A list of facilities with potential staffing issues is being provided to CMS regional offices and state survey agencies to support survey activities for evaluating sufficient staffing, according to a memo released by CMS back in November, 2018. The memo states that “while CMS is encouraged by facilities’ efforts to improve staffing,” payroll based journal (PBJ) data has raised a few concerns, prompting them to inform state survey agencies of facilities with potential staffing issues. These issues include facilities with significantly low nurse staffing levels on weekends and facilities with several days in a quarter without an RN onsite.
Once you come to understand how reimbursement will be calculated under the new skilled nursing facility (SNF) prospective payment system (PPS) model, Patient Driven Payment Model (PDPM), you may wonder why it wasn’t named the Primary Diagnosis Driven Payment Model, but that’s a conversation for another day. What we should be focusing on is the fact that under PDPM, each resident’s primary diagnosis code entered into line I0020B of the minimum data set (MDS) (a new MDS field that will be added effective 10/1/2019) will be used to place the patient into one of ten PDPM clinical categories. These clinical categories are then used as part of the patient’s classification under the physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) components. A resident’s primary diagnosis code is essentially the hinge for that resident’s clinical documentation and reimbursement path, so getting it right is essential in order to achieve accurate reimbursement under PDPM.
The purpose of the MDS chart audit tool is to ensure documentation is present in the medical record to support the findings of the MDS. Use the tool at the end of the month or the episode of care. If documentation that supports the MDS is present for each item, place a checkmark. If it is not, highlight the area so it can be followed up on to ensure completeness. This form can be completed by the MDS coordinator, DON, medical records, therapy director, or delegated per area of specialty. Download this Billers’ Association for LTC member resource.
SNFs must provide quality care to residents in a field that is being suffocated by regulation and paperwork, and that is placing ever-increasing importance on data. The key is to ensure the data does not eclipse the care. SNFs must adhere to the principle that putting residents first will improve quality measures, increase reimbursement rates, and ensure a successful survey. Enhancing resident care will then give a facility the reputational excellence it needs to fill its beds.
Skilled Nursing Facility (SNF) Provider Preview Reports have been updated and are now available. Providers have until June 30, 2018 to review their performance data prior to public display on the Nursing Home Compare site. Corrections to the underlying data will not be permitted during this time. However, providers can request a CMS review during the preview period if they believe their data scores displayed are inaccurate.
Q: What should we do if we feel that the auditor’s findings are blatantly wrong?
A: If it is felt the auditor was blatantly wrong, providers should contact the agency immediately to discuss it. For instance, if there was a prescription, but it wasn’t in the file that the auditor had, then it would not be considered an error on the auditor’s part, and the facility should follow the appropriate appeals process. But if the auditor made a mistake, he or she should correct it accordingly before proceeding with an overpayment. If the auditor won’t fix the error, then ask to speak with his or her superior about the issue. Providers have the right to accurate decision-making when it comes to claims processing, medical review, and audits.
On Friday, April 27, 2018, the Centers for Medicare & Medicaid Services (CMS) published a highly anticipated proposed rule containing a recommendation to replace the existing case-mix classification methodology, the Resource Utilization Groups, Version IV (RUG-IV). The proposed model, Patient-Driven Payment Model (PDPM), significantly revises the Resident Classification System, Version I (RCS-I), which was introduced as a potential RUG-IV replacement last April in an Advanced Notice of Proposed Rulemaking.
The Billers’ Association is seeking long-term care managers, revenue cycle enthusiasts, and billing professionals to join our growing ad-hoc list of experts interested in contributing to articles in our monthly publication, Billing Alert for Long-Term Care. This digital newsletter provides expansive regulatory coverage, including MDS changes, reimbursement issues, and expert advice and analysis to help improve job performance in all aspects of the revenue cycle management system.
In 2013, several OIG studies and investigations found that SNFs had deficiencies in quality of care, did not develop appropriate care plans, and failed to provide adequate care to beneficiaries. In fiscal year 2012, Medicare paid $32.2 billion for SNF services. The reviewers determined the extent to which SNFs developed care plans that met Medicare requirements, provided services in accordance with care plans, and planned for beneficiaries’ discharges as required. Reviewers also identified examples of poor-quality care.