These past few weeks of on-site audits with the Harmony Team continue to reinforce the need for everyone to get back to basics. All of the hype and frenzy over payment reform is distracting and disrupting the focus on the simplest of tasks. What task you ask? Spell of Illness.
In order to successfully operate in the Skilled Nursing Facility space, Kris Mastrangelo continually messages these 3 focal points:
On July 13, 2015, the Centers for Medicare and Medicaid Services published a Proposed Rule that revises the requirements for participation in Medicare and Medicaid programs for long-term care facilities. This CMS proposal is due to the fact that as CMS states, “The population of nursing homes has changed, and has become more diverse and more clinically complex.” Evidenced based research has been conducted that has provided greater knowledge about resident safety, health outcomes, individual choice and quality assurance and performance improvement. Major changes have not been made to the conditions for participation since 1991 despite the significant changes to service delivery in this setting.
The Jimmo agreement (Jimmo v. Sebelius) settles once and for all that Medicare coverage is available for skilled services to maintain an individual’s condition. Under the maintenance coverage standard articulated in the Jimmo Settlement, the determining issue regarding Medicare coverage is whether the skilled services of a health care professional are needed, not whether the Medicare beneficiary will "improve." Pursuant to Jimmo, medically necessary nursing and therapy services, provided by or under the supervision of skilled personnel, are coverable by Medicare if the services are needed to maintain the individual’s condition, or prevent or slow their decline (To learn more about the Jimmo Settlement, click here).
When considering how to approach setting goals for a patient receiving maintenance therapy delivered by a clinician, analyze the at-risk behavior or decline that would result from a lack of skilled intervention.
CMS Proposed Rule FY2015: On May 6,2014, the Centers for Medicare and Medicaid Services (CMS) issued a Proposed Rule [CMS-1605-P] under the Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities. The Proposed Rule illustrates the proposed Fiscal Year 2015 Medicare payment rates for skilled nursing facilities (SNFs). The Proposed Rule outlines an estimated increase in SNF payments of 2.0%. This estimated increase is attributable to the 2.4% market basket increase, reduced by the 0.4% point multifactor productivity adjustment required by law. As the actual amount of change in the market basket index at -0.3 did not exceed the 0.5 percentage point threshold, the payment rates for FY2015 do not include a forecast error adjustment.
The Centers for Medicare & Medicaid Services (CMS) revised Chapter 8 ”Coverage of Extended Care (SNF) Services Under Hospital Insurance” with implementation on January 7, 2014. This manual is the Medicare authoritative publication for making skilled coverage decisions and ensuring documentation supports the care provided. This source document is utilized by Medicare reviewers in detailing why a claim for skilled rehabilitation or nursing services is denied.
One of the most frequently asked questions during our facility site visits is about how to improve the accuracy in coding of Section G; ADL Functional Status. The answer is always education, education, education! Staff turnover and "urban myths" about coding are two barriers that make frequent education a must.
Surviving the Medicare adjustments in FY2012 has been a major topic of discussion and debate in most SNF's throughout the US. To maintain a viable Medicare program in the SNF you must analyze the admission and discharge process for the Medicare Part A caseload. A component of this analysis critical to successful clinical outcomes and preserving the integrity of the program is the clinically anticipated Medicare length of stay. Case management by the Rehab professional is one of the primary factors affecting length of stay. Generally, when a patient is admitted for short term rehab their underlying medical conditions stabilizes before they have met their functional potential. Therefore, it is very likely that the Rehabilitation Department is the driving force behind the patient's discharge plan.