CMS launches five-star rating system
Contents
1. plans and compliance with HIPAA s privacy and security rules Don t put compliance on the shelf The information released by the OIG in September supplements the initial compliance program guidance for nursing homes which the agency provided in 2000 The message many facilities got was that having no compliance program was safer than having written pol icies and procedures collecting dust Many long term care providers reacted by not implementing a compli ance program at all or by using a one size fits all com pliance program says Mary Malone Esq a healthcare attorney at Hancock Daniel Johnson amp Nagle PC in Richmond VA However neither of those responses are beneficial to nursing facilities Malone says Failing to implement a compliance program may put your facility at risk for OIG investigations If your facil ity comes under scrutiny having a compliance plan may help you avoid entering a corporate integrity agreement CIA amandatory compliance program imposed by the OIG The terms and reporting requirements of a CIA gt continued on p 10 Tips for jump starting your compliance program Compliance programs aren t mandatory but they can protect your nursing facility from Office of Inspector General OIG investigations and other legal problems Mary Malone Esq a healthcare attorney at Hancock Daniel Johnson amp Nagle PC in Richmond VA and Betsy Anderson BSA vice president2. facilities with a four or five star staffing rating add one star to the health inspection rating For facil ities with a one star staffing rating subtract one star from the inspection rating 3 For facilities with a five star rating for quality mea sures add one star For facilities with a one star quality measure rating subtract one star A facility cannot receive more than five stars or few er than one star Additional rules apply to the rating calculation for Special Focus Facilities that have not graduated and facilities that received a one star health inspection rating For a detailed explanation of the cal culation find CMS technical users manual by visiting www cms hhs gov CertificationandComplianc and clicking on the Five Star Quality Rating System manual on the left side of the page Scroll down to the Downloads section Using survey to score facilities Long term care industry groups object that the rat ing system is based on what they call a broken survey 2009 HCPro Inc For permission to reproduce part or all of this newsletter for external distribu system ion or use in educational packets contact the Copyright Clearance Center at www copyright com or 978 750 8400 February 2009 PPS Alert for Long Term Care Page 3 Members of the long term care industry are con cerned that a survey deficiency could skew a facility s rating says Sherrie Dornberger RNC CDONA FACDONA pr
3. nurse practi tioner or physician assistant When therapists write the telephone or fax order for the therapy orders it is most likely that the diagnoses they are using are included there If so when the physician signs the order that is all you need e A resident has been in our facility on Medicaid since admission in 2005 She has had a tube feeding for 100 of her nutrition during her entire stay She became eligible for Part A benefits in 2007 She just returned from the first three day hospital qualifying stay since she became eligible for Medicare My understanding is that she can t be covered on Part A in the SNF now be cause she has had a skilled level of care with the tube feeding all this time Is this correct AW No Since she never used any Part A days she has A 100 days available as long as she s had a three day qualifying hospital stay and meets all other coverage criteria You might be thinking about a situation in which a resident has exhausted Part A benefits for a benefit pe riod and continues to receive a skilled level of care in the SNF In that case even though Medicare is not the pay er the resident cannot earn a new 100 day benefit pe riod until he or she goes for 60 consecutive days without an inpatient hospital admission and without receiving a skilled level of care in a SNF Once that 60 day break in skilled care occurs then if the resident has a three day qualifying hospital stay at some poi
4. of FR amp R Healthcare Consult ing Inc in Deerfield IL offered the following tips for facili ties that want to implement a new compliance program or improve an existing one gt Read the OIG s guidance documents You can find the OIG s original compliance program guidance for nursing facilities released in 2000 at http oig hhs gov authorities docs cpgnt pdf and the supplemental guidance released in September 2008 by visiting www oig hhs gov and clicking News Room under the Quick Links section Click on the press release dated 9 30 2008 and scroll to the bottom of the document where there is a link to the supplemental compliance Identify areas that are particular risks for your facility such as submission of accurate claims Customize your compliance program for your facility s individual needs rather than using a generic plan Integrate compliance efforts into your facility s existing Medicare and quality assurance meetings rather than adding meetings Involve as many staff members as possible in compli ance efforts and gain their support for your compliance program 2009 HCPro Inc For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at www copyright com or 978 750 8400 Page 10 PPS Alert for Long Term Care February 2009 Compliance lt continued from p 9 are likely to be harsher
5. process is as follows 1 Look at the number of minutes days of therapy documented in section P 2 Based on the treatment plan project how much more therapy the resident is expected to receive from the day after the assessment reference date through day 15 3 Add the two together that s your projection Facilities should routinely audit the accuracy of pro jections by comparing them to the amount of therapy actually provided At times projected days minutes will not be delivered because the resident was too tired or got sick Most of the time the projection should be fairly accurate or it probably isn t being done correctly E Questions Comments Ideas Contact Associate Editor Emily Beaver Telephone 781 639 1872 Ext 3406 E mail ebeaver hcpro com Your source code N0001 Name Title Organization Address City State ZIP Phone Fax E mail address Required for electronic subscriptions Q Payment enclosed Q Please bill me Please bill my organization using PO Charge my Q AmEx Q MasterCard QO VISA Discover Signature Required for authorization Card Expires Your credit card bill will reflect a charge to HCPro the publisher of PPSA For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at www copyright com or 978 750 8400
6. question of the month Find out what your peers are asking about at MDSCentral p 11 PPS Q amp A Rena R Shephard MHA RN RAC MT C NE answers questions about respiratory therapy ICD 9 coding and more about their successes says Barbara Bruhm RN BN HSM executive director of consulting services at Land mark Health in Haverhill MA But the buildings that didn t score well need to tell their story too and explain to families residents and staff why they received the rating they did and the actions that they take every day to maintain quality care Educating consumers about quality At a December press conference Kerry Weems CMS acting administrator said he wouldn t tell consumers to eliminate one star facilities from consideration but would recommend that The biggest miss with the consumers carefully five st is that it evaluate those facil ive star system Is tnat doesn t measure what we ities to understand ae f think is a very important why they received measure and that s one star ratings Weems added that when choosing a customer satisfaction Richard C Bane MBA FACHCA facility no rating system or Web site can substitute for visiting a nursing home and talking with nursing facility management state ombudsmen and residents families However many long term care providers are con cerned that consumers will rely too heavily on star ratings Un
7. requires skilled care v g 3 x 8 SIS S Q e 3 P 2009 HCPro Inc For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at www copyright com or 978 750 8400 Page 8 PPS Alert for Long Term Care February 2009 Guide to SNF beneficiary notifications lt continued from p 7 SNF ABN Process O e Expedited Review Process eee ee EE e Kea Situation SNF ABN Denial Letters NEMB Volunta ED Notices Part B Stay Ends Because Beneficiary is in a continuing stay not covered under Part AAND Requires short term PT covered under Part B to address a significant decline in function AND PT ends Requires short term PT and OT covered under Part B to address a significant decline in function AND OT only ends Requires short term PT and OT covered under Part B to address a significant decline in function AND both PT and OT end All skilled Part B services are ending because the provider determines that it is no longer reasonable and necessary Beneficiary may want to extend therapy BEYOND the date the provider determines is reasonable and necessary Examples Beneficiary is approaching the therapy cap o This form is voluntary The expedited review process is distinct If a physician s order However issuing a NEMB from the ABN process Expedited reclarifies that a Par
8. than your own compliance pro gram Malone says Some facilities buy premade compliance plans from vendors attorneys or consultants Using a template as a starting point is fine but simply purchasing a generic compliance plan and placing your facility s name on it isn t a good idea Malone says Without tailoring the plan to your facility it s hard to have ownership and buy in to the program and those are key elements of a successful compliance program she says The impending CMS Recovery Audit Contractor pro gram which will use contractors to find and recover what are deemed improper Medicare payments to pro viders may give nursing facilities another incentive to start focusing on compliance Anderson says If facilities aren t auditing their practices to ensure compliance with Medicare rules the contractors may do so and require facilities to return Medicare payments Compliance program components Most facilities compliance programs will vary based on individual needs and resources but all programs should include some common elements established by the OIG s guidelines Malone says According to the guidelines a compliance program should contain gt A code of conduct gt A compliance officer committee gt Written policies and procedures to implement a compliance plan Training and education Auditing and monitoring A reporting mechanism such as a hotline VV VY A method to investigate and r
9. the five star rating system doesn t account for customer satisfaction The biggest miss with the five star system is that it doesn t measure what we think is a very important measure and that s customer satisfaction explains Richard C Bane MBA FACHCA president of 2009 HCPro Inc BaneCare LLC which operates several nursing facilities in Massachusetts In Massachusetts long term care providers worked with the state legislature and department of public health to conduct customer satisfaction surveys in 2005 and 2007 In both surveys nine out of 10 respondents statewide said they would recommend their nursing home to a friend or family members To have that kind of performance and to have that not be recognized in a five star rating is crazy particularly because the five star rating is intended to focus on the needs of the consumer Bane says At the December press conference Weems said CMS would like to include customer satisfaction in the rating system in the future Communicating with customers and CMS Word of mouth is still the No 1 factor for families and residents choosing a nursing home but more people are using the Internet to get information about facilities Bane says Providers should encourage people to make sure the Internet is not the only source of information used when selecting a nursing facility Matching the needs of the resident with the skill set of the particular nursing home
10. 2008 SNF Long Term Care Open Door Forum CMS officials said they hoped the re vised SNF ABN would be available this spring or summer The revised SNF ABN would require providers to issue only the SNF ABN in conjunction with the appropriate EDN according to a CMS Town Hall presentation Using the NEMB The NEMB is used when the technical requirements for coverage within a Part A stay such as a three day qualifying hospital stay are not met Reingruber says The NEMB is voluntary Many long term care facilities don t complete the NEMB at all Lang says adding that although you may not technically be required to give the NEMB using it is a good opportunity to inform residents and their families about Medicare benefits The expedited review process SNFs are required to notify Medicare beneficiaries of their right to an expedited review process when they 2009 HCPro Inc expect Medicare coverage of services will end This process involves issuing EDNs which may need to be given in addition to ABNs For more information about when ABNs and EDNs are issued see Guide to SNF beneficiary notifications on p 7 The Generic Notice CMS 10123 must be given to the beneficiary two days before services are discontinued The Detailed Notice CMS 10124 must be provided to the beneficiary and the QIO when a beneficiary requests an expedited determination Medicare Advantage residents receive different EDNs than Medicare fee fo
11. HCPro An Integrated Approach to February 2009 Vol 12 No 2 the LTC Industry PPSALERT FOR LONG TERM CARE CMS launches five star rating system Providers need to communicate true quality to the public Now that consumers can easily access nursing home quality ratings long term care providers say the industry needs to communicate the aspects of nursing home qual ity that the five star rating system doesn t capture In December 2008 CMS posted its five star quality rating system on the Nursing Home Compare Web site The rating system uses data from surveys staffing rates and 10 quality measures to calculate star ratings ranging from one to five When the rating system was unveiled many long term care providers said the system oversimplified nursing home quality and didn t account for customer satisfaction Regardless of the system s flaws long term care providers will still have to live with the five star rat ing system I think the centers that got five stars should tell all of their families their staff and their residents IN THIS ISSUE p 4 Beneficiary notifications We give you a complete guide to simplifying the beneficiary notification process at your facility including a chart of notifications and a quiz p 8 Compliance programs The Office of Inspector General recently released supplemental compliance guidance for nursing facilities Learn how to get started at your facility p 10 MDS 3 0
12. Sheahan HCPro Associate Editor Emily Beaver ebeaver hcpro com Sandra Fitzler Ronald A Orth RN NHA Senior Director of Clinical Services RAC CT CPC American Health Care Association President Washington DC Clinical Reimbursement Solutions LLC Milwaukee WI Rita Roedel MS RN National Director of Clinical Reimbursement Bonnie G Foster RN BSN MEd Long Term Care Consultant Columbia SC Cindy Frakes Extendicare Health Services Inc Owner Milwaukee WI Winter Meadow Homes Inc Rena R Shephard MHA RN Topeka KS RAC MT C NE Julia Hopp MS RN CNAA BC PPSA Senior Advisor Vice President of Patient Accounting Founding Chair and Executive Editor Paramount Health Care Company American Association of Nurse San Antonio TX Assessment Coordinators President Steven B Littlehale MS GCNS BC Executive Vice President i Healthcare Chief Clinical Officer Consulting Services PointRight Inc San Diego CA Lexington MA Holly F Sox RN RAC C MDS and Staff Development Coordinator NHC Lexington West Columbia SC RRS Healthcare PPS Alert for Long Term Care ISSN 1521 4990 print 1937 7428 online is published monthly by HCPro Inc 200 Hoods Lane Marblehead MA 01945 Subscription rate 239 year PPS Alert for Long Term Care P 0 Box 1168 Marblehead MA 01945 Copyright 2009 HCPro Inc All rights reserved Printed in the USA Except where specifically encouraged no part of this publication
13. eral OIG still won t look favorably upon a facility tect your SNF from OIG investigations and penalties 2009 HCPro Inc For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at www copyright com or 978 750 8400 February 2009 PPS Alert for Long Term Care Page 9 Fortunately ensuring that your facility stays in com pliance doesn t have to become an enormous project Anderson says Start by learning the key elements of a successful compliance program identifying your facili ty s risk areas and incorporating compliance procedures and personnel into your current quality improvement efforts Guidance for compliance In September 2008 the OIG the enforcement arm of the Department of Health and Human Services released supplemental compliance guidance The guidance which offers guidelines for nursing fa cilities that are implementing or evaluating their compli ance programs highlighted the following four risk areas for facilities gt Quality of care specifically naming sufficient staff levels comprehensive resident care plans appropri ate medication management resident safety and appropriate psychotropic medication use gt Submission of accurate claims y The federal anti kickback statute gt Other risk areas including providing objective information about Medicare Part D prescription drug
14. esident of the National Association of Directors of Nursing Administration Dornberger offers an example from a facility she worked in The facility served raisin toast at breakfast which was extremely popular with residents However during a survey a surveyor turned a toaster upside down and a raisin fell out The facility received an infec tion control deficiency Most nursing facility staff members understand that a seemingly minor infraction can lead to a survey defi ciency that remains on a facility s record for a long time However consumers may not be aware of this when viewing a nursing home star rating Using ratings to improve Although imperfect the five star rating system offers nursing facilities opportunities to compare themselves to other facilities and improve in certain areas Dornberger says she was pleased to see that the sys tem highlights the importance of providing RN hours for resident care and gives facilities a federal benchmark for staffing hours Facilities should look at their rating from a performance improvement point of view Bruhm says Members of the interdisciplinary team should meet and analyze their facil ity s ratings Does the facility have ADL decline Why does it have a high percentage of catheters Are we managing residents continence Are we aware of regulations and complying with them Counting customer satisfaction Many members of the long term care industry are disappointed
15. espond to detected noncompliance Put compliance guidance in action If implementing a compliance program seems daunt ing or you think your facility doesn t have the resources 2009 HCPro Inc keep in mind that compliance isn t an all or nothing proposition Anderson says She recommends that pro viders start by reading the OIG s guidance and identify ing risk areas they want to address For example if your facility has a large Medicare pop ulation you might identify risks related to Medicare Try to deal with your targeted risks within your current qual ity assurance framework Identify staff members who should be involved in fa cility compliance and incorporate compliance issues in to existing Medicare and quality assurance meetings rather than scheduling additional compliance meetings Anderson says If your facility s compliance committee includes administrators or other staff members who do not regularly attend Medicare meetings invite them to the compliance portion of the meeting Nursing facilities developing or evaluating compliance programs may want to work with a consultant or attor ney who is familiar with healthcare compliance issues Malone says Involve as many staff members as possible she adds Without buy in from your staff members your compli ance program won t succeed Achieving compliance is an ongoing effort Anderson says If you incorporate compliance into daily operations your pr
16. ho will remain in the facility a True b False 3 During a care conference it was determined that Mrs Montagne could benefit from two more weeks of therapy Mrs Montagne decides she does not want to stay and will be going home tomorrow Which notices are the facility required to give her prior to discharge a Generic Notice b Notice of Non Coverage c Both notices d No notice is required 4 Mr Lopez is being cut from Medicare Tuesday due to lack of a daily skilled service He will remain in the facility under Medicaid Which of the following notices must be given to Mr Lopez prior to being cut a Notice of Non Coverage cut denial letter or SNF ABN b Notice of Exclusion from Medicare Benefits Generic Notice Detailed Notice 2009 HCPro Inc For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at www copyright com or 978 750 8400 February 2009 PPS Alert for Long Term Care Page 7 Guide to SNF beneficiary notifications Situation SNF ABN Denial Letters olunta D Notices Medicare Part A services are Medicare Part B An ABN form would not Medicare covered items or reduced or eliminated but services such as be appropriate The services are discontinued The the resident remains in the _ therapy are form is used for benefit expedited review process gives SNF i i i beneficiaries the opportunity
17. ight com or 978 750 8400 Page 6 PPS Alert for Long Term Care February 2009 SNF lt continued from p 5 contain specific instructions about the proper procedures for contacting responsible parties by telephone and mail FIs and Medicare administrative contractors can re quest beneficiary notices for a process review Creating a process for notification Many facilities don t have a process for issuing benefi ciary notifications or have several different people or po sitions issuing notifications Ask who is responsible for notifications Lang says If no one knows your facility may not be issuing all of the required notices Reingruber suggests assigning notifications to specif ic staff members Make sure the people who are respon sible for beneficiary notifications are part of your daily Medicare meeting and are aware of when notices should be issued she says Everyone at the meeting needs to be on the same page about a resident s Medicare benefits and what notices should be distributed Assign the responsibility for beneficiary notices based on your facility s needs If you have 300 bed facility with two MDS nurses MDS nurses may issue notifications be cause they are aware of residents need for skilled servic es and benefit periods Connor says But that system may not work in a smaller facility where the MDS nurse takes on multiple roles she says Make sure more than one person at your facil
18. is the most important thing Bane says There s not a consumer Web site nor any information you can get on the Web that can tell you whether nursing home X Y or Z is the right place for your mother Nursing facilities should tell consumers about measures of quality not included in the five star system such as spe cial programs or high customer satisfaction says Bruhm Providers are hoping to work with CMS as a partner to give feedback on how to improve the rating system says Bane E Relocating Taking a new job If you re relocating or taking a new job and would like to continue receiving PPSA you are eligible for a free trial subscription Contact customer service with your moving information at 800 650 6787 For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at www copyright com or 978 750 8400 Page 4 PPS Alert for Long Term Care February 2009 Beneficiary notifications Simplify the process at your SNF A Continuing Education Learning Objectives After reading this article you will be able to gt State which beneficiary notifications are mandatory gt Identify the rights processes associated with advanced beneficiary notifications ABN and expedited determination notices EDN gt Name the notices that must be issued under Medicare Part A and Part B gt Explain when the Notice of Excl
19. ity can issue notifications Lang says If only one person can is sue notifications your facility may not be able to give out notices within the appropriate time frames when that person is not available E Beneficiary notification quiz Test your understanding of beneficiary notifications with the following quiz Check your answers on p 12 1 Mr Johnson s son visits the local SNF to ask about place ment for his father Mr Johnson spent three days in the hospital two weeks ago and has been at home for about a week His physician would like him to have physical thera py due to the amount of time he was in the hospital The facility believes Mr Johnson will qualify for a Medicare Part A stay On the day of admission Mr Johnson walks into the facility without any difficulty or aids and shows no other signs of having a clinical need for therapy What should the facility do a Explain to Mr Johnson and his son that Medicare will not likely cover his stay and provide an Advanced Ben eficiary Notification ABN for rethinking their option b Admit Mr Johnson and bill Medicare for the stay c Collect the first month s payment for the SNF stay up front from Mr Johnson d Report Mr Johnson s son for fraud and misrepresenta tion of his father s condition 2 With implementation of the expedited review process SNFs no longer need to issue a Medicare Notice of Non Coverage cut denial letter for a resident w
20. less consumers really understand the crite ria that went into the rating system and the criteria that didn t they re not going to have all the information to make the best choice for themselves and their family members Bruhm says We need to educate people How the ratings work The five star rating system s methodology is fairly complex and can be difficult to understand even for long term care providers gt continued on p 2 Page 2 PPS Alert for Long Term Care February 2009 Five star rating lt continued from p 1 In a nutshell facilities receive one to five stars for each of the following domains gt The health inspection domain is calculated from the three most recent years of surveys as well as results from complaint investigations in the previous three years Deficiencies are weighted according to scope and severity and the number of repeat revisits required to correct a deficiency is considered The staffing domain is based on the number of RN and overall staff hours this combines RN licensed practical nurse and nursing assistant hours each resident receives per day The score is adjusted for case mix differences gt The quality measure domain is derived from long and short stay quality measures from the MDS For long stay residents the system evaluates what per cent of a facility s residents Editorial Advisory Board PPS Alert for Long Term Care Group Publisher Emily
21. may be reproduced in any form or by any means without prior written consent of HCPro Inc or the Copyright Clearance Center at 978 750 8400 Please notify us immediately if you have received an unauthorized copy For editorial comments or questions call 781 639 1872 or fax 781 639 2982 For renewal or subscription information call customer service at 800 650 6787 fax 800 639 8511 or e mail customerservice hcpro com Visit our Web site at www hepro com Occasionally we make our subscriber list available to selected companies vendors If you do not wish to be included on this mailing list please write to the marketing department at the address above Opinions expressed are not necessarily those of PPSA Mention of products and services does not constitute endorsement Advice given is general and readers should consult professional counsel for specific legal ethical or clinical questions Experienced activities of daily living ADL decline Experienced decline of mobility Have high risk pressure ulcers Have catheters Are physically restrained Have urinary tract infections Have moderate to severe pain For short stay residents the rating system evaluates what percentage of residents have Pressure ulcers gt Delirium gt Moderate to severe pain The system uses the following calculation to determine a nursing home s overall star rating 1 Start with the facility s health inspection rating 2 For
22. ments When counting minutes include only the minutes that the trained nurse spends with the resident provid ing the treatment For example you can count the minutes for the re spiratory assessment you do prior to starting the treat ment and you can count the set up time and the time getting the resident started on the treatment But if the resident can take it from there without your help you can t count any more time until you do the reassessment after the treatment and take the equipment away If the resident needs you to stay to assist throughout the treat ment all of that time can be counted e A consultant told me I m not supposed to do ICD 9 coding since I m not a certified coder Also for sec tion I Disease Diagnosis do we need to put the after care diagnoses that physical and occupational therapy use as treatment diagnoses under that section The consultant told me not to add these diagnoses because they are not in the history and physical or physician progress notes A There isn t a regulatory requirement that the person doing the ICD 9 coding be certified Nurses are doing 2009 HCPro Inc the coding in many nursing homes However ICD 9 coding is a specialty and it is very different for nursing homes than it is for hospitals so it is important that the person doing the coding be properly trained Any diagnosis that is entered in section I must be sup ported by a diagnosis from the physician
23. nt after that he or she will earn a new 100 day SNF benefit period gt continued on p 12 For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at www copyright com or 978 750 8400 Page 12 PPS Alert for Long Term Care February 2009 Q amp A lt continued from p 11 e am trying to understand the projection in section T How can it be okay to bill for a category if the min utes haven t been provided Also if the projection shows that the resident will be getting enough minutes to reach the Rehab Very High category why does the facility get paid at the Rehab High level AW The projection which covers the first 15 days of the A Part A stay allows the facility to be paid for the lev el of services the resident is expected to receive even though that level of rehab might not be delivered during the seven day observation period of section P1b Beneficiary notification quiz answer key 1 A Although specific scenarios for use of the ABN in a SNF are still gray the best choice in this case would be to inform the patient and family of the likely denial of payment from Medicare and review other payment options prior to admission 2 B The expedited review process is in addition to the Notice of Non Coverage requirements 3 D No notice would be required since the resident is making her own decisi
24. ogram is more likely to be successful E MDS 3 0 question of the month e am a case manager and I do our MDS here for our swing bed patients Will the MDS 3 0 apply to swing beds We are a rural hospital that can keep up to 10 swing bed patients To read Regulatory Specialist Diane Brown s answer to this question visit www mdscentralonline com Click on the Ask Diane icon and then on the Diane Brown link above her picture Diane answered this question on De cember 19 2008 For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at www copyright com or 978 750 8400 February 2009 PPS Alert for Long Term Care Page 11 PPS Q amp A Editor s note PPS Q A is written by Rena R Shephard MHA RN RAC MT C NE founding chair and executive ed itor of the American Association of Nurse Assessment Coordi nators and president of RRS Healthcare Consulting Services in San Diego To submit a question contact Associate Editor Emily Beaver at ebeaver hcpro com e Is it true that only a respiratory therapist can do the initial respiratory evaluation on a SNF resident Also please explain how to count the minutes when giving respiratory treatments A No a nurse who has been trained in respiratory as sessment and treatments can also do the initial and follow up evaluations as well as the treat
25. on to end Medicare coverage 4 A and C Both notices are required when a resident has benefits remaining and will be staying in the facility PPSA Subscriber Services Coupon Q Start my subscription to PPSA immediately Options No of issues Cost Shipping Total Q Electronic 12 issues 239 ppsazE N A O Print amp Electronic 12 issues of each 239 ppsape 24 00 Order online at www hemarketplace com Sales tax see tax information below Be sure to enter source code N0001 at checkout Grand total For discount bulk rates call toll free at 888 209 6554 Tax Information Please include applicable sales tax Electronic subscriptions are exempt States that tax products and shipping and handling CA CO CT FL GA IL IN Ky LA MA MD ME MI MN MO NC NJ NM NY OH OK PA RI SC TN TX VA VT WA WI WV State that taxes products only AZ Please include 27 00 for shipping to AK HI or PR HCPro 2009 HCPro Inc Mail to HCPro P O Box 1168 Marblehead MA 01945 Tel 800 650 6787 Fax 800 639 8511 E mail customerservice hcpro com Web www hcmarketplace com The instructions for completing section T are in Chap ter 3 of the RAI User s Manual It explains the process for projecting therapy days and minutes for the first 15 days of the Medicare stay The projection must be based on the treatment plan resulting from the evaluation The
26. onal says Claudia Reingruber CPA managing shareholder of Reingruber amp Company PA in St Petersburg FL All of the notifications can be found at CMS Benefi ciary Notices Initiative Web page at www cms hhs gov BNI SNFs must provide the following kinds of beneficiary notices gt SNF ABN or SNF denial letters for Part A services gt ABN for Part B services gt EDNs for Part A and Part B ABNs and EDNs represent two different appeal rights and processes The EDN gives the beneficiary the right to an expedited review through a QIO and the ABNs or SNF denial letters give the right to appeal to the fiscal intermediary FI using the demand bill process For example if your facility has a resident in a Medi care Part A stay and Part A services are ending you would issue the SNF ABN or denial letters and an EDN says Reingruber If you have a resident who is receiving therapy under Part B and the resident s family wants him or her to con tinue therapy beyond medical necessity provided the therapy caps have not been met you would need to issue an EDN and an ABN ABN G she says Note SNFs must begin using the revised ABN in place of the ABN G beginning March 1 according to CMS officials Notifications and the therapy caps Providers should inform residents they are responsible for all costs of therapy beyond the therapy caps accord ing to Medicare Transmittal 1106 The 2009 cap is 1 840 for physical and speech thera
27. py combined and 1 840 for occupational therapy Transmittal 1106 states that although use of the NEMB form is not a Medicare requirement Medicare contractors shall advise providers to use the NEMB form or a similar form of their own design to inform For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at www copyright com or 978 750 8400 February 2009 PPS Alert for Long Term Care Page 5 beneficiaries of the therapy financial limitation and the cap exclusion process However the exceptions process is in place for 2009 so residents for whom therapy is deemed medically nec essary may receive therapy services exceeding the caps Note The word should means it s good practice rather than mandatory Also deductibles and coinsur ance apply to the therapy caps so notify beneficiaries well before they approach the limit Revised SNF ABN Part of SNFs confusion about beneficiary notices results from having to choose from multiple kinds of ABNs when issuing that form of beneficiary notification When Part A services are ending but the resident will remain in the SNF for custodial care or therapy SNFs can issue the SNF ABN form CMS 10055 or one of five SNF denial letters SNFs are still awaiting the arrival of anew SNF ABN form which is expected to replace the use of multiple ABNs At a December 11
28. r service residents Medicare Advan tage residents receive the Notice of Medicare Non Cover age which alerts them that Medicare covered items or services are ending and gives them the opportunity to request an EDN from a QIO The Detailed Explanation of Non Coverage is issued when a QIO review is requested to give more explana tion of why coverage is ending Beneficiary notification basics SNF staff members should also understand how to issue notices properly Lang says she frequently sees providers using outdat ed beneficiary notification forms If your facility completes beneficiary notices improp erly your notifications could be considered invalid says Karen Connor director of business operations for Land mark Health in Haverhill MA Connor suggests ensuring that notices have The beneficiary s correct name and Medicare number gt The correct font size if applicable ABNs must be issued in a 12 point or larger font gt Been issued in the proper time frame e g the EDN Generic Notice must be issued two days before servic es are discontinued Facilities should also ensure that staff members are tak ing the proper steps when contacting residents responsi ble parties with notices Connor says Beneficiary notices gt continued on p 6 For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at www copyr
29. t B SNF can be a good determination notices often must be service is no longer required opportunity to speak with issued in conjunction with ABN forms It it is not necessary for the SNF residents and family members went into effect on July 1 2005 to issue the ABN However if about what services are a resident or family member covered by Medicare wants to continue the service under private pay the ABN must be issued Disclaimer This table is not intended to be used as a comprehensive guide to all situations Source HCPro Inc based on CMS regulation and HCPro reporting Taking steps toward compliance at your SNF OIG releases supplemental guidance for nursing homes If you ve justified the reason your SNF does not have with no compliance program during an investigation a compliance program because you ve heard that having says Betsy Anderson BSA vice president of FR amp R no program is better than having unused policies and Healthcare Consulting Inc in Deerfield IL procedures you may be headed for trouble Now is a good time for nursing facilities to revisit com Although having compliance policies that your facil pliance programs since the OIG has recently released ity doesn t apply or enforce may be riskier than having supplemental compliance program guidance Although no compliance program at all the Office of Inspector compliance programs are not mandatory they can pro Gen
30. to i an expedited review from a Quality Improvement Organization QIO one of five SNF Denial 2009 SNFs must use 20014 10123 must be provided no Letters the revised ABN for Part fewer than 2 days before B services CMS R services are discontinued The 131 This form replaces Detailed Notice CMS 10124 the ABN G CMS R 131 must be provided when G beneficiary requests an expedited determination SNFs must provide different notices for Medicare Advantage E SNF ABN CMS 10055 or Starting on March 1 NEMB SNF CMS The Generic Notice CMS Admission to SNF Beneficiary does NOT meet technical or benefit level day qualifying hospital stay or is not admitted within 30 days of hospitalization Beneficiary MEETS technical requirements BUT doesn t require DAILY Skiled care e g PT is ordered only 3 days week OR has MD orders for care BUT only requires custodial care Part A Stay Ends Because SNF provider determines that beneficiary no longer requires daily skilled services BUT remains in facility for custodial care To be discharged from SNF BUT will receive Part B therapy at a non skilled level e g 3 days a week AND all therapy services are terminated AND beneficiary is discharged to hospital due to acute illness OR is transferred to another SNF and will continue Part A coverage OR is discharged AMA OR elects hospice benefit Benefit days are exhausted 100 days BUT still Y
31. usion from Medicare Benefits NEMB form may be used gt Name the notifications issued under the Expedited Review Process Beneficiary notifications give Medicare beneficiaries important information about their benefits and protect SNFs from financial liability but the regulations for the notification process can be confusing SNFs must issue several kinds of notifications and many facilities have several staff members responsible for notifications A lot of facilities don t have a process for issuing no tifications and assume a certain person is doing it says Theresa Lang RN BSN RAC C WCC vice president of clinical consulting at Specialized Medical Services Inc in Milwaukee Sometimes when that staff member leaves the facil ity beneficiary notification isn t reassigned and notices may not be issued properly Lang says It s not until you wind up with a survey problem de mand bill or a Quality Improvement Organization QIO request that facilities realize that the notices aren t being issued correctly she says Avoid survey and financial liability problems by learn ing which notices your facility must issue and creating a system for issuing beneficiary notifications properly Beneficiary notification background One of the first steps to improving the beneficiary no tification process at your facility is understanding which 2009 HCPro Inc notifications are mandatory and which are opti
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