On August 1, 2013, the Centers for Medicare & Medicaid Services (CMS) published the Final Rule for the Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities (SNF) for FY 2014. The Medicare rates posted in Final Rule will go into effect October 2013.
SNF rates will increase for FY 2014 based on the following factors:
- A budget neutrality factor change to 1.006
- 2.3% Update factor
- -0.5% Market basket forecast error or adjustment
- -0.5% Multifactor productivity (MFP) adjustment per ACA 2010.
- CMS estimates the sum of these rate adjustments will result in a 1.3% increase equating to $500 million increase in total SNF payments (approximately $7 per Medicare patient day) for FY 2014.
CMS solidifies the changes to Section O of the Minimum Data Set (MDS) to include reporting the number of distinct calendar days of therapy for Physical, Occupational and Speech-Language Pathology. In addition, there is a new RAI User's Manual reporting requirement for coding co-treatment minutes on the MDS. Although reporting the number of distinct therapy days will impact the classification criteria for Rehabilitation RUG-IV Medium and Low categories, at this time reporting minutes of co-treatment under of modes of therapy will not impact the SNF PPS RUG-IV requirements. Harmony (HHI) notes that potential MDS changes to Section K for coding IV Hydration in the RAI User's Manual were not addressed in the Final Rule. There is the potential for coding clarifications to further impact SNF PPS RUG-IV classification for the Special Care High category.
Reporting the number of distinct calendar days of therapy aligns the MDS and SNF PPS RUG-IV grouper with existing Medicare Part A coverage requirements. Existing Medicare Part A skilled coverage criteria requires therapy to be delivered to a beneficiary on at least five days per week if therapy is the only skilled service in order to meet the daily skilled coverage requirements. The daily basis requirement can be met by furnishing multiple therapy types on different days of the week that collectively add up to "daily" skilled services. CMS clarified that to meet this requirement the patient must actually need skilled rehabilitation services to be furnished on each of the days. Conversely, the Rule states, "It is not sufficient for the scheduling of therapy sessions to be arranged so that some therapy is furnished each day, unless the patient's medical needs indicate that daily therapy is required." This would not satisfy the Medicare Part A skilled coverage requirement for on a "daily basis." In other words, the reason for providing services on different days must be clinically based. The Medicare Benefits Policy Manual (Chapter 8) supports the details in the Final Rule.
Currently, SNF PPS RUG-IV grouping for the Rehabilitation Medium and Low categories is solely based on a combined amount of therapy minutes and days provided to a patient during the 7 day look back period. With the inclusion of reporting distinct calendar days on the MDS, 5 distinct calendar days of therapy and 150 minutes or greater of therapy will be required to achieve a Rehabilitation Medium RUG. In addition, three or more distinct calendar days of therapy and 45 minutes or greater (in addition to restorative nursing requirements) will be required to achieve a Rehabilitation Low RUG. In the case that overlapping days of therapy during the look back prevent a Rehabilitation RUG classification, the RUG could reduce to a Nursing RUG, potentially misrepresenting the clinical picture of the patient.
Harmony (HHI) recommends that facilities be in close communication with their MDS and Rehabilitation software providers to ensure they are prepared for the October 1st changes. Harmony (HHI) reminds facilities that the distinct calendar days requirements will also apply when determining if Change of Therapy (COT) requirements are met.
CMS will continue to designate the upper 52 RUG-IV groups for purposes of this administrative presumption. CMS states, "This administrative presumption policy does not supersede the SNF's responsibility to ensure that decisions relating to level of care are appropriate and timely, including a review to confirm that the services prompting the beneficiary's assignment to one of the upper 52 RUG-IV groups (which, in turn, serves to trigger the administrative presumption) are themselves medically necessary."
CMS continues to monitor the impact from FY 2012 policy changes. CMS reported in the Final Rule that 99.5% of therapy time reported is individual therapy. In addition, 11% of MDS submissions are COT OMRA assessments. CMS reports no unanticipated or undesirable changes in regards to recalibration of the parity adjustment, group therapy allocations and simultaneous implementation of the COT OMRA with FY 2012 changes. CMS did not address trends in the number of provider liable and default days or increased staff resources utilized to monitor and complete COT OMRAs.
A SNF therapy research project will be conducted to identify potential alternatives to the current method of payment for therapy services. CMS will “regularly” update the public on the progress of this project. Providers can view updates at https://www.cms.gov/Medicare/Medicare-Fee-forServicePayment/SNFPPS/therapyresearch.html. CMS stated, "it would be premature to speculate on when a new model will be ready to be implemented.”
The Final Rule did not report any changes to consolidated billing excluded services. Corrections to the annual pricer exclusion files will show that HCPCS codes 11042, 11043, and 11044 (surgical debridement codes) will be corrected to ensure that they are excluded from consolidated billing.
CMS details what diagnosis codes will be used to determine the 128% for the AIDS add-on payment with conversion to ICD-10-CM. ICD-10-CM diagnosis code of B20 will be utilized for purposes of defining the AIDS add-on.
CMS finalized revisions to the regulation related to the SNF level of care certification and re-certifications by including Physician Assistants in the provision authorizing nurse practitioners and clinical nurse specialists to sign SNF level of care certifications and re-certifications.
Harmony (HHI) encourages providers to read the Final Rule in its entirety at https://gpo.gov/fdsys/pkg/FR-2013-08-06/pdf/2013-18776.pdf.
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