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2/13/2015 CAN ISKILL THIS PERSON?? CarolSiemRN,MSN,BC,GNP ClinicalEducator U‐MOColumbia HOW DO WE DECIDE? STEP 1 Whenareferralcomesinyoumust systematicallygothroughthe informationandaskyourselfseveral questions… Technicallydotheyqualify? TraditionalMedicareCareCardordo theyhaveaMedicareHMO? 3dayin‐patienthospitalstay 30daytransferismet Medicalpredictabilitydocumentationif necessary 1 2/13/2015 VERIFY BENEFIT ELIGIBILITY Medicare(FFS) Benefitdaysremaining – Prioruseddays – Fullbenefitperiod Priorstayinvestigation 3dayqualifyingstay Dailyskilledneed MedicareAdvantage 3dayqualifyinghospital stayrequired?? Priorauthorization? Weeklyupdates? Paymentrequirements – – – SNFPPS Levels Contractualrate 65yearsofageorolder,eligiblefor SocialSecurityorRailroadbenefits 65yearoldspouseofsomeoneeligible DisabledandcollectingSocialSecurity orRailroadRetirementbenefitsfor24 months(5monthwaitperiod) Hasbeneficiarystarted disenrollmentprocess? MEDICARE ELIGIBILITY MEDICARE ELIGIBILITY Receivedcontinuous dialysisforpermanent kidneyfailure(3month waitingperiod)* Receivingakidney transplant* ENROLLMENT AutomaticformanyMedicareeligible beneficiaries Othersshouldapply3monthspriorto age65or4monthsafter PartAispremiumfree PartBpremium‐based *Anyage 2 2/13/2015 EFFECTIVE DATE Medicarebecomeseffective,ifenrolled, the1st dayofthemonthinwhich beneficiaryturns65 Ifbirthdayfallson1st ofthemonth, benefitbegins1st ofpreviousmonth COMMON WORKING FILE C‐SPAN Isnotalwaysaccurate – – – – PRIOR STAY INVESTIGATION Priorstay – – No:Full100daybenefit Yes: Withinlast60days Updatedbasedonclaimsreceived CWFinformationisjustonepieceofthe “puzzle” Shouldbecheckedmorethanonce! Needtoconductpriorstayinvestigation BENEFIT PERIOD Nonewbenefitperiod Beginswithinitialqualifyingstay Endsafter60consecutivedaysfacility‐free orstaysinSNFanddoesnotreceiveskilled services Newbenefitperiodstartswithnew3day hospitalstay Nolimitsonnewbenefitperiods Not relatedto:calendaryear,diagnosisor exhaustionofbenefits 3 2/13/2015 BENEFIT PERIOD END Atleast60consecutivedaysinwhich theresidenthadnoinpatienthospital admission Atleast60consecutivedayswithout receivingaskilledlevelofcareinaSNF HOSPITAL STAY AcuteHospital AcuteRehabilitationHospital Long‐TermAcuteCareHospital PsychHospitals BENEFIT PERIOD 60daysinnon‐certifiedbeddoesnotend benefitperiodifresidentremainsatskilled levelofcare Hospitalstayfor“new”ordifferentdiagnosis doesnotbeginnewbenefitperiod Oncebeneficiaryusesup100partAdays,no moreSNFbenefitsareavailableuntilone benefitperiodendsandresidentqualifiesfor anewbenefitperiod BENEFIT PERIOD HomeHealthhasnobearingonthe benefitperiod “Old”vs“new”tubefeedingnota decidingfactor Diagnosisisnotdecidingfactor PartBservices5x/wkdoesimpact benefitperiods;lessthan5daysdoes not impact 4 2/13/2015 HOSPITAL STAY Countdayofhospitaladmission Donotcountdayofdischarge Mustbeinpatient status,not observation Dayofhospitaldischargemustoccur aftereffectivedateofMedicare Verifyhospitalstatus PSYCH Skilledobservationandassessmentmayalsoberequiredforpatients whoseprimaryconditionandneedsarepsychiatricinnatureorfor patientswho,inadditiontotheirphysicalproblems,haveasecondary psychiatricdiagnosis.Thesepatientsmayexhibitacutepsychological symptomssuchasdepression,anxietyoragitation,whichrequire skilledobservationandassessmentsuchasobservingforindicationsof suicidalorhostilebehavior.However,theseconditionsoftenrequire considerablymorespecialized,sophisticatednursingtechniquesand physicianattentionthanisavailableinmostparticipatingSNFs.(SNFs thatareprimarilyengagedintreatingpsychiatricdisordersare precludedbylawfromparticipatinginMedicare.) Therefore,thesecases mustbecarefullydocumented. Page25oftheMedicareBenefitPolicyManual,Chapter8‐ Coverage ofExtendedCare(SNF)ServicesUnderHospitalInsurance OBSERVATION STAYS DoNOTcounttowardsthe3day qualifyingstay What’sitmeantothebeneficiary? – – Co‐payforeachindividualservice Thecopaymentforasingleoutpatienthospital servicecan’tbemorethantheinpatienthospital deductible;however,yourtotalcopaymentfor alloutpatientservicesmaybemorethanthe inpatienthospitaldeductible STEP 2‐ SKILLED LEVEL OF CARE Requiresskillednursingorrehabilitationby professionalpersonnel Needstobedoneadailybasis Practicalmatter,consideringeconomyand efficiencymustdoneasaninpatient Servicesarereasonableandnecessaryfor treatmentofaresident’sillnessorinjury 5 2/13/2015 CRITERIA Servicesprovidedbyaskilledprofessional, orderedbyMDandcarebeganwhileinthe hospital Theresidentrequirestheseskilledservices onadailybasis Asapracticalmatter,consideringeconomyand efficiency,thedailyskilledservicescanbe providedonlyonaninpatientbasisinaSNF Servicesmustbereasonableandnecessary DAILY PRACTICAL MATTER Dailyskilledcanbeprovidedonlyin SNFiftheyarenotavailableonan outpatientbasisortransportation wouldbe: – – – Anexcessivephysicalhardship Lesseconomical Lessefficientoreffectivethan Combinationofrehab/nursingservices required7days/week Skilledrehabservicesprovided5 days/weekmeetsthedailyrequirement definition Forrestorativenursing,itisexpectedto beprovidedatleast6days/week SKILLED CARE QUALIFIERS Reasonableandnecessary Servicesarereasonableinregardsto durationandquantity(keepinmindthe priorleveloffunction) Meetpresumptionofcoverage 6 2/13/2015 MEDICAL PREDICTABILITY Skilledservicesarenormallyinitiatedwithin 30daysafterdischargefromaninpatient hospitalstay Whenspecificcriteriaismet,anelapsed periodofmorethan30daysispermitted whenthepatient'sconditionmakesit medicallyinappropriatetobeginanactive courseoftreatmentinanSNFimmediately afterhospitaldischarge MEDICAL PREDICTABILITY Toqualifyforthisexception,itmustbe medicallypredictableatthetimeof hospitaldischarge thatacoveredlevel ofSNFcarewillberequiredwithina predictableperiodoftimeforthe treatmentofaconditionforwhich hospitalcarewasreceivedandthe patientmustbeginreceivingsuchcare withinthattimeframe MEDICAL PREDICTABILITY Thisexceptionappliesonlywhenthe SNFcareconstitutesacontinuationof careprovidedinthehospitaland is applicableonlywhenthetreatmentfor aparticularconditionindicatesthata coveredlevelofSNFcarewillbe requiredwithinapre‐determinable timeframe EXAMPLE OF MEDICAL PREDICTABILITY Itismedicallypredictable(inaccordancewithPub 100‐2,Chapter8,20.2.2.1)atthetimeofhospital dischargethataskilledlevelofnursingfacilitycare willberequiredwithinapredictableperiodoftime forthepropercontinuationoftreatmentfor _______________withsurgicalrepairinitiatedduring thehospitalstayandthepatientwillbegin receivingsuchcarewithinthattimeframeof _______________afterhospitaldischarge,whenweight bearingcanbetoleratedduetothemedical predictabilityoftheskilledtherapyservices neededforafractureofthisnature 7 2/13/2015 STEP 3‐ PRESUMPTION OF COVERAGE Treatmentcontinuationthatwas initiatedduringthehospitalstay Skilledlevelofcarewillberequiredata pre‐determinedtimeframe Residentbeginscarewithinthattime frame PRESUMPTION OF COVERAGE Medicare5dayplacesresidentinUpper 52RUG’sassumecoveragethrough ARD – – – – SPECIAL SERVICES Leaveofabsence Beneficiaryleavesforcertain excludedservices Clinicallycomplexandabove Appliesupondirectadmission Doesnotapplytosubsequentassessments Servicesmustbereasonableand necessary MIDNIGHT RULE Dayprecedingthemidnightonwhichthe beneficiarywasabsentfromthefacility, facilitycannotbillforthatday Lessthen24hours,notadmittedthenaLOA Uponreturn,mayneedasignificantchange Medicare“dayclock”isalteredbut“T”clock keepsonticking 8 2/13/2015 STEP 4 Meetsoneofthe5indirectordirect servicesoflevelsofcare: – – – – – Managementandevaluationofcareplan Observationandassessmentofcondition Teachingandtrainingactivities Directskillednursingservices Directskilledtherapyservices SPECIFIC EXAMPLES Managementandevaluationofa residentcareplan Recordasawholeclearlyestablishes thattherewasalikelypotentialfor seriouscomplicationswithoutskilled management SKILLED NURSING Involvesaprofessionalnurseproviding anaggregateofcare Orderedbyaphysician Documentationofoverallcondition Skilledservicesareclearlydocumented Teachingofself‐maintenanceprogram withbeneficiarypresent SPECIFIC EXAMPLES Observationandassessmentof resident’scondition Teachingandtrainingactivities 9 2/13/2015 DOCUMENTATION IMPORTANCE MDSassessments Reimbursement Qualityofcare Clinicalcare Nursinglicense PHYSICIAN DOCUMENTATION SKILLED NURSING DOCUMENTATION Reflectsmedicalnecessity Showscurrentstatus – – – Servicesperformed Responsetoservices Stability/instability Indicatewhyaskilledprofessionalis required MDdocumentationthatsupports resident'sconditionlikelytochange Signedtransferdocumentationortransfer form Historyandphysical Hospitaldischargesummary Physicianprogressnotes,consultationnotes Physicianorders Certsandre‐certs SKILLED NURSING DOCUMENTATION Observationandassessmentfactors andoutcomeevident Identifyneedtoobserve/assesshigh riskorpotentiallyhighrisk Dailydocumentationofsituationofhigh probabilityofanunstablecondition 10 2/13/2015 SNFPPS Residentsaregroupedbyacuity accordingtoanticipatedcostofcare (resourceutilization) – – – – – MinimumADLdependencyscoreof2or more Receivingcomplexclinicalcareorhave seriousmedicalconditions – – – – Diagnosis Clinicalcondition Extentofservicesrequired Functionalstatus Intensityofnursingand/orrehabcare SPECIAL CARE HIGH EXTENSIVE SERVICES Comatose Septicemia Diabeteswithinsulininjectionsandinsulinorder changes QuadwithADLscoreof5orgreater MinimumADLdependencyof2ormore Whilearesident,receivingcomplex clinicalcare: Tracheostomycare Ventilator/respirator and/or – Infectionisolation – – SPECIAL CARE HIGH (CONT) Receivingcomplexclinicalcareorhave seriousmedicalconditions – – – – COPDwithshortnessofbreathwhenlying flat Feverwithpneumonia,vomiting,weightloss, ortubefeedingmeetingintakerequirement Parental/IVfeeding Respiratorytherapy 11 2/13/2015 SPECIAL CARE LOW MinimumADLdependencyscoreof2or more Receivingcomplexclinicalcareorhave seriousmedicalconditions: – – – – – CerebralpalsywithADLdependencyscoreof>5 MSwithADLdependencyscoreof>5 Parkinson’sdiseasewithADLdependency>5 Respiratoryfailurewithoxygenwhilearesident Tubefeedingwithintake requirement CLINICALLY COMPLEX Complexclinicalcareorhaveconditions requiringSkilledNursinginvolvinganyofthe following: – – – – – – – – Pneumonia HemiplegiawithADL>5 Surgicalwoundsoropenlesionswithtreatment Burns Chemotherapywhilearesident Oxygentherapywhilearesident IVmedicationswhilearesident Transfusionswhilearesident SPECIAL CARE LOW Ulcertreatmentwith2ormoreulcers includingvenous,arterialorstageIIPU UlcertreatmentwithanystageIIIorIV Footinfectionsorwoundswithdressing Radiationtherapywhilearesident Dialysiswhilearesident MAGIC KEY TO SKILLING DOCUMENTATION Whydotheyneedtosleepatthenursinghome?? Whatisthestaffdoing24hoursadaythatcouldnot bemanagedathome?? 12 2/13/2015 MEDICARE MANUAL QUESTIONABLE SITUATIONS Thefollowing isinformation fromthe manual regarding skilledcare EXAMPLES OF SKILLED NURSING SERVICES IVorIMinjectionsandIVfeedings Enteralfeedingatleast26%ofdaily caloriesandprovidesatleast501ccof fluiddaily Naso‐pharyngealandtrach aspiration Insertion,sterileirrigationand replacementofsuprapubiccatheters Primaryserviceneededisoral medication Patientiscapableofindependent ambulation,dressing,feeding,and hygiene Palliativecareforextendedperiodof time EXAMPLES OF SKILLED NURSING SERVICES Applicationofdressing TreatmentofPUstageIIIorworseor widespreadskindisorder Rehabnursingproceduresrelatedto teachingandadaptiveaspectssuchas bowelandbladdertraining Initialphaseofadministrationofmedical gases Colostomycarewithteaching 13 2/13/2015 REFERRALS Pre‐Admission/AdmissionProcess – – Respondquickly‐ otherswantthesameresident Verifyinsurancecoverage(s) – MedicarevsManagedCare MedicareasaSecondaryPayer(MSP) Benefitperiods‐ daysavailable 3dayhospitalstay 30Daytransferrequirement Dailyskilledcoverage – MedicareBenefitManualSNFCoverage http://www.cms.gov/manuals/Downloads/bp102 c08.pdf MedicareBenefitManualBilling http://www.cms.gov/manuals/downloads/clm10 4c06.pdf http://www.wpsmedicare.com/j5macparta/resou rces/provider_types/ – – – – Understandingthemajorcategoriesofexclusionfrom consolidatedbilling MedicarePaymentScheduler SpellofIllnessChart MDS3.0manual Trainingmaterial Technicalinformation http://www.cms.gov/Manuals/IOM/list.asp – RESOURCES – Consolidatedbilling Staffcompetencies – Anticipateclinicalneeds http://cms.gov/NursingHomeQualityInits/2 5_NHQIMDS30.asp Verifytechnicaleligibilityrequirements – REFERENCES MedicareBenefitPolicyManual Medicareclaimsprocessing RESOURCES http://www.cms.gov/Medicare/Medica re‐General‐Information/BNI/ABN.html http://www.medicareadvocacy.org http://www.medicare.gov/publications /pubs/pdf/11435.pdf 14
