Friday, May 31, 2013

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.govmary.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


DEDICATED TO GOVERNMENT HEALTH PROGRAMS

Thursday, May 30, 2013

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.  

Tuesday, May 28, 2013

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.........

Saturday, May 25, 2013

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

Wednesday, May 22, 2013

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.

Tuesday, May 21, 2013

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.

Saturday, May 18, 2013

Updated Error Message Table as promised by CMS


This is not the new RAI manual.  The MDS 3.0 Provider User's Guide: Section 5, Error Messages, has been updated.  This is the guide for the transmission system, and Section 5 is the table of all error messages on the final validation report.  There is no change table associated with this update, but I think it is likely that this is related to the promised update of the system to allow for the new modification/inactivation policy that goes into effect May 19th.  (See my earlier posts and/or resource page for more on this)  Links below:
 https://www.qtso.com/mds30.html
 https://www.qtso.com/download/guides/MDS/mds_30/Users_Sec5.pdf

Saturday, May 11, 2013

RUG distribution FY2012: Are you an outlier?

The full year (FY12)  RUG distribution has been posted by CMS on the SNF PPS website (http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Spotlight.html), called "SNF Monitoring."  It is helpful to keep up with these stats, because this is one way CMS decides who is an outlier for Medical Review.  If your Rehab Ultra numbers are much greater than this, you can expect medical review.  Crucial numbers are:  RU:  48.6%   COT: 11%.

Here are some of the stats from this report:


Table 2: SNF Case-Mix Distribution for Therapy RUG-IV Groups, by Minor RUG-IV Therapy
Categories


FY 2011
FY 2012
Ultra-High Rehabilitation (≥ 720 minutes of therapy per week)
44.8%
48.6%
Very-High Rehabilitation (500 – 719 minutes of therapy per week)
26.9%
25.6%
High Rehabilitation (325 – 499 minutes of therapy per week)
10.8%
10.1%
Medium Rehabilitation (150 – 324 minutes of therapy per week)
7.6%
6.2%
Low Rehabilitation (45 – 149 minutes of therapy per week)
0.1%
0.1%



Table 4: Distribution of MDS assessment types


FY 2011
FY 2012
Scheduled PPS assessment
95%
84%
Start-of-Therapy (SOT) assessment
2%
2%
End-of-Therapy (EOT) assessment (w/o Resumption)
3%
3%
Combined SOT/EOT
0%
0%
End-of-Therapy assessment (w/ Resumption) (EOT-R)
N/A
0%
Combined SOT/EOT-R
N/A
0%
Change-of-Therapy (COT) assessment
N/A
11%

Friday, May 10, 2013

Wage Index changes in PFR FY14: Your 1.4% increase may be eaten up in a lower labor cost adjustment

The SNF proposed final rule (See link on resources page)  has changes to some wage indexes.  Some areas have changed from urban to rural and vice versa.  The CMI for RUG-IV is different for urban and rural facilities.  It is worth looking your area up (I download the file as an adobe document then use "search")  to see if you are getting an additional break or additional hit in your rates for FY14.  For example,  my home, Virginia Beach, VA had a wage index last year (FY13)  of 0.9208  and this  year the wage index is 0.8928.  So,  the 1.4% increase will be mitigated somewhat by the lower wage index adjustment.  The wage index adjustment is explained in the final rule, but basically,  they take about 70% of the per diem rate and apply the wage index adjustment to it.  That means the base urban or rural rate will be adjusted upwards or downwards.  (Accountants, forgive me for the oversimplification & number rounding).  Let's say the daily rate is $400.00.  They take roughly 70% of that, which would be about $280, then apply your wage index adjustment:  280 x .8928 = $250.  That $280 becomes $250, and they add the $250 to the 30% of the rate that was not labor costs, so:  250 + 120 =  $370.  
Summary:  The $400 daily rate becomes, for my facility, $370.

Now, let's use Virginia Beach again to show what adjusting your wage index does for you:

RUC in FY13:  $569  (after labor cost adjustment  $538)
RUC in FY14:  $577  (after labor cost adjustment  $534)

RUC with FY13 labor cost adjustment for Virginia Beach:(roughly)  70% of 569 = $398 x .9208 = $367 + 171 = 538

RUC with FY14 labor cost adjustment for Virginia beach (roughly)  70% of 577 = 403 x .8928 = 360 + 174 = 534

So,  the 1.4% increase becomes roughly a four dollar decrease.

New RAI manual now scheduled to be published next week

The semi-annual RAI Manual update is going to be posted some time next week according to CMS SNFODF email distribution.

Thursday, May 9, 2013

NEW Medical Review Organization for CMS: SMRC


The Centers for Medicare & Medicaid Services (CMS) has contracted with StrategicHealthSolutions, LLC, a Supplemental Medical Review/Specialty Contractor (SMRC) to perform and/or provide support for a variety of tasks aimed at lowering the improper payment rates and increasing efficiencies of the medical review functions of the Medicare and Medicaid programs.

This is in addition to the MACs and RACs.  This is yet another medical review initiative.

One of the primary tasks will be conducting nationwide medical review as directed by CMS. The medical review will be performed on Part A, Part B, and DME providers and suppliers. Services/Provider Specialties to be reviewed will be selected by CMS, Provider Compliance Group/Division of Medical Review and Education (DMRE).  The SMRC will evaluate medical records and related documents to determine whether Medicare claims were billed in compliance with coverage, coding, payment, and billing practices.

Read more at:  

CMS Website:  http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/SMRC.html

Contractor Website:  http://www.strategichs.com/index.php/contracts/

StrategicHealthSolutions is based in Omaha, NE.  From their website:  StrategicHealthSolutions, LLC (Strategic) is a woman-owned small business designed to provide professional health care-related solutions and services for State and Federal Government. The primary focus is on the Department of Health and Human Services, specifically, the needs of State Agencies and the Centers for Medicare and Medicaid Services (CMS).

Margaret (Peg) StessmanPresident
Chief Executive Officer 
Ms. Stessman has more than 22 years of senior management experience in healthcare administration, including commercial insurance, Medicare, and Medicaid. Having worked in all three arenas has given her a thorough knowledge and understanding of both Medicare and Medicaid Fee-For-Service and Managed Care programs. She has a strong background in Quality Assurance and Utilization Management, clinical practice guideline development, data analysis and interpretation, practice pattern identification, as well as in-depth knowledge of operational and financial program management and insurance company practices, including claims processing, provider relations, and appeals and grievances. Ms. Stessman is a Registered Nurse and has maintained an active license in the State of Nebraska since 1985.


This contractor has gotten multiple CMS contracts in the past two years and is currently hiring for multiple positions.  Be alert to records requests from them.  If SNF providers receive any records requests from them, let me know and I will post a running tally here of what they are doing.  Here are their current openings.  I think it is significant that they are prepared to hire this many people at once.  Looks like they are well funded and preparing to begin some significant Medical Review initiatives based on how many folks they are taking on  now.  No word on whether SNF (A or B)  charts are one of their concerns at present.

Administrative Assistant I - Omaha, NE

Coding Specialist I - Omaha, NE (3 Positions) and Columbia, MD (1 Position)

Controller - Omaha, NE

Customer Support Representative - Omaha

Dental Auditor (Pediatric Consultant)

Healthcare Data Analyst I - Omaha, NE

Medical Review Nurse I-III - Omaha, NE or Columbia, MD

Medical Review Nurse Supervisor - Omaha, NE (1 Position) and Columbia, MD (1 Position)

Medical Review (Nurse) Training and Quality Assurance Specialist - Omaha, NE

Project and Risk Manager - Columbia, MD

Review Coordinator (Medicare Part D)

SharePoint Developer/Administrator - Omaha, NE

Graphic Artist II - Omaha, NE



Wednesday, May 8, 2013

CMS posts new DRAFT RUG IV Grouper for Oct 1 updates


MDS 3.0 Technical Information  


http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIMDS30TechnicalInformation.html

What's New -

May 8, 2013
A new version of the RUG-IV Specifications and DLL Package (V1.03.0) was posted.  This version is scheduled to become effective October 1, 2013.  This Version 1.03.0 of the RUG-IV grouper should be considered provisional or draft and is subject to change until the final specifications are published.  Please refer to the “RUGIV grouper overview” document for a summary of the changes that were made to this version.
A new version (V1.13.1) of the data submission specs was posted.  Documents associated with this version are dated 04/09/2013.  This version is scheduled to become effective October 1, 2013.  Version 1.13.1 should be considered provisional or draft and is subject to change until the final specifications are published.  Please refer to the Data Specifications Overview document for a summary of the changes that were made to this version.  Details about the changes are contained in the Edit Change Report and the Item Change Report.  Note that an errata document for V1.13.1 has also been posted which addresses several errors that have been identified.




 This is user documentation for the DLL provided in the RUG-IV Logic Version 1.03 Code Version 1.03.0 Grouper package. The DLL conforms to the SNF PPS Proposed Rule for FY2014. Because this version is based on the Proposed Rule, it is labeled as “DRAFT”. When the Final Rule is published, a “Final” version of the grouper package will be released. 
The changes with version 1.03.0 are: 
1. Add a new value to rehabilitation classification type parameter (sRehabType). This new value of MCAR3 for FY2014 Medicare classification works the same as the MCAR2 (FY2012 and FY2013 Medicare classification) value but changes the classification requirements for Medium Rehabilitation and Low Rehabilitation as follows: a. For Medium Rehabilitation, the requirement of 5 or more therapy days across the three disciplines (sum of O0410A4, O0400B4, and O0400C4) is being replaced by 5 or more distinct calendar days of therapy (O0420). 
b. For Low Rehabilitation, the requirement of 3 or more therapy days across the three disciplines (sum of O0410A4, O0400B4, and O0400C4) is being replaced by 3 or more distinct calendar days of therapy (O0420). 

2. As of October 1, 2013, the MDS 3.0 nutrition item K0700A indicating the proportion of calories by artificial route in the last 7 days is being replaced by three new calorie proportion items K0710A1 (received while not a resident), K0710A2 (received while a resident), and K0710A3 (received in the entire 7 days). For assessments with assessment reference date (A2300) on or after 10/1/2013, K0700A is being replaced by K0710A3 in the RUG classification logic. 
3. As of October 1, 2013, the MDS 3.0 nutrition item K0700B indicating the average fluid intake by artificial route in the last 7 days is being replaced by three new fluid intake items K0710B1 (received while not a resident), K0710B2 (received while a resident), and K0710B3 (received in the entire 7 days). For assessments with assessment reference date (A2300) on or after 10/1/2013, K0700B is being replaced by K0710B3 in the RUG classification logic. 

ABN for Part B therapy in a SNF now mandatory, not voluntary, for services after cap with no exception

CMS issued a memo in a Q&A format that can be found here:  http://www.cms.gov/Medicare/Billing/TherapyServices/Downloads/ABN-Noncoverage-FAQ.pdf.

Here is the applicable portion that is a change to previous guidance, but the entire memo needs to be read and understood.  The ABN they are talking about is the CMS-R-131:



 Q1: How did the American Taxpayer Relief Act (ATRA) of 2012 (PL 112-240, January 3, 2013) affect liability provisions for services above the therapy cap? 
A1: Prior to the ATRA, original (fee-for-service) Medicare claims for therapy services at or above therapy caps that did not qualify for a coverage exception were denied as a benefit category denial, and the beneficiary was financially liable for the non-covered services. CMS encouraged suppliers and providers to issue a voluntary Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, as a courtesy, to alert beneficiaries to potential financial liability. However, issuance of an ABN wasn’t required for the beneficiary to be held financially liable. 
Section 603 (c) of the ATRA amended §1833(g)(5) of the Social Security Act (the Act) to provide limitation of liability (LOL) protections (See §1879 of the Act) to beneficiaries receiving outpatient therapy services on or after January 1, 2013, when services are denied and the services provided are in excess of therapy cap amounts and don’t qualify for a therapy cap exception. Now, the provider/supplier must issue a valid, mandatory ABN to the beneficiary before providing services above the cap when the therapy coverage exceptions process isn’t applicable. The ABN informs the beneficiary why Medicare may not or won’t pay for a specific item or service and allows the beneficiary to choose whether or not to get the item or service and accept financial responsibility. ABN issuance allows the provider to charge the beneficiary if Medicare doesn’t pay. If the ABN isn’t issued when it is required and Medicare doesn’t pay the claim, the provider/supplier will be liable for the charges. 



Tuesday, May 7, 2013

AMDA Seminar on managing mood/behavior challenges in LTC


amda:  Dedicated to Long Term Care Medicine

Navigating Mood and Behavior Challenges in Long Term Care:

Strategies for Optimal Outcomes


Mood and behavioral problems impact the majority of patients in long term care. State surveyor guidance will continue to review the use of atypical antipsychotic medications to treat Behavioral and Psychological Symptoms of dementia (BPSD). Overuse of antidepressants is also a growing concern and the treatment of the “depression of Alzheimer’s disease” needs to be understood.
This course will pursue an evidence-based approach to non-drug interventions. Physicians need to know when, how and why to use a wide complement of diagnostic tools and interventions for better patient care. We will also describe AMDA’s quality initiative with the National Quality Forum and two measures that impact both short-term and long-term stay residents who have dementia or Alzheimer’s disease but do not yet carry an accurate diagnosis. Breakout workshops will again provide practical strategies and solutions in navigating mental health challenges in the long term care setting. Case based presentations in abstract form will be submitted by attendees for full panel discussion in the afternoon. Relevant handouts and take home tools will be disseminated.

Target Audience: Medical directors, attending physicians, practitioners, nurses and other professionals practicing in long term care.

Overall Course Objectives

Upon completion of the course, participants should be able to:
  • Review AMDA and CMS initiatives regarding atypical antipsychotic prescribing in long term care settings.
  • Utilize the checks and balances in F tag 329 that protect patients and practitioners alike.
  • Identify criteria that characterize advanced stages of dementia including Alzheimer’s disease.
  • Discuss treatment options for long term care residents with depression.
  • Explain the evidence supporting non-pharmacologic interventions to improve the behavioral disturbances of advanced dementia.
  • Apply AMDA NQF diagnostic criteria for dementia and Alzheimer’s disease for both long-term and short-term stay residents.
  • Engage in case presentations illustrative of the mood and behavioral challenges faced in today’s long-term care environment.
Sep 21, 2013  New Orleans, LA             More information:  AMDA.com  click "education"  

Friday, May 3, 2013

SNFABN/Denial Letters

See the Resources section of my website (JudyWilhide.com)  for CMS web links for these notices.  A resident who is remaining in the Nursing Facility under another pay source after the last covered day (LCD)  on the Notice of Medicare Non-Coverage (NOMNC)  must be issued a second letter.  This letter gives the resident the right to a standard claim appeal, also known as a demand bill.  This is in addition to and not instead of the NOMNC.    You have six choices for which form to use.  You can use either the SNFABN or one of the five denial letters on the CMS website.

Judy's opinion:  Folks who use the SNFABN get more demand bills because of the poor wording on the SNFABN.  Folks who use a denial letter don't get as many demand bills.   Read the choices on the SNFABN and then read the choices on the denial letters and decide for yourself.

If you choose the denial letters, there are two of the five that are appropriate in most cases.  I have posted these two in my Resources on my website.  One is called "SNF Determination on Continued Stay."  This one is used when the resident has used some SNF Part A days and you are cutting them because they no longer meet SNF level of care (LOC)  criteria.  The second one, rare but possible, is the "Determination on Admission."  This one is used if they have a three day qualifying stay,  have days available, but do not meet SNF LOC criteria.  They have no skilled need so you never put them on Medicare.

The Rose Blumkin Jewish Home Omaha Nebraska

I was honored to tour the Rose Blumkin Jewish Home in Omaha Nebraska yesterday, and my life and practice will never be the same.  This community is physically located in the same structure as the Omaha Jewish Community Center.  I encourage you to check out "Main Street"  within the community at this link:  http://www.rbjh.com.   Don't miss the  virtual tour link.  Once you've fully explored this website,  go to the link for the JCC at:  http://www.jewishomaha.org.   I saw the young children enrolled in the JCC Child Development Center (CDC)  joyfully visiting the elders on Main Street, where the playground for the CDC was located.  I saw the elderly residents engaged and honored as a vital part of this vibrant intergenerational  community.    I enjoyed  one of the best deli egg salad sandwiches with coffeecake I've ever eaten from their on-site catering service Star Catering.   Imagine a world where the food in the nursing community is so good that it's open to the public every Friday, and they serve over a hundred folks from the surrounding area for lunch.  The neighborhoods in the Jewish Home blend seamlessly with the Main Street activities and the rest of the JCC.  Painted in large golden letters at the entrance to each neighborhood is the mitzvah: 
"You shall rise and show respect to the aged."  

Some were visiting for short term rehab, some were fortunate enough to be home.   This  place isn't  a "home like environment,"  or a "community like setting."  This is home.  This is a community where the elders are honored for their wisdom and life experiences.  I could go on and on, but you have to see it for yourself.  I encourage you to visit their website and if you are ever in Omaha,  stop by and visit!  

Wednesday, May 1, 2013

Some surprises in the new Modification Policy

According to the PPTs posted on the CMS website (See my blog item earlier today for link),  we will get some relief from losing money over innocent typos, but not what we have hoped for.
Here are the rules:

You can modify the ARD, Discharge date, entry date, and reason for assessment*(with qualifications) for typos only.

If you want to modify a reason for assessment (A0310)  the Item Set Code (ISC)  must NOT change.

The ISCs are found on page 2-10 of the RAI manual.

Example:  You coded a PPS 30 day/COT OMRA, but you meant to code it as just a PPS 30 day.  You may modify and remove the COT, because the ISC for this combination is "NP", and the ISC for a stand alone 30 day is NP.

BUT, you may not modify this combination to remove the PPS 30 day and leave the COT, because the stand alone COT ISC is  "NO."

AND, you may only modify ARDs for a typo in the ARD.   Example, the 14 day was done by the team with and ARD of 5/12, but MDSC typed in 5/21.  You can modify that.

When you CAN'T modify:   You did the MDS for ARD of 5/12, but you would have a better RUG if you had used 5/13.  You are still out of luck.


One MDS change in Proposed Final Rule FY14

There are no new OMRAs or other big MDS changes in the FY 14 proposed final rule.  There is a change in how one qualifies for Rehab Medium and Rehab Low (+extensive).  Since the implementation of PPS,  one could qualify for Rehab Medium with 5 treatment days, not 5 calendar days.   One could also qualify for Rehab Low with 3 treatment days, not 3 calendar days.  Example:  One day with OT, PT and ST, and another day with OT and PT is five treatment days.  If the total RTM for those 5 treatment days is at least 150,  the MDS qualified for Rehab Medium.

CMS is proposing to add block O0420 to the MDS on October 1st that will collect distinct calendar days of therapy.   CMS says it was always the intent to require distinct calendar days, but the  grouper and the MDS has never been written in a manner to capture the distinct days.

There is a small rate increase.  For example, the Urban RUC is about seven dollars more.  

They discuss rebasing the rates using FY10 cost reports, and they discuss the on-going project to attempt to determine another way to reimburse therapy in a SNF.