Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency
This week’s travels uncovered another pattern. Many MDS Teams appear to be combining the Change of Therapy (COT) with the next scheduled PPS Assessment. In many instances, this is not only unnecessary but the combination results in decreased reimbursement for 6 days, (specifically in the case of combing a COT with the scheduled 14-Day MDS).
It is important to know when to combine the COT MDS Assessment and when to complete the Standalone Scheduled MDS Assessment.
If Day 7 of the COT observation period falls within the ARD window of a scheduled PPS assessment, the SNF may choose to complete the scheduled PPS Assessment alone by setting the ARD of the scheduled PPS assessment for an allowable day that is on or prior to Day 7 of the COT observation period. This effectively resets the COT observation period to the 7 days following that scheduled PPS assessment ARD.
If the facility fails to set the ARD within the assessment window while the resident is still in a Part A Covered Stay, the Facility must complete a late assessment. If the Facility sets the ARD of the late assessment prior to the end of the period, during which the late assessment controls the payment (had the ARD been set timely) and no intervening assessments occurred, Medicare will pay the default rate for the number of days the assessment is out of compliance.
If an ARD is not set prior to the end of the last day of the assessment window and the resident is no longer in a Part A covered stay, the Provider may not bill for those days. Medicare will not pay for these days because the Medicare-required assessment is non-existent in the Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System for the payment period.
Billing at the Default Rate for a Medicare-Required Assessment that is not in QIES is permissible only in the following situations:
- The stay is less than 8 days within a spell of illness;
- The SNF is notified on an untimely basis of, or is unaware of, a Medicare Secondary Payer Denial;
- The SNF is notified on an untimely basis of a beneficiary’s enrollment in Medicare Part A;
- The SNF is notified on an untimely basis of the revocation of a payment ban;
- The beneficiary requests a demand bill; or
- The SNF is notified on an untimely basis of, or is unaware of, a beneficiary’s disenrollment from an MA (Medicare Advantage)Plan.
Harmony Healthcare International (HHI) strives to share with you the most cutting edge information. But, we also want to remind you to stay focused on the basic concepts that seem to be frequently overlooked during this time of Regulatory and Reimbursement change.
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