When trying to understand something complex, it sometimes helps to use food as a metaphor. Under the Patient-Driven Payment Model (PDPM), therapy becomes a piece of the pie, rather than the whole thing. For providers considering ways to minimize therapy services or reduce therapy staffing, a few additional considerations should be looked at before making any cuts.
Developing a proactive internal approach to identifying and correcting billing issues before they become problematic is always good practice. Education and training on billing, coding, and documentation are essential. And as with any solid system, success depends heavily on continued monitoring of the process.
The UB-04 is made up of form locators (FL), or boxes to be completed. Some of the FLs are required, some are optional, and some are not used in the SNF setting. If any required pieces are missing, the claim will not pass the system edits when it is submitted to the MAC. Although most Medicare billing is done electronically and the UB-04 is completed largely by the billing software, it is important for Medicare billers to be familiar with the pieces of information required on the claim and how to complete the form.
When a Medicare Part A beneficiary is absent but not discharged, for reasons other than hospital or other SNF admission, a leave of absence (LOA) bill is required. The day of discharge, the day of death, or the day on which a beneficiary begins an LOA is not counted as a utilization day and is not billed. The exception to this rule is when the beneficiary is admitted to the SNF with the expectation that he or she will remain overnight but is discharged, dies, or is transferred to a nonparticipating provider before midnight of the same day.
During a Skilled Nursing Facilities (SNF)/Long Term Care Open Door Forum (ODF) held Tuesday, April 23, 2019, Centers for Medicare and Medicaid Services (CMS) officials discussed the Proposed Fiscal Year 2020 Payment and Policy Changes for Medicare Skilled Nursing Facilities (CMS-1718-P) published in the Federal Register on April 25, 2019.
Q. Should therapy treatment practices change under the Patient-Driven Payment Model (PDPM)?
A. Even though therapy minutes are no longer relevant to the provision and payment for therapy, CMS has assumed that most therapy will continue to be provided one-on-one. SNFs with contract providers need to take great care to ensure that the contractor does not automatically ramp up inpatient therapy on a group and concurrent basis to the 25% threshold!
Unless the facility has experienced a significant change in overall case mix from when under resource utilization groups (RUG) to PDPM (fewer therapy-qualified residents), there would be no logical clinical reason to change treatment practices.
Three changes happened recently for therapists that billers should know about: Medicare’s outpatient therapy cap was repealed and the therapy threshold was lowered; new modifiers for therapy assistants were added; and the requirement for functional limitations reporting was removed.
SNFs see zero reimbursement value from no-pay bills and benefits exhaust claims, so no-pay bills often go overlooked. Billers are instead looking to deal with issues that will result in cash flow for the facility. So what exactly are no-pay bills, and where does a benefits exhaust situation come into play?