SKILLED NURSING FACILITY (SNF) CONSOLIDATED BILLING 1
SKILLED NURSING FACILITY (SNF)
CONSOLIDATED BILLING
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AGENDA
SNF Coverage SNF Consolidated Billing (CB) MDS Resource Utilization Groups (RUGs) Documentation Medical Review Common Errors
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SNF COVERAGE
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PART A SNF COVERAGE Coverage criteria - Beneficiary is entitled to Medicare Part A benefit Require daily skilled level of care services Daily skilled services can only be provided on an
inpatient basis in a SNF Must be medically reasonable & necessary for
treatment of the patient’s illness or injury
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PART A SNF COVERAGE Qualifying hospital stay of at least 3 consecutive
days of inpatient care for related illness/injury Not counting day of discharge or time in observation Stay can be in one or more Medicare participating
hospital Or institution that meets at least the conditions of
participation for emergency service hospital
Admitted to SNF within 30 days of hospital discharge
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QUALIFYING STAY EXCEPTION Exception to the 3 day qualifying hospital stay - Disenrollment from a Medicare Advantage (MA)
plan due to termination when there is no 3 day hospital stay before SNF admission If admitted to SNF prior to effective date of disenrollment
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TRANSFER REQUIREMENT 30 day transfer requirement Must be transferred to a participating SNF within 30
days after discharge from hospital Unless patient’s condition makes it medically inappropriate
to begin active treatment in a SNF immediately after hospital discharge and;
It is medically predictable at time of hospital discharge that patient will require covered care within a predetermined time
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SNF READMISSIONS If patient is discharged from skilled level of
care (LOC) & subsequently is readmitted at a skilled LOC to same or another facility within 30 days, a new qualifying stay is not required If readmission occurs more than 30 days after
discharge, a new qualifying stay is required unless there’s a medically appropriate delay
Care must be related to prior hospital or SNF stay
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BENEFIT PERIOD May be more than one benefit period in a
calendar year or one benefit period may overlap a calendar year Diagnoses do not affect benefit period determination Renewed every 60 days if there is no inpatient
hospitalization
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BENEFIT PERIOD Begins with first day patient is furnished
inpatient hospital or extended care services by a qualified provider in a month for which patient is entitled to hospital insurance benefits Midnight to midnight method of counting
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BENEFIT PERIOD Ends when patient has not been inpatient in
hospital, SNF or Swing Bed (SB) for 60 consecutive days Count begins with day patient was discharged For benefit period purposes, SNF/SB inpatient
status ends when patient no longer meets daily skilled care requirements
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BENEFIT PERIOD SNF/SB = 100 post-hospital days 20 days paid in full by Medicare 80 days coinsurance ($167.50 for 2018) Lifetime Reserve Days do not apply in a SNF/SB
Date of discharge, death or leave of absence are not counted as SNF days
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SNF CONSOLIDATED BILLING
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SNF CB - BACKGROUND BBA 1997 mandated payment for the majority
of services provided to patients in a Medicare covered Part A SNF stay be bundled in PPS Excluded services not subject to Consolidated Billing
Bundled services required to be billed by SNF/SB Entities that provide services for patients in a SNF
stay cannot bill separately for those services
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FACILITIES SUBJECT TO CB Medicare participating SNFs Short term hospitals, long term hospitals, &
rehabilitation hospitals certified as swing beds Except Critical Access Hospitals (CAH) SB
All Part A & B physical, occupational & speech therapy services must be provided directly or indirectly, & billed by SNF Includes covered & non-covered stays
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SNF CB - REQUIREMENTS Requirement makes SNF responsible for billing
almost all services during a Medicare stay Services must be furnished directly by SNF
resources or obtained under arrangement with an outside entity
SNF must reimburse entity for services subject to CB whether agreement is in place prior to services or after
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SNF CB - REQUIREMENTS Exception to specifically excluded services
Excluded services are separately furnished & billed to Part B by outside sources
http://www.cms.gov/SNFConsolidatedBilling/
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http://www.cms.gov/SNFConsolidatedBilling/
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UNDER ARRANGEMENT o Private agreement/contract between SNF &
outside entity is recommended • Both parties should reach common understanding on
terms of payment • Absence of a valid arrangement does not invalidate
SNF responsibility to reimburse outside entity • CMS sample agreement forms at:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/BestPractices.html
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https://www.cms.gov/Medicare/Medicare-Fee-for
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SNF CB – MAJOR CATEGORIES CMS divides services affected by SNF CB into
major categories General Explanation of Major Categories for SNF CB
Must understand these major categories to apply CB principles correctly to billing
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FIVE MAJOR CATEGORIES FOR CB I -Exclusion of services beyond SNF Scope
II - Add. excluded services when rendered to specific benes
III - Add. excluded services rendered by certified providers
IV - Add. excluded preventive & screening services
V -Part B services included in SNF CB
Broken into sub -categoriesNote: F. Outpatient Surgery & Related Procedures -Inclusion
SNF TOB 22x SB TOB 12x
PT, OT, & SLP included in CB for patientsin Part A stay
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MAJOR CATEGORY I Computerized Axial Tomography (CT) Scans Cardiac Catheterization Magnetic Resonance Imaging (MRIs) Radiation Therapy Angiography, Lymphatic, Venous & Related
Procedures Outpatient Surgery & Related Procedures
(Inclusion) Emergency Services Ambulance Transportation
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MAJOR CATEGORY II Dialysis – Home dialysis supplies & equipment
and self-care home dialysis support services
Institutional dialysis services & supplies
Erythropoietin (EPO) & Darbepoetin (DPA),
Hospice Care for a Beneficiary’s Terminal Illness
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MAJOR CATEGORY III Additional Excluded Services Rendered by
Certified Providers Chemotherapy Chemotherapy Administration Radioisotopes & their Administration Customized Prosthetic Devices
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MAJOR CATEGORY IV Additional excluded preventive & screening
services
Mammography Prostate Cancer Screening Vaccines – Pneumococcal, Glaucoma Screening Flu or Hepatitis B Diabetic Screening Vaccine Administration Cardiovascular Screening Screening - Pap Smear & Pelvic Exams
Initial Preventative Physical Exam (IPPE)
Colorectal ScreeningServices
Abdominal Aortic Aneurysms(AAA) Screening
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MAJOR CATEGORY V Therapies billed with revenue codes: 42x (physical therapy) 43x (occupational therapy) 44x (speech-language pathology)
SNFs will bill for therapy services for patients in certified bed in a non-covered stay on a 22x TOB
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CB INCLUSIONS SNF must bill for all services provided to Part A
residents covered in a Part A stay Psychological services furnished by a clinical
social worker Services “incident to” the professional services
of a physician or other health care professional
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CB EXCLUSIONS A number of services excluded from SNF CB These services are outside the PPS bundle They remain separately billable to Part B when
furnished to an SNF resident by an outside supplier
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CB EXCLUSIONS Excluded RHC/FQHC Physician Services Physician/Non-Physician Practitioner services
included within the scope of RHC and FQHC services RHC = Type of Bill (TOB) 71x FQHC = TOB 77x
Only this subset of RHC/FQHC services may be covered & paid separately during Part A stay
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INCIDENT TO SERVICES o CB excludes professional services a practitioner
performs personally o Exclusion does not apply to physician "incident
to" services furnished by someone else as "incident to“ practitioner's professional service • These "incident to" services furnished by others to
SNF residents are subject to CB • HCPCS for services subject to SNF CB editing
https://www.cms.gov/Medicare/Billing/SNFConsoli datedBilling/2018-Part-A-MAC-Update.html
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https://www.cms.gov/Medicare/Billing/SNFConsoli
EXCLUDED SERVICES Excluded Services Excluded ‘Incident to’ Physician services - Physician, Cardiac catheterizations PA, NP, certified nurse midwife, Certain lymphatic & venousCRNA, qualified psychologist procedures Home dialysis supplies/ Ambulatory surgery; involvesequipment, self-care home use of operating roomdialysis support services & Emergency services Institutional dialysis svs/supls EPO & DPA for certain dialysis CT scans, MRIs, angiographypatients & custom prosthetic devices Hospice care Chemotherapy items &
administration Ambulance trip Radiation therapy &
radioisotope services
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AMBULANCE EXCLUSIONS Initial trip to SNF admission Trip home after discharge not followed by readmission to same or another SNF by midnight Trip for inpatient admission to hospital/CAH
Trip to/ from hospital/CAH for ER services or other outpatient exclusions Trip home for services under HHA plan of care Trip for Part B dialysis services
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FREQUENCY OF BILLING SNF claims are billed to Medicare monthly Submit claims to Palmetto GBA monthly
Submit in sequence for patient Current claim must finalize before next claim is submitted
Upon discharge of the patient When patient’s benefits have exhausted Patient no longer needs skilled care
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MINIMUM DATA SET (MDS)
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RESOURCE UTILIZATION GROUPS Classification of patients into specific resource
utilization groups (RUGs) for payment purposes Measurement of characteristics & health status
information to determine type, amount & intensity of services needed to provide appropriate care
Determines per diem reimbursement Scores determined by Minimum Data Set (MDS)
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MINIMUM DATA SET (MDS) Primary purpose is to identify resident care
problems addressed in individualized care plan Capture care & services Tracking tool for changes in patient condition Must be completed & submitted to repository
All scheduled assessments
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/SNF-PPS/SNFAssessHTML022817f.html
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https://www.cms.gov/Outreach-and-Education/Medicare-Learning
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MINIMUM DATA SET (MDS) Unscheduled assessments Significant change in status assessment Significant correction to prior comprehensive
assessment Start of Therapy (SOT) Other Medicare Required
Assessment (OMRA) End of Therapy (EOT) OMRA Change of Therapy (COT) OMRA
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ASSESSMENT INDICATOR (AI) 1st digit of AI code identifies schedule PPS
assessment that establish RUG payment rate for standard PPS scheduled payment period HIPPS rate codes are alphanumeric five-digit codes
made up of a three digit RUG & AI combo HIPPS represents LOC which determines payment
HIPPS Master Code List
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MDS ASSESSMENTS Schedule = 5, 14, 30, 60 & 90 day assessments Complete 5 day assessment when patient
Admits or readmits (not anticipated) Returns home more than 30 days after discharge (anticipated) Terminates MA plan & is Part A covered
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DOCUMENTATION
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SKILLED DOCUMENTATION Physician Order - legible, signed & dated Illegible; send signature log & attestation
statement
Orders for skilled services
Medications, weight sheets, vital sign records, care plan & treatment plans
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SKILLED DOCUMENTATION Document look-back period for each MDS
billed (may be prior to billing period) Therapy minutes, IV administration, ADLs
Laboratory tests & reports for billing period Automatic, routine or generic standing orders for
labs are not allowable under Medicare
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SKILLED DOCUMENTATION PT/OT/SLP = Initial evaluation, POC & progress
reports on or before every 10th treatment day Treatment encounter notes & discharge summary Overall condition, instability Intervention & patient response Physician involvement & treatment plan
modifications
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COMMON ERRORS Minutes on MDS do not match
documentation Missing orders for therapy and/or therapy
minutes not documented Missing signature log to validate physician
signature Documentation doesn’t support the level of
RUG billed, but supports a lower level RUG
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CERTIFICATION/RECERTIFICATION Signed & dated by physician Must be legible!
Continued need for extended care services Estimated period of time Plans for home care
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CERTIFICATION/RECERTIFICATION Missing Physician certification/recertification Refer to MLN SE1428
Initial certification is due at time of admission First certification must be no later than 14th day Subsequent recertification required every 30 days Delays MUST include an explanation!
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THERAPY DOCUMENTATION Orders
Initial therapy evaluations & active written treatment plan for all therapies (every claim)
Progress notes
Therapy minute logs
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THERAPY MINUTES Actual minutes - do not round!
Subsequent evaluations
Only Skilled modalities Require the skill, knowledge & judgement of a
qualified therapist Must be part of medical record
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THERAPY MINUTES Minutes not to be reported on MDS Non-skilled services Initial evaluation time Refusal or trying to persuade patient Non-therapeutic rest Documentation Not medically necessary
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SUPPORTING DOCUMENTATION Hospital information Physician involvement Medication, treatment & wound care Discharge planning or summary Activities of Daily Living (ADL) flowsheet
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ADLS What actually occurred
Self-Performance coding - Rule of three: ≥ 3 at any level, code that level ≥ 3 at multiple levels, code most depended level ≥ 3 at multiple levels, but not 3 times at one level
convert to weight bearing If none of the above met - code supervision
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ADLS Every time ADL occurred Code 0 Independent Code 4 Total dependence
Activity occurred less than 3 times = Code 7
Activity did not occur or non-staff = Code 8
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BILLING TIPS Bill in sequence
Non-utilization days Leave of absence (LOA) Discharged Death
Discharged, then returns before midnight on the same day is not a discharge!
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BILLING TIPS OSC 70 = Qualifying inpatient stay
Patient status codes 01 Home 06 Home health 30 Remains in facility
MDS matches HIPPS rate code Assessment dates & RUG levels entered correctly
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MEDICAL REVIEW COMMON ERRORS
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ADL CORRECTION Error: Claims noted to have inconsistent or
incorrect ADLs throughout documentation Required correction on the MDS
Review RAI Manual, Chap. 3, Section G0100 Ensure accurate documentation of ADLs Coding of MDS supported by submitted
documentation
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OSC 70 Error: Claims noted to have incorrect OSC 70
dates that required correction
Verify the qualifying hospital stay is of at least 3 consecutive days Only inpatient days, no observation Never admitted or less than 3 days; add remarks
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PATIENT STATUS CODE Error: Claims billed with incorrect patient
status codes that required correction
Verify patient discharge status Discharge planning process
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INCOMPLETE CERTIFICATION Error: late or incomplete certifications Incomplete statements, no date and/or illegible Missing physician signatures
Support reason for continued need, estimated period of time bene will remain in SNF & any plans for home care Medicare signature requirements Support reasoning, if late
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NON-SKILLED MODALITY Error: Claims noted to have non-skilled
modality minutes captured on MDS Modalities such as electrical stimulation
Documentation did not support minutes as skilled
Only the actual minutes provided for skilled therapy should be recorded on the MDS That required the skill, knowledge & judgement
of a qualified therapist and meets all other requirements for skilled therapy
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MISSED COT-OMRA Error: Claims noted to have missed COT OMRA Days denied with provider liability
Ensure all unscheduled assessments are completed (Review RAI Manual, Chapter 2)
Ensure only skilled minutes are counted in evaluating therapy intensity
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THERAPY ORDERS Error: Claims noted to have missing therapy
initial orders or continuation orders
Ensure submitted documentation contains valid physician orders for all skilled services If orders have through dates, ensure continuation
orders
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PALMETTO GBA RESOURCES Skilled Nursing Facilities (SNF) webpage Go to www.palmettogba.com, choose Articles,
then open Skilled Nursing Facilities (SNF)
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http://www.palmettogba.com/
Pa lmetto GBA develop,ed a Skilled Nursing Facil ity (SNF) Basics educational series that consists of seven Web-based
Training modules. These training modules provide an overview of SNF Part A and SNF Part B of A eligibility, billi ng and
coverage, consolidated billing, no payment and exhaust bi lling, as well as when to submit a generic notice versus
an Advance Beneficiary Notice {ABN). Thie following training modules are available,:
• Skil led Nursing Faci lity Basics I: Overview ~
• Skil led Nursing Faci lity Basics Ill: Consolidated Bil li,ng ~
• Skil led !Nursing Faci lity Basics Ill: Prospective Payment System~
• Skilled Nursing Faci lity Basics IV: General BiJiing Requ irements~
• Skil led Nursing Faci lity Basics V: Part B of A Bi lling & Coverage~
• Skil led Nursing Faci lity Basics VI: Special Bi lling Processes ~
• Skil led Nursing Faci lity Basics VI I: Special Required Notices ~
SNF Basic Training Modules
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Resources
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Select: tthe but::1ton.s bek:irv..r fo r nnore Llf1'lfonina1tion 011"11 each ttop ic.
CERTIIFICATION RECERTIFICATION
HOW & WHEN TO DOCUMENT
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UPCOMING EDUCATION
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Hyperbaric Oxygen (HBO) Therapy
• Quarterly Medicare Updates webcasts Next Part A is June 13, 2018
Use the Event Registration Portal to Register to Attend!
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Skilled Nursing Facility (SNF) ��Consolidated BillingDisclaimerAgendaSNF CoveragePart A SNF Coverage Part A SNF Coverage Qualifying Stay ExceptionTransfer RequirementSNF ReadmissionsBenefit PeriodBenefit PeriodBenefit PeriodBenefit PeriodSNF Consolidated BillingSNF CB - BackgroundFacilities Subject to CBSNF CB - RequirementsSNF CB - RequirementsUnder ArrangementSNF CB – Major CategoriesFive Major Categories for CBMajor Category IMajor Category IIMajor Category IIIMajor Category IVMajor Category VCB InclusionsCB ExclusionsCB ExclusionsIncident to ServicesExcluded ServicesAmbulance Exclusions Frequency of BillingMinimum Data Set (MDS)Resource Utilization GroupsMinimum Data Set (MDS)Minimum Data Set (MDS)Assessment Indicator (AI)MDS AssessmentsDocumentationSkilled DocumentationSkilled DocumentationSkilled DocumentationCommon ErrorsCertification/RecertificationCertification/RecertificationTherapy DocumentationTherapy MinutesTherapy MinutesSupporting DocumentationADLsADLsBilling TipsBilling TipsMedical Review �Common ErrorsADL CorrectionOSC 70Patient Status CodeIncomplete CertificationNon-Skilled ModalityMissed COT-OMRATherapy OrdersPalmetto GBA ResourcesSlide Number 64Slide Number 65Upcoming EducationSlide Number 67Slide Number 68