Kerry Dunning, MHA, MSH, CPAR, RAC-CT Kerry Dunning LLC May 2017 - PowerPoint PPT Presentation

Kerry Dunning, MHA, MSH, CPAR, RAC-CT Kerry Dunning LLC May 2017

Kerry Dunning has no proprietary interest in any product, instrument, device, service, or material discussed during this learning event. This presentation was current at the time it was presented. Medicare regulations and state policies change frequently so this information is intended to be a general summary. It does not take place of written law and regulations as the final source of information.

Do you believe your swing bed program is in compliance with Medicare compliance? YES NO NOT SURE 3

After attending this presentation, attendee will be able to: 1. Recognize the need for improved focus on Swing Bed Programs in CAH hospitals -- AUDITS 2. Demonstrate an understanding of the factors that impact Medicare rate and revenue -- MEDICAL NECESSITY 3. Identify methods to improve swing bed related outcomes -- TEAMWORK

 Comply with CoPs  Conform to Federal/State laws and regulations  Complete Medicare required paperwork  Admit patients appropriate to a post-acute, skilled level of care  Use RAI and MDS  Meet medical necessity documentation requirements  Be compliant with billing and coding regulations specific to skilled services 5

 Medicare requirements include:  Verification of days available for skilled nursing care  3 night qualifying stay  MSP  Physician Certification  Practical Matter  Physician Orders/H&P  Physician sign/date Therapy POC  Medical Necessity Documentation and Daily Documentation  ADLs  Beneficiary Notices 6

How are your coders aware of primary services used 1. in skilled nursing? When is the 3-midnight rule still in play? 2. Do you allow LOAs? 3. What services should not occur in a swing bed? 4. When are swing bed claims submitted? 5. How are you tracking outcomes? Trends? Cost? 6. 7

 CERT-- Comprehensive Error Rate Testing  ZPICs-- Zone Program Integrity Contractor  MAC-- Medicare Administrative Contractor (FI)  GAO-- Government Accountability Office  RA – RAC Auditors  OIG – Office of Inspector General 8

• One MAC recently reported that out of 508 errors identified in a CERT audit of certain Medicare claims, the contractor found that: – 311 errors were due to “insufficient documentation.” • Notably, a majority of the errors in this category were because the medical record “did not contain a valid physician’s signature” or because a diagnostic test performed “did not contain a valid physician’s order” or an identification of the provider who rendered the service – 132 errors were due to “lack of medical necessity” based on the medical documentation submitted 9

 Findings of the 100 claims reviewed through February 2016 are as follows: ◦ 54 claims were accepted ◦ 35 claims received correction for the following reasons:  RUG level adjusted due to incorrect therapy minutes  No therapy orders  Occurrence code 50 (ARD)  Occurrence span code 70 (3 day stay)  6 claims were partially denied for the following reasons: ◦ Incorrect therapy minutes/use of E-stim minutes toward total therapy minutes ◦ Late certification/recertification  5 claims were denied in full for the following reasons: ◦ Untimely certification/recertification ◦ No qualifying hospital stay ◦ No skilled care ◦ Incorrect billing 10

 CAH Swing beds are exempt from SNF consolidated billing, however they do need to follow the direction in the CMS Internet Only Manual (IOM), Publication 100-4, Chapter 3, Section 10.4 on bundling hospital charges. These charges should be included on the 18X type of bill  Services provided by the CAH, while the beneficiary is inpatient in the CAH Swing bed that are considered exclusions from SNF Consolidated Billing, shall be billed on an 85X type of bill. All related outpatient charges shall be included on the 85X type of bill that would typically be billed for outpatient services.  As stated in the IOM, Publication 100-4, Chapter 3, Section 60, swing bed services must be billed separately from inpatient hospital services. Therefore, any swing bed patient who requires inpatient hospital services must be discharged from the swing bed and admitted as a hospital inpatient. 11

 Scenario: George, a Medicare patient, was in a covered swing bed stay receiving skilled nursing for complications related to a heart attack. During the stay, George began to complain of severe headaches, so the physician ordered a CT of the brain with and without contrast. After reviewing the exam, the physician determined the findings were normal and no additional treatment or skilled services were required, so the physician discharged George and he was free to go home. The CAH will bill the charges for the CT scan on an outpatient claim because the procedure is listed as one of the major categories for skilled nursing facility (SNF) consolidating billing. TRUE OR FALSE? 12

 False. Although the CT scan is considered a major category and is an “excluded” service under the SNF PPS consolidated billing requirements, CAHs are exempt from using the list and services provided while the patient is in a CAH’s swing bed should be included on the swing bed claim, regardless of the reason for the service, the findings, or whether additional services were required. <Social Security Act §§ 1888(e)(7), 1883(b)(3), 42 CFR 413.114, MLN Matters SE0606> 13

 What is skilled care? ◦ It is not ACUTE  Determination for skilled services: ◦ If the inherent complexity of the service is such that it can only be performed safely and/or effectively under the general supervision of skilled nursing or skilled rehabilitation personnel ◦ A non-skilled service could be considered skilled when, because of special medical complications, skilled personnel are required to perform or supervise the service, or to observe the patient 14

 Skilled Therapy ◦ Be directly and specifically related to an active treatment plan, designed by the physician after consultation with a qualified therapist ◦ Be of a level of complexity , or the patient’s condition such that the judgment, knowledge and skills of a qualified therapist are required ◦ Be provided with an expectation that the condition of the patient will improve in a reasonable and predictable period of time, or the services must be required to establish a safe and effective maintenance program ◦ Be reasonable and necessary under accepted standards of clinical practice, in terms of the amount, frequency and duration of the services 15

 Who – Performing, supervising and referring practitioners  What (and how many) – Services and quantities of services performed  Where – Place of service  When – Date of service  Why – Medical necessity and diagnosis  How – Interdisciplinary Team approach 16

• Daily Documentation is required to reflect the skilled services being provided. – Objective measures of the current level of assistance required for functional tasks – A description of the skilled services provided – Assessment of the patient's response to the services. – Progress towards the treatment goals – Documentation of any treatment variations with the associated rationale – Accurate documentation of treatment time in minutes, to be recorded on the MDS 17

 The facility must conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each resident’s functional capacity  The assessment process must include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts State Operations Manual Appendix W -Survey Protocol, Regulations and Interpretive Guidelines for Critical Access Hospitals 18

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 The RAI helps Swing Bed staff look at patients holistically — as individuals for whom quality of life and quality of care are mutually significant and necessary. Interdisciplinary use of the RAI promotes this emphasis on quality of care and quality of life.  Importance? OIG Report: SNFs often fail to meet Care Planning and Discharge Planning Requirements (2013)  An interdisciplinary team that includes at least the attending physician and a registered nurse with responsibility for the beneficiary must prepare the care plan. SSA, § 1819(b)(2)(B), 42 U.S.C. 1395i – 3(b)(2)(B).  OIG says discharge planning be conducted by an IDT including a physician  IDT can include SWB Coordinator, Therapy, Social Services, Dietary, Medicare Nurse/DON, etc. 21

 Do you meet every morning (or morning huddle with nursing and therapy)? Once a week? Only at Discharge?  Do you document discussions? Do you document on individual charts?  How is the physician involved? Medicare requires double checks – what is yours? 22

 Who gets MSP and what is the double check?  If patients are coming from another hospital what is the verification of the 3 midnight stay?  Who makes sure all the signatures are on patient rights?  What is the process for the patient’s care plan and discharge planning?  Is the nursing admission assessment completed within 24 hours of admission and what is the swing bed policy on completion? 23