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.