Today's Objectives - Community Physical Therapy

Plante Moran, PLLC 2013 614-222-9020

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Presented by:

Jane Belt, RN, MS, RAC-MT

Plante & Moran, [email protected]

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Medicare Reviews and

Successful Medicare Documentation}

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Today’s ObjectivesToday’s Objectives

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� Review history of the federally mandated

Recovery Auditor program from the 2005

pilots to the present national roll-out

� Identify the three (3) major audit issues found

in the pilot project that generated the greatest

SNF Medicare overpayments

� Delineate strategies for development of

internal or external audits


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Today’s ObjectivesToday’s Objectives

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� Discuss the strategies and tools for the nursing

facility to prepare for the Medicare audits

� Discuss key elements in successful Medicare

documentation

� Detail the risks associated with inadequate

documentation

� Review current audit trends

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What is the Medicare What is the Medicare RA Program?RA Program?

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� “RA” stands for Recovery Auditor

� Efforts by CMS to “identify improper payments and fight fraud, waste and abuse in the Medicare

Program”

� 3 year, 3 state demonstration/pilot program identified ~$1.0 billion in improper claims across all healthcare providers

� Demonstration focused on highest Medicare utilization states: NY, CA, and FL in 2005


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What is the MedicareWhat is the MedicareRA Program? RA Program?

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� Demonstration expanded in 2007 to MA, SC, AZ

� Permanent RA program began in 2009; by January 2010

all 50 states had RA reviews

� Four contractors hired on a performance contingency

basis to identify overpayments (and underpayments) by

reviewing Medicare claims data and medical records

Program designed to identify and recoup $10.8 billion(1) in annual improper Medicare payments

(1) The Medicare Recovery Audit Contractor (RAC) Program: An Evaluation of the 3-Year Demonstration, June 2008; as estimated by the GAO and OMB

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Top 5 Services with RA Initiated Top 5 Services with RA Initiated Overpayment CollectionsOverpayment Collections(1)(1)

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By number of claims, the delivery of medically unnecessary therapy in SNFs was the most common overpayment cited during the RAC demonstration by a factor of >2x the next most common overpaid service

Service / Item Provider Type # of Claims % of Total(1) $(mm)

PT & OT (medically unnecessary)

SNF 77,911 14.8% $6.8

Items during hospital inpatient stay or SNF stay(other error type)

DME 38,257 7.3% $4.8

ST (medically unnecessary) Outpatient hospital 24,991 4.8% $3.2

Infusion services (medically unnecessary) Outpatient hospital 19,271 3.7% $2.3

Pharmaceutical injectibles (incorrect coding) Physician 18,930 3.6% $5.8

Source: The Medicare Recovery Audit Contractor (RAC) Program: An Evaluation of the 3-Year Demonstration, June 2008, Appendix G, page 38.(1) Ranked on the basis of number of claims. The top services measured by dollars are all found in inpatient hospitals and inpatient rehabilitation facilities given a materially higher fee per claim associated with those provider settings.


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Most Common Improper Most Common Improper Payment Areas for SNFsPayment Areas for SNFs

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22%Other (no qualifying hospital stay,

inadequate documentation)

SNF SNF Top Top

ErrorsErrors

38%Billed for excessive and/or

multiple units

40%Failed to meet Medicare

criteria for skilled therapy

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Additional Documentation Additional Documentation Requests LimitsRequests Limits

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� Number of medical records that can be requested by RA for review during a 45-day period. Statutory limit increased 3/15/12� Limit based on provider’s Tax Identification Number (TIN) and first 3

characters of the zip code along with number of claims in prior CY;

� Maximum request is per campus – could be 1 or more facilities under

the same TIN located in same zip code;

� 400 records per 45 days or 2% of all claims submitted for previous year

divided by 8;

� If amount < 34 ADRs – RA may request 35 records every 45 days

� For SNF claims, ADR represents the beneficiary’s entire stay

� May exceed 45 days between requests, but no sooner than 45 days

� CMS can allow RA to exceed limit – provider notified in writing


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Good News Good News –– Some RA Some RA ImprovementsImprovements

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� Reduction of fee-driven motivation� In the demo, RAs required to return contingency fee

only if overpayment determination overturned on the first-level appeal.

� National program requires fees to be returned if determination is overturned at ANY level

� RAs must disclose areas of focus when looking for overpayments www.cms.hhs.gov/RAC

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A Powerful Financial Incentive for A Powerful Financial Incentive for RAs to Find OverpaymentsRAs to Find Overpayments

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� The RA program is CMS’s first foray into contingent-based contractor payment structures

� Incentivizes contractors to find improper payments (bounty hunters)

Contingency Fee Schedule(1)

Region A 12.45%

Region B 12.50%

Region C 9.00%

Region D 9.49%

RAs earned over $187m in contingency fees during the demonstration

(1) Federal Business Opportunities web site: www.fbo.gov; www.cms.hhs.gov/RAC/


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How do RA Reviews Work?How do RA Reviews Work?

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� There are 2 types of RA reviews —

1. Automated

2. Complex

“These two review processes—automated review and complex review—are similar to those employed by the Medicare claims processing

contractors to identify improper payments.”

Medicare Recovery Audit Contract (RAC) Program: An Evaluation of the 3-Year Demonstration, June 2008

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Review TypesReview Types

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�� Automated ReviewsAutomated Reviews = RAs identified improper

payments via automation where the provider clearly

billed in violation of Medicare policy

� Certainty that service is not covered or is

incorrectly coded ANDAND

� A written Medicare policy, Medicare article or

Medicare-sanctioned coding guideline (e.g., CPT

statement) exists


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More on Automated More on Automated ReviewsReviews

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Automated Reviews Automated Reviews

� Completed when “improper payment” can be identified without “human analysis”

� Can be done without a facility being notified until an “error” is found and payment adjusted or denied

� Uses the facility submission UB-04 or electronic submissions and looks for coding errors or looks for missing validation of acceptance into federal repository

� Payment due within 40 days or recoupment becomes automatic (with interest accrued from date of demand letter)

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Examples of Reasons for Examples of Reasons for Automated RA ReviewsAutomated RA Reviews

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� Coding errors HIPPS and modifiers (RUG scores and

reason for assessment)

� ARD on MDS doesn’t match ARD on the UB-04

� Duplicate claims

� Bill submitted prior to MDS transmitted to QIES ASAP

� Pricing mistakes

� Missing codes

� Mistakes in coverage periods


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Reviews TypesReviews Types

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Complex ReviewsComplex Reviews = RA identifies likely improper payment and

requests records from provider to conduct more in-depth review

� Improper payment suspected, but record review needed to make determination

� Performed by clinical personnel and medical directors� Medical directors must discuss claim denial with the provider if

requested

� Medical record limits based on type of provider

� Providers will have 45 days to provide requested medical records; RA will have 60 days from receipt of records to make a final determination

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Examples of Reasons for Examples of Reasons for Complex RA ReviewsComplex RA Reviews

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� Diagnosis code inconsistent

� Inconsistency with therapy minutes and ADL score

(RUA)

� Static therapy treatment (holding at the same RUG

level for lengthy treatment periods)

� Medical necessity


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CGI CGI –– Region B Recovery Region B Recovery Auditor MapAuditor Map

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Region B: CGI Federal, Inc.

CMS must approve CMS must approve audit issues before

the RAs may pursue them

widespread review

Approved issues posted to RA

website BEFORE widespread review

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Recovery Auditor Web EmailTelephone Number

Region B: CGIStates: IL, IN, KY, MI, MN, OH and WI

http://racb.cgi.com [email protected] 1-877-316-7222

RA Contact InformationRA Contact Information

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Make certain CGI has the correct facility address and contact person’s name so that any mailings go directly to that person without delay. Timing is of the essence!


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More About CGI More About CGI -- MissionMission

� Identify improper payments through detection and

collection of overpayments, the identification of

underpayments, and the implementation of actions

that will prevent future improper payments utilizing

their Customized Auditing Software (CAS) 5.0

software for “data mining” to identify unusual patterns

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What is an Improper Payment?What is an Improper Payment?

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Payments made for services that do not meet

Medicare’s medical necessity criteria

Payments made for services that are incorrectly coded

Providers failed to submit documentation when

requested or enough documentation to support the

claim

Provider was paid twice because duplicate claims were

submitted


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Type of Contractor Responsibility

Recovery Auditors (RAs)

Identify and correct improper payments, find overbilling practices, fraudulent activities –all Medicare Fee for Services Providers (FFS), i.e., Part A and B, DME, physician, hospital, therapy, home health, hospice• Some limitation on the documents they

can request, and• Paid on a contingency fee basis

Medicare ContractorsMedicare Contractors

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Region B – CGI – posted complex review issues for Skilled Nursing Facilities

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Skilled Nursing Facility (SNF) Psychiatric Condition

ComplexSkilled Nursing Facility

MN, WI, MI, IL, IN, OH, KY

12/7/2012 Details

Skilled Nursing Facility (SNF) Unrelated to Terminal Condition

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Patients with only a psychiatric condition who are transferred from a psychiatric hospital to a participating SNF are likely to receive only non-covered care. Also, patients whose primary condition/needs are psychiatric in nature often require considerably more specialized, sophisticated nursing techniques and physician attention than is available in most participating SNFs. (SNFs primarily engaged in treating psychiatric disorders are precluded by law from participating in Medicare.) Skilled Nursing Facility (SNF) Psychiatric Condition

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Date Approved

12/7/12

A hospice beneficiary certified as having a terminal illness with a life expectancy of 6 months or less waives all rights to Medicare payment for services related to the terminal condition. Services unrelated to the terminal condition may still be payable and are designated by the presence of condition code 07. SNF Part A claims with a condition code 07 will be reviewed to validate that the services did not relate to the patient’s terminal condition and met SNF coverage criteria.

SNF Unrelated to Terminal Condition


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Issue Details

Name SNF Consolidated Billing

Number B002132010

Description

Services are being billed separately that should be included in the Skilled

Nursing Facility Consolidated billing. Consolidated Billing is when services

provided during the resident's stay in a skilled nursing facility (SNF) are

bundled into one package and billed by the Skilled Nursing Facility. Under the

Consolidated Billing requirement, a Skilled Nursing Facility itself must submit

all Medicare claims for the services that its residents receive (except for

specifically excluded services).

Claim Type Outpatient

Issue Type Automated

Overpayment /

Underpayment Overpayment

Dates of Service 7/1/2008 - Open

States MN, WI, MI, IL, IN, OH, KY

Policy Related

Links

• https://www.cms.gov/manuals/downloads/clm104c06.pdf

CMS Pub 100-04; Chapter 6 § 10, 20, 80 and 110.2.2; and,CMS Pub

100-04; Chapter 20 § 211

• http://www.cms.hhs.gov/transmittals/downloads/R1608CP.pdf

Pub 100-04 Medicare Claims Processing Centers for Medicare &

Medicaid Services (CMS)

• http://www.cms.hhs.gov/transmittals/downloads/R1750CP.pdf

CMS Manual System Department of Health & Human Services

(DHHS) Pub 100-04 Medicare Claims Processing Centers for

Medicare & Medicaid Services (CMS) Transmittal 1750 Date: June 5,

2009

Date Approved 7/26/2011

Other Known Region B Other Known Region B RA Automated Review RA Automated Review –– 7/20117/2011

SNF Consolidated Billing

� Services being billed

separately that should be

included in consolidated

billing

� Under CB, a SNF itself must

submit all Medicare claims

for the services that its

residents receive (some

exclusions may apply)

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Some Other Known RA ActivitySome Other Known RA Activity

� RAs may audit a limited number of “test claims” in

order to seek CMS approval of proposed issues

� Region B RA “test” claims issued for “ultra

high” therapy with low ADL scores - initiated in

October of 2011; more seen in 2012

� Pre-curser to actual RA reviews

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What Does the RA Mean What Does the RA Mean

For ProviderFor Provider ??

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� Increased scrutiny

� Negative cash flow implications

� Potential for declining profit margins

� Administrative burden to comply with documentation requests

� Expensive and lengthy appeals processes

� Current and historical exposure (not before 10/01/07)

Potential for significant financial exposure

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Getting the DataGetting the Data

� All FFS paid claims subject to RA review – except

those that have already been reviewed by another

Medicare entity (i.e., MAC or ZPIC)

� No Medicare Advantage claims

� No Medicare Part D claims

� RAs search CMS data looking for:

� Coding errors

� Patterns and trends in the claims

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� Increased competition to recoup Medicare dollars

However, the RA Is Not Our However, the RA Is Not Our Only Concern!!Only Concern!!

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“CMS will not limit either carriers/FIs/MACs or RACs but instead will rely on a ‘first come first serve’ philosophy for post payment reviews.”

--CMS Final RAC RFP Solicitation Questions & Answers(1)

� Since same claim cannot be reviewed by multiple Medicare reviewers (i.e., MACs and RAs), likely will create competition to mine a finite set of claims

� $1.9 billion in denied claims by claims reviewers in NY, CA, and FL plus ~$1.0 billion in RAC recouped funds during pilot

� Other claims contractors have added checks into their claims processing systems to deny claims with certain obvious errors based on RA demonstration findings

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� Centers for Medicare & Medicaid Services (CMS) has

implemented numerous initiatives to prevent improper

payments before a claim is processed and to identify and

recoup improper payments after the claim is processed

� Overall goal of CMS’ claim review programs is to reduce

payment error by identifying billing errors (coverage and

billing) made by providers

� Government estimates that 8.6% of all Medicare Fee-For-

Service (FFS) claim payments are improper

Improper Payment InitiativeImproper Payment Initiative

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� On 11/20/09 President issued Executive Order -

Reducing Improper Payments aimed at intensifying

efforts to eliminate payment error, waste, fraud, and

abuse in the major federal programs, while continuing to

ensure that the right people receive the right payment for

the right reason at the right time

� Improper Payments Elimination and Recovery Act of

2010 requires agencies to assess every federal program

and dollar for improper payment risk, measure payment

accuracy annually, and initiate improvements to ensure

payment errors are reduced


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� As required by the President’s Executive Order, a website was created with information about: � Current and historical rates and amounts of improper

payments� Why improper payments occur� What agencies are doing to reduce and recover improper

payments

http://paymentaccuracy.gov/about-site

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From Payment AccuracyFrom Payment Accuracy

� Government achieves greatest return on investment by

ensuring that improper payments are eliminated in the

“high-error programs”

� Each program presents unique challenges and

obstacles to overcoming the improper payment problem

� Strengthening financial management controls allows

agencies to better detect and prevent improper

payments and the government can better ensure

taxpayer dollars are spent wisely and efficiently33

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HighHigh--Error Programs Error Programs

Program AgencyTotal

Payments (outlays)

Improper Payment Amounts

Improper Payment Rates

Medicare FFS

Dept. of Health and

Human Services

$349.7B $29.6B 8.5%

Medicaid DHHS $271.0B $19.2B 7.1%

Medicare Advantage (Part C)

DHHS $115.2B $13.1B 11.4%

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� The problem:

� Funds go to the wrong recipient;

� The right recipient receives the incorrect amount of

funds (including overpayments and

underpayments);

� Documentation is not available to support a

payment; or

� The recipient uses funds in an improper manner

Improper PaymentsImproper Payments

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Percentage Distribution of Percentage Distribution of Improper Payments (FY 2012)Improper Payments (FY 2012)

Medicaid 17.9%

MA (Part C) 12.2%

Medicare FFS 27.5%

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Long Term Care Scrutinized Long Term Care Scrutinized From All SidesFrom All Sides

The Health Care Reform Act provides $350 million to fight fraud, waste and abuse

LTC

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The Focus on Skilled Nursing The Focus on Skilled Nursing FacilitiesFacilities

The Federal Government zeroed in on Medicare

payments to SNFs as initially identified in 2010 Office of

the Inspector General (OIG) report. Subsequent reports

maintain the scrutiny

� SNFs increasingly billed Medicare for higher paying

RUGs from 2006-2008 even though the OIG states

beneficiary characteristics remained the same

� Reported that for-profit SNFs were more likely to bill for

higher paying RUGs than for nonprofit SNFs

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Skilled Nursing Facility FocusSkilled Nursing Facility Focus

OIG recommendations to CMS included:

�Monitor payments to SNFs;

�Strengthen monitoring of SNFs that are

billing for higher paying RUGs

(Comparative Billing Reports recently

issued to providers);

� Follow-up on the SNFs identified as having

questionable billing

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� CMS employs a variety of contractors to process claims

and submits payment to providers in accordance with

the Medicare and Medicaid rules and regulations

Who Else Is Watching?Who Else Is Watching?

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And the private sector managed care insurance reviews are very busy scrutinizing as well


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Affiliated Contractors (ACs) – Medicare claims processing contractors such as carriers and Fiscal Intermediaries (FIs) and Medicare Administrative Contractors (MACs)

Process claims submitted by physicians, hospitals, and other HC providers/suppliers, and submit payment to those providers in accordance with Medicare regulations. This includes identifying and correcting underpayments and overpayments. The purpose of MACs is to educate providers, process and conduct billing, correct the behavior in need of change and prevent future inappropriate billing, and recover payments.

Medicare Contractors Medicare Contractors

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Current State & Workload Cutover Date

NGSIllinois – Part AWisconsin – Part A

July 13, 2013

WPSWisconsin – Part BIllinois – Part B

September 7, 2013

Transitioning to National Government Services


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Contractor Responsibility

Zone Program Integrity Contractors (ZPICs) / Program Safeguard Contractors (PSCs)

Identify cases of suspected fraud and take appropriate corrective actions across entire MCR program. Take place of 2 auditors – Program Safeguard Contractors (PSC) and Medicare Drug Integrity Contractors (MEDIC). ZPIC responsible for program integrity – Part A & B, hospitals, home health, hospice, DME, Part C - Medicare Advantage & Part D.• Do not conduct random audits• No specification regarding look-back periods• Can make unlimited document requests• Not paid on a contingency fee basis, although

they do get performance bonuses

RAs Bark, but ZPICs Bite

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1. Safeguard Services: American Samoa, California, Guam, Hawaii, Mariana Islands,

Nevada

2. NCI (previously AdvanceMed Corp.): Alaska, Arizona, Idaho, Iowa, Kansas, Missouri,

Montana, Nebraska, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming

3. Cahaba Safeguard Administrators: Illinois, Indiana, Kentucky, Michigan, Minnesota,

Ohio, Wisconsin

4. Health Integrity: Colorado, New Mexico, Oklahoma, Texas

5. NCI: Alabama, Arkansas, Georgia, Louisiana, Mississippi, North Carolina, South Carolina,

Tennessee, Virginia, West Virginia

6. Cahaba Safeguard Administrators: Connecticut, Delaware, District of Columbia, Maine,

Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode

Island, Vermont

7. SafeGuard Services: Florida, Puerto Rico, U.S. Virgin Islands

ZPIC ZPIC Zones (7 Compared to the Zones (7 Compared to the Previous 17 PSCs)Previous 17 PSCs)

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Comprehensive Error Rate Testing (CERT)

Collect documentation; perform reviews on a statistically-valid random sample of Medicare FFS claims to produce annual improper payment rate FIs & MACs, but still review SNFs’ claims and the providers have to repay any overpayments found

Payment Error Rate Measurement (PERM)

Perform statistical calculations, data processing reviews of FFS, managed care and beneficiary eligibility in both the Medicaid program and CHIP (Children’s Health Insurance Program)

Medicare ContractorsMedicare Contractors

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Contractor Responsibility

Medicaid Integrity Contractors (MICs)

Payment watchdogs auditing nursing homes and other providers. The MICs will use a data-driven approach to focus efforts on aberrant billing practices. Facilities may be more likely to get medical requests the MICs than the RACs. Three types of contractors:1. Review – mine the data to find issues indicative

of erroneous claims2. Audit – conducts audits onsite or as desk audits3. Education – Pick up concerns from the other 2 to

educate providers and others

And Last but Certainly And Last but Certainly Not LeastNot Least

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Making Sense of the DifferentMaking Sense of the DifferentMedicare ReviewersMedicare Reviewers

Medicare Reviews Already in Place

Bill/Claim

Error

Processing

Error

Medical

Necessity

Payment

Amount

Incorrect

Non-

Covered

Services

Error in

Coded

Services

Duplicate

Services

RACs

FIs

Carriers

MACs

PSCs

CERT

Medicare Reviews in PlaceBill / Bill / Claim Claim ErrorError

Processing Processing ErrorError

Medical Medical NecessityNecessity

Payment Payment Amount Amount IncorrectIncorrect

NonNon--Covered Covered ServicesServices

Error in Error in Coded Coded ServicesServices

Duplicate Duplicate ServicesServices

RAs

FIs

MACs

PSCs

ZPICs

CERT

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RA and Any Other Medicare RA and Any Other Medicare Reviewer Initiates ReviewReviewer Initiates Review

� Request for medical records

� Typically the process will begin with a

notice of a possible overpayment and a

request for medical records

� The RA will request certain records to

support the claim and provide a deadline

for the provider to submit the records

� Due 45 calendar days from date of letter

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This Is This Is NotNot Junk MailJunk Mail

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Sample ADR Sample ADR Letter from CGILetter from CGI

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More of the Sample LetterMore of the Sample Letter

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Entire letter on web site

and is 5 pages in

length

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Responding to Record RequestsResponding to Record Requests

� Was the request sent to the right place?

� CGI received a data file over a secured data

line from each MAC/FI/Carrier containing

facility/provider information. CGI uses this

contact information, unless provider supplies

an update via e-mail or call CGI and since

1/1/2012 CGI uses the information from the

web site. Keep contact information currentKeep contact information current

� Check to make sure the RA did not exceed

the record request limit

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Responding to Record RequestsResponding to Record Requests� Review all records before they are released

� Permits early identification of issues

� Establishes priority for appeals

� Intensive work

� Must have a team and must be organized with a system of

collection and organization

� Has the claim been reviewed by another contractor

� Did the RA follow the “New Issue Review” Process?

� Letter should clearly state basis for the request

� Look at CMS and RA websites; confirm issue was posted53

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� Stamp date and time received

� Calculate 45 calendar days from date of letter

� Can request an extension with explanation of need

� Notify reviewer if significant discrepancy between

date of letter and date of receipt

� Identify any internal issues in expeditiously getting the

mail for processing

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� Document Management

� Bates stamp number on each page

� Scan/copy everything produced to Medicare reviewer

and keep separate from the original medical record

� RAs will accept imaged medical records on CD/DVD

(follow instructions at website) – check letters from

other reviewers for details

� Use cover letter itemizing contents of box or CD

� Send certified mail or, if regular mail, complete

affidavit of service by mail – time frame = 45 days

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CheckCheck Your Review Status and Your Review Status and Additional Documentation LimitsAdditional Documentation Limits

� If disagree with the Additional Documentation

Limits calculation, contact CGI and they will

work with the provider to help explain what

constitutes the limits that were calculated

� RAs were required to have provider access on

the website to monitor status of review

� If ever not available, can call RA for status report

� CMS has urged providers to keep up with the

status of their record reviews

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Finding OutFinding OutReview Results LetterReview Results Letter

� Comes from the Medicare reviewer to facility: reason

for the review and details their findings

� Narrative description of improper payment issues

� Specific explanation of why services determined not to

be covered or were incorrectly coded

� No review letter for automated – demand letter from RA

– amount, policy, summary, time frames for

recoupment, and how to stop recoupment (appeal)

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Review Results LetterReview Results Letter

� No appeal information in this letter

� **New** CGI has changed process for the discussion

period. Experience indicates that discussions requested

following audits handled more effectively if a written request

and additional documentation are sent to us rather than

receiving the request by phone

� We have also found that many of the requests, particularly

when additional documentation is submitted to support the

claim, can be resolved without the need for a teleconference

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� Updated PROVIDER REQUEST FOR DISCUSSION form

� Send documents to location shown on Request for Discussion

form

� When request received, the auditor and Medical Director will

determine if phone call is needed, or if response can be put in

writing based on the submitted documentation.

� If a phone call is needed, facility contacted to set a time. Letter

sent detailing the outcome of each written or oral discussion

� The auditors involve the Medical Director as needed in the initial

review and discussion process, whether the discussion is

completed as a written review or a teleconference.

New Process for New Process for Discussion PeriodDiscussion Period

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Notification on the Remittance Notification on the Remittance AdviceAdvice� When RA finds overpayment either during an automated or

complex review, Remark Code N432 will appear on the

Remittance Advice

If found, notify other members of RA team

Review other claims for the denial issue

Adjust claims as needed or contact FI/MAC

� The Remittance Advice with N432 will be followed by the

demand letter

� Date of demand letter starts the timing for recoupment and

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Demand Letter Demand Letter -- Date Starts Date Starts 41 day Clock for Recoupment41 day Clock for Recoupment� Arrives directly from the Medicare reviewer

� Contains list of claims (over or underpaid) and reason the

claims denied and:

� Amount of denial and calculation method

� Reason original payment incorrect

� Cites regulatory basis

� Describes appeal rights

� Recoupment, payment and interest options and the

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Key TimeframesKey Timeframes

� Rebuttal

� Opportunity to submit rebuttal statement and accompanying

evidence why the overpayment will cause a financial

hardship and

� Not intended to review supporting medical documentation

nor disagreement with the overpayment decision

� Claims Processing Contractor will make the decision

� Time frame is 15 days beginning with the date of the

demand letter

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Key TimeframesKey Timeframes

� 30 days

� Full payment – no interest

� Interest begins to accrue on 31st day – assessed for each full 30-day

period

� If unable to pay the entire amount, contact to determine possibility of

approval of repayment plan

� After 40 days Medicare will begin withholding – applies to

current and future claims until full overpayment and

applicable interest has been recouped or acceptable

repayment request received64


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Stopping RecoupmentStopping Recoupment

� Even if overpayment not paid in full, recoupment can

be stopped – how?

� Medicare receives a valid and timely request for

redetermination within 30 days of the demand letter

� If the appeal is later than 30 days, recoupment stopped

at whatever point that an appeal is received – however

– Medicare may not refund any recoupment already

taken

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Stopping RecoupmentStopping Recoupment

� If redetermination decision is not favorable, Medicare

can begin to recoup no earlier than 61st day from the

date of the redetermination notice, or

� If decision partially favorable, can begin to recoup no

earlier than the 61st day from the date of the Medicare

revised overpayment Notice/Revised Demand Letter

� Can resume recoupment following reconsideration by

the QIO

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NO

YES

RA requests medical records

Provider has up to 45 days +/- 10 calendar days to

respond

RA has up to 60 days to review medical records

RA makes a claim

determination

Complex Review

AutomatedReview

RA makes a claim

determination

RAC issues Review Results Review Results

LetterLetterto provider (does NOT communicate

improper amount or appeal rights; and/or including “no findings”)

RA decides whether medical records are required to make determinations

If nofindingsSTOP

Complex Review Discussion Period Begins

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On Day 41On Day 41,

Carrier/FI/MACrecoupsby offset

Day 1 Day 1

RAC issues Demand Demand LetterLetter which includes amount and appeal

rights

Complex Review Discussion Period Continues

Automated ReviewDiscussion Period

NOTE: Detailed review results letter

and claims information to

Carrier/FI/MAC are done simultaneously

RA sends claim info to

Carrier/FI/MAC

NOTE: This is an informational

entry only on the RA. No actual money taken at

this point

Carrier/FI/MAC adjusts & issues RemittanceRemittanceAdviceAdvice to provider.

Code “N432”Code “N432”

NOTE: The date of the demand letter starts the

41 day clock for recoupment

NOTE: Offset occurs if the provider has not submitted an appeal

request within 30 days of the date on the demand letter. No claim detail for the overpayment appears on the Remittance Advice

at the time the recoupment occurs


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Provider Options Regarding RA Provider Options Regarding RA Overpayment DeterminationsOverpayment Determinations

69

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Identify Your RA RisksIdentify Your RA Risks

70

�Medicare daily rate exceeds peers

�How does the facility stand compared to others in your

CBSA (core-based statistical area)

�Are there patterns or trends that are easily identified –

same RUG category for several of the Medicare required

assessments for the same resident

�High percentage of resident treated exactly to RUG

minimum

�Medical necessity not substantiated in medical record


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� PSCs and now ZPICs use extrapolation with audit findings. The RAs can

use it, too, but one difference is that they have to obtain CMS approval

� In many extrapolations, claims reviewed frequently span a 12- to 24-month

period. The review date or date of the medical record request occurred

more than a year after most claims in the sample were paid by Medicare.

The Medicare contractor calculates an error rate and applies that error rate

to all similar claims within the sample period to produce an overpayment

estimate that greatly exceeds the combined value of the individually denied

claims, sometimes by more than 100 times the actual amount.

� Overpayment amounts assessed by reviewers are huge and, after a

certain level of appeal has been exhausted, CMS may recoup the

overpayment from future reimbursements while the appeal continues

Added Risk of Claim Reviews = Added Risk of Claim Reviews = ExtrapolationExtrapolation

71

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Greatest RisksGreatest Risks

72

DOJDOJOIGOIG

ZPICZPIC

RARA

MMICIC

MACMAC

QIOQIOCERTCERT Routine

business

Compliance

Legal


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The Microscope of MedicareThe Microscope of Medicare

73

Criteria

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� All four of the following factors must be met:

1. Requires skilled nursing or skilled rehabilitation services

2. Requires these skilled services on a daily basis

3. Daily skilled services can only be provided only on

inpatient basis in SNF

4. Services must be reasonable and necessary for

treatment of patient’s illness or injury

Requirements for SNF CoverageRequirements for SNF Coverage

74


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� Facility primarily engaged in providing skilled

nursing care and related services for residents who

require medical or nursing care, or rehabilitation

services for injured, disabled, or sick persons based

on Medicare requirements

What Is a Skilled Nursing What Is a Skilled Nursing Facility?Facility?

75

CMS IOM Publication 100-01,Medicare General Information, Eligibility and Entitlement Manual, Chapter 5, Section 30

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Principles of DeterminingPrinciples of DeterminingSkilledSkilled

� Service must be so inherently complex inherently complex of a service

prescribed for a patient that it can be performed safely

and/or effectively only by or under the general supervision

of skilled nursing or skilled rehabilitation personnel; then

the documentation must reflect medical complications that documentation must reflect medical complications that

require the provision of the services by skilled personnelrequire the provision of the services by skilled personnel

� Medical condition is a valid factor, but diagnosis or

prognosis should never be the sole factor in deciding that

a service is not skilled

76


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“Reasonable and Necessary”“Reasonable and Necessary”

� From Medicare Policy Manual, Chapter 8: Services

must be:

� consistent with nature/severity of illness and

individual’s needs

� within accepted standards of medical practice

� appropriate as per level of caregiver

� appropriate intensity of service

77

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Practical MatterPractical Matter

� Daily skilled services can be provided only in an SNF

� They are not available on an outpatient basis in the area in which the individual resides

� Transportation to the closest facility would be:

� An excessive physical hardship;

� Less economical; or

� Less efficient or effective than an inpatient institutional setting

78


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Related ConditionRelated Condition

� Services are needed for a condition which was

treated during the qualifying hospital stay

OR

� For a condition that arose while in the SNF and while

the beneficiary was still under treatment for a

condition for which the patient was previously treated

in the hospital

79

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Benefit PeriodBenefit Period

� Up to 100 days per “Spell of Illness”

� Benefit period is not based on calendar year

� Days 1 to 20

� 100% paid by Medicare

� Days 21 – 100

� Coinsurance billing required

� 2013 rate = $148.00/day

80


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Medicare Benefit PeriodMedicare Benefit Period

� The beginning and ending of a benefit period is

based on the level of care that the patient requires

Beginning of a Benefit Period:

� Begins when a patient is admitted to a hospital for

inpatient care, and the beneficiary has not received

skilled services for at least 60 days

81

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Continuing a Benefit Period:

� Continues as the patient is admitted to a skilled nursing facility as an inpatient and requires a skilled level of care

� As long as the patient continues to require a Medicare skilled level of care, the benefit period does not end even if the patient exhausts their 100 days of Part even if the patient exhausts their 100 days of Part A coverageA coverage

82


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Ending a Benefit Period:

� Ends when the care required by the patient no

longer meets the requirement for a Medicare skilled

level of care

� Patient must remain at a non-skilled level of care for

60 consecutive days before being eligible for a new

benefit period

83

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� Begins

� Beneficiary enters qualified hospital or SNF as inpatient

by a qualified provider in a month for which the patient

is entitled to hospital insurance benefits

Starting and Ending a Benefit Starting and Ending a Benefit PeriodPeriod

84

� Ends

� 60 consecutive days from date of discharge and was

not in the hospital OR

� If the beneficiary stays in the facility, but does not

receive skilled care for at least 60 days


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Spell Of IllnessSpell Of Illness

• 3 day hospital stay• 30 day transfer rule

• Assigned to 1 of top 52 RUGs (5-day PPS) (presumption of coverage) and

• After that must meet the skilled level of care criteria

May receive up to 100 days per spell of illness

• At a non-skilled level of care for 60 consecutive days

85

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Teaching &

Training

Direct Skilled CareNURSINGNURSINGOr Or

THERAPYTHERAPY

Skilled Care Building BlocksSkilled Care Building Blocks

86


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SNF SNF –– Medicare Part A Medicare Part A ––What’s Skilled?What’s Skilled?� Resident requires the skills of a licensed nurse or therapist

� Often a continuation of care for the reason of hospitalization

� Skilled care is delivered through:

� Direct nursing (7 days/week) OROR

therapy (5 days/week) services

� Teaching and Training

� Nursing Observation and Assessment

� Care Plan Management87

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Direct Skilled CareDirect Skilled Care

�� NursingNursing - 7 days per week7 days per week

� IV, IM Injections and IV feedings

� Tube Feedings*

� Suprapubic Catheter Care

� Suctioning (tracheal, nasopharyngeal)

� Dressing Changes

� Ulcer/Surgical Wound Care

� Heat treatments

� Initial phases of medical gases (oxygen)

� Restorative nursing (2 programs each 15 minutes/day for 6 days)

/week)

�� TherapyTherapy

� PT

� OT

� SLP

� RT (provided by a nurse or

respiratory therapist)

5 days per 5 days per

weekweek

88*TF = 51% daily calories or at least 26% of total calories and 501cc of fluid


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� Several from CMS Transmittal 161 (CR 8044) for

MBPM, Chapter 8: Coverage of SNF Services

� Extended care services must have been treatment for which

the beneficiary was receiving inpatient hospital services

(including ER) or a condition which arose while in the SNF

for treatment for which was previously hospitalized. In other

words, the applicable hospital condition need not have been

the principal diagnosis that actually precipitated the

beneficiary’s admission to the hospital, but could be any one

of the conditions present during the qualifying hospital stay

Some Medicare A Manual Some Medicare A Manual Changes for April 2013Changes for April 2013

89

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� Daily basis requirement for skilled services (7 days) and therapy services (5 days):� The daily requirement for therapy must be a single type of

skilled services on at least 5 days per week. It can be met by the single type of service daily or by furnishing various types of skilled services on different days of the week that collectively add up to “daily” skilled services. However, arbitrarily staggering the times of various therapy modalities during the week in order to have some type of therapy occur each day, would not satisfy the SNF coverage requirement for daily services. To meet this requirement –the resident must actually NEED services furnished daily.


90Continued


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� Daily basis requirement for skilled services (7 days) and therapy services (5 days):

� Not sufficient to arrange the therapy so that it is furnished each day – unless there is a resident medical need. For example, if PT is furnished on 3 days each week and OT is furnished on 2 other days each week, the “daily basis” requirement would be satisfied only if there is a valid medical reason why both cannot be furnished on the same day.


91

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� HIQA not HIPAA compliant and replaced now with Medicare

Health Insurance Portability and Accountability (HIPAA)

compliant Eligibility Transaction System (HETS)

� In real–time mode handles requests for eligibility verification for

Part A and/or Part B; determines payment responsibility with

regard to deductible/co-payment; determines eligibility for

preventive services; determines if Medicare is primary or

secondary payer; MCR plan, MA plan or Part D; proper billing

� Check with your software vendor with any questions about

HETS http://www.cms.gov/Outreach-and-Education/Medicare-

Learning-Network-MLN/MLNMattersArticles/downloads/SE1249.pdf

Reminder about Verifying Reminder about Verifying Benefits Benefits –– After 4/1/2013 After 4/1/2013

92


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Documents Needed At Documents Needed At AdmissionAdmission

� Benefit eligibility confirmation – HETS

� Admission agreement with authorization to treat;

� Authorization to bill Medicare or insurance;

� Medicare Secondary Payor form;

� Copies of Medicare and Insurance cards

93

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� Physician Documentation

� Therapy Evaluation and Documentation

� Nursing Documentation

� Ancillary Documentation

So What Documentation So What Documentation Do We Need?Do We Need?

94


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� Order to admit for skilled services

� Initial certification of skilled care as a continuation of a service or need arising during the hospitalization

� Orders for skilled care

� History and Physical detailing the skilled need

� Progress notes to support ongoing skilled services

Physician DocumentationPhysician Documentation

95

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Physician CertificationPhysician CertificationRecertificationRecertification

Requirements

� Content of Certification – Post hospital SNF care is or was required because the individual needs or needed on a daily basis skilled nursing care (furnished directly by or requiring supervision of skilled nursing personnel) or other skilled rehabilitation services that, as a practical matter, can only be provided in a SNF on an inpatient basis; and and

96

Remember :

Physician

signature and

date should

be in the

same

handwriting


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� The care is needed for a condition for which the patient received inpatient hospital services

� Timing of Certification – the certification must be obtained at the time of admission or as soon thereafter as is reasonable and practicable which is no later than the third day following the day of admission. This provides for consideration of weekend admissions

� Remember – faxed signatures are acceptable

97

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� Content of recertifications

� Reasons for continued need of SNF care

� Estimated time the individual will need to remain in the SNF

� Plans for home care, if any and

� If appropriate, the fact that continued services are needed for a condition that arose after admission to the SNF and while the individual was still under treatment for the condition for which he or she had received inpatient hospital services

98


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� The recertification statement must contain an adequate

written record of the reasonsreasons for the continued need

for services, the estimated period of time required for

the patient to remain in the facility, and any plans,

where appropriate, for home care. The recertification

statement made by the physician does not have to

include this entire statement if, for example, all of the

required information is in fact included in progress.

40.3 40.3 -- Recertifications Recertifications for Extended for Extended Care Services Care Services ((Rev. 1, 09Rev. 1, 09--1111--02)02)

99

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� NOTE: In such a case, the physician's statement could

indicate that the individual's medical record contains

the required information and that continued post-

hospital extended care services are medically

necessary. A statement reciting only that continued

extended care services are medically necessary is not,

in and of itself, sufficient.

40.3 40.3 -- Recertifications Recertifications for Extended for Extended Care Services Care Services ((Rev. 1, 09Rev. 1, 09--1111--02)02)

100

Medicare General Information, Eligibility, and Entitlement Chapter 4 - Physician Certification and Recertification of Services

(Rev. 76, 01-13-12)


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Must be signed and dated within 30 days of the previous date

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Physician CertificationPhysician CertificationTiming and DocumentationTiming and Documentation� Upon admission

� By day 14

� Every 30 days thereafter (from the

physician signature date)

� Certification must include:

� Reason for certification (skilled care)

� Estimated of time services needed

� Discharge plans

can be signed at same timecan be signed at same time

102

Who Can Sign?

� Attending physician

� Physician on the staff who has knowledge of the case

� Physician extender who is not employed by the facility, but working in collaboration with a physician


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� No less than monthly for residents receiving skilled

care – especially Medicare Part A and replacement

plans;

� Must reflect an awareness of the treatment plan;

� Must reflect an awareness of the resident’s goals

and status;

� Include all skilled care provided at the time of the

visit

Physician DocumentationPhysician Documentation

103

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Documentation Documentation

� Should “paint a picture” of the resident and their ability

� Must reflect the skilled service provided

� Assessment of acute medical conditions – spell it out

� Description of delivered services and resident’s response

� Teaching and training

� Provision of skilled care

� Show the interdisciplinary approach to skilled services

104


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Direct Skilled Therapy ServicesDirect Skilled Therapy Services

� Reasonable and necessary to the treatment of the illness or injury

� Documentation components:

� Evaluation

� Treatment plan = established by a physician after consultation by a qualified therapist

� Progress notes

� Updated treatment plan (recertification)

� Discharge Summary

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� Must be of such a level of complexity and

sophistication or the condition of the resident must

be such that the services required can be safely

and effectively performed only by a qualified

therapist or under his/her supervision

Therapy ServicesTherapy Services

106


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� Reason for Referral – supporting hospital documentation or decline as noted in the nursing documentation

� Should include the medical diagnosis resulting in the need for therapy services

� Should include the treatment diagnosis that describes the symptoms or problems to be treated and needs to be supported by objective or descriptive documentation

TherapyTherapyEvaluationEvaluation

107

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� Prior Level of Function (PLOF) – very important in

establishing why therapy treatment is warranted

� Should establish baseline data necessary for

assessing expected rehab potential

� Should incorporate standardized tests that can be

repeated throughout the POC process


108


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� Should include impressions and clinical summary of the deficits identified during the evaluation:

“What is wrong with the resident?”

� Should establish why the resident has a “NEED” for therapy from a functional standpoint


109

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� Should include:

� Goals

� Resident focused with resident’s input

� Functional, objective and measureable

� Long term (LTG) – reflective of final level resident

is expected to achieve

� Short term (STG) – components of the LTGs with

a 2-3 week timeframe

Plan of CarePlan of Care(aka Treatment Plan)(aka Treatment Plan)

110


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� Should include:

� Specific treatment – description of the treatment or intervention (modalities):

� Gait training

� Therapeutic exercise

� ADL training

� Frequency – number of times in a week treatment will be provided

� Duration – number of weeks (Part A) or treatment sessions (Part B) for the Plan of Care (PoC)

Plan of Care Plan of Care (aka Treatment Plan) (aka Treatment Plan) (continued)(continued)

111

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� Daily –

� Describes what was done in the treatment session

that day

� Supports why a code was billed and supports length

of time they were billed

� Requires a signature WITH credentials

� Does not need to support medical necessity

TherapyTherapyProgress NotesProgress Notes

112


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� Weekly –

� Provides justification for ongoing treatment

� Must show complexity of treatment and service provided

� Should detail significant progress

� If not – detail the barriers to the progress

� If no progress by the second weekly note – consider

change in treatment plan or determine need to transition

out of therapy. Progress needs to be monitored from the

initiation of treatment – not 3-4 weeks into treatment

TherapyTherapyProgress NotesProgress Notes

113

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� Describe the skilled components of the intervention,

activity or technique that only the clinician has the

knowledge to provide

� “Skill” is not shown by only documenting the following:

� What patient or therapist did

� Exercise name, number of repetitions, amount of weight,

amount of assistance and distance ambulated

� Skilled treatment requires more documentation that just

“therapeutic activities”

Documenting Skilled Documenting Skilled TreatmentTreatment

114


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� When you read the therapy note – why does this

resident need the skills of the therapist to do this?

The medical record must justify all of the modalities

and services being provided to that individual resident

� Example – for gait training the regulation states that

the resident has to have a deficiency in orthopedic,

neurological, or musculoskeletal problem to qualify for

skilled gait training

Tips for Therapy Tips for Therapy DocumentationDocumentation

115

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OneOne--onon--One TreatmentOne Treatment

� Need information to prove that services billed were

provided, medically necessary and required the skills of

a therapist or assistant under supervision of a therapist

� Type of exercises or activities performed

� Sets and repetitions of exercise

� Weight or resistance used

� Variations and progression of specific interventions

� Gait distance

� Assistive device used

� Patient/caregiver training

� Observations made before, during and after116


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CPT 97110 CPT 97110 Therapeutic ExercisesTherapeutic Exercises

� Supportive documentation recommendations include but are not limited to:

� Objective measurements of loss of strength and range of motion and effect on function

� If used for pain – include pain rating, location, effect of pain on function

� Specific exercises performed, number of sets and reps, amount of weight or resistance, purpose of exercise related to function, instruction provided and any assistance provided

� Any vital sign monitoring required related to clinical condition (pulse oximetry, heart rate, blood pressure)

117

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CPT 97112 CPT 97112 Neuromuscular ReNeuromuscular Re--educationeducation

� Supportive documentation recommendations include

but are not limited to:

� Objective loss of ADLs, mobility, balance,

coordination deficits, hypo and/or hypertonicity

and posture and effect on function.

� Specific exercises/activities performed, purpose of

the exercise as it relates to function, instruction

provided, and assistance needed

118


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CPT 97116 CPT 97116 Gait TrainingGait Training

� Supportive documentation recommendations include but

are not limited to:

� Objective measurements of balance and gait distance,

assistive devices used, assistance required, gait deviations

and limitations being addressed, use of orthotics or

prosthesis, need for and description of verbal cueing

� Presence of complicating factors (pain, balance deficits, gait

deficits, stairs, architectural or safety concerns)

� Specific gait training techniques used, instructions provided,

and/or assistance needed, resident response to interventions

119

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CPT 97535 SelfCPT 97535 Self--Care Home Care Home Management TrainingManagement Training


� Objective measurements of the patient’s ADL and instrumental activity of daily living (IADL) impairment to be addresses

� The specific ADL and/or compensatory training provided, specific safety procedures addressed, specific adaptive equipment/assistive technology utilized, instruction provided, assistance provided and resident response to the interventions to support the services provided required the skills of the therapist

120


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CPT 97530 CPT 97530 Therapeutic ActivitiesTherapeutic Activities

� Supportive documentation recommendations include

but are not limited to:

� Objective measurements of loss of ADLs, balance,

strength, coordination, range of motion, mobility

and effect on function

� Specific activities performed and amount and type

of assistance to demonstrate the skills and

expertise of the therapist were required

121

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CPT 97542 CPT 97542 Wheelchair ManagementWheelchair Management


� Recent event prompting the need for a skilled w/c assessment

� Any previous w/c assessments completed

� Most recent prior level of function

� Any previous interventions attempted by the nursing staff, caregivers and/or resident that may have failed

� Functional deficits related to poor positioning or seating

� Objective assessments of applicable impairments such as range of motion, strength, sitting balance, skin integrity, sensation and tone

� Response of the resident or caregiver to the fitting and training

122


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� Should outline the progress demonstrated since treatment initiated;

� Should include impact on resident’s functional status

� Should include the reason for continued need of therapy – LTGs as it relates to the resident’s return to community or transition to long term care

� What still needs to be accomplished?

ReRe--certificationcertification

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Includes the following:

� Criteria to discontinue treatment

� Current functional status

� Detail goals achieved

� Details reasons for unmet goals

� Describe plan related to resident’s continuing care (restorative, home care, out-patient)

� Referrals for additional services

� Equipment provided or ordered

Discharge SummaryDischarge Summary

124


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Skilled Nursing DocumentationSkilled Nursing Documentation

� Must be completed no less than daily

� Describe skilled care was provided � Medication administration record (MAR)

� Treatment administration record (TAR)

� IV sheet

� Behavior grids

� Wound grids

� Nurses notes/progress notes

� Assessments pertaining to skilled services – what, why, action taken, resident’s response

125

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� Describe resident’s response

� Tolerance

� Discomfort

� Side effects experienced

� Describe need for change of treatment or physician

notification

� Must detail what skilled care the resident received

� Should include ADL status

Skilled Nursing DocumentationSkilled Nursing Documentation

126


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Documentation of ServicesDocumentation of Services

� Reflect resident self performance and staff

support for activities of daily living (ADLs) – note

what the resident can or cannot do

� Walking

� Dressing/am and pm care

� Toileting

� Eating

� Bed mobility and transfers

127

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� Therapy will document what the resident does in therapy

� Nursing must document:

� Therapy attendance

� Pain related to therapy (if reported)

� Compliance

� If the resident refuses therapy – let someone know immediately

� Safety factors observed

� Resident self performance of care in and out of room

� Document the problems the resident is having caring for self (if

present

Nursing DocumentationNursing Documentation(As It Relates to Therapy)(As It Relates to Therapy)

128


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Quick Word on MDS Quick Word on MDS ADLs ADLs and Therapy ADL Lingoand Therapy ADL Lingo

MDS Therapy

Independent Independent

Supervision Stand By Assist

Limited Assistance Contact Guard

Extensive AssistanceMin Mod Max

Assist

Total Dependence Dependent

129

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Know the ADL Definitions of Know the ADL Definitions of SelfSelf--PerformancePerformance

0 Independent

1 Supervision

2 Limited Assistance

3

Extensive Assistance

4 Total Dependence

7 Activity Occurred Only Once or Twice

8 Activity Did Not Occur

Staff’s hand on top

Staff’s hand underneath - hand, finger, arm, leg, hip, foot of resident

130


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ADL Values for Bed Mobility, ADL Values for Bed Mobility, Toilet Use, TransferToilet Use, Transfer

RUGs IV

Support

Performance None (0)/

Setup (1)

1-person (2)

2-person (3)

Independent(0)/Supervision (1) 0

LimitedAssistance (2) 1

Extensive Assistance (3) 2

4TotalDependence (4) 3

Includes self-performance codes (7) and (8)

131

What makes HUGE difference in ADL scoring?

Column 2: Support

One or two staff person assistance

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RUGs IV

Support

Performance None (0)/

Setup (1)

None (8)

1-person

(2)

2-person

(3)

Independent(0)/Supervision (1)

0 2Limited

Assistance (2)1 or 2 times (7)None (8)

Extensive

Assistance (3)

23

TotalDependence (4) 4

ADL Values for EatingADL Values for Eating

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� Office of the Inspector General in November 2012 report called

“Inappropriate Payments to Skilled Nursing Facilities Cost

Medicare More than a Billion Dollars in 2009” focused on

importance of medical record supporting the need for skilled

care and the accuracy of MDS coding. The RUG system forces

them to be connected. Some statistics:

� SNFs reported inaccurate information not supported in

medical record for at least one MDS item for 47% of claims.

Therapy was the source of most errors, but also special

care and ADLs showed mistakes

Speaking of the MDSSpeaking of the MDS

133

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� Another report from the OIG (February 2013) called “Skilled

Nursing Facilities Often Fail to Meet Care Planning and

Discharge Planning Requirements” reported that 37% of stays,

SNF did not develop care plans that met requirements or did

not provide services based on the plans of care. Reviewers

found that therapy played a significant role and either provided

more or less services than care planned.

� The area that had the most common problems of not

addressing needs identified in the assessments was the

care area of ADLs – impacting 86% of resident stays.

Speaking of More Hits from Speaking of More Hits from the OIGthe OIG

134


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Observation and Observation and AssessmentAssessment

� Nursing

� Resident condition is unstable for medical reasons

� Risk for occurrence of acute problem

� Skills of a licensed nurse are required on a daily basis to assure resident safety

� Examples: COPD, CHF, recent MI, medication changes

135

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� If admitted for skilled observation but did not develop

a further acute episode or complication, skilled

observation services are covered so long as there

was reasonable probability for such a complication or

further acute episode

� "Reasonable probability" means that a potential

complication or further acute episode was a likely

possibility

Observation and AssessmentObservation and Assessment

136


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A patient with arteriosclerotic heart disease with congestive heart failure requires close observation by skilled nursing personnel for signs of decompensation, abnormal fluid balance, or adverse effects resulting from prescribed medication. Skilled observation is needed to determine whether the digitalis dosage should be reviewed or whether other therapeutic measures should be considered until the patient's treatment regimen is essentially stabilized

Observation and AssessmentObservation and AssessmentExample 1Example 1

137

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A frail 85-year-old man was hospitalized for pneumonia. The infection was resolved, but the patient, who had previously maintained adequate nutrition, will not eat or eats poorly.The patient is transferred to a SNF for monitoring of fluid and nutrient intake, assessment of the need for tube feeding if required. Observation and monitoring by skilled nursing personnel of the patient's oral intake is required to prevent dehydration.

Observation and AssessmentObservation and AssessmentExample 2Example 2

138


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Care Plan ManagementCare Plan Management

� Nursing

� Multitude of non-skilled services (which are

able to be performed by non-licensed persons)

� Licensed nurse required to manage the care

� Potential for complications with relation to those

services

139

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Care Plan ManagementCare Plan Management

� Development, management, and evaluation of a patient care plan, based on the physician's orders

� In terms of the patient's physical or mental condition

� Services require the involvement of skilled nursing personnel to:

� Meet medical needs

� Promote recovery

� Ensure medical safety

140


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Care Plan Management Care Plan Management Example 1Example 1

An aged patient with a history of Diabetes Mellitus and angina is recovering from hip surgery requires:

� Careful skin care

� Oral medications

� Diabetic diet

� Therapeutic exercise program to preserve muscle tone and body condition

� Observation to notice signs of deterioration in his condition or complications resulting from his restricted (but increasing) mobility

141

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� Since the nature of the patient's condition, his age and his immobility create a high potential for serious complications, such an understanding is essential to assure the patient's recovery and safety.

� The management of this plan of care requires skilled nursing personnel until the treatment regimen is essentially stabilized.

� Even though the individual services involved are supportive in nature and do not require skilled nursing personnel

Care Plan Management Care Plan Management Example 1 (continued)Example 1 (continued)

142


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An aged patient is recovering from pneumonia, is

lethargic, disoriented, has residual chest congestion,

is confined to bed as a result of debilitation, and

requires restraints at times. To decrease the chest

congestion, the Dr. has prescribed:

� Frequent changes in position

� Coughing and deep breathing

Care Plan Management Care Plan Management Example 2Example 2

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� The residual chest congestion alone would not

represent a high risk factor, but immobility and

confusion represent complicating factors which, when

coupled with the chest congestion, could create high

probability of a relapse

� Skilled overseeing of the non-skilled services would

be reasonable and necessary, pending the

elimination of the chest congestion, to assure the

patient's medical safety

Care Plan Management Care Plan Management Example 2 (continued)Example 2 (continued)

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Teaching and TrainingTeaching and Training

� Learn self-maintenance skills, such as:

� Restorative programs � G-tube feedings, flushes� Dressing changes� Medication administration� Skin treatment � Self-catheterization, ostomy or catheter� Diabetic diet, foot care, blood glucose monitoring � Oxygen administration, adjustments of equipment

145

� Incorporate into

treatment plan from

beginning

� Document patient’s

response

� Do not add extra days

on for education

� Improve resident’s functional status by

teaching new techniques

� Nursing

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Who Reads Your ChartingWho Reads Your Charting

� Remember charting is not just for the next shift to read, it’s for:

� Doctors

� Administrative staff

� Consultants

� Medicare Administrative Contractors

� State Surveyors

� Medical Staff outside facility

� Medicare and/or Medicaid reviewers – RA, MIC, ZPIC,

exception reviewers, CERT, PERM

� Attorneys

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Charting TipsCharting Tips

� Take time to gather your thoughts before beginning to document

� Don’t take shortcuts – use only approved abbreviations by your facility, write it out for a clear understanding

� Be complete – describe the event in complete sentences with enough detail that the reader will get a clear picture

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� Documentation of preceding events is helpful

� If it’s important enough to be in shift report then it’s

important enough to document in the medical record

� Chart about the resident not yourself, with focus on

resident’s reaction to treatment and outcome

� Document phone calls to the physician as the

resident’s advocate and the persistence in expressing

the resident’s needs

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� Remember to chart:

� What you see

� Action taken

� Effectiveness of the interventions implemented

� Discrepancies between therapy and nursing need

to be investigated and clarified

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Medicare providers are faced with the challenges of providing quality healthcare while meeting ever increasing regulatory and compliance regulations. Many are investing in Electronic Health Records (EHR) to increase the quality of their documentation, decrease or minimize documentation time and improve their overall record keeping capabilities. Providers need to be aware that EHR can inadvertently cause some documentation pitfalls such as making the documentation appear cloned. Cloned documentation could cause payment to be denied in the event of a medical review audit of records.lllll

Documentation is considered cloned when it is worded exactly like or similar to previous entries. It can occur when the documentation is exactly the same from patient to patient. Individualized patient notes for each patient encounter are required. Documentation must reflect the patient condition necessitating treatment, the treatment rendered and if applicable the overall progress of the patient to demonstrate medical necessity.

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Cloned Documentation Could Resultin Medicare Denials for Payment 08/12


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An EHR allows default options. Defaults cause a provider to overlook

significant new findings that may result in safety/quality issues. Default data

may document a more extensive history and physical exam than is medically

necessary and may not differentiate new findings or changes in condition. It is

important to document patient progress. Cloned documentation also applies

to disciplines where the documentation must demonstrate the patient is

making progress towards goals, or documenting the findings or changes

in a patient’s condition to meet Medicare medical necessity.l

No matter if the documentation resulted from EHR, a pre-printed template, or

handwritten documentation, cloned documentation will be considered

misrepresentation of medical necessity requirement due to the lack of specific

individual information for each unique patient. Identification of this type of

documentation will lead to denial of services for lack of medical necessity and

the recoupment of all overpayments made 151

Cloned Documentation Could Resultin Medicare Denials for Payment 08/12

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� Patient slept well all night, alert and verbally

responsive. Noted episodes of incontinence,

kept clean and dry, assisted in using the bed

pan. Bed placed in the lowest position, bed

alarm in place. Call light in reach.

� Patient slept well all night, alert and oriented,

continent of b/b, assisted to the bathroom.

Scheduled meds given as ordered. Call light in

reach, needs attended to. Afebrile

Sample Skilled Nursing NotesSample Skilled Nursing Notes

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SkilledServices

SkilledServices


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� Pt. alert and ambulatory w/walker. No c/o

pain during shift. All meds administered

w/o any adverse effect. Pt. ate in the dining

room w/ good appetite. Continue w/therapy

services w/o any issues. Pt. showered

w/staff assistance. Will follow up

Sample Skilled Nursing NotesSample Skilled Nursing Notes

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SkilledServices

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� Pt. assessed to be alert and oriented x 3. No distress noted. Right knee

incision, assessed to be clean, intact and dry. Has order for weight bearing

as tolerated on right LE. Limited weight bearing assistance is needed for

ADLs of bed mobility, transfer, dressing, toileting & positioning. On

anticoagulant therapy as post-op. precaution, monitored for signs and

symptoms of bleeding which were negative at this time. Meds given as

ordered. Fall precautions observed. Copy of Transition Summary &

Recapitulation form given to patient with instructions, verbalized

understanding. Patient assisted & supervised with ADLs. Pain assessed

and evaluated and managed with prn pain medication, polar care

application, and rest. Patient on modified independence, ambulates with

the use of cane with steady gait. Patient denies any chest pain/heaviness.

No SOB/dizziness at this time. Call light within reach. Needs attended. 154

Sample Skilled Nursing NotesSample Skilled Nursing NotesSkilled Services


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� Interventions provided: Therapeutic exercises 2# weighted bar for

chest press, bicep curls, shoulder flexion and shoulder horizontal

abduction/adduction. Omnicycle x 15 minutes. Therapeutic activities:

fine motor coordination training, buttoning, zipping and hooking

clothing fasteners to improve fine motor coordination,

throwing/catching activities to facilitate strength, coordination,

balance and dynamic function activities to increase strength, ROM,

flexibility in a progressive manner. OmniVR for sit to stand activities.

Neuromuscular Re-Ed and dynamic standing balance training and

facilitation of weight shift/dynamic stability. Self-care mgmt.: dressing

techniques and analysis of sequencing during ADLs. W/C Mgmt.:

training in locking/unlocking brakes to facilitate safety.155

Sample Skilled Therapy NotesSample Skilled Therapy Notes

continued

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Pt. and caregiver training: Instructed patient in safe transfer

techniques to reduce the risk for falls.

Continued Skill: Reason for skilled Services: Patient requires skilled

OT services to assess safety and independence with self care and

functional tasks of choice, facilitate dynamic standing balance and

increase functional activity tolerance in order to enhance patient’s

quality of life by improving ability to facilitate ability to live in

environment w/least amount of supervision and assistance.

Patient demonstrates good rehab potential as evidenced by high

PLOF.

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Sample Skilled Therapy NotesSample Skilled Therapy Notescontinued

Was NOT from Alden facility


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� Pt. progressing toward goals/continue per

POC.

� Balance, gait, transfer, strength & ROM.

Continue with current tx.

� Pt. has achieved STG #2 & STG #1.

Continue to work to achieve LT goals

� Progressing Therapeutic ex & progressing

gait training, continue with current tx

strategies.

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Sample Skilled Therapy NotesSample Skilled Therapy Notes

Progress notes do not provide justification for the medical necessity of treatment

Individual Resident Therapy Notes

� The facility utilizes a check-off sheet, in addition to a note, for exercises and modalities provided; this lacks objective measurement; e.g., grey Thera-band checked off without any indication of why it is useful or the resident’s response.

Additional Comments

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� Resident name must match that reflected on the Medicare

card

� Correct Medicare number

� Days of Therapy – no longer units

� HIPPS and Modifier coding matches the MDS

� Diagnosis selection and coding

� Consolidated billing requirements

� Cannot be submitted until the MDS is accepted for

residents in a Medicare Part A stay

UBUB--04 Completion and 04 Completion and SubmissionSubmission

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So Let’s Talk About So Let’s Talk About Diagnosis CodingDiagnosis Coding

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Now – Don’t Get THAT Excited!!

What we will cover:� Types of diagnoses� Describe what is the

“primary/principal” diagnosis for LTC

� Secondary and supporting diagnoses

� Risks for miscoding� Strategies for success

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� Accuracy of the MDS

� Reimbursement

� Audit risks

Why IsWhy IsDiagnosis Coding Important? Diagnosis Coding Important?

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� ICD 9 – International Statistical Classification of

Diseases and Related Health Problems approved

by:

� CMS

� American Hospital Association

� American Health Information Association

� National Center for Health Statistics

ICDICD--9 9 –– What is it?What is it?

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� Updates every October 1 – although 2011 seems

to be the last publication for the Official Guidelines

� Scheduled to adopt ICD-10 in October 1, 2014 to

be in line with the World Health Organization

� Expands codes from 17,000 to 155,000

ICDICD--9 9 –– What is it?What is it?

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Guidance for LTC ICDGuidance for LTC ICD--9 Coding9 Coding

� CMS updated Chapter 6, Section 30 of the Medicare Claims Processing manual to include a definition of principal diagnosis and the use of V codes in LTC billing

� The principal diagnosis is the first diagnosis listed on the UB-04 billing form in field 67

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UBUB--0404CMS 1450CMS 1450

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� Secondary diagnoses can be listed in the additional fields, with no sequencing requirements

� Supportive treatment diagnoses can be listed in no sequencing order

Guidance for LTC ICDGuidance for LTC ICD--9 9 CodingCoding

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Medlearn Matter MM3664Medlearn Matter MM3664

� Principal Diagnosis Code – Code must be reported according to Official ICD-9-CM Guidelines, including appropriate use of V-codes

� Other Diagnosis Codes Required – CMS does not have additional requirements regarding reporting or sequencing of codes

www.cdc.gov/nchs/data/icd9/icdguide09.pdf

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� Section I: General Coding Guidelines for Late Effects

� Residual condition (late effect) = condition that remains after

acute phase of an illness

� Sequenced first unless otherwise instructed

� Cause of late effect listed second

� Do not use code for the acute phase of illness

Ex: Quadriplegia (344.00) following Cervical Fracture (907.2)

Guidance for Guidance for LTCLTCICDICD--9 Coding9 Coding

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� Section II: Selection of principal diagnosis applies to

all inpatient care settings including LTC

� Principal diagnosis for LTC: Condition chiefly

responsible for resident’s admission to the facility

(therapy, aftercare or diagnosis), or reason for

resident remaining in the facility

� In LTC where claims are submitted for extended stays,

the principal diagnosis listed may change to the reason

for which the resident remains in the facility

Guidance for LTC ICDGuidance for LTC ICD--9 Coding9 Coding

168


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� Section III: Reporting Additional Diagnoses applies to

all inpatient care settings including LTC. The definition

for “other diagnoses” is interpreted as additional

conditions that affect patient care in terms of requiring:

clinical evaluation; or therapeutic treatment; or

diagnostic procedures; or extended length of hospital

stay; or increased nursing care

Guidance for LTC Guidance for LTC ICDICD--9 Coding9 Coding

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� Create a listing of diagnoses and codes

� Select principal diagnosis and list first

� List additional diagnoses that reflect services

provided or clinical conditions

� Do not list diagnoses that are not pertinent to

nursing facility stay

� Do not list diagnoses that have been resolved or

are historical unless clinically significant to staff

Tips for LTC ICDTips for LTC ICD--9 Coding9 Coding

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� Use of Diagnoses on the MDS

� V-codes can be reported in I8000

� Do not report V57.xx codes for therapies (captured

elsewhere on the MDS [Section O])

� DO NOT include code if already captured in other

sections of MDS (therapies, g-tube)

More Tips for LTC ICDMore Tips for LTC ICD--9 Coding9 Coding

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Coding Process in LTCCoding Process in LTC

� High acuity residents (i.e., Medicare or managed care)� Review codes monthly

Codes on MDS, billing claim forms (i.e., UB-04) and in medical record need to support:� Medical necessity� Skilled services provided (may include therapy

treatment diagnosis)� Resource Utilization Group (RUG) selection as

applicable

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Chart diagnosis list

UB-04MDS

Develop Consistency of DataDevelop Consistency of Data

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� Accurate reporting of ICD-9-CM codes affects:

� Medicare billing

� Quality Measures

� Data collected for long term care residents

� Overall accuracy of the MDS/RUG categories

Develop Consistency of DataDevelop Consistency of Data

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� Not all diagnoses reported on MDS are appropriate

for billing claim forms (i.e., UB-04);

� Not all diagnoses on the MDS relate to the reason(s)

for Medicare coverage;

� Keep in mind time frame of MDS vs. billing claim form

Accurately Reporting ICDAccurately Reporting ICD--99Codes: MDS vs. Billing Claim FormsCodes: MDS vs. Billing Claim Forms

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� Use I8000 to report additional diagnoses not listed in

Section I – Diagnoses Items I0100 to I6500 that affect

current status

� Consider listing therapy treatment diagnoses in I8000

I8000 I8000 –– Other Current or More Other Current or More Detailed Diagnoses and ICDDetailed Diagnoses and ICD--9 Codes9 Codes

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I8000 I8000 –– Other Current or More Other Current or More Detailed Diagnoses and ICDDetailed Diagnoses and ICD--9 Codes9 Codes

� Annual ICD-9 code updates take effect on October 1 of each year

�� V codes may be used if they affect resident’s V codes may be used if they affect resident’s current statuscurrent status

� American Health Information Management Association coding and practice guidelines resource: www.ahima.org/infocenter/guidelines/ltcs/

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I8000 I8000 –– Using VUsing V--CodesCodes

� V Codes – Aftercare� Used when

� Initial treatment of disease or injury has been performed ANDAND

� Continued care required during the healing or recovery phase OROR

� Continued care required for the long-term consequences of the disease

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I8000 Using VI8000 Using V--CodesCodes

� Supplementary Classification of factors influencing health status and contact with health services

� ICD-9-CM Official Guidelines for Coding and Reporting: Section I, General Coding Guidelines –Categories of V codes, Aftercare

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I8000 I8000 –– Using VUsing V--CodesCodes

� V Codes – Aftercare� DO NOT use if treatment is directed at a current,

acute disease or injury� Use diagnosis code for current disease or

injury (the code must be the full ICD-9-CM diagnosis code, including all five digits where applicable)

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VV--Codes (V01Codes (V01--V82)V82)

� Assign V-code as first listed, or principal diagnosis when main reason for resident’s admission or continued stay is for:� Rehab services (V57) – Can only be used as first listed code

� Orthopedic aftercare (V54) – can be listed first or additional

� Surgical aftercare (V58.4x and V58.7x) – can be listed first or additional diagnosis

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� Other V-codes that can be assigned as first listed or principal diagnosis but are typically used as secondary diagnosis in LTC include:� Attention and management of artificial openings

(V55)� Amputation status (V49.6x or V49.7x)� Acquired absence of organ (V45.7x)� Monitoring therapeutic drug uses – i.e., Coumadin

(V58.83)

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� While it is technically possible to assign the following V codes as “first-listed” or principal diagnosis, it is extremely rare and should be discussed with manager prior to coding:� “History” of impacts or affects current care of the

resident� Personal history codes (range V10 – V13)� Family history (V16 – V19)

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V Codes (V01V Codes (V01--V82)V82)

� V codes that can ONLYONLY be listed as secondary diagnosis include:� Drug resistance present (V09)� Personal history codes (range V14 – V15) except except

V15.88 history of fall which can be first listed or additional

� Organ replacement status (V42 or V43)� Long term (current) drug use (V58.6x)� Hospice (V66.7)

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More on Using Code V57.xxMore on Using Code V57.xxin LTCin LTC

� Assign code from V57.xx (care involving use of rehabilitative procedures) if resident is admitted specifically for rehabilitative therapy:� Use V57.89 (multiple therapies) when two or

more therapies services are provided� Use additional code(s) to identify underlying

condition(s)

185

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More on Using Code V57.xx More on Using Code V57.xx in LTCin LTC

� V57.xx is:� First listed or principal diagnosis for admission if

resident admitted primarily for therapy intervention. Can only be used as first listed

� Coupled with codes for medical conditions (related to the need for therapy) and a treatment diagnosis

� Not used as a therapy medical diagnosis

186


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Coding ExamplesCoding Examples

A resident is admitted for physical therapy following a hip replacement for an intertrochanteric right hip fracture due to a fall

187

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Physical therapy:� V57.1 = Physical Therapy: Hip replacement:� V54.81 Aftercare following joint replacement due

to fracture (fractured not coded since repaired with prosthesis)

� V43.64 Joint replacement, hip� Due to a fall: V15.88 History of a fall

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�� V57.1V57.1�� V54.81V54.81�� V43.64V43.64�� V15.88V15.88

Chart

MDS

UB-04

�� I3900 (hip fracture)I3900 (hip fracture)�� I8000: V54.81, V43.64, V15.88I8000: V54.81, V43.64, V15.88

�� V57.1, V54.81, V43.64, V15.88V57.1, V54.81, V43.64, V15.88

189

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A resident is admitted for physical therapy and occupational therapy following a hip fracture after a fall. The physician indicated that the fracture was due to osteoporosis. The Discharge Summary stated that old compression fractures of the vertebrae due to osteoporosis were present on x-ray

190


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Physical and occupational therapy:� V57.89 Multiple therapies

Hip fracture (due to osteoporosis):� V54.23 Aftercare for continuing treatment of healing

pathological fracture of hip

Osteoporosis:� 733.00 Osteoporosis

Compression fractures of vertebrae:� V54.27 Pathological fractures of vertebrae

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�� V57.89V57.89�� V54.23V54.23�� 733.00733.00�� V54.27V54.27

Chart

MDS

UB-04

�� I3900(hip fracture); I4000 I3900(hip fracture); I4000 (pathological (pathological fracture); fracture); I3800 I3800 (osteoporosis)(osteoporosis)

�� I8000: V54.23, V54.27, I8000: V54.23, V54.27,

�� V57.89, V54.23, 733.00, V54.27V57.89, V54.23, 733.00, V54.27

192


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A resident is admitted for physical therapy and occupational therapy following a below knee amputation of the left leg due to peripheral vascular disease secondary to Type II Diabetes Mellitus

193

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Physical and occupational therapy:� V57.89 = Multiple therapies

Below knee amputation:� V54.89 Aftercare for amputation stump� V49.75 Lower limb amputation status, below knee

Peripheral vascular disease 2° to Type II diabetes� 250.70 Diabetes w/ peripheral circulatory disorders� 443.81 PVD 2° Type II Diabetes Mellitus

194


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�� V57.89V57.89�� V54.89V54.89�� V49.75V49.75

Chart

MDS

UB-04

�� I2900 (DM); I0900 (PVD)I2900 (DM); I0900 (PVD)�� I8000: V54.89, V49.75, 250.70, I8000: V54.89, V49.75, 250.70,

443.81 443.81

�� V57.89, V54.89, V49.75, 250.70, V57.89, V54.89, V49.75, 250.70, 443.81443.81

�� 250.70250.70�� 443.81443.81

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Documenting to Support Skilled Care

� Do the treatment records, medication administration records support care provided based on the presenting clinical diagnoses?

� Has the physician documented applicable diagnoses and are they supported by diagnostic studies when necessary (pneumonia, sepsis, UTI,…)?

Section I Section I -- Disease DiagnosesDisease Diagnoses

196


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Section I Section I –– Active DiagnosesActive Diagnoses

� Code diseases that have a relationship to the

resident’s:

� Current functional status

� Cognitive status

� Mood or behavior status

� Medical treatments

� Nursing monitoring

� Risk of death

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� Diagnoses required to have documentation from a

physician or other authorized licensed staff as

permitted by the state (PA, NP, CNS)

� 12 major divisions

� Use a 60-day look-back period to identify diagnoses

� Determine diagnosis status

� Active or inactive

� Use a 7-day look-back period

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� Step 1 = include ONLY diagnoses identified in the

last 60 days

� Step 2 = active or inactive (7-day look-back)• Transfer documents • Nursing care plans

• Physician progress notes • Medication sheets

• Recent History & Physical • Doctor’s orders

• Recent discharge summaries • Consults

• Nursing assessments • Official diagnostic reports

• Physician order sheets

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� Specific documentation of active diagnosis in medical record

� Recent onset or acute exacerbation indicated by a positive study,

test, or procedure, hospitalization for acute symptoms and/or

recent change in therapy

� Symptoms and abnormal signs indicating ongoing or

decompensated disease

� Symptoms must be specifically attributable to a disease

� Ongoing therapy with medications or other interventions to

manage a condition that requires monitoring for therapeutic

efficacy or to monitor potential adverse effects

Indicators of Active DiagnosisIndicators of Active Diagnosis

200


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� Determine whether diagnoses are active – do not include

conditions that have been resolved or have no longer

affected the resident’s function or care plan

� Adds definition to what is an active disease process as

“physician documented diagnoses in the last 60 days

that have a direct relationship to the residents functional

status, cognitive status, mood or behavior, medical

treatments, nursing monitoring or risk of death in the 7-

day look back period

More on Section I More on Section I

201

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� Admissions

� Director of Nursing (or designee)

� MDS Nurse

� Therapy

� Billing

So Who Is Responsible?So Who Is Responsible?

202

Diagnosis Coding


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� Provide preliminary referral information

� Check on any observation days in the hospital

� Obtain hospital information for team review

� Complete face sheet with appropriate primary

diagnosis listed

AdmissionsAdmissions

203

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� Review diagnosis for referrals in clinical stand up (if available)

� Review diagnosis for new admissions first day after admission to validate team awareness of primary diagnosis

AdmissionsAdmissions

204


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� Review referrals pre-admission

� Assign primary diagnosis (reason admitted to SNF)

� Discuss new admissions in clinical stand up (confirm

diagnosis)

� Communicate with clinical team reason for admission

and primary diagnosis at time of admission

Director of NursingDirector of Nursing

205

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� Include primary diagnosis on MDS

� Conduct Medicare/PPS meeting - review primary

diagnosis each meeting (it may/should change

during the stay)

MDSMDS

206


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� Obtain therapy treatment diagnosis for

inclusion on the MDS (use I8000)

� Validate primary diagnosis use within

nursing documentation

� Attend end of the month pre claim release

audit

MDSMDS

207

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� Review referral information

� Review hospital therapy documentation

(if available)

� Confirm and include primary diagnosis

on therapy evaluation

TherapyTherapy

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� Provide resident specific treatment codes to MDS

� Include primary and treatment codes on all

therapy documentation

� Attend Medicare/PPS meetings

� Attend end of the month pre claim release audit

TherapyTherapy

209

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� Complete UB-04

� Include primary diagnosis as selected

by clinical team on UB-04

� Validate primary diagnosis is

consistent with services provided

BillingBilling

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� Include secondary and supportive diagnoses on the

UB-04 best reflective of reasonreason for SNF stay

� Attend Medicare/PPS meeting

� Review with team all the diagnoses used on the UB-

04 at end of the month pre-claim release audit

BillingBilling

211

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� Education – ongoing – ALL disciplines, including the

physicians and physician extenders - Medicare basics,

ADL coding and documentation

� Communication – physician, therapy, nurse, MDS, and

billing, condition and status

� Collaboration – PPS meetings, nursing and therapy,

scheduling

� Audits – all skilled documentation and Medicare billing

components – internal and external; therapy

Basic Strategies For Success toBasic Strategies For Success toReducing Review RiskReducing Review Risk

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� Communication must start prior to resident admission

� Discuss primary diagnosis for admission

� Obtain and review hospital treatment information

(therapy) if available

� Share referral information with team

� Communication between therapy and MDS is critical

� Part of communication is continued discussion of

diagnoses to be used on MDS, chart, and the UB-04s

Strategies for Reducing Risks Strategies for Reducing Risks of an Auditof an Audit

213

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Communication Is EssentialCommunication Is Essential

Admissions

Billing

Ancillary Providers

Clinical

214


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Communication IsCommunication IsEssentialEssential

�� Admissions must supplyAdmissions must supply::

� Correct Medicare numbers and coverage eligibility

� Correct qualifying hospital stay dates

� Correct and verified information regarding coinsurance billing sources

� Correct information regarding MSP status

� Correct info re: prior use of Part-A days in benefit period or status of resident during the last 60 days to determine eligibility of a new benefit period

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�� Clinical must supplyClinical must supply::

� Immediate notification of any resident who is technically eligible for Medicare A, but does not meet medical criteria

� Immediate notification of any resident who has Medicare A days remaining in his/her benefit period, but no longer meets medical criteria

� Weekly summary that includes accurate list of Medicare A residents with correct RUGs IV codes, HIPPS codes, and assessment reference dates

� Notification of changed RUG IV categories based on MDS Correction Policy

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Communication Is EssentialCommunication Is Essential

�� Ancillary Provider must supplyAncillary Provider must supply::

� Timely and accurate charges for Medicare A residents

� Pharmacy

� Radiology

� Lab

� Therapy

� Ambulance, if applicable

� Outpatient Hospital Services, if applicable

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�� Billing must supplyBilling must supply::

� Timely information to ancillary providers of admission date and termination/exhaust date of all Medicare A residents

� Immediate notice to clinical and admissions of rejection or termination of MSP pay sources so that the MDS process will begin without default

� Immediate notice to admissions if coinsurance source is invalid or terminated

� Immediate notice to clinical and admissions if prior use of Medicare A days is different than anticipated so that the MDS schedule can be adjusted

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� SNF managers can ensure that care is

interdisciplinary and that therapy is aligned with the

rest of the IDT is to set aside time for more in-depth

discussion, especially at the Medicare meetings

� Assessment Reference Date

� RUG level

� ADL abilities – performance in nursing versus therapy

Communication is EssentialCommunication is Essential

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� End of the month review to include� MDS

� Validation report and RUG scores� Diagnosis coding

� Therapy� Treatment/MDS/UB-04

� Business � HIPPs and modifiers� Therapy units� Diagnosis� HCPCs

� Administrator (monitor processes for completion)

Another Strategy For Reducing Another Strategy For Reducing Medicare AuditsMedicare Audits

220


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� What do we check?

� ARD and type of assessment

� Signature verification and completed forms – orders, certs

and re-certs, treatment evaluations, MDS

� Therapy ARD, days and minutes – match logs and MDS

� Primary diagnosis – UB-04, MDS, therapy evaluations

� Treatment diagnoses – UB-04, MDS, therapy evaluations

� RUG group and assessment modifier

� Date MDS accepted into QIES ASAP

Internal Checking SystemInternal Checking System

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Find or develop a list that works for

your team – as team

progresses should be able to reduce time involved and

items to check

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� Audit using RA targets and/or identified risks

� Facility based audits

� Internal by corporate (should not be facility

staff)

� External provider

� Identify corrective actions for compliance

� Watch the trends within the clinical areas

� Compare facility to peer groups

� Analyze effectiveness of Medicare meetings

Strategies for Reducing the RiskStrategies for Reducing the Riskof Auditsof Audits

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Therapy ReviewsTherapy Reviews

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� Signed and dated plans of care

� Documentation supports the minutes and the RUG level billed

� Progress notes completed within required period

� Demonstrate skilled therapy within the context of documentation

� Documentation supports medical necessity of interventions

� Required components in place and timely


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ConsiderConsider

� Verification of 3-day inpatient hospital stay (not in

observation stay)

� Support for billed services

� Therapy documentation to support RUG

� Diagnosis coding and correlation

� Proper treatment of consolidated billing items and

services

� Timely submission of no-pay and benefit exhaust claims225

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SNF CaseSNF Case--Mix Distributions by Mix Distributions by Major RUGMajor RUG--IV CategoryIV Category

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SNF CaseSNF Case--Mix Distributions by Mix Distributions by Minor RUG Therapy CategoriesMinor RUG Therapy Categories

How Does Your Facility Compare?

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Flags for a Medicare Flags for a Medicare Claim ReviewClaim Review

� Claim history for treatment of same diagnosis

� Medicare daily rate exceeds peers

� Patterns or trends that are easily identified –

same RUG category for several of the

Medicare required assessments

� High percentage of resident treated exactly to

RUG minimum

� Exceeding RUG trends

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Flags for a Medicare Flags for a Medicare Claim ReviewClaim Review

� Inconsistent documentation from therapy to

MDS to UB-04 (Medicare claim - bill)

� Improper diagnosis codes

� High rehab index

� Exceptionally high average ADL score

� Low ADL scores and a high Medicare rate

(RUA, RVA)

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LearnLearn from Others’ Mistakesfrom Others’ Mistakes

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� Know where to find other improper payments found by

the RAs

� Demonstration findings: www.cms.hhs.gov/rac

� Permanent RA findings: will be listed on the RAs’ websites

� Look to see what improper payments have been found

in OIG and CERT reports

� OIG reports: www.oig.hhs.gov/reports.asp

� CERT reports: www.cms.hhs.gov/cert


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� No support for service provided – services not of

complexity requiring skilled professional

� Conflicting information

� Documentation supports lower level of service delivery

– no need for the therapist

� Illegible documentation

� Missing daily documentation

� No indication of decline in condition prior to Part B

therapy pick-up

Identified Denial Reasons Identified Denial Reasons

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Identified Denial ReasonsIdentified Denial Reasons

� Excessive therapy services – resident’s condition does

not support the frequency of treatment and or the

amount of treatment provided in a given day

� Certification not signed prior to the claim being billed –

certification is a condition for payment

� Resident reached maximum benefit of PT/OT and care

can be performed by supportive personnel

� Documentation did not support medical necessity

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� No supporting therapy diagnosis on the UB-04

� Therapy goals not measurable or not clearly defined

� Services considered unskilled, such as activities usually conducted through repetitive activity or exercises:

� Increasing general activity tolerance

� Improving overall endurance

� Improving general fitness

� Increasing distance ambulation or of w/c propulsion

� Increasing upright tolerance


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� Documentation did not support a significant decline in

function for PT/OT and did not appear reasonable or

necessary for the condition or diagnosis of the resident

� Documentation did not support the statutory

requirement for the physician’s certification of the plan

of care was met

� Discrepancy in record regarding resident’s function

between nursing and PT/OT

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� Resident did not make significant measurable progress or

improvement with PT/OT

� Notes did not indicate a valid expectation of improvement

when PT/OT were initiated

� Resident reached maximum benefit of PT/OT and care can

be performed by supportive personnel

� Signature/credentials were illegible or missing and

therefore unable to determine if the appropriate personnel

provided the treatment PT/OT

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Psychology of Maintaining a Psychology of Maintaining a Successful Medicare ProgramSuccessful Medicare Program

� No one individual or discipline is responsible for entire

process

� Involve team members

� Encourage participation/communication and

discussion about timing, ADLs, diagnoses, RUGs

� Maintain physical log of ongoing activities

� Regular review of activities

� Keep up-to-date with all regulatory changes236


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Are These Pieces Are These Pieces in Place?in Place?

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� Educate facility staff about MDS accuracy both in

the clinical sense and reimbursement

� Make sure most recent RAI Manual on hand (v1.09)

� Clear policies for required documentation

� Routinely check MDS Validation Reports – compare

acceptance date with billing date

� MDS Validation Reports warning messages may

indicate a trend in the MDS process

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Is Your Review Is Your Review Team Ready?Team Ready?

238

� Establish internal Medicare Review team

– who is lead

� Who’s the team? Interdisciplinary Team:

Legal, Finance, Clinical, Compliance, IT

� Prepare a system in advance of RA audits or ANY Medicare review

� Designate a lead person to organize and track audit requests

� Develop central tracking mechanisms/database for all reviews


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Look at Your Medicare Review Look at Your Medicare Review Team ProgramTeam Program� Coordinate the tracking mechanism with communications

structure – record reviews and appeal of recoupment deadlines

� Create a response “file format” – easy to read and easy to use - - incoming and outgoing (who)

� Identify the RA process for Region B – CGI – who is responsible and how often is web site monitored?

� Who is monitoring the MAC web site? Any other helpful site

� Knowledge is power – training on billing, coding and documentation – critical! Training is an ongoing process

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Look at Your Medicare Review Look at Your Medicare Review Team ProgramTeam Program� Conduct self audits to identify potential problems

� Participate in RA trainings and outreach

� Monitor news sources, CMS, associations, and your own reports to stay abreast of trends

� If desired, development of unique forms for Redeterminations and other appeal levels once issues identified

� Make sure Corporate Compliance Committee activeactive

� Develop a QAPI process to learn from findings240


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� Notify the Compliance Officer as soon as possible

� Activate the Medicare Readiness Review team

immediately

� Review the letter very carefully – type of review, claims

involved, timing, how documentation can be sent

� Must use the UB-04 for the claim period to compile a

documentation gathering checklist to be used for each

claim based exactly on the request letter

We Got a RequestWe Got a Request

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ADR Checklist ADR Checklist Sample for Sample for Gathering Gathering

Documents Documents Per LetterPer Letter

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ABN Guideline ABN Guideline SheetSheet

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� Team approach – billing, nursing, and therapy gather

appropriate and requested documentation

� Consider not only the claim time frame for

documentation, but the look-back period of any billed

MDS. Documentation needs to be provided for the

look-back period even if not in the claim period

� Arrange the packet in the order that the documents

were requested in the letter received


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� Set a target date for mailing

� Provide every piece of documentation requested

� Have an outside set of eyes review packet for

completeness, risk areas

� Maintain a copy of each packet sent to the review

contractor – put original documents back in medical

record, but keep a copy of the packet separate. You

need to know exactly what was sent to the reviewer


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� Once an initial claims determination is made by a

contractor, providers have the right to appeal the

determination

� All appeal requests must be writing

� All time frames critical for process to have success at

all

Medicare Appeals ProcessMedicare Appeals Process

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Appeals Process Appeals Process –– Five LevelsFive Levels

1. Redetermination – performed by Medicare

Administrative Contractor (MAC) - must be

requested within 120 days of decision. They have

60 days to complete review.

2. Reconsideration – performed by qualified

independent contactor (QIC)– must be requested

within 180 days of redetermination decision. They

have 60 days to complete the review.

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Appeals ProcessAppeals Process(continued)(continued)

3. Administrative Law Judge (ALJ) Hearing* - must be

requested within 60 days of QIC decision. They have 90

days to complete the review. *$140 for CY 2013

4. Medicare Appeals Council (MAC) (aka Departmental

Appeals Board) - must be requested within 60 days of

ALJ decision. They have 90 days to complete the review.

5. Federal Court Review* - Federal District Court. Must be

requested within 60 days of MAC decision. *$1,400 for CY 2013

* Minimum dollar amount required to enter level 248


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Medicare Appeal Flow ChartsMedicare Appeal Flow Charts

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QuestionsQuestions

250


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Jane Belt

614-222-9020

[email protected]

Regina Loncaric

614-222-9070

[email protected]

Mary Poplstein

216-274-6544

[email protected]

Brenda Sowash

419-842-6204

[email protected]

Judy Vogel

513-744-4768

[email protected]

Plante Plante MoranMoran Clinical GroupClinical Group

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� HETS information:

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-

Network-MLN/MLNMattersArticles/downloads/SE1249.pdf

� RAI MDS Manual http://www.cms.gov/Medicare/Quality-

Initiatives-Patient-Assessment-

Instruments/NursingHomeQualityInits/MDS30RAIManual.html

� Guidelines for Therapy Certification: Medicare Benefit Policy

Manual Chapter 15 – Covered Medical and Other Health

Services (Rev. 161, 10-26-12); Section 220.3

ResourcesResources

252


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� CMS IOM Publication 100-01, Medicare General

Information, Eligibility and Entitlement Manual, Chapter

5, Section 30http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ge101c05.pdf

� CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 8 - Coverage of Extended Care (SNF) Services Under Hospital Insurancehttp://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c08.pdf

ResourcesResources

253

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� CMS IOM Publication 100-02, Medicare Benefit Policy

Manual Chapter 15, Covered Medical and Other Health

Services, Sections 220-230

http://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

� CGI https://racb.cgi.com/Issues.aspx

� Signature Guidelines for Medical Reviews

http://www.cms.gov/Outreach-and-Education/Medicare-

Learning-Network-

MLN/MLNMattersArticles/downloads/MM6698.pdf

ResourcesResources

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� UB-04 Fact Sheet: http://www.cms.gov/Outreach-and-

Education/Medicare-Learning-Network-

MLN/MLNProducts/downloads/ub04_fact_sheet.pdf

� CGI: Additional Documentation Letter

http://racb.cgi.com/Docs/Letters/ADRDUAL-

Additional%20Documentation%20Letter%20Dual%20Sample%2002

122013.pdf

� Medicare General Information, Eligibility, and Entitlement,

Chapter 4 - Physician Certification and Recertification of

Services http://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/downloads/ge101c04.pdf

ResourcesResources

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� Cloned Documentation http://www.ngsmedicare.com/wps/portal/ngsmedicareEducation and Training, Part B, Posted 09/05/2012

� ICD-9 Official Guidelines for Coding and Reporting

http://www.cdc.gov/nchs/data/icd9/icd9cm_guidelines_2011.pdf

� Medicare Claims Processing Manual, Chapter 6 - SNF Inpatient Part A Billing and SNF Consolidated Billing, (Rev. 2573, 10-26-12); Section 30: http://www.cms.gov/Regulations-

and-Guidance/Guidance/Manuals/Downloads/clm104c06.pdf

ResourcesResources

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� Davis, Caralyn; AANAC LTC Leader, January 9, 2013;

“Upcoming Medicare A Manual Changes for April 2013”, pages

1, 2, and 8

� Shephard, Rena: AANAC LTC Leader, January 23, 2013; “Part

A Skilled Care: Keys to Success”; pages 1, 2, 9

� CMS BPM, Chapter 8; Section 30.4.I.2; Application of

Guidelines

� Belt, Jane: AANAC LTC Leader, March 21, 2013, OIG:

“Therapy a Culprit in Medicare Care Planning, Quality Issues”

page 2

ResourcesResources

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Today's Objectives - Community Physical Therapy

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