NQF Endorses SNF QM concerning re-hospitalizations along with many others: NQF EMail

From Judy:  This does not mean the measure is implemented.  It means NQF has endorsed the measure and sent it back to CMS who has final say on implementation.  Measure 2510, below is the one for SNFs and can be downloaded by clicking the link.  The following is from an NQF email sent today:

All-Cause Admissions and Readmissions Measure Endorsement 

The National Quality Forum (NQF) has endorsed 17 All-Cause Admissions and Readmissions Measures. Many new measures submitted to this project examined readmissions in post-acute care settings (SNR, IRF, LTCH, Dialysis Facilities, and Home Health). The All-Cause Admissions and Readmissions Standing Committee evaluated these 17 measures, which consisted of 15 new measures and two measures undergoing maintenance review, against NQF's standard measure evaluation criteria.

The Executive Committee unanimously ratified the CSAC's recommendation to endorse admission and readmission measures only with the following conditions:

1. The Admissions/Readmissions Standing Committee will determine which measures must enter the trial period for consideration of Socio-demographic Status (SDS).
2. One-year look-back assessment of unintended consequences. NQF staff will work with Admissions/Readmissions Standing Committee and CMS to determine a plan for assessing potential unintended consequences. The evaluation of unintended consequences will be initiated within approximately one year and possible changes to the measures based on these data will be discussed at that time.

These measures were endorsed with these conditions to ensure that the concerns expressed throughout the consensus process were addressed. To address the lack of consensus in the membership, NQF held a stakeholder webinar with members to discuss the measures under consideration. There were 134 participants on the webinar representing members from all councils. The call provided an opportunity for NQF Members to voice their concerns about overarching issues and specific measures. Based on polling of webinar participants, the highest priority issue related to adjustment of the measures for SDS. There were also concerns regarding the relationship between admission and readmissions rates.

The Admission/Readmission Standing Committee reviewed a total of 18 measures, 15 new measures and three undergoing maintenance review. During the Committee's review of the measures, 15 of the 18 measures were recommended for endorsement. The committee did not reach the 60 percent approval threshold on three measures (Measure # 0327 Risk-Adjusted Average Length of Inpatient Hospital Stay; Measure 2496 Standardized Readmission Ratio (SRR) for dialysis facilities; and Measure # 2512 All-Cause Unplanned Readmission Measure for 30 Days Post Discharge from Long-Term Care Hospitals (LTCHs)). Two of the three measures without consensus were approved by the CSAC and the Board. These include readmission measures for dialysis facilities and LTCHs. While concerns regarding attribution were cited for the dialysis measure, the measure was approved to facilitate systems of care to work together to better coordinate care and reduce readmission. For the LTCH readmission measure, concerns focused on the inclusion of readmission to LTCH or acute care hospitals. Additional analyses demonstrated that the number of patients readmitted to LTCHs is relatively low and the strategies to reduce readmissions and improve care coordination should reduce readmissions to either setting.

1. NQF will convene the Admissions/Readmissions Standing Committee to determine which of the recommended measures in this project must enter the trial period for consideration of SDS adjustment.
2. Measure developers and CMS will be required to provide additional analyses outlined by the SDS Expert Panel on the conceptual and empirical relationship between SDS factors and the outcome measured.
3. NQF will work with measure developers and CMS to determine what type of additional analyses would be appropriate for examining potential unintended consequences identified by stakeholders, in particular the relationship between admissions and readmissions.
4. A one-year look-back assessment will examine whether SDS adjustment is appropriate, along with an examination of potential unintended consequences identified by stakeholders.

Measures Endorsed with Conditions:

• Measure 0505: Hospital 30-day all-cause risk-standardized readmission rate (RSRR) following acute myocardial infarction (AMI) hospitalization (ZIP)
• Measure 0695: Hospital 30-Day Risk-Standardized Readmission Rates following Percutaneous Coronary Intervention (PCI) (ZIP)
• Measure 2375: PointRight® Pro 30™ (ZIP)
• Measure 2380: Rehospitalization During the First 30 Days of Home Health (ZIP)
• Measure 2393: Pediatric All-Condition Readmission Measure (ZIP)
• Measure 2414: Pediatric Lower Respiratory Infection Readmission Measure (ZIP)
• Measure 2496: Standardized Readmission Ratio (SRR) for dialysis facilities (ZIP)
• Measure 2502: All-Cause Unplanned Readmission Measure for 30 Days Post Discharge from Inpatient Rehabilitation Facilities (IRFs) (ZIP)
• Measure 2503: Hospitalizations per 1000 Medicare fee-for-service (FFS) Beneficiaries (ZIP)
• Measure 2504: 30-day Rehospitalizations per 1000 Medicare fee-for-service (FFS) Beneficiaries (ZIP)
• Measure 2505: Emergency Department Use without Hospital Readmission During the First 30 Days of Home Health (ZIP)
• Measure 2510: Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM) (ZIP)
• Measure 2512: All-Cause Unplanned Readmission Measure for 30 Days Post Discharge from Long-Term Care Hospitals (LTCHs) (ZIP)
• Measure 2513: Hospital 30-Day All-Cause Risk-Standardized Readmission Rate (RSRR) following Vascular Procedures (ZIP)
• Measure 2514: Risk-Adjusted Coronary Artery Bypass Graft (CABG) Readmission Rate (ZIP)
• Measure 2515:Hospital 30-day, all-cause, unplanned, risk-standardized readmission rate (RSRR) following coronary artery bypass graft (CABG) surgery(ZIP)
• Measure 2539: Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy (ZIP)

Any party may request reconsideration of the 17 endorsed quality measures by submitting an appeal no later than January 28. To submit an appeal, go to the NQF Measure Database. For an appeal to be considered, the notification must include information clearly demonstrating that the appellant has interests directly and materially affected by the NQF-endorsed recommendations and that the NQF decision has had (or will have) an adverse effect on those interests. All appeals are published on the NQF website.

Please contact the project team at readmissions@qualityforum.org with any questions.

Notice for Part B charges in a SNF for the first of the year 2015

This is from the email list serve for CMS MLN Connect Special Edition dated Monday, Dec 29, 2014.  I suspect the MACs will also post and disseminate it.

This applies to (among other things)  Part B therapy in a SNF.  The CPT codes for Part B are from the Physician's Fee Schedule:

Holding of 2015 Date-of-Service Claims for Services Paid Under the 2015 Medicare Physician Fee 

On November 13, 2014, the CY 2015 Medicare Physician Fee Schedule (MPFS) final rule was published in the Federal Register. In order to implement corrections to technical errors discovered after publication of the MPFS rule and process claims correctly, Medicare Administrative Contractors will hold claims containing 2015 services paid under the MPFS for the first 14 calendar days of January 2015 (i.e., Thursday January 1 through Wednesday January 14). The hold should have minimal impact on provider cash flow as, under current law, clean electronic claims are not paid sooner than 14 calendar days (29 days for paper claims) after the date of receipt.

MPFS claims for services rendered on or before Wednesday Dec 31, 2014 are unaffected by the 2015 claims hold and will be processed and paid under normal procedures and time frames. 

Page 2-38 diagram incorrect and should not be used, per CMS

From North Carolina Myers & Stauffer newsletter:

Subsequent to the October 1, 2014 CMS release, there was an additional update dated October 9, 2014. However,

the later October 2014 (R) page 2-38; Entry, Discharge, and Reentry Algorithm diagram has been deemed incorrect by CMS and is expected to be corrected in the next revisions slated for 2015. Guidance from the RAI coordinators is to adhere to the prior (October 2014) diagram for accuracy. Please refer any questions to your state RAI coordinator.

Dec 4: Updated info on submitting HIPPS codes on MA Plan Claims: Some Relief on the Admission HIPPS Requirements

We have a new memo from the CMS Medicare Plan Payment Group.  It is posted on my website at:  http://media.wix.com/ugd/255ff5_771cdbdff5614bfab8650429f758dfa7.pdf.

AHIMA: ICD-10 Delay Left Out of Proposed Spending Bill

From AHIMA E-Alert:  Links from AHIMA article likely will not work but more info is at www.AHIMA.org:

PROPOSED SPENDING BILL DOES NOT INCLUDE ICD-10

On Tuesday night, after over two uncertain weeks in which select physician groups, including the Texas branch of the American Medical Association (TMA), pushed lawmakers to include a two-year delay of ICD-10-CM/PCS implementation in a federal spending bill to be passed before the end of this year, the bill was introduced before Congress without language to delay ICD-10. The spending bill must be signed into law by Congress to avoid a government shutdown.

The bill, dubbed a "cromnibus" (part continuing resolution, part omnibus) and officially titled "HR 83 – Consolidated and Further Continuing Appropriations Act, 2015," next has to pass the House of Representatives and the Senate without amendment. The House is slated to consider this legislation later today. AHIMA is encouraging members to continue to advocate for ICD-10 implementation and contact Congress to ensure that amendments are not added to this funding bill.

The Coalition for ICD-10 has cautioned supporters of the October 1, 2015 implementation date to remain vigilant in case language delaying ICD-10 is slipped into the bill as an amendment. In keeping with that message, an #ICD10Matters Twitter Rally yesterday focused on getting the "no delay" message to legislators resulted in approximately 5,000 tweets in one hour.

On Wednesday afternoon, chairman Fred Upton (R-MI) and Chairman Pete Sessions (R-TX), to whom the TMA specifically appealed to add legislation delaying ICD-10 to the current "lame duck" Congress, released this statement on ICD-10 through the Energy & Commerce Committee, chaired by Upton: "As we look ahead to the implementation date of ICD-10 on October 1, 2015, we will continue our close communication with the Centers for Medicare and Medicaid Services to ensure that the deadline can successfully be met by stakeholders." In the 114th Congress, Upton and Sessions will be asking key stakeholders for information about ICD-10 readiness, including both supporters and opponents of the code sets.

Read more at the Journal of AHIMA website.

WHAT DO OPPONENTS HAVE AGAINST ICD-10?

Among some physicians who oppose ICD-10, "misinformation and scare tactics" such as "ICD-10 is too expensive, too difficult to learn, and too complex to implement" may have been "repeated so often people began to believe them," AHIMA official Sue Bowman, MJ, RHIA, CCS, FAHIMA, senior director of coding policy and compliance, and public policy & government relations, said this week. A Q&A with Bowman on the website HITECH Answers, outlines the negative impacts that would be associated with any further delay of ICD-10.

Read the Q&A.

New SNF Educational Material Published by CMS

"Skilled Nursing Facility (SNF) Billing Reference<http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/SNFSpellIllnesschrt.pdf>" Fact Sheet (ICN 006846) was revised and is now available in downloadable format. This fact sheet is designed to provide education on Medicare Part A which covers skilled nursing and rehabilitation care in a SNF under certain conditions for a limited time. It includes information for SNF providers about: SNF coverage; SNF payment; and SNF billing.

This covers the benefit period and some unusual billing situations.  


"Skilled Nursing Facility Prospective Payment System<http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/CMS1243671.html?DLPage=1&DLFilter=skilled&DLSort=0&DLSortDir=ascending>" Fact Sheet (ICN 006821) is designed to provide education on the Skilled Nursing Facility Prospective Payment System (SNF PPS). It includes the following information: background and elements of the SNF PPS.

CDC Long Term Care Toolkit for Influenza Season Free and Available Now

From LeadingAge:

LeadingAge has been collaborating directly with the Centers for Disease Control and Prevention (CDC) in developing resources and disseminating information to members on influenza immunization and the best approaches in combatting the flu virus. 

LeadingAge’s role includes distributing CDC materials as the information becomes available, providing links to relevant webinars and additional staff education resources. 

This flu season, for the 1^st time, the CDC National Vaccine Program Office (NVPO) has developed a toolkit specifically targeted to supporting staff vaccination programs in long-term care.

The toolkit includes resources for increasing influenza vaccination among healthcare personnel in long-term care settings; suggestions for implementing flu vaccine programs at the workplace; and data on flu vaccines and why it's important that employees receive them.

The CDC’s long-term care toolkit is free-of-charge and is now live at: http://www.cdc.gov/flu/toolkit/long-term-care/.

CMS Revises Appendix PP to the SOM: Guidance to Surveyors Many sections 'effective 11-26-14'

This iteration of Appendix PP has several sections that are listed as "effective 11-26-14."    There are also additions that have been previously released in S&C Memos but not incorporated into  the actual SOM available for download online.  You can see the actual document Here.  


SUBJECT: Revisions to State Operations Manual (SOM), Appendix PP - "Guidance to
Surveyors for Long Term Care Facilities"

I. SUMMARY OF CHANGES: This instruction revises the Interpretive Guidelines and, in
some instances, associated Investigative Protocols for several F Tags to reflect incorporation of
Survey & Certification policy memo guidance issued from Fiscal Year 2003 through May 2014.

NEW/REVISED MATERIAL - EFFECTIVE DATE: November 26, 2014
IMPLEMENTATION DATE: November 26, 2014

Disclaimer for manual changes only: The revision date and transmittal number apply to the
red italicized material only. Any other material was previously published and remains
unchanged. However, if this revision contains a table of contents, you will receive the
new/revised information only, and not the entire table of contents.

II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual not updated.)
(R = REVISED, N = NEW, D = DELETED) - (Only One Per Row.)

R/N/D CHAPTER/SECTION/SUBSECTION/TITLE
R Appendix PP/F155/§483.10(b)(4) and (8)
R Appendix PP/F161/ §483.10(c)(7) Assurance of Financial Security
R Appendix PP/F202/§483.12(a)(3) Documentation
R Appendix PP/F208/§483.12(d) Admissions Policy
R Appendix PP/F222/§483.13(a) Restraints
R Appendix PP/F278/§483.20(g) Accuracy of Assessment
R Appendix PP/F281/§483.20(k)(3)
R Appendix PP/F286/§483.20(d) Use
R Appendix PP/F309/§483.25 Quality of Care
D Appendix PP/F321/§483,25(g) Naso-Gastric Tubes
R Appendix PP/F322/§483.25(g) Naso-Gastric Tubes
R Appendix PP/F329/§483.25(l) Unnecessary Drugs
R Appendix PP/F332andF333/§483.25(m) Medication Errors
R Appendix PP/F371/§483.35(i) Sanitary Conditions
R Appendix PP/F388/§483.40(c)(3) Except as provided in paragraphs (c )(4) and (f) of this section, all required physician visits must be made by the physician personally.
R Appendix PP/F390/§483.40(e) Physician Delegation of Tasks in SNFs

R Appendix PP/F425/§483.60 Pharmacy Services

SNF Co-Pay to be $157.50 in CY 2015

Medicare deductible/copay for CY 2015


SNF Co-pay up $5.50/day to $157.50 for 2015 from 152.00 in CY 2014.  The SNF benefit incurs the co-payment beginning on day 21 of the SNF Stay.  This is a 3.62% increase.  If a beneficiary uses all 80 remaining SNF days, the  out-of-pocket cost will be $12,500.00.  Many beneficiaries have insurance to assist with the co-pay.

In 2013 it was $148/day. In two years the co-pay has increased 6.42%.

CY 2015 Therapy Cap Values Announced

Therapy Cap CR to 100-04

Pub. 100-04

Transmittal: 3120

Date: November 14, 2014

Change Request: 8970

SUBJECT: Therapy Cap Values for Calendar Year (CY) 2015 

EFFECTIVE DATE: January 1, 2015 

*Unless otherwise specified, the effective date is the date of service. 

IMPLEMENTATION DATE: January 5, 2015 

I. GENERAL INFORMATION 

A. Background: The Balanced Budget Act of 1997, P.L. 105-33, Section 4541(c) applies, per beneficiary, annual financial limitations on expenses considered incurred for outpatient therapy services under Medicare Part B, commonly referred to as “ therapy caps.” The therapy caps are updated each year based on the Medicare Economic Index. An exceptions process to the therapy caps for reasonable and medically necessary services was required by section 5107 of the Deficit Reduction Act of 2005. The exceptions process for the therapy caps has been continuously extended several times through subsequent legislation. Most recently, section 103 of the Protecting Access to Medicare Act of 2014 extended the therapy caps exceptions process through March 31, 2015. 

B. Policy: Therapy caps for CY 2015 will be $1,940. 

Contractors shall update the allowed dollar amount for CY 2015 outpatient therapy limits to $1,940 for physical therapy and speech-language pathology combined and $1,940 for occupational therapy.

In April, 2015 we will have 45 days instead of 30 to respond to ADRs for pre-payment review

MLN Matters®Number: MM8583 Revised	Related Change Request (CR) #: CR 8583
Related CR Release Date: November 14, 2014	Effective Date: April 1, 2015
Related CR Transmittal #: R554PI	Implementation Date: April 6, 2015

 This article is based on Change Request (CR) 8583, which instructs MACs and Zone Program Integrity Contractors (ZPICs) to produce pre-payment review Additional Documentation Requests (ADRs) that state that providers and suppliers have 45 days to respond to an ADR issued by a MAC or a ZPIC. Failure to respond within 45 days of a pre-payment review ADR will result in denial of the claim(s) related to the ADR. Make sure your billing staffs are aware of these changes. 

The official instruction, CR 8583, issued to your MAC regarding this change, is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R554PI.pdf on the Centers for Medicare & Medicaid Services (CMS) website. 

The MLN Article is can be found Here.

Latest on Virginia Price Based Reimbursement for Nov 1, 2014 from VHCA

Price Based Reimbursement Update – RUGs Billing as of November 1st

As you know, Virginia Medicaid has made the shift to individual RUGs-based billing for dates of service on and after November 1st.  DMAS has made some updates to the FAQs available on their website and we encourage you to review the questions and answers.

For example, DMAS indicates that under the price-based RUGs methodology, “If the calculated price-based reimbursement exceeds the charges, DMAS will pay the calculated rate. The lesser of billed charges theory will not apply to price-based reimbursement payments (emphasis added).”  This is very important to some members who were concerned that the price-based rates for the high intensity RUGs could actually exceed the private pay rate (charges).  As indicated, DMAS will pay the calculated rate even if that rate exceeds charges.  As CCC nursing facility reimbursement is required to follow the FFS methodology, the MMPs are required to take the same approach (if you experience otherwise, please let us know immediately through the CCC Issue Log.

In other updates related to RUGs-based payment, DMAS Claims processing can now accept multiple RUGs with relevant dates of service on one claim.  The September 26th billing memo indicated that “Unlike Medicare, if there is a change in the RUG assignment during the billing period, a separate claim should be submitted with revenue code “0022” and the new RUG code should be reported for the dates of service to which the new RUG assignment applies.”  DMAS has just provided VHCA notice that “We have tested the system and confirmed the ability to accept multiple RUGs for both FFS and crossover claims as of November 3rd.  We have updated the billing guidance to allow nursing facilities to bill multiple RUGs on a claim.  We will be issuing a notice to nursing facilities to announce the updated billing instructions through GoFileRoom on Wednesday [11/5].”

DMAS has also announced they will be publishing a recorded WebEx session detailing billing instructions for nursing facility price-based reimbursement effective November 1, 2014.  The recorded session will be available for providers to view no later than November 5, 2014, according to DMAS (the presentation can be found by clicking here).  DMAS will also be conducting live Question and Answer (Q&A) sessions on November 13 (2 pm) and 14 (9 am and 2 pm), according to their website, to answer questions about the billing procedures for price-based reimbursement.  Registration for the live sessions will be available on the DMAS websiteunder Learning Network, Current and Upcoming Training Events, or Upcoming WebEx Sessions.

Finally, DMAS has also provided a copy of a clean claim and resulting remittance advice that reflects the testing of the claim submission and payment process for the new methodology.

Virginia DMAS Posted New FAQ and New Link to Webinar to Explain Nov 1 Changes to State Medicaid Payment System for Nursing Facilities

DMAS has posted two new items on Nov 4, 2014 pertaining to the Nov 1 changes to how the nursing facility per diem medicaid rate will be set.

Instructions to watch the webinar are here. 

The new FAQ dated 11/4/14 are here.


The rates to be used to calculate the per diem rate on Nov 1 are posted here.

CMS Publishes new S&C Letter on Expansion of MDS Focused Survey: Will also verify staffing levels

CMS S&C Letter Posted for Expansion of MDS Focused Survey: Staffing Verification Added for 2014 In mid-2014, CMS piloted a short-term focused survey to assess MDS 3.0 coding practices and its relationship to resident care in nursing homes in 5 states. Surveyors (who received specialized training for these surveys) reviewed the nursing home resident assessment processes in more depth than annual surveys. The pilot was completed in 8/14. Findings from the surveys include inaccurate staging and documentation of pressure ulcers, lack of knowledge regarding the classification of antipsychotic drugs, and poor coding regarding the use of restraints. Deficiencies were identified and cited on all but one survey (i.e., 24 of 25 surveys). CMS will expand these surveys in 2015 to be conducted nationwide. The scope of some or all of the focused surveys will also be expanded to include an assessment of staffing levels. “…This assessment will aim to verify the data self-reported by the nursing home, and identify changes in staffing levels throughout the year.” Surveyors collect the CMS-671 [staffing] form in conjunction with Task 2 of the standard/annual survey process (SOM Appendix P). However, as this is the only “snapshot” currently collected, CMS is seeking more information on how staffing levels may fluctuate throughout the year.MDS/Staffing Focused Surveys will be conducted by State Agencies (SAs) nationwide and the number of surveys conducted will vary from state to state. Similar to the 2014 pilot, States will be expected to allocate 2 surveyors for each survey, requiring an estimated 2 days on average. The expanded Focused Surveys are expected to begin in early FY2015. “CMS will work with States to determine how many surveys should be conducted, and when they should take place throughout the year.” CMS will also collaborate with States to identify the specific facilities to be surveyed, and is developing both the survey protocol and tool for the States’ to use. “Record review, augmented by resident observations and staff and/or resident interviews, will be used by surveyors to validate MDS 3.0 coding and staffing levels. Additionally, while on-site, surveyors will ask a series of questions regarding staffing and MDS-related practices of the facility staff, leadership, and others as appropriate.” In addition to phone and email support while SAs are conducting the reviews, CMS will provide a mandatory half day web-based training for the SA staff conducting reviews as well as one manager or trainer within the SA, prior to initiating the surveys. These focused surveys will be surveys of record. o“…MDS 3.0 inaccuracies and/or insufficient staffing noted during the survey will result in relevant citations, including those related to quality of care and/or life, or nursing services. If patterns of inaccuracies are noted, the case will be referred to the CMS RO and CO for follow-up. In the event that care concerns are identified during on-site reviews, the concerns may be cited or referred to the SA as a complaint for further review.

Revised 10/28/14 6:55 PM EST: New Clarification for Virginia Medicaid Per Diem Payments: October 27, 2014

Yesterday DMAS posted a set of FAQs that changed the rules on 'late completion' of an OBRA assessment. Here is the specific Q&A:

Q26. How does DMAS define a late assessment?

A26. If the Omnibus Budget Reconciliation Act (OBRA) quarterly assessment is not scheduled within the timelines as defined by the requirements in the Resident Assessment Instrument (RAI) manual published by CMS, the assessment shall be considered late. The nursing facility shall bill the default RUG code until a new assessment has been completed and accepted.

Assessments with Assessment Reference Dates (ARD) that do not comply with OBRA scheduling requirements are subject to default. For example, a quarterly assessment is required to have an ARD no more than 92 days after the most recent OBRA assessment’s ARD. If the provider does not open this assessment until after the last required date, then the provider will need to bill the default rate from 92 days after the most recent OBRA assessment until the next OBRA assessment’s ARD. All OBRA scheduling requirements as listed in the RAI manual apply.

Comment:  Notice, you  get default for the number of days that ARD is out of compliance,  not for late completion or late transmission.  If you have late OBRAs now that will be used to pay in November,  it would be wise to set a new one now so the latest one won't be late.  

I also notice they do not use the definition of "Late ARD"  for a comprehensive that is more than 366 days from the ARD of the last comprehensive.  They only use the 92 day timeframe.

Additionally there are some troublesome issues in this Q&A.  For example,  it alludes to "opening" the assessment, but they seem to mean "setting the ARD."  I don't think they have finished refining this yet.  It is prudent to strive for timely ARD, completion and transmission to mitigate the possibility of having to bill default.    The phrase  "until a new assessment has been completed and accepted"  can be troublesome as well.  The final implementation memo,  posted in the 'resources' section of my website says this:
 "The new RUG code should not be billed until the MDS assessment has been completed and accepted in the Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system. Once the MDS submission is transmitted and accepted, the new RUG should be billed retroactive to the Assessment Reference Date (ARD) for the MDS submission for the RUG."

So, I believe they mean this:  If the ARD is late,  you bill the default rate for the number of days it is late.  You can't bill at all until the MDS has been accepted.  I do not think they mean that there is a direct financial penalty for late 'completion' or late 'transmission.'

Here is the link to the official document, revised yesterday:

http://www.dmas.virginia.gov/Content_atchs/pr/NF%20Price-Based%20FAQs%20as%20of%2010%2027%2014%20%282%29.pdf

I have been asking many questions to  our state representatives.  I do not believe they fully understand the difference between late ARD, late completion,  late transmittal, etc, so I am asking for your help.  If you also find that questions arise when you read the final memo and the new FAQ document, please ask DMAS at this email:  NFPayment@dmas.virginia.gov.
If they hear from all of you, instead of just me,  it may prove to them that they need to clarify more items.  

A0600 Medicare Number and A030B PPS assessment Fatal Error

Below is guidance provided today (10/20/14)by CMS, from the Virginia & North Carolina RAI Managers. This question has been asked frequently since the October 1^st software update, and CMS has responded to industry questions about the requirement for a Medicare number on PPS MDS assessments.

Question:

 A third-party, private insurance company requires that facilities complete and submit an assessment to them for reimbursement.  Since the beneficiary does not have a Health Insurance Claim Number (HICN) to enter into Item A0600B, the new edit for this item is causing a problem with our software in that the facility cannot “lock” the assessment in order to generate a RUG.  What can a vendor do to assist the facility in order to generate a RUG to send to the third-party insurance company? 

The answer is:

Answer:

 Edit (-3571) for Item A0600B states: “If this is a PPS assessment (A0310B= [01,02,03,04,05,06,07]), then the Medicare or comparable railroad insurance number (A0600B) must be present (not [^]).  Thus, the submission will be rejected if this is a PPS assessment and A0600B is equal to [^].”  In effect, if an assessment is coded as a PPS assessment, it will fail edit -3571 if the HICN or comparable Railroad Insurance number is not present (left blank) in Item A0600B.

Rationale:

Assessments that are being completed for third party billing must NOT be submitted to the QIES ASAP system.  Marking assessments as a PPS assessment when it is not for a Medicare part A Stay does not follow RAI coding instructions.  Submitting assessments marked as PPS to CMS when a facility is not seeking payment for a Medicare part A stay, is a violation of HIPAA’s minimum necessary standard. 

Vendors should work with their providers to meet their needs.  How these needs are met are between the provider and the vendor, i.e., a business arrangement.  A vendor is permitted (and encouraged) to add additional functionality that the free, CMS provided software, jRAVEN, does not provide. 

An example of a possible vendor solution to the question above: The vendor may choose to not enforce this edit until the RUG has been generated since the assessment is for third-party insurance purposes and would not be submitted to CMS. 

Changes to 5 Star Rating System in 2015

CMS Announces Two Medicare Quality Improvement InitiativesAdministration redoubles its efforts to improve quality of post-acute care for Medicare beneficiaries
 

Today, the Centers for Medicare & Medicaid Services (CMS) announced two initiatives to improve the quality of post-acute care.  First, the expansion and strengthening of the agency's widely-used Five Star Quality Rating System for Nursing Homes will improve consumer information about individual nursing homes' quality. Second, proposed new conditions of participation for home health agencies willmodernize Medicare's Home Health Agency Conditions of Participation to ensure safe delivery of quality care to home health patients.

"We are focused on using as many tools as are available to promote quality improvement and better outcomes for Medicare beneficiaries," said Marilyn Tavenner, CMS administrator. "Whether it is the regulations that guide provider practices or the information we provide directly to consumers, our primary goal is improving outcomes."

Nursing Home Five-Star Rating System

Beginning in 2015, CMS will implement the following improvements to the Nursing Home Five Star Quality Rating System:

• Nationwide Focused Survey Inspections:Effective January 2015, CMS and states will implement focused survey inspections nationwide for a sample of nursing homes to enable better verification of both the staffing and quality measure information that is part of theFive-Star Quality Rating System. In Fiscal Year (FY 2014), CMS piloted special surveys of nursing homes that focused on investigating the coding of the Minimum Data Set (MDS), which are based on resident assessments and are used in the quality measures.
• Payroll-Based Staffing Reporting:CMS will implement a quarterly electronic reporting system that is auditable back to payrolls to verify staffing information. This new system will increase accuracy and timeliness of data, and allow for the calculation of quality measures for staff turnover, retention, types of staffing, and levels of different types of staffing. Implementation will be improved by funding provided in the recently enacted, bipartisan Improving Medicare Post-Acute Care Transformation Act (IMPACT) of 2014.
• Additional Quality Measures:CMS will increase both the number and type of quality measures used in theFive-Star Quality Rating System. The first additional measure, starting January 2015, will be the extent to which antipsychotic medications are in use. Future additional measures will include claims-based data on re-hospitalization and community discharge rates. 
• Timely and Complete Inspection Data:CMS will also strengthen requirements to ensure that States maintain a user-friendly website and complete inspections of nursing homes in a timely and accurate manner for inclusion in the rating system. 
• Improved Scoring Methodology:In 2015, CMS will revise the scoring methodology by which we calculate each facility's quality measure rating, which is used to calculate the overallFive Starrating.  We also note that sources independent of self-reporting by nursing homes already are weighted higher than self-reported components in the scoring methodology.

"Nursing homes are working to improve their quality, and we are improving how we measure that quality," said Patrick Conway, M.D., deputy administrator for innovation and quality and CMS chief medical officer. "We believe the improvements we are making to the Five Star system will add confidence that the reported improvements are genuine, are sustained, and are benefiting residents."

Home Health Conditions of Participation

The proposed Home Health Conditions of Participation would improve the quality of home health services for Medicare and Medicaid beneficiaries by strengthening patient rights and improving communication that focuses on patient wellbeing. Currently there are more than 5 million people with Medicare and Medicaid benefits that receive home health care services each year from approximately 12,500 Medicare-certified home health agencies.

The proposed regulation, to be displayed Monday, October 6, at the Federal Register, would modernize the home health regulations for the first time since 1989 with a focus on patient-centered, well-coordinated care. Elements in the regulation include expansion of patient rights requirements; refocusing of the patient assessment on physical, mental, emotional, and psychosocial conditions; improved communication systems and requirements for a data-driven quality assessment; and performance improvement (QAPI) program.

For more information, visit: http://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.html.

RAI MANUAL ERRATA ON THE WAY & Virginia specific guidance from State RAI Manager

From: Bullard, Priscilla (VDH)
Sent: Friday, September 19, 2014 10:11 AM
To: Bullard, Priscilla (VDH)
Subject: RAI manual updates and CCC information

Dear Colleagues,

As you know, CMS has released the October 2014 RAI manual. There are some known issues with missing parts to this manual, as well as some textual errors. CMS will be sending out an errata or updated manual, which will be at the same site:  http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html

If you print your manual out, I recommend waiting until the clarifications are released by CMS. Some of the issues with the current release include missing item sets, incorrect or unclear text examples, and conflicting instructions.

Please realize there are changes to the actual MDS items. There is a new field, A1900, which captures the original admission date for the resident. CMS will be releasing further information for this field as the terms used in the new manual are not defined clearly. If you have not liaised with your software company regarding updates, please do so- any assessments with an ARD of 10/1/14 or later need to use the new item sets. I recommend that providers be able to manually enter data into A1900, as I have heard anecdotally that some software vendors are pre-populating this field from A1600 of the prior assessment. Under some circumstances, this date could be incorrect and the provider needs the ability to enter correct data.

I will be posting a webinar about the updates on the VDH website after the manual is finalized, and will email the link when it is posted.

Lastly, I wanted to address the questions about Medicaid information on the MDS for any Commonwealth Coordinated Care(CCC) residents. DMAS has confirmed the following:

·         For CCC residents, A0700 will continue to have the traditional Medicaid number for the resident, not the CCC number

·         For CCC residents,  S9100 is coded as managed care for the pay source on the ARD, and with the resident’s original Medicaid start date

·         For traditional Medicaid residents, A0700 and S9100 will be completed with the resident’s regular Medicaid data(number and start date). See pages A-10 and A-11 of the RAI manual

·         For residents with other pay sources, A0700 will be completed as per the RAI manual

·         For residents with other pay sources, S9100 will show the resident’s pay source on the ARD and 1/1/1950 will be used as a start date so that the assessment can be locked

Cil Bullard RN,CPC | Virginia RAI/OASIS Coordinator | Training Division | Office of Licensure and Certification|  Virginia Department of Health | 9960 Mayland Dr Suite 401 |Henrico, VA 23233-1485|     ( 804-367-2141      7 804-527-4502    priscilla.bullard@vdh.virginia.gov

SNF Stay is protected even when hospitals rebill Part B for a medically unnecessary stay

From the Center for Medicare Advocacy


Hospitals May Begin Rebilling Medicare Patients Who Were Hospitalized After October 1, 2013 

Medicare patients need to be aware that if they were hospitalized after October 1, 2013, hospitals may be contacting them about their bills.
Final rules that were published in August 2013 and became effective October 1, 2013 created a new regulatory provision, 42 C.F.R. 414.5, "Hospital services paid under Medicare Part B when a Part A hospital inpatient claim is denied because the inpatient admission was not reasonable and necessary, but hospital outpatient services would have been reasonable and necessary in treating the beneficiary."[1]  Section 414.5(a) authorizes a hospital to rebill Part B if a claim under Part A is denied or, on its own initiative, if the hospital determinesafter the patient is discharged that the patient's hospital stay should have been billed as outpatient rather than as inpatient.[2] 
Under the new rebilling option, CMS gives a hospital only one year after providing services to a patient to change its decision about the patient's inpatient status and to submit a bill to Medicare under Part B instead of Part A.  The one-year deadline is approaching for services provided on or after October 1, 2013, the effective date of the regulations.
If a hospital rebills Medicare under Part B, it must refund the Part A deductible to the patient (or supplemental insurer) and it may bill the patient both for copayments for services provided under Part B and for medications.[3]  
If a hospital exercises its rebilling option, patients may want to submit the medication bill to their Part D plan and request that the plan pay the pharmacy bill as an out-of-network pharmacy, since the hospital pharmacy is unlikely to be in the patients' pharmacy network.[4]
Part A-Covered SNF Stay Is Protected Even When the Hospital Rebills Medicare Part B
If a hospital exercises its rebilling option and submits a Part B claim for a patient following the patient's discharge from the hospital, the patient retains inpatient status for purposes of Medicare Part A coverage of the subsequent SNF stay.  CMS explicitly provides in the preamble to the final rules:

The status of the beneficiaries themselves does not change from inpatient to outpatient under the Part B inpatient billing policy.  Therefore, even if the admission itself is determined to be not medically necessary under this policy, the beneficiary would still be considered a hospital inpatient for the duration of the stay – which, if it occurs for the appropriate duration, would comprise a "qualifying" stay for SNF benefit purposes so long as the care provided during the stay meets the broad definition of medical necessity above [referring to the Medicare Benefit Policy Manual, Chapter 8, §20.1].[5]

CMS reiterates this point later in the preamble:

[W]hen the inpatient hospital stay is paid under Part B, the hospital stay remains inpatient from the time of admission and may continue to count towards qualification for skilled nursing facility coverage, and the beneficiary is liable for the Part B inpatient charges.[6]

CMS Notice to Medicare Patients
CMS rejects commenters' suggestions that patients be provided with an additional standardized notice or a Frequently Asked Questions sheet, or that information be added to the Important Message from Medicare (IM) form to alert patients at the time of their inpatient admission to an acute care hospital that their status at the hospital might be changed during, or after, their hospital stay.  CMS describes such notices as "likely [to] create undue confusion and concern for beneficiaries"[7] and says it will engage in an educational campaign for beneficiaries. 
CMS writes that it will provide information in its publication "Are You a Hospital Inpatient or Outpatient? If You Have Medicare – Ask!" but the May 2014 revision does not explain that the hospital may change a patient's status after discharge.[8]  CMS also writes that it will add new messages in the Medicare Summary Notice, but the Center for Medicare Advocacy did not find a new code in the updated list of MSN codes released on July 24, 2014.[9]  CMS'sMedicare & You briefly discusses observation status.[10] 
CMS Offers Hospitals Settlement of Short Inpatient Claims Before October 1, 2013
Hospitals have been appealing denials of inpatient claims.  On August 29, 2014, CMS offered "an administrative agreement to any hospital willing to withdraw their pending appeals in exchange for timely partial payment (68% of the net allowable amount)."[11]  CMS defines eligible claims under the settlement offer as:

currently pending appeals of inpatient-status claim denials by Medicare contractors on the basis that services may have been reasonable and necessary, but treatment on an inpatient basis was not, with dates of admission prior to October 1, 2013, and where the patient was not a Part C [managed care] enrollee.

Hospitals may accept the settlement for some inpatient claims while continuing to pursue other claims through the administrative process.
Hospitals choosing to settle pending appeals with CMS may "not seek additional payment from any Medicare beneficiary or collect any deductible or coinsurance amount regarding any claim resolved through this Agreement that is not subject to a repayment plan existing as of the effective date of this Agreement," but they "may retain any Medicare beneficiary deductible or coinsurance amounts already paid as of the effective date of this Agreement."[12]
Medicare patients will not hear from hospitals that settle with CMS on the terms offered.  The hospitals will retain the inpatient deductibles that patients paid. 
Conclusion
October 1, 2013 is an important date for Medicare patients' hospitalizations.
Medicare beneficiaries may receive letters from hospitals about their hospitalizations after October 1, 2013 if hospitals decide to withdraw their Part A charges and, instead, bill Medicare Part B and bill the patients for Part B copayments and medications.  Patients' entitlement to Part A coverage of their skilled nursing facility care is not affected.
Medicare beneficiaries who were hospitalized before October 1, 2013 may hear nothing from their hospitals, though the hospitals may either accept the settlement terms offered by CMS or continue to pursue their administrative appeals.  These patients' SNF coverage is also unaffected.

---

[1] 78 Fed. Reg. 50495 (Aug. 19, 2013).  See Center for Medicare Advocacy, "Observation Status: New Final Rules from CMS Do Not Help Medicare Beneficiaries" (CMA Alert, Aug. 29, 2013),http://www.medicareadvocacy.org/observation-status-new-final-rules-from-cms-do-not-help-medicare-beneficiaries/.[2] The rebilling option was one of two changes to federal regulations that the Centers for Medicare & Medicaid Services (CMS) made in 2013, in part to address the issue of Observation Status.  Observation Status is the classification of hospitalized patients as outpatients, not inpatients, even though the care they receive in the hospital may be identical.[2]  If patients are outpatients or are said to be in Observation Status, Medicare Part A will not pay for their post-acute care in a skilled nursing facility (SNF).  The other change created in 2013 was the two-midnight rule.  Under this time-based analysis, physicians admit patients to inpatient status if they believe the patients will be in the hospital for two or more midnights.[3] 78 Fed. Reg., 50918, 50930-50931 (coordination of benefits with supplemental insurers).[4] See CMA, "Submitting Claims to Part D for Prescription Drugs Administered in a Hospital During an Observation Status Stay" (Weekly Alert, May 1, 2014), at http://www.medicareadvocacy.org/submitting-claims-to-part-d-for-prescription-drugs-administered-in-the-hospital-during-an-observation-status-stay/.[5] 78 Fed. Reg. 50921.  The Medicare Benefit Policy Manual, Ch. 8, §20.1, states that medical necessity for a hospital stay will be presumed and that, “The intermediary will rule the stay unnecessary only when hospitalization for 3 days represents a substantial departure from normal medical practice.”  http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c08.pdf.  Scroll down to page 8 for §20.1. http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2877CP.pdf
[6] 78 Fed. Reg., 50934.[7] 78 Fed. Reg., 50919.[8] https://www.medicare.gov/Pubs/pdf/11435.pdf. [9] 78 Fed. Reg. 50919.  MSN Codes, https://www.cms.gov/Medicare/Medicare-General-Information/MSN/index.html?redirect=/MSN/.[10] http://www.medicare.gov/Pubs/pdf/10050.pdf, see pages 32 and 97.[11] CMS, Inpatient Hospital Reviews," http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/InpatientHospitalReviews.html. [12] Administrative Agreement, ¶8, available in the Downloads section," http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/InpatientHospitalReviews.html.