Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency
What are the hot topics from last week on the audit front? Medicare and Medicare Advantage claims are being denied for a misunderstanding of the “Medicare Week”. Denials occur when the service delivery exceeds the Physician Ordered frequency of treatment.
What is the Medicare week? Is it Sunday to the following Saturday? Depicted by facility specific policy? Or some misconstrued term that evolved over the years like camp fire ghost stories.
Here is the Deal
A therapist must treat within the confines stated in the MD order. Simply speaking, if the therapist obtains an order today for therapy 5 times per week for two weeks, the 14 days is inclusive of the day of the order.
Let me say this in a different way. If the MD orders a medication Wednesday June 1st for 7 days, but you declared a “Medicare Week” Sunday to Saturday, does this allow the administration of the medication June 8th, 9th, and 10th? You see my point. For those of you without coffee today, the medication cannot be administered after June 7th without an additional MD order.
Medical reviewers adhere closely to the written Medicare requirements. Per the Medicare Benefit Policy Manual Chapter 8 (Coverage of Extended Care (SNF) Services Under Hospital Insurance),
“The Skilled Nursing and/or Skilled Rehabilitation services are those services, furnished pursuant to physician orders”.
The physician orders for therapy in relation to the number of visits delivered are not calculated from Sunday to Saturday, or any other configuration of a designated week. Instead, the 7 day period for a therapy treatment week begins upon the completion of the evaluation (and the MD clarification order entry) and ends 7 days later and continues every 7 days thereafter.
The schedule for therapy can get confusing if you consider that the MDS schedule begins on the patient’s day of admission. These two periods, the “MDS Schedule” and the “Therapy Week”, may not coincide as therapy clarification orders are often written a few days after the patient’s admission. This difference in time periods makes it especially important to proactively communicate and track the therapy week for documentation purposes.
For example; if the evaluation is completed on Tuesday (and the clarification orders are entered that day) the week begins on Tuesday and ends the following Monday. The frequency of visits would be planned for that period.
Most therapy progress notes contain both the frequency and the number of treatments rendered on the documentation forms. This is an easy way to double check if the scheduled treatments are in line with the therapy orders. In the case that more treatments are provided than are ordered per week by the physician, it is recommended that the physician be notified to determine if supplemental orders are indicated for additional skilled treatments.
Harmony Teachable Moment
Do not lose reimbursement over the simple task of tracking MD orders in relation to the services provided. Train all therapists on the above information and have them track MD orders and visits manually on a calendar until the concept is ingrained into their daily mental checklist and ultimately automated into the software.
If you have questions about Medicare Week, please contact Harmony Healthcare International by clicking here or calling our office at 1.800.530.4413.