Say hello to 3.0: The new MDS` effect on billers
Contents
1. gt The development The Health Information Technology for Economic and Clinical Health HITECH Act which was signed into law February 17 2009 is one provision of the American Recovery and Reinvest ment Act of 2009 The HITECH Act aims to promote 2010 HCPro Inc use of federal stimulus money to advance the design development and implementation of a nationwide health information infrastructure that promotes the use and exchange of information via electronic health re cords EHR Congress included stiffer penalties for noncompliance with HIPAA greater breach notification requirements and expanded enforcement to address growing privacy and security concerns For example business associates BA now must comply with the HIPAA security rule and HITECH s security provisions Rebecca Herold president of Rebecca Herold amp As sociates LLC in Van Meter IA calls it one of the most significant developments For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at www copyright com or 978 750 8400 March 2010 There are many times more business associates than there are covered entities Herold says Covered entities now must notify HHS of any breach es no later than 60 days after learning of them They also must notify prominent media outlets in the state when a breach affects more than 500 individuals gt2. on Part A claims to receive pay ment at the default rate bringing the total to five gt The stay is less than eight days within a spell of illness cited in Transmittal 196 If a resident expires or is transferred within the first eight days of the ben efit period a SNF should prepare an assessment as best as possible so a HIPPS rate code can be assigned within the assessment schedule however if an as sessment is not submitted in this case a claim using the default rate code is accepted gt The beneficiary requests a demand bill cited in Transmittal 196 If a SNF determines that care of a beneficiary isn t covered or if the beneficiary hasn t met the SNF stay technical requirements the facility is not required to assess the beneficiary for purposes of classifying the individual into a resource utilization group category Instead the SNF is eligible to submit a claim using the default rate code to ensure payment should the SNF reverse it s coverage determination gt The SNF is notified on an untimely basis or is unaware of a Medicare Secondary Payer denial If an assessment hasn t been performed and the resi dent exhausted primary payer benefits the SNF can bill at the default rate gt The SNF is notified on an untimely basis of the revocation of a payment ban The date the pay ment ban is lifted becomes day one of the Medicare assessment schedule gt The SNF is notified on an untimely basis or is unaware of a
3. 5 Start of Therapy OMRA combined with End gt If unscheduled assessment gives a therapy group Medicare RUG Z0100A of Therapy OMRA 1 Use the unscheduled assessment Medicare RUG Z0100A from the earliest start of thera Do NOT use if py date through the latest therapy end date gt Medicare Short Stay assessment 2 Use the unscheduled assessment Medicare non therapy RUG Z0150A from the day after gt Combined with unscheduled OBRA the latest therapy end date through the end of standard payment period gt Combined with Swing Bed CCA gt If unscheduled assessment does not give a therapy group Medicare RUG Z0100A do not use the unscheduled assessment RUG for any part of the standard payment period This is not a valid assessment and it will not be accepted by CMS 6 Start of Therapy OMRA combined with End gt If unscheduled assessment gives a therapy group Medicare RUG Z0100A of Therapy OMRA and combined with either 1 Use the unscheduled assessment Medicare RUG Z0100A from the earliest start of thera an unscheduled OBRA assessment or Swing py date through the latest therapy end date Bed CCA 2 Use the unscheduled assessment non therapy RUG Z0150A from the day after the latest Do NOT use if therapy end date through the end of standard payment period gt Medicare Short Stay assessment gt If unscheduled assessment does not give a therapy group in the Medicare RUG Z0100A do not use the unscheduled assessment RUG for any par
4. Bill Ulrich president of Consolidated Bill ing Services Inc in Spokane WA There are five approved default billing scenarios Out side of those if a MDS assessment was not completed in accordance with the assessment schedule the SNF will not receive payment for that time period Permitted default billing scenarios The consolidated billing final rule for fiscal year 2009 set the precedence for situations in which it s acceptable to bill for the default rate which put to rest an ongoing debate over the topic That debate stemmed largely from Transmittal 196 Re leased in March 2007 it was intended to update SNF PPS medical review policies It all goes back to Transmittal 196 says Theresa Lang vice president of clinical services at Specialized Medical Services Inc in Milwaukee Transmittal 196 is really what started this whole thing It s where CMS came up with 2010 HCPro Inc Billing Alert for Long Term Care Page 5 the rules of when you can bill the default Up until that point basically the industry standard was if you got a late or a missed assessment you just bill the default The rules that were specified in Transmittal 196 allowed for only two scenarios when facilities could submit a late assessment and bill for the default rate a stark contrast to the previous industry interpretation In 2008 CMS cited three more circumstances in which SNF billers could use the HIPPS code AAAO0O
5. What to do now HHS began enforcing the amended breach notification provisions in February Covered entities must fine tune their processes now This means that all personnel volunteers and agents need to know what to do if they discover a data breach says Rebecca L Williams Esq RN partner at Davis Wright Tremaine LLP in Seattle Covered entities had to amend their BA contracts by February 18 Organizations should work with their legal department to revisit existing contracts and ensure that they have the proper template for new ones Incentives for meaningful use of EHRs will begin in 2011 Congress would like stakeholders to purchase and implement EHRs in 2010 to prepare for 2011 However stakeholders may be slow to react because of up front costs The push for healthcare providers to go paperless has created more electronic health records and repositories than ever before says Herold Take time to determine the timetable and EHR option that are most cost effective for your organization Major pharmacy company fined for breaches gt The development On February 18 2009 HHS and the Federal Trade Commission FTC fined CVS Caremark Corp 2 25 million for inappropriate disposal of protected health information PHI An investigation of CVS practices followed reports that the company dis carded patient information in industrial trash containers outside some of its stores CVS failed to secure the con taine
6. beneficiary s disenrollment from a gt continued on p 6 For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at www copyright com or 978 750 8400 Page 6 Default billing lt continued from p 5 Medicare Advantage MA plan If a SNF discov ers after discharge that a resident had disenrolled from the MA program the SNF can bill at the default rate All five exceptions were included in Chapter 6 of the Resident Assessment Instrument RAI User s Manual Version 3 0 and will carry over to MDS 3 0 in October Communicating for cohesiveness Much of the past confusion involving default billing stemmed from a lack of understanding as to when the default rate could be used Lang says Outside of that how ever there are other contributing factors one of which may be a lack of communication between the billing office and clinical staff she adds Billers need to have access to information that is necessary in terms of a resident s stand ing with Medicare Part A By creating an open dialogue with nursing this information can more easily be shared Additional issues may occur if the billing and nurs ing departments are using different software programs as even more direct communication will be required to Billing Alert for Long Term Care March 2010 ensure that both sides are receiving the correct informa tion La
7. different medical reason b To a hospital other than the one from which the resident was originally discharged c Botha amp b d None of the above Business associates are not required to comply with the HIPAA security rule and the Health Information Technology for Economic and Clinical Health HI TECH Act s security provisions a True b False Are you stumped Wondering whether you got the late assessment and bill for the default rate answer Find the correct answers on page 12 E 2010 HCPro Inc For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at www copyright com or 978 750 8400 March 2010 Billing Alert for Long Term Care Page 11 BALTC Q amp A Editor s note Q A was written by Lee A Heinbaugh president of The Heinbaugh Group a long term care consult ing company in Lakewood OH To submit a question for up coming issues e mail Associate Editor Justin Veiga at jveiga hepro com e I am new to working in a SNF billing office was read ing through our policies and procedures for Medicare billing and the Medicare Interactive Voice Response IVR system is mentioned several times We use the Medicare online system to monitor our claims and verify eligibility when should we be using the IVR system A The Medicare IVR system can be used for several tasks Medicare eligibility c
8. that are causing the overlap This allows you gt continued on p 12 MDS 3 0 is coming Let HCPro help you prepare with consulting and cus tom education programs Our team of experts have years of experience in the long term care industry and are on the cutting edge of MDS 3 0 training An HCPro consultant can perform a detailed analysis of your facility s operations to help you best prepare for MDS 3 0 s effect Bring an HCPro long term care consultant to your facil ity for help in any of the following areas gt MDS 3 0 preparation and modeling Survey readiness gt gt Medicare compliance audits gt Documentation improvement For more information or a facility specific needs analysis contact Client Relations Manager Elizabeth Petersen at epetersen hcpro com or 781 639 1872 Ext 3432 For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at www copyright com or 978 750 8400 Page 12 BALTC Q amp A lt continued from p 11 to review your census and correct your claim accordingly Or in the event there is a mistake you will know who to contact in order for corrections to be made to the dates of service used on their claim The other reason to use the IVR is to reactivate claims that are not available online Some claims can be activat ed using the IVR but you may still need to contact the provide
9. California s newspapers and state legislature Notable cases involved the late Farrah Fawcett in 2007 and Britney Spears in 2008 These high profile cases inspired a bill that Gov Arnold Schwarzenegger signed into law January 1 2009 The new law permits the state to impose heavy financial penalties as much as 250 000 on healthcare providers who inappropri ately peek in patients medical records It didn t take long for the state to flex its newfound muscle State regulators slapped the maximum penalty on Kaiser Permanente s Bellflower CA Hospital in May 2009 Regulators found that Bellflower failed to prevent employees from snooping in the medical records of Nadya Suleman who gave birth to octuplets in January 2009 gt What to do now These high profile cases cast gt continued on p 8 For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at www copyright com or 978 750 8400 Page 8 HIPAA lt continued from p 7 a spotlight on inappropriate behavior in hospitals and pressure all providers to improve their processes Con duct a risk assessment to determine whether your or ganization is vulnerable Consider strategies such as monitoring system access logs or using honeypots to catch snooping staff members It s important for organizations to work harder to eliminate and detect snooping when workers loo
10. HCPro March 2010 Vol 12 No 3 BILLING LERT FOR LONG TERM CARE Say hello to 3 0 The new MDS effect on billers The October 1 implementation of MDS 3 0 means big changes for SNFs The latest PPS assessment will demand much attention from MDS coordinators especially lead ing up to its debut and during its first few months of op eration as there are a variety of new features including adjustments to regulations involving therapy and the HIPPS coding system As a result facilities should use the implementation of MDS 3 0 as an opportunity for process improve ments says Rena Shephard MHA RN RAC MT C NE founding chair and executive editor of the American Association of Nurse Assessment Coordina tors and president of RRS Healthcare Consulting Servic es in San Diego I really encourage everybody to take the MDS 3 0 as a brand new assessment not look at it as sort of an up grade or a revision of the 2 0 because there s so much in it that s different Shephard says IN THIS ISSUE p 5 The details of default billing Knowing when to bill for the default rate isn t easy Get some tips here p 6 HIPAA in the headlines Find out what happened with HIPAA in 2009 and how it will affect your SNF in 2010 p 9 No longer a simple reimbursement issue Columnist Barbara Griffin Gulliver explains the intricacies of same day transfers p 10 LTC billing IQ Test your billing knowledge with these LTC sc
11. an be verified using the IVR Although this is often done using the Medicare Common Working File health insurance query access files on the rare occasion when you can t access the online system the IVR system can be used as a backup This way there is no interruption in the verification pro cess To use the IVR system to check eligibility you will need to do the following Identify the facility gt Facility NPI number gt Facility Medicare number or Provider Transaction Access Identifier gt Facility tax identification number Provide resident information gt Medicare number gt Name gt Date of birth gt Date of service Verify items gt Effective and or termination date of eligibility for Part A and Part B gt Date of death 2010 HCPro Inc gt Medicare Secondary Payer MSP Name of MSP Type of MSP Effective and or termination date gt Medicare managed care plan information Name of Medicare Advantage plan Effective and or termination date gt Last billing date y Number of SNF days available gt Amount applied to the current year Medicare Part B deductible gt Amount applied to the current year therapy limits gt Hospice Name of hospice Effective and or termination date If your facility is receiving rejected claims due to an overlap in dates of service the IVR will provide the name of the hospital and the dates the hospital billed to Medicare
12. ard says Unlike with the MDS 2 0 the MDS 3 0 is able to cal culate a non therapy resource utilization group RUG and therapy RUG on a single assessment In other words if a resident enters a facility and does not begin receiving therapy until a week after admittance the start of therapy OMRA comes into play It allows for the calculation of the non therapy RUG during the resident s first week and starting the day of therapy the new calculation with the therapy RUG They re going to want to know what these assess ments are that affect the billing the start of therapy the end of therapy and the MDS actually calculating in some cases the therapy RUG as well as a non therapy RUG for Part A Shephard says The potential of a RUG IV delay MDS 3 0 wasn t supposed to be the only introduction October 1 The new assessment was supposed to coincide with RUG IV However at the time of publishing there is an amend ment in the Senate health bill the Patient Protection and Affordable Care Act which would delay the implementa tion of RUG IV to October 1 2011 The amendment is not present in the House bill Nego 2010 HCPro Inc For permission to reproduce part or all of this newsletter for external distribu tiations in Congress will determine whether the provision ion or use in educational packets contact the Copyright Clearance Center at www copyright com or 978 750 8400 March 2010 is included in the f
13. are has never reimbursed a cost report day for a same day transfer resident who leaves the SNF against medical advice AMA or requests and receives trans fer to another SNF on the day of admission The first SNF may however privately bill the AMA resident for room and board using a facility invoice It s unnecessary to bill Medicare for denials in this situation in order to privately bill the resident The first SNF may also submit a claim to Medicare for ancillary services provided to a resident who transfers to another SNF on the day of admission E Illustration by David Harbaugh Would you say that your medical school experience helped develop your facility with unapproved abbreviations and prohibited acronyms For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at www copyright com or 978 750 8400 Page 10 Billing Alert for Long Term Care March 2010 LTC billing IQ Think you re a long term care LTC billing pro Test your knowledge of SNF billing by answering the follow ing questions which are based on the facts and informa tion found in this issue s articles 7 1 In the MDS 3 0 the start of therapy Other Medicare Required Assessment OMRA and the end of therapy OMRA can potentially appear on the same assessment a True b False 2 The amendment to delay the implementation of Re sou
14. diately if you have received an unauthorized copy For editorial comments or questions call 781 639 1872 or fax 781 639 2982 For renewal or subscrip tion information call customer service at 800 650 6787 fax 800 639 8511 or e mail customerservice hcpro com Visit our Web site at www hepro com Occasionally we make our subscriber list available to selected companies vendors If you do not wish to be included on this mailing list please write to the marketing department at the address above Opinions expressed are not necessarily those of BALTC Mention of products and services does not constitute endorsement Advice given is general and readers should consult professional counsel for specific legal ethical or clinical questions As a result billers might need to take it upon them selves to understand the function of the OMRAs with the MDS 3 0 which is a worthwhile undertaking Shephard says The billing office staff should know as much as possible about the start of therapy and end of therapy OMRAs and how they should be used because that knowledge could go a long way in ensuring correct reimbursement It s easy to say Well the billers just put this on the claim so they don t have to worry about the MDS But the billers I know really want to have it in context and they really do want to understand what it is they re do ing so they can provide another level of cross check be fore the bill goes out Sheph
15. e include 27 00 for shipping to AK HI or PR HCPro 1 Charge my LJ AmEx I MasterCard OVISA Q Discover Signature Required for authorization Card Your credit card bill will reflect a charge to HCPro the publisher of BALTC Expires 2010 HCPro Inc Mail to HCPro P O Box 1168 Marblehead MA 01945 Tel 800 650 6787 Fax 800 639 8511 E mail customerservice hcpro com Web www hcmarketplace com For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at www copyright com or 978 750 8400
16. enarios and questions p 11 BALTC Q amp A Columnist Lee A Heinbaugh discusses the Medicare IVR system and hospital stay requirements Those differences will have far reaching affects which emphasizes the value of taking a fresh look at the sys tems that support Medicare Part A says Shephard The changes included in the new assessment also show that MDS coordinators will not be the only staff members who need to develop a thorough understand ing of MDS 3 0 says Carol Maher RN BC RAC CT director of clinical I think there s a lot in the MDS 3 0 that s going to affect billers I ve already reimbursement at Ensign Facilities Inc in Mission Viejo CA I think there s a lot in the MDS 3 0 that s going kind of given my company a heads up that the business office managers have to be very much involved in the MDS 3 0 to affect billers training Mah T AE Carol Maher RN BC RAC CT already kind of given my company a heads up that the business office managers have to be very much involved in the MDS 3 0 training According to Chapter 6 With the January 13 release of Chapter 6 of the Resi dent Assessment Instrument RAI User s Manual Version 3 0 CMS sheds light on what that training will need to include Based on the content it appears the most signif icant piece of the MDS 3 0 that will affect billers involves the HIPPS codes I think you can see from the table for
17. he CMS Web site at www cms hhs gov manuals Downloads bp 102c08 pdf Please review and reproduce this section and share with your staff members and colleagues It is imperative that the resident meet this qualification for coverage un der the Medicare Part A program E LTC billing IQ answer key J Electronic 12 issues 259 Battce N A A Print amp Electronic 12 issues of each 259 pattcre 24 00 Order online at Sales tax www hcmarketplace com see tax information below Be sure to enter source code Grand total N0001 at checkout For discount bulk rates call toll free at 888 209 6554 a True b Senate health bill b False a True d 2009 b False c The SNF is unaware of a same day transfer a True c Botha amp b 1 2 3 4 5 6 7 8 9 10 b False Your source code N0001 Name Title Organization Address City State ZIP Phone Fax E mail address Required for electronic subscriptions 1 Payment enclosed U Please bill me Li Please bill my organization using PO Tax Information Please include applicable sales tax Electronic subscriptions are exempt States that tax products and shipping and handling CA CO CT FL GA IL IN KY LA MA MD ME MI MN MO NC NJ NM NV NY OH OK PA RI SC TN TX VA VT WA WI WV State that taxes products only AZ Pleas
18. he hospital admission The related manual reference can be found in the Medicare Claims Processing Manual Chapter 6 Section 40 3 3 Although the reimbursement remains in place for this same day transfer situation the SNF s ability to collect payment has become more complicated since 2005 Effective January 3 2005 hospitals were required to bundle inpatient admissions for any individual who was discharged and was readmitted to the same hospital as an inpatient on the same day and for the same medical con dition CMS goal in issuing this new policy was to curb early hospital discharges for medically unstable beneficia ries and to avoid payment of two separate hospital PPS diagnosis related group amounts The related instructions can be referenced in CMS MLN Matters article MM3389 With the implementation of this new policy same day transfer claims from the SNF overlap the combined hos pital stays CMS answer to this problem was to direct hospitals to pay the SNF for the Medicare cost report day 2010 HCPro Inc amount The SNF must petition the hospital for the pay ment Most SNFs do not find this to be an easy task SNFs can continue to submit same day transfer claims for direct Medicare reimbursement if the resi dent is discharged gt Back to the hospital on the day of admission for a different medical reason gt Toa hospital other than the one from which the resident was originally discharged Medic
19. inal bill sent to the president Should it be upheld and RUG IV is delayed one year a crosswalk for the state case mix systems between RUG III and RUG IV would be used with MDS 3 0 which could add an extra layer of confusion Maher says Trying to crosswalk a RUG system with an entirely different MDS is going to be very different especially if it s only going to be for one year she says That would be very difficult for everyone to be able to manage The Senate bill states that the concurrent therapy ad justment and changes to the look back period to en sure that only services provided after SNF admission are counted toward RUG placement which are both compo nents of RUG IV would still take place with the imple mentation of MDS 3 0 October 1 But postponing implementation of the remaining components such as the increase from 53 groups un der RUG IIJ to 66 groups under RUG IV would still have profound affects on billers SNFs as a whole and soft ware vendors says Jean Bean RN C director of clini cal services at Covenant Retirement Communities in Skokie IL My biggest concern is that they ve got all of these vendors who are ramping up for the electronic versions Bean says They haven t been given any leeway that you can t stop transmitting electronically and if they re building their software based on what they re supposing to happen October 1 2010 we could have a mess Software stra
20. k at the medical records of people they have no business looking at says Michael C Roach Esq of Meade amp Roach LLP in Chicago OCR became responsible for HIPAA security rule enforcement gt The development HHS announced July 27 2009 that it would transfer HIPAA security rule oversight from CMS to OCR CMS had overseen the rule since it became effective in 2003 gt What to do now Be prepared for greater enforce ment of the HIPAA privacy and security rules they both now fall under OCR s umbrella It is likely no coinci dence that a plan for increased penalties for privacy and security violations is part of the HITECH Act that was en acted only four months earlier OCR now will evaluate whether HIPAA security stan dards preempt any state laws impose financial penalties for violations and issue subpoenas pertaining to security violations according to HHS Meaningful use evolving definition timetable and application gt The development In mid July 2009 the Health IT Policy Committee approved a work group s revised recommendations for defining the meaningful use of EHRs This was the first step in a federal Medi care and Medicaid program that uses incentives to re quire physicians and hospitals financial commitment to EHRs The final definition of meaningful use could lead to 2010 HCPro Inc Billing Alert for Long Term Care March 2010 y Easier exchange of patient information
21. nd CEO CDONA LTC Connor LTC Consulting Clinical Services Consultant Haverhill MA LTC Systems Instructor Joseph Gruber RPh CGP FASCP Vice President amp Clinical Products Specialist Mirixa headquartered in Reston VA HCPro Boot Camps Bella Vista AR Elise Smith JD Finance Policy Counsel Finance and Managed Care American Health Care Association Washington DC Bill Ulrich Lee A Heinbaugh President The Heinbaugh Group Lakewood OH Richard S lannessa Senior Vice President of Fi ial O ti President manda Perauons n Consolidated Billing Services Inc SunBridge Healthcare Corporation Spokane WA Londonderry NH P 5 Elizabeth Malzahn pt aed Sil Health and Wellness Finance Manager R ae The van Halem Group LLC Covenant Retirement Communities Atlanta GA Skokie IL Mary H Marshall PhD President Management and Planning Services Inc Fernandina Beach FL Billing Alert for Long Term Care ISSN 1527 0246 print 1937 7452 online is published monthly by HCPro Inc 200 Hoods Lane Marblehead MA 01945 Subscription rate 259 year Billing Alert for Long Term Care PO Box 1168 Marblehead MA 01945 Copyright 2010 HCPro Inc All rights reserved Printed in the USA Except where specifically encouraged no part of this publication may be reproduced in any form or by any means without prior written consent of HCPro Inc or the Copyright Clearance Center at 978 750 8400 Please notify us imme
22. ng says Also software vendors interpretation of the CMS de fault billing regulations could have an effect Tf billers don t understand the clinical process and the software does something incorrectly it s impossible to correctly file a claim Lang says Potential default billing issues can be taken care of through simple due diligence says Missy Tieken vice president of operations at Consolidated Billing Services I think they need to make sure that they are getting ev erybody on the MDS schedule right from the get go Tieken says If they re doing their Common Working File checks and finding out what the benefits are with these HMOs prior to residents coming so if they re ac tually doing these verifications of benefits I don t think they re going to have as much of an issue By verifying information up front Tieken says SNFs will be more apt to avoid default billing complications altogether It s just a matter of them being proactive on all of it she says E HIPAA in the headlines in 2009 Anticipate impact in 2010 The quality efficiency safety and privacy of health care in the United States were front page news in 2009 Specific developments weren t mere flashes in the pan experts say the ripple effect will continue into 2010 with long ranging effects for most Let s revisit the most significant events of 2009 and explore their potential effect in 2010 HITECH Act
23. r relations department for some claims The use of the IVR system to verify benefits is easy and available any time It is always good to have a back up plan to access the eligibility information to be sure you have the necessary information when making an admission decision Note If you enter the Social Security number using the telephone buttons identify the alpha character by pressing then the button that corresponds with the alpha character and then pressing the number for the position of the alpha character Example for the alpha suffix A 2 1 a We do billing for a SNF and must find the regula tions for the three day qualifying hospital stay dates We need to communicate to our nursing and ad mission staffs that we cannot bill Medicare Part A if the resident was not admitted to the hospital for three con secutive days The hospitals in our area sometimes keep BALTC Subscriber Services Coupon Start my subscription to BALTC immediately Options No of issues Cost Shipping Total Billing Alert for Long Term Care March 2010 our residents in an observation status and do not admit them to the hospital as an inpatient Where can we find the documentation we need to support what qualifies as an inpatient hospital stay A This is a common problem The three day prior hos pital stay requirements are included in Chapter 8 Section 20 1 of the Medicare Benefit Policy Manual This chapter can be found on t
24. rce Utilization Group Version Four RUG IV to October 1 2011 appears in the 8 a House health bill b Senate health bill c Both bills d Neither bill 3 RUG IV includes 53 groups a True b False 9 4 The MDS assessment schedule is determined by when the assessment reference date is set a True b False 5 The consolidated billing final rule for which of the following fiscal years set the precedence for situations in which it s acceptable to bill for the default rate 10 a 2003 b 2005 c 2007 d 2009 6 Transmittal 196 issued in March 2007 listed five sce narios in which facilities were allowed to submit a a True b False In which of the following scenarios are SNFs not al lowed to bill for the default rate a The stay is less than eight days within a spell of illness benefit period b The beneficiary requests a demand bill c The SNF is unaware of a same day transfer d The SNF is notified on an untimely basis or is unaware of a beneficiary s disenrollment from a Medicare Advantage plan Beginning in 2005 hospitals were required to bun dle inpatient admissions for any individual who was discharged and was readmitted to the same hospi tal as an inpatient on the same day and for the same medical condition a True b False SNFs can submit same day transfer claims for direct Medicare reimbursement if the resident is discharged a Back to the hospital on the day of admission for a
25. rs making the PHI accessible to anyone according to HHS The privacy rule requires health plans healthcare clearinghouses and most healthcare providers covered entities including most pharmacies to safeguard the 2010 HCPro Inc Billing Alert for Long Term Care Page 7 privacy of patient information even during its disposal Specifically HHS said CVS violated the privacy of mil lions of its customers when it Failed to implement adequate policies and proce dures to appropriately safeguard patient informa tion during the disposal process Failed to adequately train employees to discard such information properly gt What to do now The CVS fines made it clear that HHS and FTC and now OCR currently operate under a sort of zero tolerance policy The fines also served as a warning that anyone violating the privacy rule is subject to substantial fines and embarrassment Pursuant to the HITECH Act HHS issued guidance April 17 2009 requiring providers to shred or destroy any paper film or other hard copy media to ensure that no one can read or reconstruct the PHI Celebrity privacy cases publicized in California gt The development The problem of curious hos pital workers who snoop inappropriately in medical records has long existed During the past few years it has become news as well Celebrities angry because healthcare workers have sold their information to tab loids have fought back in
26. structions and procedures gt Exchange health information where possible y Submit insurance claims electronically Verify insurance eligibility electronically when it is possible E For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at www copyright com or 978 750 8400 March 2010 Same day transfers No longer a simple reimbursement issue Editor s note This article was written for BALTC by Barbara Griffin Gulliver director of Medicare policy at Zimmet Healthcare Services Group LLC in Morganville NJ For many years SNFs were able to collect Medi care payment for a Part A resident who returned to an acute care hospital on the day of his or her SNF admis sion It was one of the rare situations when a patient did not have to be in the SNF bed at census taking time in order for the SNF to receive payment for the daily care provided In effect SNFs were paid a cost report day for same day transfer residents but a SNF benefit day was not taken A hospital benefit day was taken because that was where the individual resided at the time of mid night census Special coding on the SNF claim condition code 40 in combination with a hospital discharge status of 02 and the from and thru dates of the claim being the same permitted a cost report day payment to the SNF without the claim overlapping with t
27. t of the standard payment period This is not a valid assessment and it will not be accepted by CMS Source RAI User s Manual Version 3 0 CMS 2010 HCPro Inc For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at www copyright com or 978 750 8400 March 2010 The details of default billing Although it may not be a SNF s ideal means of re imbursement billing Medicare Part A for the default rate and doing so correctly is financially critical to any facility Missing an MDS assessment based on the assessment schedule which is determined by when the assessment reference date is set leaves a SNF with two options re ceive no payment for that time period or the better op tion file a late assessment to receive payment at the default rate However choosing the latter isn t always up to the SNF The 2010 final rule did not include any changes from the default billing regulations that were clarified in the 2009 final rule Those regulations limit a facility s eligibility to bill the default rate When they first came up with default days it was the interpretation that anytime you didn t have a com pleted MDS you could bill default days CMS changed that or clarified that and they said No that s not true but there are some situations where default days can be EH used says
28. t unscheduled with another assessment If the second digit value is 0 then the first digit must be 1 through 6 indicating a scheduled PPS assessment or an OBRA assessment used for PPS 1 Either an unscheduled OBRA assessment or gt Ifthe ARD of the unscheduled assessment is not within the ARD window of any scheduled Swing Bed CCA PPS assessment including grace days the first digit is 0 Do NOT use if Use the Medicare RUG Z0100A from the ARD of this unscheduled assessment through gt Combined with any OMRA the end of standard payment period gt Medicare Short Stay assessment gt If the ARD of the unscheduled assessment is within the ARD window of a scheduled PPS as sessment not using grace days Use the Medicare RUG Z0100A from the ARD of this unscheduled assessment through the end of standard payment period gt If the ARD of the unscheduled assessment is a grace day of a scheduled PPS assessment Use the Medicare RUG Z0100A from the start of the standard payment period for the scheduled PPS assessment 2 Start of Therapy OMRA gt If the unscheduled assessment gives a therapy group in the Medicare RUG Z0100A Do NOT use if Use the Medicare RUG Z0100A from the unscheduled assessment s earliest start of ther gt Medicare Short Stay assessment apy date speech language pathology services in O0400A5 occupational therapy in gt Combined with End of Therapy OMRA 0400B5 or physical therapy in O0400C5 through
29. tegies Not only is software instrumental in the eventu al implementation of RUG IV it is critical in the use of MDS 3 0 as the HIPPS codes will be self calculated by the software Shephard says this will be a big help and should limit the chances of incorrect codes being used especially within facilities that have their MDS software communi cating with their billing software This allows the HIPPS code to automatically populate the claim However that doesn t mean person to person com munication shouldn t take place says Shephard The 2010 HCPro Inc Billing Alert for Long Term Care Page 3 software should be checked routinely to make sure it s correctly doing what it s supposed to she says People who are using the software need to use it as a tool but not rely on it in the absence of their own knowledge she adds Quality assurance reviews should be completed pe riodically to verify that the software is calculating properly And to do this billers and other SNF staff members must have a thorough understanding of the MDS 3 0 Being familiar with the material could save time as well as help billers avoid headaches should the software make an error or request action that is unnecessary Even with all of the changes that will take place due to the implementation of MDS 3 0 in October Shephard says some things will remain the same The key things like making sure the correct service date is on
30. the assessment indicator see p 4 this is a really big change Shephard says If you look at the table of HIPPS codes in the 2 0 manual it s a pretty simple thing It is important that billers know information is avail able in the new RAI User s Manual Shephard adds It s a resource that billing office staff members could certainly gt continued on p 2 Page 2 Billing Alert for Long Term Care March 2010 Say hello to 3 0 lt continued from p 1 benefit from especially as they attempt to build an early understanding of the changes in MDS 3 0 Among the changes present in the table are the new Other Medicare Required Assessments OMRA The end of therapy OMRA is required but the start of therapy OMRA is not Maher says So it will be interesting to see if facilities pick up on the start of therapy OMRA It may be that MDS coordinators are so overwhelmed by a whole new instrument and all the things that go with it that facilities miss out on some billing opportuni ties says Maher Editorial Advisory Board Billing Alert for Long Term Care C P ro Group Publisher Emily Sheahan Associate Group Publisher Jamie Carmichael Associate Editor Justin Veiga jveiga hcpro com Kate Brewer PT MBA GCS Laura McDonnell President Corporate Business Manager Progressive Rehab Solutions Merrimack Health Group Hartland WI Haverhill MA Karen Connor Frosini Rubertino RN CRNAC C NE President a
31. the end of standard payment period gt Combined with unscheduled OBRA gt If the unscheduled assessment does not give a therapy group in the Medicare RUG gt Combined with Swing Bed CCA Z0100A do not use the unscheduled assessment RUG for any part of standard payment period This is not a valid assessment and it will not be accepted by CMS 3 Start of Therapy OMRA combined with ei gt If unscheduled assessment gives a therapy group in the Medicare RUG Z0100A ther an unscheduled OBRA assessment or a Use the unscheduled assessment Medicare RUG Z0100A from the earliest start of therapy Swing Bed CCA date through the end of standard payment period Do NOT use if gt If unscheduled assessment does not give a therapy group in the Medicare RUG Z0100A gt Medicare Short Stay assessment do not use the unscheduled assessment RUG for any part of the standard payment period gt Combined with End of Therapy OMRA This is not a valid assessment and it will not be accepted by CMS 4 Whether or not combined with unscheduled Use the unscheduled assessment Medicare non therapy RUG Z0150A from the day after the OBRA assessment and whether or not com latest therapy end date speech language pathology services in O0400A6 occupational therapy bined with Swing Bed CCA in O0400B6 or physical therapy in O0400C6 through the end of standard payment period Do NOT use if gt Combined with Start of Therapy OMRA gt Medicare Short Stay assessment
32. there which is the assessment reference date on the MDS and making sure that they have the correct number of days that they re billing and that there aren t any nonbillable days on there none of that is going to be changing she says Despite the ease with which information is electroni cally transferred Shephard notes that someone from the billing office should continue to be present at weekly Medicare meetings as this promotes accuracy and serves as a chance to confirm any questionable material with other SNF staff members The whole team therapy nursing the MDS co ordinator and the billing office already have to be in strong communication but I think there s going to be even more need for strong communication between those disciplines after MDS 3 0 starts Maher says E Questions Comments Ideas Contact Associate Editor Justin Veiga Telephone 781 639 1872 Ext 3933 E mail jveiga hcpro com For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at www copyright com or 978 750 8400 Page 4 Billing Alert for Long Term Care March 2010 Assessment indicator second digit table Second Digit Values Assessment Type Impact on Standard Payment Period 0 Scheduled PPS assessment not combined No impact on the standard payment period the assessment is no
33. when necessary Greater availability of patient information Appropriate data and transmission security Better quality of care VV VY Greater efficiency The work group also recommended that providers allow patients to access their personal health records by 2013 Its initial recommendations proposed patient access by 2015 The new recommendations also require providers to participate in a national health data exchange by 2015 The verdict is still out on how beneficial the final definition of meaningful use will be to healthcare says Chris Apgar CISSP president of Apgar amp Associates in Portland OR It can have great value and it can also hamper health information technology adoption if it is too expensive requires too much and or is not well thought out gt What to do now Privacy and security officers must do more than conduct research and prepare to implement EHRs They also should prepare to strength en their policies because violations may directly affect EHR incentives and reimbursement The work group recommended that CMS withhold incentive payments until a provider resolves any pending HIPAA violation charges Meanwhile providers must demonstrate meaningful use by ensuring that their EHRs Allow patients to access their health records quickly gt Implement at least one clinical decision support rule for a specialty or clinical priority Provide patients electronic copies of discharge in
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