MEDICARE POLICY MANUALS UPDATED TO CLARIFY SKILLED CARE FOR MAINTENANCE

I. SUMMARY OF CHANGES: In accordance with the Jimmo v. Sebelius Settlement Agreement, the Centers for Medicare & Medicaid Services (CMS) has agreed to issue revised portions of the relevant chapters of the program manual used by Medicare contractors, in order to clarify that coverage of skilled nursing and skilled therapy services "...does not turn on the presence or absence of a beneficiary's potential for improvement, but rather on the beneficiary's need for skilled care." Skilled care may be necessary to improve a patient's current condition, to maintain the patient's current condition, or to prevent or slow further deterioration of the patient's condition. The following are some significant aspects of the manual clarifications now being issued: • No "Improvement Standard" is to be applied in determining Medicare coverage for maintenance claims that require skilled care. Medicare has long recognized that even in situations where no improvement is possible, skilled care may nevertheless be needed for maintenance purposes (i.e., to prevent or slow a decline in condition). The Medicare statute and regulations have never supported the imposition of an "Improvement Standard" rule-of-thumb in determining whether skilled care is required to prevent or slow deterioration in a patient's condition. Thus, such coverage depends not on the beneficiary's restoration potential, but on whether skilled care is required, along with the underlying reasonableness and necessity of the services themselves. The manual revisions now being issued will serve to reflect and articulate this basic principle more clearly. • Enhanced guidance on appropriate documentation. Portions of the revised manual provisions now include additional material on the role of appropriate documentation in facilitating accurate coverage determinations for claims involving skilled care. While the presence of appropriate documentation is not, in and of itself, an element of the definition of a "skilled" service, such documentation serves as the means by which a provider would be able to establish and a Medicare contractor would be able to confirm that skilled care is, in fact, needed and received in a given case. Thus, though the Jimmo settlement does not explicitly reference documentation requirements, CMS has nevertheless decided to use this opportunity to introduce additional guidance in this area, both generally and as it relates to particular clinical scenarios. An example of this material appears in new section 30.2.2.1 of the revised chapter 8, in the guidelines for SNF coverage under Part A. • The Settlement Agreement. The Jimmo v. Sebelius settlement agreement itself includes language specifying that "Nothing in this Settlement Agreement modifies, contracts, or expands the existing eligibility requirements for receiving Medicare coverage." Rather, the intent is to clarify Medicare's longstanding policy that when skilled services are required in order to provide care that is reasonable and necessary to prevent or slow further deterioration, coverage cannot be denied based on the absence of potential for improvement or restoration. By contrast, coverage in this context would not be available in a situation where the beneficiary's maintenance care needs can be addressed safely and effectively through the use of nonskilled personnel. As such, the revised manual material now being issued does not represent an expansion of coverage, but rather, provides clarifications that are intended to help ensure that claims are adjudicated accurately and appropriately in accordance with the existing policy. EFFECTIVE DATE: January 7, 2014 IMPLEMENTATION DATE: January 7, 2014 http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2013-Transmittals-Items/R175BP.html?DLPage=1&DLSort=1&DLSortDir=descending OR: R175BP [PDF, 525KB] MM8458 [PDF, 73KB]

Largest SNF settlement to date: unnecessary rehab therapy services - $48 million

Department of Justice

Office of Public Affairs

FOR IMMEDIATE RELEASE

Tuesday, November 19, 2013

Nursing Home Operator to Pay $48 Million to Resolve Allegations That Six California Facilities Billed for Unnecessary Therapy

The Ensign Group Inc., a skilled nursing provider based in Mission Viejo, Calif., that operates nursing homes across the western U.S. has agreed to pay $48 million to resolve allegations that it knowingly submitted to Medicare false claims for medically unnecessary rehabilitation therapy services, the Justice Department announced today. Six of Ensign's skilled nursing facilities in California allegedly submitted the false claims: Atlantic Memorial Healthcare Center, located in Long Beach; Panorama Gardens, located in Panorama City; The Orchard Post-Acute Care (a.k.a. Royal Court), located in Whittier; Sea Cliff Healthcare Center, located in Huntington Beach; Southland, located in Norwalk; and Victoria Care Center, located in Ventura.

"Skilled nursing facilities that place their own financial interests above the needs of their patients will be held accountable," said Assistant Attorney General for the Justice Department's Civil Division Stuart F. Delery. "We will continue to advocate for the appropriate use of Medicare funds and the proper care of our senior citizens."

Between January 1, 1999, and August 31, 2011, these six Ensign skilled nursing facilities allegedly submitted false claims to the government for physical, occupational and speech therapy services provided to Medicare beneficiaries that were not medically necessary. Specifically, Ensign provided therapy to patients whose conditions and diagnoses did not warrant it, solely to increase its reimbursement from Medicare. The government further alleged that Ensign created a corporate culture that improperly incentivized therapists and others to increase the amount of therapy provided to patients to meet planned targets for Medicare revenue. These targets were set without regard to patients' individual therapy needs and could only be achieved by billing at the highest reimbursement levels. The government also alleged that Ensign billed for inflated amounts of therapy it had not provided and that certain patients were kept in these facilities for periods of time exceeding what was medically necessary for treatment of their conditions.

"The case against The Ensign Group involves a company that regularly bilked Medicare by submitting inflated bills that, in some cases, sought money for services that simply were never provided to patients," said U.S. Attorney for the Central District of California André Birotte Jr. "This settlement - one of the largest Medicare fraud cases against a nursing home chain in U.S. history - demonstrates our commitment to protecting taxpayers who fund important programs that benefit millions of Americans, but don't want to see their hard-earned money wasted on fraud or abuse."

In addition to paying the settlement amount, Ensign also agreed that each of its skilled nursing facilities across the nation would be bound by the terms of a Corporate Integrity Agreement with the Department of Health and Human Services Office of Inspector General (HHS-OIG).

"Billing Medicare for costly, unnecessary skilled nursing services -- as the government alleged here -- inflates health care costs borne by taxpayers," said Special Agent in Charge for the Los Angeles Region of the HHS-OIG Glenn R. Ferry. "This settlement again puts on notice those who would consider defrauding federally funded health care programs."

This civil settlement illustrates the government's emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced in May 2009 by Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sebelius. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in this effort is the False Claims Act. Since January 2009, the Justice Department has recovered more than $16.7 billion through False Claims Act cases, with more than $11.9 billion of that amount recovered in cases involving fraud against federal health care programs.

The allegations settled today arose from lawsuits filed by two former Ensign therapists under the qui tam, or whistleblower, provisions of the False Claims Act, which allow private citizens to bring suit on behalf of the government and to share in any recovery. The dollar amount that the whistleblowers in this case, Gloria Patterson and Carol Sanchez, will receive has not been determined. The lawsuits are captioned as United States of America ex rel. Gloria Patterson v. Ensign Group Inc.,Case No. SACV 06-6956 CJC (ANx) (C.D. Calif.) and United States of America ex rel. Carol Sanchez v. Ensign Group Inc., Case No. SACV 06-0643 CJC (ANx) (C.D. Calif.).

The case was handled by the U.S. Attorney's Office for the Central District of California, with assistance from the Commercial Litigation Branch, Civil Division, U.S. Department of Justice and the U.S. Department of Health and Human Services Office of Inspector General. This action was supported by the Elder Justice and Nursing Home Initiative, which coordinates the department's activities combating elder abuse, neglect and financial exploitation, especially as they impact beneficiaries of Medicare, Medicaid and other federal health care programs.


The claims settled by this agreement are allegations only; there has been no determination of liability.

CMS Transition Memo for October 1st RUG changes and billing instructions

 Transition for Implementation of FY 2014 SNF PPS MDS 3.0 Policy Changes 

Addition of Distinct Calendar Days of Therapy Item to MDS 3.0 

Policy Summary 

For all assessments with an assessment reference date (ARD) that is on or after October 1, 2013 and on which a provider would be coding the amount of therapy that a resident received during the assessment look-back period, item O0420 must be coded with the number of distinct calendar days that the resident received therapy services. 

Transition Policy 

1. For all assessments with an ARD before 10/1/2013, an FY2014 transition RUG will not be produced. Providers should bill all days of service associated with that assessment using the FY 2013 RUG provided by that assessment in Item Z0100A or Z0150A, even if some of those days of service are on or after 10/1/2013. 

2. For all assessments with an ARD from 10/1/2013 through 10/13/2013, an FY2013 transition RUG will be produced where the total days of therapy (items O0400A4, O0400B4, O0400C4) will be used for RUG classification. This should produce a FY2013 RUG exactly equivalent to that for an assessment with an ARD date before 10/1/2013. This FY2013 transition RUG should be used to bill any days of service before 10/1/2013 which are associated with that assessment. 

3. For all assessments with an ARD date after 10/13/2013, an FY 2013 transition RUG will no longer be produced. 

Revised Swallowing and Nutritional Status Items 

Policy Summary 

For all assessments with an ARD that is on or after October 1, 2013 and on which a provider would be coding the resident’s swallowing and nutritional status, specifically the percent intake by Artificial Route, item K0710A and item K0710B must be coded with the proportion of total calories the resident received through parental or tube feeding and the average fluid intake per day by IVor tube feeding, respectively. 

Transition Policy 

1. For all assessments with an ARD before 10/1/2013, an FY2014 transition RUG will not be produced. Providers should bill all days of service associated with that assessment using the FY 2013 RUG provided by that assessment in Item Z0100A or Z0150A, even if some of those days of service are on or after 10/1/2013.

2. For all assessments with an ARD from 10/1/2013 through 10/13/2013, an FY2013 transition RUG will be produced where: 

a. The value for non-oral calories in last 7 days (K0710A3) will be copied to the prior item (K0700A) for use by the FY2013 grouper. 

b. The value for non-oral volume in last 7 days (K0710B3) will be copied to the prior item (K0700B) for use by the FY2013 grouper. 

This FY2013 transition RUG should be used to bill any days of service before 10/1/2013 which are associated with that assessment. 

3. For all assessments with an ARD after 10/13/2013, an FY 2013 transition RUG will no longer be produced. 

Addition of Co-Treatment Minutes Item to MDS 3.0 

Policy Summary 

For all assessments with an ARD that is on or after October 1, 2013 and on which a provider would be coding the amount of therapy that a resident received during the assessment look-back period, items O0400A3A, O0400B3A, and O0400C3A must be coded with the total number of minutes the respective discipline of therapy was administered to the resident in co-treatment sessions during the previous 7 days. 

Transition Policy 

For all assessments with an ARD on or after 10/1/2013, but where the assessment look-back period for therapy includes days prior to 10/1/2013, co-treatment sessions delivered by a given therapy discipline must be recorded on the assessment, within items O0400A3A, O0400B3A, and O0400C3A as appropriate.

SNF PEPPER Reports: Medicare Billing Vulnerabilities

The first release of the Skilled Nursing Facility (SNF) PEPPER (version Q4FY12) was completed on August 30, 2013. SNFs administered through short-term acute care hospitals received their SNF PEPPER electronically. The SNF PEPPER file was uploaded to the File Exchange inbox of hospital QualityNet Administrators and user accounts with the PEPPER recipient role. QualityNet Administrators received download instructions in a separate email.

SNF PEPPER Envelope

Free-standing SNFs and SNFs administered through long-term acute care hospitals and inpatient rehabilitation facilities will receive their PEPPER in hard copy format via USPS first-class mail, shipped on August 30, 2013. The envelope containing the PEPPER will appear as at left and is addressed generically to the Chief Executive Officer/Administrator. SNFs should be on the look-out for this envelope and ensure it is appropriately routed internally.

What is PEPPER?
PEPPER is a report that summarizes a SNF's Medicare claims data in areas that may be at risk for improper Medicare payments. It compares the SNF's statistics with aggregate national statistics to identify whether it may be at risk for improper Medicare payments. PEPPER is distributed by TMF® Health Quality Institute under contract with the Centers for Medicare & Medicaid Services.

For more information on the SNF PEPPER, including training and resources for SNFs, the SNF PEPPER User's Guide, and to accessinformation about My QualityNet accounts and frequently asked questions, please visit PEPPERresources.org.

Do you have questions or comments about PEPPER or need help obtaining your report? We have aHelp Desk available on PEPPERresources.org or you may provide your feedback through ourfeedback form.

The PEPPER Team

S&C Letter re: Completion of Discharge Assessments

Certification Group

Ref: S&C: 13-56-NH

DATE:             August 23, 2013                      

TO:                  State Survey Agency Directors 

FROM:            Director

                        Survey and Certification Group

SUBJECT:     Minimum Data Set (MDS) 3.0 Discharge Assessments that Have Not Been Completed and/or Submitted

Memorandum Summary MDS 3.0 Discharge Assessments: The Centers for Medicare & Medicaid Services (CMS) is clarifying steps to take to address Minimum Data Set (MDS) 3.0 discharge assessments that have not been completed and/or submitted as required under 42 CFR §483.20(g) and 42 CFR §483.20(f)(1). The memo is intended to help surveyors understand both (a) what nursing homes should do to address inactive residents remaining on their resident roster due to incomplete and/or unsubmitted discharge assessments and (b) how nursing homes can ensure compliance with discharge assessment requirements. Action by September 30, 2013: We are providing this information in order to promote nursing home completion of discharge assessments for inactive residents by September 30, 2013.

Background

CMS regulations at 42 CFR §483.20(g) Accuracy of Assessment require that Skilled Nursing Facilities (SNFs) and Nursing Facilities (NFs) provide that assessments “accurately reflect the resident’s status.”  Further, 42 CFR §483.20 (f) requires facilities to encode the following information for each resident in the facility within seven (7) days after completing a resident’s assessment: (i) Admission assessment. (ii) Annual assessment updates. (iii) Significant change in status assessments. (iv) Quarterly review assessments. (v) A subset of items upon a resident’s transfer, reentry, discharge, and death. A “subset of items upon…discharge…” means discharge assessment.  See State Operations Manual (SOM), Appendix PP, Interpretive Guidance for F287: “Background (face-sheet) information refers to the MDS Entry tracking record, while the discharge subset of items refers to the MDS discharge assessment.” 

Page 2 - State Survey Agency Directors

In addition, within 14 days after a facility completes a resident’s assessment, it must electronically transmit to the CMS system the encoded data and ensure that it is accurate and complete. 

The failure to submit or complete MDS 3.0 discharge assessment records leads to inaccurate MDS 3.0 Quality Measures (QMs) data, potentially affecting the resident, the facility’s payment, and facility liabilities.  For example, failure to submit or complete MDS 3.0 discharge assessment records can also lead to citation of a facility under 42 CFR §483.20(f) and 42 CFR §483.20(g).

Discharge assessments capture a resident’s clinical condition at discharge.  When discharge assessments are not completed or submitted as required, the true length of stays and episodes are difficult to construct.  Lack of completion and/or submission of discharge assessments causes errors on several reports, such as a facility’s MDS 3.0 Roster report, the MDS 3.0 Facility Characteristics Report, and MDS 3.0 Missing Assessment report.  For example, in the case of the current MDS 3.0 Roster, the lack of discharge assessments in the Quality Improvement and Evaluation System Assessment Submission and Processing (QIES ASAP) system results in more residents appearing on the Roster than the facility has residents and/or beds. 

Facility Procedures

Beginning October 1, 2013, MDS assessments older than 3 years will no longer be accepted. Also, to minimize impact on QM data, CMS has selected a reference date of October 1, 2012. The CMS is requiring facilities to take the following steps when facilities have not completed discharge assessments and/or have not submitted discharge assessments prior to September 30, 2013:

1. Identify any residents appearing on the facility’s current MDS 3.0 Roster report who are no longer active residents. 

2. If the resident was discharged prior to October 1, 2012, a discharge assessment must be completed for the resident indicating the actual date of discharge in Item A2000, Discharge Date. This assessment must have demographic information completed in Section A. Clinical information in Sections B through Z must be dash-filled.  Items Z0400, Signatures of Persons Completing the Assessment or Entry/Death Reporting, and Z0500, Signature of RN Assessment Coordinator Verifying Assessment Completion, must reflect the actual completion date of this assessment.

3. If the resident was discharged on or after October 1, 2012, a discharge assessment must be completed for the resident indicating the actual date of discharge in Item A2000, Discharge Date. This assessment must have demographic information completed in Section A. Clinical information in Sections B through Z must be completed as much as possible to reflect the actual

status of the resident at the time of discharge.  The following coding instruction is applicable for

Page 3 - State Survey Agency Directors

coding BIMS, PHQ-9 and Pain interviews for these late discharge assessments: In lieu of the interviews, the staff assessments should be completed if appropriate based on the clinical record

information that is available.  In this case the gateway questions (Items C0100, D0100 and/or J0200) should be coded No (0) and the staff assessment should be completed. Z0400, Signatures of Persons Completing the Assessment or Entry/Death Reporting, and Z0500, Signature of RN Assessment Coordinator Verifying Assessment Completion, must reflect the actual completion date of this assessment.

CMS is providing this opportunity to rectify the current situation related to missing and incomplete discharge assessments.  Facilities must complete the above steps to address the completion and submission of discharge assessments as soon as possible, but no later than September 30, 2013. 

Importance and CMS Policy

The CMS emphasized the importance of meeting requirements related to discharge assessments in the March 2012 MDS Provider Training.  QM data integrity is heavily dependent on Discharge assessments.  Therefore, facilities should have policies and procedures that ensure timely and accurate completion and submission of these assessments.  Details about the timing requirements for Discharge assessments are available in Chapter 2 of the Long-Term Care Facility Resident Assessment Instrument User’s Manual, Version 3.0 accessible via the following link: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html. 

The previous steps listed under facility procedures above address any currently incomplete and/or unsubmitted discharge assessments in existence from the date of the release of this memo through September 30, 2013. The following is CMS policy for the completion and submission of stand-alone discharge assessments:

·       A discharge assessment must be completed when the resident is discharged from the facility (whether or not return is expected).

·       A discharge assessment must be completed (Item Z0500B) within 14 days after the discharge date (A2000 + 14 calendar days).   

·       Submission of the discharge assessment must occur within 14 days after the MDS completion date (Z0500B + 14 calendar days).

Please note that for a discharge assessment, the Assessment Reference Date (ARD) is not set prospectively, as with other assessments.  The ARD for a discharge assessment is always the discharge date. 

In situations where the resident is discharged prior to the end of the prescribed ARD window, including grace days when appropriate, for a required assessment (e.g., PPS, OBRA) where the discharge assessment is to be combined with the required assessment, the ARD of that required assessment must have been set in order for the facility to adjust the ARD to equal the discharge

Page 4 - State Survey Agency Directors

date. In the event the ARD has not been set to allow for adjustment of the ARD of the PPS- or OBRA-required assessment, the stand-alone discharge assessment must be completed and the other PPS- or OBRA-required assessment is considered a missed assessment.

Contact: Please direct any additional questions or concerns regarding this memorandum to your State Resident Assessment Instrument (RAI) Coordinator.

Effective Date: Immediately. This information should be communicated with all survey and certification staff, their managers, and the State/Regional Office training coordinators within 14 days of this memorandum.

/s/

Thomas E. Hamilton

cc:  Survey and Certification Regional Office Management

New Hospital-Acquired Condition (HAC) Reduction Program: What does it mean for my SNF?

As part of the new HAC Reduction program, beginning in FY 2015 hospitals that rank in the lowest quartile for medical errors or serious infections, that patients contract while in the hospital, will be paid 99 percent of what they otherwise would have been paid under the IPPS. This rule finalizes the criteria to rank hospitals with a high rate of hospital-acquired conditions.

If past trends continue,  we can expect some hospitals to choose not to bill Medicare or anyone else when one of these conditions presents itself.  Unfortunately, when they don't bill Medicare, there is no qualifying stay, so there is no SNF benefit available.  

FY14 SNF & CB FInal Rule Published

Press Release: 
 CMS finalizes fiscal year 2014 payment and policy changes for Medicare skilled nursing facilities

Overview

On July 31, 2013, the Centers for Medicare & Medicaid Services (CMS) issued a final rule [CMS-1446-F] outlining fiscal year (FY) 2014 Medicare payment rates for skilled nursing facilities (SNFs). The major provisions of the final rule are summarized below.

Changes to payment rates under the SNF Prospective Payment System (PPS) for FY 2014

Based on the changes contained within this final rule, CMS estimates that aggregate payments to SNFs will increase by $470 million, or 1.3 percent, for FY 2014 relative to payments in FY 2013. This estimated increase is attributable to the 2.3 percent market basket increase, reduced by the 0.5 percentage point forecast error correction (explained below) and further reduced by the 0.5 percentage point multifactor productivity adjustment required by law.

The FY 2014 SNF PPS payment rates and policies will be effective on October 1, 2013.

Revise and rebase the market basket

The Medicare statute requires CMS to establish a SNF market basket index that reflects changes over time in the prices of an appropriate mix of goods and services included in covered SNF services. CMS has developed a SNF market basket index that encompasses the most commonly used cost categories for SNF routine services, ancillary services, and capital-related expenses. The SNF market basket index is a factor used to update the SNF PPS payments on an annual basis. CMS is rebasing and revising the SNF market basket for FY 2014 and subsequent years to reflect more recent data. The current SNF market basket reflects data from FY 2004 and CMS is updating the SNF market basket using data from FY 2010. In addition, CMS will make changes to the components of the SNF market basket index by adding five new cost categories and dividing the existing Nonmedical Professional Fees cost category into two separate categories, labor-related and non labor-related Nonmedical Professional Fees (for a total of 29 cost categories), and revising several price proxies, including the price proxy for the Wages and Salaries and Employee Benefit cost component.

Reporting of distinct therapy days

To ensure accuracy in case-mix assignment and payment, CMS is adding an item to the Minimum Data Set (MDS) to record the number of distinct calendar days of therapy provided by all the rehabilitation disciplines to a beneficiary over the seven-day look-back period. CMS is clarifying that the qualifying condition for the Medium Rehab (RM) Category requires five distinct calendar days of therapy. Similarly, CMS is clarifying that the qualifying condition for the Low Rehab (RL) Category requires three distinct calendar days. Currently, the number of days for each therapy discipline reported on the MDS is summed without regard to the number of separate and unique days per week during which the patient receives therapy services across all rehabilitation disciplines. This results in some residents qualifying inappropriately for an RM or RL Resource Utilization Group (RUG). The addition to the MDS ensures SNFs are paid accurately for the therapy services they provide to their residents.

Forecast error correction

A forecast error correction is applied when the difference between the actual and projected market basket percentage change for a given year (the most recent available FY for which there is final data) exceeds the 0.5 percentage point threshold. While CMS normally reports the forecast error to one significant digit, such reporting makes it difficult to determine if the threshold has been exceeded in those instances where the difference between the projected and actual market basket percentage change rounds to 0.5 percentage point. Therefore, only in those instances where the difference between the projected and actual market basket percentage change rounds to 0.5 percentage point at one significant digit, CMS will report the difference to the second significant digit to determine if the threshold has been exceeded. The most recent available FY for which there is final data is FY 2012. For FY 2012, the projected market basket percentage change exceeded the actual market basket percentage change by 0.51 percentage point. As the projected market basket percentage change exceeded the actual market basket percentage change by an amount greater than the 0.5 percentage point threshold, the FY 2014 market basket update will include a downward adjustment of 0.5 percentage point.

A link to the final rule, which will be published in the Federal Register on August 6, 2013, is available at:https://www.federalregister.gov/public-inspection.

For further information about the SNF PPS, please visit http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/index.html.

New CMS MDS Training video is now posted to YouTube

From the SNF ODF Website (See Resources on my website):

‘Discharge Assessments and the Use of Dashes’ video is activated on the DHHS YouTube site;  Access to this video is available on the MDS 3.0 Training page  in the Related Links section or at:  http://youtu.be/Qkn22jv2HSY. Discharge Assessments and the Use of Dashes are addressed in our new MDS 3.0 Provider Update Training Series. This training series is the first web-based training offered in 2013 to providers addressing post-acute care topics. Video No. 1 covers MDS 3.0 updates for the Nursing Home setting. It includes a CMS Introduction, a panel presentation explaining what the MDS 3.0 RAI Manual and the MDS 3.0 Assessment Instrument are, and includes two training topics. The first training topic focuses on our relatively new discharge assessments, and the second topic explains how to properly code with dashes. 

From Judy:  This is a 30 minute video, the first 11 minutes cover general intro comments about what the MDS is.   While this portion is two speakers reading from a teleprompter,  the first portion is a great intro to brand new LTC folks about what the RAI process is.  

Then they cover two topics:  Discharge assessments  and Dashes. This is not a video on 'the use of dashes on a discharge assessment.  They cover the two separately.    I found it helpful to go to the YouTube link, open the 'transcript" button, which allows me to jump around in the video by clicking on specific parts of the transcript.

---

New Draft of the Oct 1,2013 MDS forms posted

MDS 3.0 Technical Information

What's New -

June 03, 2013

A new version (v1.11.1) of the MDS item sets was posted. This version is scheduled to become effective October 1, 2013 in conjunction with the new version of the data specs (v1.13.1). The item sets should also be considered provisional or draft and subject to change until final item sets are published.

MDS 3.0 Item Subsets V1.11.1 for the October 1, 2013 Release [ZIP, 8MB]

From Judy:  This one adds the line from the FY14 Proposed Final Rule  to list distinct calendar days of therapy for the new Rehab Medium and Low rules.  There are other changes that were in the earlier draft, but this is the latest one.  

Virginia Providers: Virginia revises Section Q fax referral form

The Department of Medical Assistance Services (DMAS) announced on Tuesday this week that the revised MDS 3.0 Section Q Referral Fax Transmittal Notification Tracking form has been uploaded to the DMAS website.  The form, DMAS-P261, and instructions can be located on the resources section of my website.
 
To assist the Nursing Facilities, Local Contact Agencies, and the Transition Coordination Providers with the Section Q referral process, the revised workflow is included with step by step instructions on the completion of the DMAS-P261 form.

A 30-minute Section Q training WebEx has also been uploaded to the DMAS website to provide further guidance for nursing facilities and local contact agencies.  

Contact Amy Burkett, State Section Q Coordinator at 804.786.0568 or via email atamy.burkett@dmas.virginia.gov with any questions about the MDS Section Q process.

2013 Medicare Trust Fund Report released Friday

To read report:  http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ReportsTrustFunds/Downloads/TR2013.pdf

"The trust fund that finances Medicare's hospital insurance coverage will remain solvent until 2026, two years beyond what was projected in last year's report,"

The Washington Post notes that the trustees "also credit lower costs and use rates in 'most ... service categories — especially skilled nursing facilities' — a development that most economists believe is in part due to the recent recession but also to more fundamental efforts to reduce costs throughout the health care industry."

All RACs now have SNF issues for review posted: In addition to MMR

All four RACs have, since May 2013, added SNF specific issues for review to their "current issues"  list on their websites.  You can find your RAC, then go to the specific website to see the issues,  by clicking:  http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/recovery-audit-program/index.html?redirect=/rac

Or just google  "CMS RAC"  and click on the cms.gov links.

Hebrew Home at Riverdale Music Video: This will make your day

We're Walking on Sunshine! The residents of The Hebrew Home at Riverdale and RiverWalk star in our very first music video! We are so excited to celebrate our community, and to highlight the strength, energy, and fun loving spirit of our residents. We hope you enjoy watching it as much as we did filming it!

Link here:  http://vimeo.com/67334113

New validation report RUG warnings for Virginia Providers re: Z0250

DMAS is running the RUG-III version 48 grouper in Z0250, per an announcement from DMAS emailed to all providers today.   They are testing this grouper to see what the financial implications are.  This will have no effect on your Case Mix CMI.  The Z0200 RUG will be used for state Case Mix CMI.
You will, hover,  get error messages on your validation report until your vendor puts this grouper into your software.

Here is a copy of the email:

From: Wendy malone [mailto:WMalone@MSLC.COM]
Sent: Friday, May 31, 2013 10:16 AM
Cc: carla.russell@dmas.virginia.gov; mary.hairston@dmas.virginia.gov; Richard Weinstein
Subject: Nursing Facility MDS Data Change - GoFileRoom Message

The Department of Medical Assistance Services (DMAS) is evaluating a new version of the Resource Utilization Group (RUG).  In order to test the new version of the grouper, DMAS will be adjusting the Minimum Data Set (MDS) requirements for Virginia nursing facilities.  Effective June 7, 2013, the RUG-IV, version 48 group will be included on the Virginia MDS data.

Once the Virginia MDS data is updated to include the alternate calculation of RUG-IV, version 48, the MDS software must be adjusted to calculate the RUG-IV version 48 group.  Nursing facilities or vendors that do not adjust the MDS software settings to allow the additional calculation will receive warning messages for MDS Items Z0250A and Z0250B.  These warning messages do not prevent the successful transmission of the MDS data.  Facilities or vendors may ignore these warning messages.

The addition of the alternate calculation for RUG-IV, version 48 will not impact the primary RUG-III, version 34 calculation.  DMAS will continue to use the RUG-III, version 34 group in the calculation of case mix scores for participating nursing facilities.

If you have any questions regarding the additional calculation, please contact Sandra Lee, Virginia Department of Health atSandy.Lee@vdh.virginia.gov, Priscilla Bullard, Virginia Department of Health at Priscilla.Bullard@vdh.virginia.gov, or Carla Russell, DMAS atCarla.Russell@dmas.virginia.gov.

Wendy Malone

Manager

Effective January 1, 2013, PHBV Partners LLP was merged into Myers and Stauffer LC. 

MYERS AND STAUFFER LC

4400 Cox Road, Suite 110

Glen Allen, VA 23060

PH 804.270.2200

FX 804.270.2311

wmalone@mslc.com

www.mslc.com

DEDICATED TO GOVERNMENT HEALTH PROGRAMS

New clarification to Claims Processing Manual for NOMNC effective Aug 2013

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2711CP.pdf

No change in policy, but helpful clarifications for the NOMNC process.  

Entire RAI Manual is now posted

When CMS posted the May updates to the RAI Manual, on May 20th, effective May 8th,  they left out several chapters.  Those chapters have now been posted.  There are no changes in those chapters and they are listed as version 1.09.  Chapter 3 Section F, Section J, Appendix D and a few title pages are what was missing.   See the Resources section of my website for the link to download.  

CMS just archived several YouTube Videos on MDS coding

From:  http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIMDS30TrainingMaterials.html

May 28, 2013

The following YouTube Training Videos in download below have been removed and transferred to the MDS 3.0 Training Archive section since they are no longer current.  New information will be posted as it becomes available:  Sections A, G, K, M, N, O, Q, X and Z.

From Judy:  It would be interesting to ask them what it was about the Section G training video that is no longer current.........

Region C RAC Announces SNF Approved Issue 5/16/13

The Region C RAC,  Connolly, Inc.  posted on May 16th a new approved issue concerning SNFs.  It looks like they are simply going to make sure the PPS assessments were scheduled and billed correctly for the number of days each assessment should cover.  The days a certain assessment pays for is in the "service unit" field of the bill with the HIPPS code from the MDS.

Details are at:  http://www.connolly.com/healthcare/pages/Approved Issues.aspx.  Connolly is the RAC for 17 states in the Southeastern US:
Alabama

Arkansas
Colorado
Florida
Georgia
Louisiana
Mississippi
North Carolina
New Mexico
Oklahoma
South Carolina
Tennessee
Texas
Virginia
West Virginia

Territories of Puerto Rico and U.S. Virgin

Issue Name:	Units in Excess of PPS Assessment Maximum - C002842013
Description:	Medicare assigns standard scheduled payment periods for SNF assessments. Overpayment occurs when additional units in excess of assessment maximums are billed.
Provider Type Affected:	SNF
Date of Service:	3 Years from Initial Determination Date
States Affected:	First Coast Region C
Additional Information:	1. RAI Manual MDS 3.0 Ch6 Section 6.4 2. CMS IOM 100-04 Chapter 6 Sections 30 and 30.1

News from VHCA: Dual Demonstration MOU - 1st in the nation

This article is from my friends at the Virginia HealthCare Association.  If you are not a Virginian,  you may want to follow this initiative.  If it works,  CMS will  expand it.  Note that for these facilities, there are some substantive changes in how Medicare is going to work for them.  For example,  no more 3 day qualifying stay for these demonstration facilities for the dual eligibles to access the SNF Medicare benefit.  The actual MOU is here:  http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/VAMOU.pdf

CMS & Virginia Announce Dual Demonstration MOU

On May 21st, the Centers for Medicare & Medicaid Services (CMS) and the Virginia Department of Medical Assistance Services (DMAS)announced that they will establish a Federal-State partnership to implement the Commonwealth Coordinated Care program (also referred to as the Dual Demonstration) to better serve individuals eligible for both Medicare and Medicaid (dual eligibles).  The Federal-State partnership will include a three-way contract with managed care organizations (MCOs) that will provide integrated benefits to Medicare-Medicaid Enrollees in the targeted geographic area(s).  The Demonstration will begin on February 1, 2014 and will continue until December 31, 2017, unless terminated earlier in accordance with provisions of the executed Memorandum of Understanding (MOU).  The demonstration is intended to test a payment and service delivery model to lessen the fragmentation and improve coordination of services for Medicare-Medicaid Enrollees, enhance quality of care, and reduce costs for both the Commonwealth and the federal government.

As previously communicated with VHCA/VCAL membership, the Demonstration will operate in five specific geographic regions within the Commonwealth – Northern Virginia, Central Virginia (including Richmond), Tidewater, Western/Charlottesville and Roanoke.  In those regions, the population that will be eligible to participate in the Demonstration will be limited to individuals ages 21 years and older at the time of enrollment who are entitled to benefits under Medicare Part A, enrolled under Medicare Parts B and D, receive full Medicaid benefits including individuals enrolled in the Elderly or Disabled with Consumer Direction (EDCD) Waiver and those residing in nursing facilities.

Under this initiative, participating health plans will be required to provide for, either directly or through subcontracts, Medicare and Medicaid-covered services, as well as additional items and services, under a capitated model of financing.  CMS, DMAS, and the MCO will ensure that beneficiaries have access to an adequate network of medical and supportive services. CMS and DMAS will jointly select and monitor the MCOs.

The Demonstration will evaluate the effect of an integrated care and payment model on serving both community and institutional populations.  In order to accomplish these objectives, comprehensive contract requirements will specify access, quality, network, financial solvency, and oversight standards. Contract management will focus on performance measurement and continuous quality improvement. Except for specific exclusions identified in the MOU, participating MCOs will be required to comply with all applicable existing Medicare and Medicaid laws, rules, and regulations as well as program specific and evaluation requirements, as will be further specified in a three-way contract to be executed among the health plans, DMAS and CMS.

The MOU outlines the activities CMS and DMAS plan to conduct in preparation for implementation of the Demonstration, before the parties execute a three-way contract with participating MCOs setting forth the terms and conditions of the Demonstration and initiate the Demonstration.  Additional details about MCO responsibilities will be included in and appended to the three-way contract.

Last week, health plans that are interested in participating in the Demonstration submitted their proposals to DMAS.  Later this month, DMAS intends to release “data books” to MCOs that will provide demographic and claims experience data related to the Medicaid services provided to targeted dual beneficiaries for recent periods.  According to materials provided by DMAS, the Department intends to announce in June the MCOs that will participate in the Demonstration.  In July, DMAS and CMS intend to begin MCO readiness reviews and draft the three-way (CMS/DMAS/MCO) contract.  During August and September, DMAS and CMS plan to finalize Medicaid capitated rates to MCOs and finalize and execute the three-way contracts.

While practical operating and payment details about the Dual Demonstration remain scarce, key planning considerations for nursing facilities located within one of the five Demonstration regions include the following:

• Any willing nursing facility provider may participate in the Demonstration as long as they are willing to accept the payment rates offered by the MCO.
• MCOs must pay nursing facilities for Medicaid-related services no less than equivalent fee-for-service rates in effect.
• The MOU officially removes the requirement for a qualifying three-day acute hospital stay in order for a beneficiary to qualify for skilled services coverage in a nursing facility.

VHCA’s Managed Care Committee will continue to closely monitor developments as DMAS and CMS work toward implementation of the Demonstration.  As we review the MOU in detail, we will continue to pass along information to our members.  Members with questions are encouraged to contact the Association.

New RAI Manual missing large sections, CMS working to resolve issue

Published by Cindy DePorter, North Carolina RAI Manager just now:  From Cheryl Wiseman at CMS:

Sent: Tuesday, May 21, 2013 10:04 AM
To: Subject: RE: The Manual v1.10 is posted.

Good morning, everyone:

We are aware that several sections and appendices in Manual v1.10 are missing. Below is a message from Cheryl Wiseman addressing this:

Please stay tuned as all the ‘missing files’ will be posted soon; there was a glitch in transferring files so numerous files fell off, including:

Six total files missing from 5-20-13 CMS posting:

1. Chapter 3 Section F

2. Chapter 3 Section J

3. Chapter 3 Section S

4. Appendix D

5. Appendix F cover page

6. Appendix H cover page

Our team is working to get these uploaded as we speak.

Thanks for your patience.