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Skilled Nursing Facility Consolidated Billing

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Skilled Nursing Facility Consolidated Billing Powered By Docstoc
					Skilled Nursing Facility Services

       Janet Weinmann, RN
     Medical Review Examiner
                &
            Ann Haug,
     Medicare Part A Education
                               Objectives

Attendees will be able to:
• Identify documentation that supports daily
  skilled care
• Describe Notice of Non-Coverage
  Process
• Describe NAS Medical Review Process
• Describe Common Errors found in
  Medical Review
• Explain CERT Process
                                   Agenda

•   Coverage Indicators/Skilled Care Factors
•   Skilled Nursing Services
•   Skilled Rehabilitation Services
•   Notice of Non-Coverage (ABN)
•   Medical Review Process
•   Common SNF Errors
•   CERT Process
                      Coverage Criteria

• Medicare Part A Entitlement
• 3-day Qualifying Hospital Stay
• Transferred to SNF within 30 days at a
  skilled level of care**
• Benefit days available
• Care must relate to Qualifying Hospital
  Stay
  **Exception to 30 day transfer rule

• Predictable Medical Needs
  • Physician order prior to discharge

  • Specific time-frame

  • Medicare Benefit Policy Manual (MBPM)
    Chapter 8, Section 20.2.2
                     Skilled Care Factors

1. Skilled Nursing and/or Rehabilitation
   Services
2. Daily Basis
  •   Nursing: 7 days/week
  •   Rehabilitation: 5 days/week
3. SNF Inpatient Care Required
4. Reasonable and Necessary
             Skilled Nursing Services

• Patient Education

• Management and Evaluation

• Observation and Assessment

• Presumption of Coverage
                         Patient Education

• Teach Self-Maintenance Program

• Skilled Nursing/Rehab Professionals

• Documentation:
  • Daily Skill
  • Bene Cognitive Skills (Ability to Retain Info)
  • Bene Improvement/Learning
                   Physician Involvement

• Patient Instability

• Document:
  • Calls
  • Orders (Signed and Legible)
  • Visits
     • Scheduled vs. Patient Unstable
          Management and Evaluation

• Physician Order
• Skilled Nursing:
  • Manage Personal Care Services due to
    condition
  • Safely Plan, Monitor, & Manage Care
• Documentation:
  • Indicate daily skilled service
                Mngmt & Eval Example

• Diagnosis: Pneumonia
• Symptoms:
  • Lethargy & Disorientation;
  • Residual Chest Congestion
• Activity: Confided to bed with restraints
• Physician orders:
  • Frequent changes in position
  • Cough and Deep Breathing
           Observation & Assessment

• Skilled Nursing or Rehabilitation
  • Possible Treatment Plan Modifications
  • Possible Medical Procedure Additions


• Unstable Treatment Regimen

• Documentation
       Obs & Assessment Example 1

• Procedure:
  • PVD Treatment with Revascularization
    Procedures (Bypass)
• Other information:
  • Open or Necrotic Areas of Skin on the
    Extremity
       Obs & Assessment Example 2

• Diagnosis: Post Heart attack

• Other information:
  • Transferred to SNF prior to mobilization
    Documentation – Skilled Nsg Care

•   Overall Condition
•   Instability
•   Interventions & Beneficiary Response
•   Physician Involvement
•   Treatment Plan Modifications
            Presumption of Coverage

• Direct SNF Admit from Hospital Stay

• Upper 35 RUG-III Group

• Care Reasonable & Necessary

• 5 Day Assessment ARD
         Skilled Rehabilitation Services

•   Physician Order
•   Related to Treatment Plan
•   Reasonable & Necessary
•   Qualified Therapist Skills Necessary
•   Coordinate with Nursing Services
           Initial Therapy Evaluations

• Physician or Licensed Therapist

• Part A Stay

• May not be counted on MDS
                 Therapy Re-Evaluations

• Indications:
  • Change in Condition
  • New Illness or Injury


• Minutes may be counted on MDS
      Rehabilitation Minutes on MDS

• Actual Treatment time
  • Cannot be based on Units of Service
  • Cannot be rounded
• Medical Record must support MDS
  capture
• RUG-III Criteria represents Minimum
  number of minutes
              Therapy Documentation

• Objective Terms

• Measurable Terms

• Functional Accomplishments

• Support for Skilled Nature
                 Notices of Non-Coverage

• http://www.cms.hhs.gov/BNI/01_overview
  .asp
  General Requirements:
  •   Written
  •   Cite Specific Service
  •   Beneficiary Signature
  •   If not given in person indicate
       • Person Notified and Manner of Notification
       • Date of Notification
       • Name of Facility Representative
               Types of Medical Review

• Pre-pay
  • Noridian
• Post-pay
  • Western Integrity Center (WIC)
  • Comprehensive Error Rate Testing (CERT)
                 Pre-pay Review Types

• Demand Bills

• Routine Review

• Probe

• Provider on Review (POR)
                       Routine Reviews

• Indicators
  • Previous MR Review Errors
  • Previous CERT Errors


• Review for MDS in FI Extract
                           Review of MDS

• Medicare Program Integrity Manual
  (MPIM) Ch 6, Section 6.1.3
• Access MDS in FI Extract
• Deny Services if No MDS Found
• Exceptions to Denial:
  • Bene Dies or is Discharged Before Day 8
  • Provider Submitted Demand Bill
                   Review of MDS (cont.)

Correct Code Claim:
• MDS does not match Billing
  • Contact Provider
• Complex (Paper) Review:
  • Verify MDS entries with Documentation
  • Correct Entries to Recalculate RUG
    • Therapy Minutes; IVs
              Determine Probe Need

• CERT Reports

• Data

• Referrals
                 Determine POR Need

• Previous Review Result

• Post-Pay Referral

• Fraud Referrals from Program Safeguard
  Contractor (PSC)
                             Review Process

• Notification Letter
  •   CEO or Administrator of Facility
  •   Type of Review
  •   Reason for Review
  •   Medical Review Contact
           Additional Documentation
                      Request (ADR)
• MDS – All that apply to Billing Period
• Documentation for Look back Periods
• Physician’s signed orders/progress notes
  – hospital if applicable & SNF
• Nurse’s notes for the SNF
• Medication sheets/treatment sheets
• Nursing Care Plan
                            ADR (cont.)

• All flow sheets, including vital sign
  records & weight charts
• Consultation Reports
• Discharge Summary
• Hosptial Transfer Form
• Any OMRAS or SCSAs that were
  completed
• Letter of Non-Coverage Issued if Demand
  Bill
                           ADR (cont)

• PT/OT/SLP Progress Notes including
  Charting of Daily Therapy & Therapy
  Minutes
• Therapy Treatment Plans & therapeutic
  goals
• Any Additional Documentation that
  Demonstrates Medical Necessity
• Itemized Billing Statement
                     Submission of ADR

•   Submit within 30 Days
•   Separate Multiple Claims
•   Attach Copy of ADR
•   Include HIC and Dates of Service
•   Include all Documentation to Support the
    Claim
                  Medical Review Process
        Start

Claim is keyed into the      Documentation is
    FISS System            received by Noridian
                           and transferred to the
If MR edit criteria is           MR Dept.
met, an ADR is sent to
     the Provider           Per CMS, MR staff
                              has 60 days to
                            complete the claim
  Claim suspends in              review.
 FISS, Provider must
submit documentation               End
    within 30 days
                      Review Process –
                     Provider Education
• Telephone Calls
• Teleconferences
• Letters
  • Updates
  • Findings & Closure
• Articles
             Common PPS Claim Errors

•   Incorrect Service Date (ARD)
•   Incorrect Service Units
•   RUG Level Errors
•   No MDS Submitted to Repository
    • Add Medicare # to remarks on claim if
      different than one on claim
• PPS Billing for No Daily Skilled Care
                       Common Demand/
                          No-Pay Errors
• No Submission of No-pay Claims after 100
  Days Used
• No Notice of Non-Coverage Submitted
• No Documentation that Bene/Family wants
  Demand Bill Submitted
• Incorrect Usage of Condition Code 20 & 21
• Claim Submitted after Expedited Review with
  no Condition Codes C3, C4, or C7
• No documentation submitted – 56900 denial
                  General Claim Errors

• Leave of Absence (LOA) Errors

• Billing Medicare for Bed Hold Days

• Incorrect Patient Status

• Bill Rehabilitation RUG with no
  Rehabilitation Charges
                  Common References

• CMS Online Manuals:
  www.cms.hhs.gov/manuals/
  • Medicare Benefit Policy Manual (MBPM)
    Chapter 8
  • Medicare Program Integrity Manual (MPIM)
    Chapter 6
• MDS Manual
• ABN Website:
  http://www.cms.hhs.gov/BNI/01_overview.asp
           Comprehensive Error Rate
                    Testing (CERT)
Purpose:
• Paying it Right the FIRST Time
• Analysis of Proper Billing
CERT Error Categories
                 MN SNF CERT Errors

• 04/01/07 – 06/17/08
• 4 Claims in Error
• Down Coding of RUG Level as Therapy
  Minutes did not support MDS Capture
• PT/OT Evaluation not Submitted resulting
  in Downcoding of RUG Level
• Laboratory Service was not Rendered
                           CERT Appeals

• NAS Processes CERT Determinations

• Do Not Adjust CERT Denied Claims

• Submit Additional Information:
  • Noridian
  • Fax Information with CID# to CDC also
                       Livanta (CDC)

CERT Documentation Contractor
Suite 9
9090 Junction Drive
Annapolis Junction, MD 20701

Fax number: 1-240-568-6131
Phone number: 1-301-957-2380
                CERT Address Changes

• CERT Address Changes Only!
• Fax to:
  Noridian Administrative Services, Part A
  701-277-6789
• Include:
  •   Provider Number
  •   Facility Contact Person
  •   E-mail Address
  •   Direct Telephone Number
                                  CERT Help

• CMS Website:
  • http://www.cms.hhs.gov/cert


• Noridian Website:
  • http://www.noridianmedicare.com
Thank you for Attending!

				
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