Skilled Nursing Facility Clinical Overview

1. Skilled Nursing FacilityClinical Overview Skilled Nursing Facility Clinical Overview Marlena Schnatz, RN CPC January 2011

2. DISCLAIMER This information release is the property of NHIC, Corp., J14 AB MAC. It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents. The information is provided �as is� without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by NHIC, Corp. and the Centers for Medicare & Medicaid Services (CMS). The most current edition of the information contained in this release can be found on the NHIC, Corp. web site at www.medicarenhic.com and the CMS web site at www.cms.gov. The identification of an organization or product in this information does not imply any form of endorsement.

3. Objectives Understanding of basic requirements of a Medicare skilled nursing facility (SNF) Prospective Payment System (PPS) benefit 2. Understanding of common denial reasons 3. Review of documentation suggestions 4. Response to additional document request

4. Eligibility Criteria Beneficiary must: Be enrolled in Medicare Part A and have available SNF days Have been in an inpatient hospital for 3 consecutive days for medically necessary treatment Be transferred to a Medicare participating SNF or swing bed unit within 30 days after hospital discharge

5. Criteria for Skilled Services Complexity Medical necessity Frequency

6. Four Required Conditions Requires skilled nursing care or skilled rehabilitation services: Managed by technical/professional Ordered by the physician Condition for which the patient received inpatient hospital services or for a condition that arose while receiving care in a SNF for a condition for which he received inpatient hospital services

7. Four Required Conditions Requires skilled services on a daily basis Can only be provided in a SNF on an inpatient basis The services must be reasonable and necessary for the treatment of the illness or injury, including duration and quantity

8. Clinical Example Irrigation of a suprapubic catheter may be a skilled nursing service, but daily irrigation may not be reasonable and necessary for the treatment of a patient�s illness or injury. Therefore, if a daily skilled service is not present, the patient does not meet skilled criteria

9. Clinical Example Mrs. Jones is a 76 year old resident of an extended care facility (ECF) who is readmitted after hospital inpatient treatment for pneumonia. She has a pre-existing diagnosis of congestive heart failure (CHF) with compromised cardiac output, poor tissue perfusion, and is short of breath with minimal exertion. Initial assessment indicates she is afebrile, has a clear productive cough, complains of dizziness and weakness with transfers, and is on Intravenous (IV) antibiotics every 8 hours.

10. Clinical Example Nursing is involved to administration of IVs, monitor lung sounds, vital signs, and other clinical signs and symptoms every shift Physical therapy (PT) and occupational therapy (OT) assess the patient and initiate therapy 5 days a week at 30 minutes for each discipline per day. The focus is on transfer techniques, to increase ambulation and strength

11. Decision on Clinical Example Is this patient appropriate for SNF PPS skilled level of care? Is the level of service being given appropriate for this patient? How would you determine if the level of service was appropriate? Is it appropriate to treat a patient for a pre-existing problem when already at a skilled level of care?

12. Technical Requirements: Certification Signed by Attending physician Physician with knowledge of the case Nonphysician or clinical nurse specialist No Centers for Medicare & Medicaid Services (CMS) specific form needed Mailed, faxed, or completed when the physician is onsite Maintained in medical record

13. Technical Requirements:Certification Initial certification On admission or as soon as possible First recertification No later than 14th day Recertification every 30 days

14. Technical Requirements:Qualifying Stay The patient must have been admitted as inpatient for 3 consecutive days for a medically necessary stay in a hospital

15. Technical Requirements:Qualifying Stay Psychiatric inpatient stays While a 3-day stay in a psychiatric hospital satisfies the prior hospital stay requirement, institutions that primarily provide psychiatric treatment cannot participate in the program as SNFs. Therefore, a patient with only a psychiatric condition who is transferred from a psychiatric hospital to a participating SNF is likely to receive only noncovered care. CMS IOM 100-02; Chapter 8; Sections 20, 20.1

16. Primary Condition and Needs are Psychiatric Skilled observation and assessment may be required for symptoms such as depression, anxiety, or agitation However, these conditions often require considerably more specialized, sophisticated nursing techniques, and M.D. attention than is available in most participating SNFs

17. Most Common Denial Reasons Documentation did not support a skilled level of service Documentation did not support the level of service billed

18. Documentation Problems Nursing notes do not support a daily skilled service Progress is not demonstrated in the therapy notes No records for look-back period

19. Clinical Example Mr. Baker is admitted on January 25, 2007 after a 4-day hospital stay for dehydration and urosepsis. He received IV antibiotics and fluids and is stable upon admission back to the SNF. The physician has ordered skilled nursing, PT, and OT for strengthening and endurance

20. Clinical Example Is Mr. Baker appropriate for SNF PPS skilled level of care? Are both skilled nursing and therapy appropriate for this patient? How long should he remain skilled?

21. Clinical Example Admission is on 1/25/10. The minimum data set (MDS) nurse selects an assessment reference date of 1/31/10 (day 7) If records are requested for a claim with DOS 2/1-2/28, is it necessary to send the admission information, 5-day MDS, and hospital records? What must be demonstrated in the documentation to support medical necessity for this patient into the month of February?

22. Documentation to Support Medical Necessity Establish a timeline of care from admission Paint a picture If it is not documented it was not completed Project a team approach to care

23. Documentation The patient must be able to benefit from and tolerate the level of therapy given Therapy notes must demonstrate progress and contain the treatment minutes for each date of service

24. Clinical Example Mrs. Brookes is on her 30th day of skilled PPS services. She is receiving PT and OT 5 times per week for 45 minutes per discipline. Her treatment diagnosis is general deconditioning. Her prior level of function was independent at home without an assistive device. She has reached a supervision/assist level of function for activities of daily living (ADL) and a stand by assist for transfers.

25. Clinical Example She is able to ambulate 150� X2 with a rolling walker with contact guard assist (CGA)/standby assist (SBA). The nursing documentation notes that Mrs. Brookes complains of extreme fatigue and muscle pain prior to dinner and is unable to eat. This condition is documented several times in the same week.

26. Clinical Example Is this patient appropriate for SNF PPS service? Are all the services provided at an appropriate level? What interventions should be completed?

27. Skilled Therapy Must Meet All of the Following Conditions Directly related to an active treatment plan approved by the physician A level of complexity and sophistication, or of a nature that requires the judgment, knowledge, and skills of a therapist Improvement in a reasonable and generally predictable timeframe, or necessary for establishment of a safe and effective maintenance program

28. Skilled Therapy Must Meet All of the Following Conditions Accepted standards of practice for effective treatment Be reasonable and necessary includes amount/frequency/duration

29. Problems Identified in Review of Therapy Services Maintenance Exercises to promote fitness and flexibility Strength and endurance (repetitive) Assistive walking Range of motion; passive exercises Continuation after patient goals achieved

30. Skilled Services�Therapies Minutes (actual)� never rounded Treatment time only� no rest breaks Documented Time patient receives therapy; not therapist�s time

31. Problems Discovered in Review Skilled Services � Therapies Documentation Goals and/or plan of care not individualized Insufficient evidence of progress in the documentation

32. Examples of Skilled Nursing Examples of skilled nursing are located in 42 Code of Federal Regulations Sections 409.33

33. Patient Education Teaching a patient or caregiver new techniques does require skilled personnel Incorporate into the plan of treatment from the beginning Document patient or caregiver�s response Do not add extra days on for education

34. Nonskilled Routine administration of oral meds, eye drops, and ointments General maintenance care of a colostomy or ileostomy Routine care/function of an indwelling catheter Dressing changes for uninfected postoperative or chronic conditions

35. Nonskilled Routine care of the incontinent patient General maintenance of a plaster cast Use of heat as palliative/comfort measure Assistance in dressing, eating, and toileting

36. Nonskilled Periodic turning and positioning in bed Prophylactic/palliative skin care, including treatment of minor skin problems

37. Administrative Level of Care Presumption Beneficiaries who are admitted/readmitted directly to a SNF after a qualified health stay (QHS) are considered to meet the level of care requirements of 42 CFR 409.31 up to and including the assessment reference date (ARD) for the 5-day assessment when correctly assigned to one of the upper 35 RUG-III groups

38. Minimum Data Set (MDS) 3.0 Became effective 10/1/2010 Medicare Required Assessments: 5 day 14 day 30 day 60 day 90 day

39. Unscheduled Prospective Payment System Assessments Significant Change in Status Assessment Start of Therapy Other Medicare Required Assessment End of Therapy Other Medicare Required Assessment Refer to the MDS 3.0 RAI Manual, Chapter 6 for complete information regarding MDS assessments

40. Medicare Requirements: Timeliness- MDS completion date must be no later than 14 days from the Assessment Reference Date (ADR) For the Admission assessment, the Care Area Assessment (CAA) completion date should be no more than 14 days from the Entry Date For all other comprehensive Medicare required assessments, the CAA completion date should be no more than 14 days from the ARD.

41. Health Insurance Prospective Payment System (HIPPS) Billing codes used when submitting Part A SNF payment claims to the Part A/B Medicare Administrative Contractor (MAC) Consists of 5 positions- first 3 RUG IV case mix code, last 2 Assessment Indicator

42. MDS Medicare Requirements The HIPPS rate code that appears on the claim must match the assessment that has been transmitted and accepted by the State in which the facility operates.

43. MDS Medicare Requirements The SNF may bill the program only after: An assessment has been completed and submitted to the State RAI Database; A Final Validation Report indicating that the assessment has been accepted by the state; and The covered day has actually been used. SNFs that submit claims that have not completed this process will not be paid.

44. MDS Pointers Complete MDS Physician visits/orders counted by days Do not include M.D. clarifications or renewals

45. MDS Pointers Therapy evaluation minutes are not counted on the MDS Calculation of therapy minutes for each discipline in the look back as: Individual therapy- capture all minutes Concurrent therapy- half of the minutes Group therapy- capture all minutes Group therapy can not account for more then 25% of total therapy minutes Treatment rendered on the day of the evaluation must be documented as separate and distinct

46. Comprehensive Error Rate Testing (CERT) Livanta is the CERT documentation contractor. Providers will receive requests for CERT medical documentation from Livanta

47. Contractor Error Rate Testing CERT Please be sure to forward requested medical record documentation to Livanta. AdvanceMed will only be responsible for medical review of the claims. Reminder: Help reduce the national Medicare claims payment error rate. Please submit medical records promptly when requested by the CERT contractor, Livanta Part A CERT Contact: Clinical.education@wellpoint.com 1(800) 338-6101

48. Primary CERT Denial Documentation does not support the level of service billed Therapy minutes not supported Documentation missing for the look back period

49. References CMS Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, 15 CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 6, 7, 30 CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 6 42 CFR Section 409.33

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