Version date: January 5, 2017 Topics covered: Project administration, Billing, Data, Clinical Question PROJECT ADMINSTRATION What is the consequence if a facility drops below 3 Stars? What if the doctor/facility is considered a Rural Health Providers? What residents in the facility are eligible? Answer Frequently Asked Questions (FAQs) Memorandum of Understanding (MOU) is renewed annually; CMS will review partnerships on an annual basis (September) to determine facility continuation. Not eligible under this initiative. Inclusion criteria: Reside in the LTC facility for 101 cumulative days from the resident s admission date Enrolled in Medicare (Part A and Part B FFS) and Medicaid, or Medicare (Part A and Part B FFS) only Reside in Medicare or Medicaid certified LTC bed Exclusion criteria: Enrolled in a Medicare Advantage plan Receiving Medicare through the Railroad Retirement Board Elected Medicare hospice benefit Medicaid only Opted-out of participating in the Initiative For Phase I2, residents MUST be eligible for the payment portion of the demonstration in order to be eligible for the clinical intervention. The following will not be included in the OPTIMISTIC intervention. Residents with Medicaid only Residents without Medicare Part B Hospice residents Residents with VA benefits and NO MEDICARE Medicare Managed care Railroad benefit A resident must have Medicare Part B in order to be eligible for both payment and clinical intervention. What we have found out from CMS is that only payment eligible 1
residents will be included in the evaluation, and therefore we are not to be intervening on other populations (this is a change from Phase 1). BILLING QUESTIONS How do we bill the new Medicare demonstration project codes? Does billing the new codes affect Medicaid cost reports and any supplemental payment system, i.e. UPL payments? Is billing other part B codes, such as CPT for therapy services on the same days as the new Medicare demonstration project codes allowable? What Revenue Codes should we use? The project can be billed using the same mechanisms for Medicare Part B billing. OPTIMISTIC demonstration is billed as supplemental Part B and can be submitted in addition to Medicaid payments- Does NOT affect UPL payments. Other Medicare Part B codes CAN be billed on the same day as the new Medicare Part B codes for this demonstration project. Per communications with CMS, we recommend facilities use revenue codes 0760 or 0769. When applying the new G codes, SNFs need to continue to follow the billing rules from the National Uniform Billing Committee. In additions, SNF providers should be aware of the following revenue code editing in 100-04, Chapter 7. The revenue codes outlined below are restricted and will result in rejection if submitted with a new G code for the initiative. 10.1.1 - Editing of Skilled Nursing Facilities Part B Inpatient Services (Rev. 3481, Issued: 03-18-16. Effective: 06-20-16, Implementation: 06-20-16) Medicare pays under Part B for physicians services and for non-physician medical and other health services listed below when furnished by a participating hospital to an inpatient of the SNF when patients are not eligible or entitled to Part A benefits or the patient has exhausted their Part A benefits. The SSM shall edit to prevent payment on Type of Bill 22x for claims containing the revenue codes listed in the table below. 010x 011x 012x 013x 014x 015x 016x 017x 018x 019x 020x 021x 022x 023x 024x 0250 0251 0252 0253 0256 0257 0258 0259 0261 0269 0270 0273 0277 0279 029x 0339 036x 2
0370 0374 041x 045x 0472 0479 049x 050x 051x 052x 053x 0541 0542 0543 0544 0546 0547 0548 0549 055x 057x 058x 059x 060x 0630 0631 0632 0633 0637 064x 065x 066x 067x 068x 072x 0762 078x 079x 093x 0940 0941 0943 0944 0945 0946 0947 0949 095x 0960 0961 0962 0969 097x 098x 099x 100x 210x 310x More information can be found at: https://www.cms.gov/regulations-andguidance/guidance/manuals/downloads/clm104c07.pdf What are the new Medicare demonstration project facility and provider G codes and what are the rates for reimbursement? Facility Codes- $218 per day COPD/Asthma Congestive Heart Failure Pneumonia Skin Infection Fluid or Electrolyte Disorder, or Dehydration UTI G9681 G9680 G9679 G9682 G9683 G9684 Practitioner certification code: G9685 $205.82 Practitioner care coordination code: G9686 $77.64 As a reminder, Medicare payments to providers for individual services under Medicare Parts A and B have been under sequestration for services beginning April 2013. This means that final payment to providers will be 2% less than the official fee schedule. For example, the official fee for the six new facility payments is $218 per day, but the final per diem payment will be $213.64. Does a provider and facility bill need to be submitted for every certified episode of care? All information related to reimbursement was published with the October 1, 2016 update to the Physician Fee Schedule. In addition, the MAC s website should provide exact information on how much each code will be reimbursed for within Indiana. No, for example patient s condition can be certified by a provider not enrolled (thus not able to bill) in the demonstration project. Please see below for additional scenarios. Scenario 1: The practitioner is APPROVED for the demonstration and certifies the condition - Provider can bill, facility can bill 3
Scenario 2: The practitioner is APPROVED but condition does not meet certification criteria- Provider can bill, facility cannot bill Scenario 3: Practitioner is NOT APPROVED and certifies the conditionpractitioner cannot bill, facility can bill Scenario 4: Practitioner is APPROVED and the patient is on a SNF part A stay (must be OPTIMISTIC eligible and in facility more than 101 days)- practitioner can bill, facility cannot bill Why do we need to submit TIN and NPI numbers for each provider? If a resident is transferred out, can the code be billed for that day? If a resident returns from the hospital on an antibiotic (but was not seen/certified prior to discharge), can the facility start the new cycle for this resident, have certified physician see him in person and certify? Providers are approved for participation based on a valid individual NPI numbers. Because some providers may bill under multiple TINs, OPTIMISTIC Demonstration requires matching and valid NPI and TIN numbers under this program for practitioners to receive payment for services at a participating facility. If an NPI or TIN number is incorrect, or does not match the practitioner, the claim will not be processed and a practitioner will not be paid. The facility may not bill a per diem on the calendar day during which a resident is discharged, regardless of the time of discharge. An assessment and certification visit should only be triggered if there is a new change in condition. If the resident is on a treatment plan and no new symptoms are evident, then there is no change in condition to trigger the assessment and certification and billing should not occur. 4
DATA QUESTIONS Question What Is the "change in condition confirmation date"? Is it the date when condition change was noted or when the certified physician certified condition in person? Where can I find data workbook materials Does the resident roster tab need to be updated with ongoing discharges and admissions? Answer The change in condition date is the day the staff identified the change in condition and notified the physician/np/pa. The certification date is the date the practitioner evaluated the resident in person. Materials are located on our website: Optimistic-care.org Under the demonstration project tab Yes Do you want the residents that are on bed holds listed in the resident roster? Yes Are hospice residents that come into the facility on hospice added to the admit tab as well as the hospice tab? Does the insurance tab need to be updated with newly admitted residents? For purposes of using the data tracking tools, how do we determine the week, ie. ends at Sunday midnight to submit data on following Wednesday? Is my facility expected to track LOS for residents? How do we track LOS for determining whether a resident is eligible for OPTIMISTIC. Yes, they are added to both. For the first submission and all submissions, insurance information should be updated for ALL residents. For newly admitted residents, the admits & insurance information should both be updated. It s midnight on Saturday (capturing all of Saturday) through 11:59 the following Friday. Yes, facilities will need to keep track of LOS for their residents to determine eligibility. To determine whether a resident s time away from the facility needs to be subtracted from the total LOS, use the following information: As long as the leave is not coded as a discharge then the individual would still be considered a resident. Eligibility would only be affected if there is a documented discharge. 5
CLINICAL QUESTIONS Question What are the documentation and enhanced monitoring recommendations? Answer The initiative will be audited annually by a support contractor. Certification of change in condition documentation requirements: 1. Detection of change in condition noted. This can include tool such as SBAR. 2. In-person visit from practitioner with determination of certification. 3. Enhanced treatment plan for the enhanced payment benefit period (5-7 days). Recommended monitoring suggestion tool available on OPTIMISTIC-care.org The new code essentially substitutes for CPT code 99310 and the same documentation requirements for the provider note would generally apply. The patient record should either reflect a diagnosis of one of the six targeted conditions, or state that one (or more) of the six conditions was suspected, considered, or ruled out. Who must be present in order to bill the care coordination meeting? If a resident, who has been assessed with one of the six conditions, is transferred to the hospital for 2 or 3 days for an unrelated condition during the benefit period, do they Per CMS, the documentation for these new codes require three components: A comprehensive review of the beneficiary s history; a comprehensive examination; and medical decision making of moderate to high complexity. Also, a practitioner may bill for the new Medicare code Acute nursing facility care even if the service is furnished because a LTC facility suspects that a beneficiary has one of the six targeted conditions, but upon examination it turns out that the beneficiary does not have one of the six targeted conditions. A minimum of three parties must be present: 1. The facility representative 2. The physician 3. Either the resident or resident's representative. The practitioner must document the conversation in the beneficiary s medical chart. This documentation should include: that the beneficiary and/or individual(s) authorized to make health care decisions for the beneficiary (as appropriate) was present the conference was for a minimum of 25 minutes at least one member of the LTC facility interdisciplinary team was present.) A re-evaluation is not needed if the resident is still within original seven-day period. As an example, consider a resident treated by a facility for Days 1-3, then transferred to the hospital for two days (Days 4-5), returning on Day 6. The facility may bill for Day 6 and Day 7 without a re-evaluation as along as the condition has not yet been resolved. 6
have to be reassessed upon return in order for the facility to continue billing for the eligible condition? Also, does the benefit period start over or would it continue from the original assessment? What is the timing required forthe certification of a condition by the practitioner after the acute change is noted? If the resident remains acutely ill and there needs to be a second assessment to re-trigger the building's ability to charge, does that need to happen on Day 7 of the first 7 days or does the second assessment happen on Day 8 (or Day 1) of the second 7 days? The resident must be evaluated by the end of the second day following the change in condition. For example, if a resident experienced an acute change in condition on June 1, the evaluation must occur no later than 11:59 pm on June 3 to satisfy Initiative requirements. In that case, facilities may bill the new codes for June 1-3 as appropriate. For this example, if the evaluation does not occur until June 4, then the facility would only be eligible for payments beginning on that day. The evaluation must occur no later than Day 9, which is the second day after the initial seven-day period ends. 7