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.