fy 2014 final rule and mds 3.0 updates

FY 2014 Final Rule and MDS 3.0 Updates

HARMONY UNIVERSITYThe Provider Unit of

Harmony Healthcare International, Inc. (HHI) Presented by:

Christine Twombly, RN, RAC-MT, LHRMRegional Consultant / Trainer

Harmony Healthcare International, Inc. 2

Speaker Bio

Clinical Consultant and Trainer with Harmony Healthcare International (HHI)Over 26 years of experience in Long-Term CareCertified Gerontological Nurse Certified AANAC Master Teacher and Certified Resident Assessment Coordinator (RAC-CT)Licensed Health Care Risk Manager (LHRM) Hands-on experience with MDS assessments and related care planning Extensive experience with SNFs to conduct Medicare documentation and billing compliance assessments and providing assistance with third-party medical review and the appeals process

Copyright © 2013 All Rights Reserved


FY 2014 Final Rule andMDS 3.0 Updates

Disclosure: The planners and presenters of this education activity have no relationship with commercial entities or conflicts of interest to disclosePlanners:

Elisa Bovee, MS, OTR/LDiane Buckley, BSN, RN, RAC-CTBeckie Dow, RN, RAC-MTKeri Hart, MS CCC, SLP, RAC-CTKristen Mastrangelo, OTR/L, MBA, NHAChristine Twombly, RNC, RAC-MT, LHRM

Presenter: Christine Twombly, RNC, RAC-MT, LHRM


Harmony Healthcare International, Inc.

FY 2014 Final Rule and MDS 3.0 UpdatesDisclosure

Speaker: Christine Twombly, RNC, RAC-MT, LHRM

The speaker has no relevant financial relationships to disclose

The speaker has no relevant nonfinancial relationships to disclose

Copyright © 2013 All Rights Reserved 4

Criteria for Successful Completion

Complete Sign-in and Sign-Out on Attendance FormAttendance for entire sessionCompletion and submission of speaker Evaluation Form

Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 5

Today’s Objectives

The learner will be able to summarize the changes to the MDS 3.0 item set, effective October 1, 2013The learner will be able to identify significant changes in the MDS process that impact the delivery and recording of therapy services on the MDS 3.0 assessmentThe learner will be able to summarize the reimbursement impact of MDS 3.0 and the 2014 PPS SNF Final Rule


Changes to MDS and PPS Effective 10/1/13

“It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is the most adaptable to

change.”

Charles DarwinCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 7


MDS 3.0 (V1.11.2): New Items


MDS 3.0 User Manual Updates

CMS had anticipated issuing the MDS Manual update on September 5, 2013Actual release date of September 24, 2013 left providers and software vendors with limited time prior to 10/01/13 effective date to learn and implement changes



Changes to the MDS form impacts every MDS with an ARD on or after 10/1/13

New items have been added to Section K and Section O Existing items have been added to additional assessment item sets

Section H0200A, M0210, and N0300 now included on more item sets

Changes to wording of existing items for clarification



Section K: Swallowing/Nutritional StatusK0700 has been replaced by K0710 Instructions have been added to the form to complete this item only if K510A and/or K510B are checkedThree columns for coding

While NOT a ResidentWhile a ResidentDuring Entire 7 Days




Section K710


Section O:Addition of item to separately code co-treatment minutes for each disciplineCo-treatment minutes are included in individual minutes count, and also coded separately under co-treatment (O-29)Addition of O0420: Distinct Calendar Days of Therapy




Section O0400A: Speech therapy



Section O0400B: Occupational therapy



Section O0400C: Physical therapy



Section O0420: Distinct Calendar Days of therapy :


RAI User’s Manual Effective October, 2013:

Item Set Changes


Items added to additional item sets:The following items previously coded only on the comprehensive item set have been added to the quarterly and additional item sets

Section H0200 Urinary Toileting ProgramSection M 210: Unhealed Pressure UlcersSection N 300: Injections



RAI User’s Manual Effective October, 2013:

Item Coding Clarifications



Chapter 2Clarification of assessment scheduling for discharge assessments, EOT OMRA and COT OMRAs

Chapter 3Clarification of The “Rule of 3” applied to self performance coding in Section GCoding instructions of new items in Sections K and O

Clarification of signing Section Z0400



Chapter 2: Discharge Assessments

Discharge assessment ARD is not set prospectively as with other types of assessments The ARD for a discharge assessment is always equal the discharge date and may be coded on the assessment any time during the discharge assessment completion period (discharge date + 14 days)


Chapter 2: Discharge Assessments:

For a stand-alone discharge assessment the facility does not have to open the assessment on day of discharge when the resident leaves unexpectedlyThis does not alleviate the requirements of other assessments that may be combined with the discharge assessment (For example: 14 day/discharge assessment combination)


Chapter 2: Discharge Assessments

Discharge Assessments and EOT OMRA :CMS has clarified the requirement for an EOT OMRA when the resident is discharged from Medicare by linking the EOT OMRA completion requirement to the End of Medicare date coded in A2400CWhen the date coded at A2400C is prior to the third consecutive day of missed therapy services, then no EOT OMRA is required Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 24

Chapter 2: EOT OMRAs

Discharge Assessments and EOT OMRAIf the date coded at A2400C is on or after the third consecutive day of missed therapy services, then an EOT OMRA would be requiredIn cases where the date coded at A2400C is the same as the date discharge coded at A2000, that is cases where the discharge from and this date is on or prior to the third consecutive day of missed therapy services, then no EOT OMRA is required


Chapter 2: EOT OMRAs

Discharge Assessments and EOT OMRA:CMS has clarified the requirement for an EOT OMRA when the resident is discharged from Medicare by linking the EOT OMRA completion requirement to the End of Medicare date coded in A2400CWhen the date coded at A2400C is prior to the third consecutive day of missed therapy services, then no EOT OMRA is requiredCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 26

Chapter 2: COT OMRAs

A COT OMRA is required when a resident was receiving a sufficient level of therapy to qualify for a Rehabilitation category and when the intensity of therapy (as indicated by the total RTM delivered, and other therapy qualifiers) changes to such a degree that it would no longer reflect the RUG-IV classification and payment assigned on the most recent assessment used for Medicare payment


Chapter 2: COT OMRAs

When the most recent assessment used for PPS, excluding an End of Therapy OMRA, has a sufficient level of therapy to qualify for a Rehabilitation category (even if the final classification index maximizes to a group below Rehabilitation), then a change in the provision of therapy services is evaluated in successive 7-day Change of Therapy observation periods until a new assessment used for PPS occurs


Chapter 2: LOA days Impact on Assessment Scheduling

Medicare days are calculated by the Midnight census. Any days the resident is not in the facility at midnight due to a LOA not Medicare utilized days When a Medicare resident is on an LOA that includes a hospital observation stay of less than 24 hours the impact of this absence on the assessment schedule depends of the type of assessment being completed


Chapter 2: LOA days Impact on Assessment scheduling

LOA days impact on MDS scheduleOBRA assessment is not affected by the LOAFrom a PPS scheduled assessment stand point any LOAs are “skipped” when setting ARDFor unscheduled assessments such as EOT and COT OMRA the LOA are including when determining the due date of the next scheduled assessments



CMS has clarified that the ARD of a scheduled Medicare Assessment can not be set outside the Medicare benefit covered days Since the day in which the beneficiary is out of the facility at midnight is not a covered day, the scheduled ARD can not be set on this date



2-72: Indicates there may be cases in which a SNF plans to combine a scheduled and unscheduled assessment on a given day, but then that day becomes an LOA day for the resident. In such cases, while that day may still be used as the ARD of the unscheduled assessment, this day cannot be used as the ARD of the scheduled assessment.


Chapter 2—Setting the ARD Outside the Benefit Period

For example:Admission May 3nd

5-day MDS was completed with an ARD of May 10The resident was in ER from 8 pm on May 17 until May 18 at 2 am May 17 is the COT date; and if the COT is required, it would need to have an ARD of May 17The scheduled 14-day MDS must have an ARD that falls on a Medicare A benefit day; therefore, the two assessment cannot be combined


Chapter 3: Section G ADLs

Accurate ADL coding is essential to quality care planning and appropriate reimbursement under PPSSection G has been identified as being at high risk for errors Significant effort has been made to clarify the code of self performance of the ADLs



Self-Performance coding:Independent: Resident completed activity with no help or oversight every time during the 7-day look-back period and the activity occurred at least three timesSupervision: Oversight, encouragement, or cueing was provided three or more times during the last 7 days



Self-Performance coding:Limited assistance: Resident was highly involved in activity and received physical help in guided maneuvering of limb(s) or other non-weight-bearing assistance on 3 or more times during the last 7 days



Self-Performance coding:Extensive assistance: Resident performed part of the activity over the last 7 days, and help of the following type(s) was provided three or more times:

Weight-bearing support provided three or more times, ORFull staff performance of activity provided three or more times during part (three or more times but not all of the last 7 days)



Self-Performance coding:Total dependence: Full staff performance of an activity with no participation by resident for any aspect of the ADL activity and the activity occurred three or more times. The resident must be unwilling or unable to perform any part of the activity over the entire 7-day look-back period



Self-Performance coding:Activity occurred only once or twice: The activity occurred but fewer than three times or moreActivity did not occur: The activity did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire 7-day look-back


Chapter 3: Section G “Rule of 3”

Developed to help determine the appropriate code to document ADL Self-Performance on the MDSAll staff who complete this section must fully understand the components of each ADL, the ADL Self-Performance coding level definitions, and the “Rule of 3”



The following ADL Self-Performance coding levels are exceptions to the Rule of 3:

Independent – Code only if resident completed the ADL activity with no help or oversight every time and activity occurred at least three timesTotal dependence – Code only if resident required full staff performance of the ADL activity every time and the activity occurred three or more times



Instructions for the Rule of 3:When an ADL activity has occurred three or more times, apply the Rule of 3 below (keeping the ADL coding level definitions and the above exceptions in mind) to determine ADL Self-Performance code These steps must be used in sequence Use the first instruction encountered that meets the coding scenario (e.g., if #1 applies, stop and code that level)



Step 1: When an activity occurs three or more times at any one level, code that levelStep 2: When an activity occurs three or more times at multiple levels, code the most dependent level that occurred three or more times



Step 3: When an activity occurs three or more times and at multiple levels, but not three times at any one level, apply the following:

a. Convert episodes of full staff performance to weight-bearing assistance b. When there is a combination of full staff performance and weight-bearing assistance that total three or more times, code extensive assistance (3)Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 44


Step 3 (Cont.)c. When there is a combination of full staff performance/weight-bearing assistance and/or non-weight-bearing assistance that total three or more times, code limited assistance (2)

If none of the above are met, code supervision



ADL Algorithm has been updated to include the following at the top of the page:

START HERE: Remember to review the instructions for the Rule of 3 and the ADL Self-Performance Coding Level definitions before using the algorithm. STOP at the first code that applies when moving down the algorithm.


Chapter 3: Section K: Percent of Intake by Artificial Means

Steps for Assessment:1. Review intake records from the last 7 days 2. Add up the total amount of fluid received each day by IV and/or tube feedings only 3. Divide the week’s total fluid intake by 7 to calculate the average of fluid intake per day 4. Divide by 7 even if the resident did not receive IV fluids and/or tube feeding on each of the 7 days



1. While NOT a residentPerformed while not a resident and in the last 7 daysIf resident has entered more than 7 days ago leave this item blank

2. While a residentPerformed while a resident and during the last 7 days

3. During the entire 7 daysPerformed during the ENTIRE 7 days



Example 1:A long-term care resident with swallowing difficulties is able to take oral fluids by mouth with supervision, but not enough to maintain hydration. She received the following daily fluid totals by supplemental tube feedings (including water, prepared nutritional supplements, juices) during the last 7 days.

How should 710b be coded?Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 50


Example 1 (Cont.)Sun. 1250 cc Mon. 775 cc Tues. 925 cc Wed. 1200 cc Thurs. 1200 cc Fri. 500 cc Sat. 450 cc

Total 6,300 cc



Example 1 (Cont.)Coding: K0710B columns 2 and 3 would be coded 2, 501cc/day or moreRationale: The total fluid intake by supplemental tube feedings = 6,300 cc 6,300 cc divided by 7 days = 900 cc/day 900 cc is greater than 500 cc, therefore code 2, 501 cc/day or more is correct



Example 2:A long-term care resident with the flu was experiencing ongoing nausea, vomiting and diarrhea and due to concern related to dehydration received 1 liter of IV fluids over 24 on day during the 7 day period.

How should 710 b be coded?



Example 2 (Cont.)Coding: K0710B columns 2 would be coded 1, 500cc/day or less Rationale: The total fluid intake by IV= 1000 cc. 1000 cc divided by 7 days = 142.8 cc/day, which is 500 cc. Column 3, should be blank Rationale: IV fluids were not provided the entire 7 days


Chapter 3: Section O: Therapy

Addition of co-treatment minutes PT, OT, STCo-treatment minutes are included in individual minutes count, and also coded separately under co-treatment (O-29)Addition of language supporting Jimmo Settlement !Addition of O0420: Distinct Calendar Days of Therapy


Therapy: Co-treatment Part A

Two clinicians each from a different disciplines treat one resident at the same time with different treatmentsBoth disciplines may code the treatment session in full All policies regarding mode, modalities and student supervision must be followed as well as all other federal, state, practice and facility policies



The decision to co-treat should be made on a case by case basis and the need for co-treatment should be well documented for each patient Because co-treatment is appropriate for specific clinical circumstances and would not be suitable for all residents, its use should be limited



When coding therapy minutes co-treatment minutes are also coded as individual minutes for both disciplines involved in the co-treatment sessionCo-treatment Minutes are also separately coded in 3A as co-treatment minutes for both disciplinesAny treatment minutes co-treatment in 3A as co-treatments do not impact the RUG


Therapy: Co-treatment Part B

Therapists, or therapy assistants, working together as a "team" to treat one or more patients under Medicare Part B cannot each bill separately for the same or different service provided at the same time to the same patient Where a physical and occupational therapist both provide services to one patient at the same time, only one therapist can bill for the entire service or the PT and OT can divide the service units


Therapy: Distinct Calendar Days

Enter the number of calendar days that the resident received Speech-Language Pathology and Audiology Services, Occupational Therapy, or Physical Therapy for at least 15 minutes in the past 7 days. If a resident receives more than one therapy discipline on a given calendar day, this may only count for one calendar day for purposes of coding Item O0420.


Therapy: Distinct Calendar Days

5 Distinct Days


Day 1 2 3 4 5 6 7 8ARD

Date 2/1 2/2 2/3 2/4 2/5 2/6 2/7 2/8

PT 15 30 0 15

OT 15 30 0 15

ST 15 30 0 15

Total 0 0 15 15 15 90 0 45

Running

0 0 15 30 45 135 135 180

How many Distinct Calendar Days?


FY 2014 Final Rule

Final Rule

On August 1, 2013, the Centers for Medicare & Medicaid Services (CMS) published the Final Rule for the Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities (SNF) for FY 2014Effective October 1, 2013 for FY 2014


New SNF Rates

The Final Rule provides for a net market basket increase for SNFs of 1.3% beginning October 1, 2013

Full market basket increase of 2.3 percentage points Less a 0.5 percentage point multifactor productivity adjustment required by Section 3401(b) of the Affordable Care Act (ACA)Less 0.5 percentage point reduction to correct for an error in forecasting the market basket in FY 2012


Impact on Reimbursement

CMS estimates that the net market basket update would increase Medicare SNF payments by approximately $500 million in FY 2014

Nationally projected $7 per Medicare patient day


Therapy Co-treatment

RAI User's Manual reporting requirement for coding co-treatment minutes on the MDS

Will not impact RUG calculation at this time


Therapy Co-treatment

Indicator that CMS is concerned about over utilization Applies to Medicare Part A onlyWhen two clinicians (therapists or therapy assistants), each from a different discipline, treat one resident at the same time with different treatments, both disciplines may code the treatment session in fullCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 67

Distinct Days of Therapy

Clarify that classification criteria for the Rehabilitation Medium RUG categories require that the resident receive 5 distinct calendar days of therapy

If not achieved, the RUG would reduce to a Nursing RUG

Applies to COT review and Management



Current RUG classification allows classification criteria for the Medium Rehab category without 5 distinct days of therapy Impact of missed therapy days

Potential Nursing RUG despite significant therapy involvement



How many Distinct Calendar Days of Therapy?

Less Than 5 Distinct Days does not =RMNursing RUG applies


Day 1 2 3 4 5 6 7 8ARD

Date 2/1 2/2 2/3 2/4 2/5 2/6 2/7 2/8

PT 0 0 60 60 60 0 0 60

OT 0 0 60 60 60 0 0 60

ST 0 60 60 60 0 0 60

Total 0 0 180 180 180 0 0 180

Running

0 0 180 360 540 540 540 720

Distinct Days of Therapy-Daily Basis

The daily basis requirement can be met by furnishing multiple therapy types on different days of the week that collectively add up to "daily" skilled services CMS clarified that to meet this requirement, the patient must actually need skilled rehabilitation services to be furnished on different days"It is not sufficient for the scheduling of therapy sessions to be arranged so that some therapy is furnished each day, unless the patient's medical needs indicate that daily therapy is required.”


Impact on Provider

Another factor in ARD ManagementIncrease in Change of Therapy (COTs)

Rate reduction retroactive 7 daysIncrease Lower 14 Nursing RUGs

Increase audits and denialsIncrease in use of Short Stay Policy

Providers still struggle with thisPotential for Rehabilitation Medium patients to not meet Rehab skilled criteria


SNF Therapy Research Project

“Currently, the therapy payment rate component of the SNF PPS is based solely on the amount of therapy provided to a patient during the 7-day look-back period, regardless of the specific patient characteristics”



“As an initial step, the project will review past research studies and policy issues related to SNF PPS therapy payment and options for improving or replacing the current system of paying for SNF therapy services received”CMS has contracted with Acumen, LLC, and the Brookings Institution to identify alternatives to the existing methodology used to pay for therapy services received under the SNF PPS CMS invites comments and ideas on the existing methodology



CMS will “regularly” update the public on the progress of this project on the project Web site: http://www.cms.gov/Medicare/Medicare-Fee-forServicePayment/SNFPPS/therapyresearch.html


http://www.cms.gov/Medicare/Medicare-Fee-forServicePayment/SNFPPS/therapyresearch.html



Impact on Providers

SNF Therapy Research Project could significantly change the reimbursement model for therapy services provided under Medicare Part ADiagnosis may factor in


Presumption of Coverage“The establishment of the SNF PPS did not change Medicare’s fundamental requirements for SNF coverage”CMS proposes to continue presumption of coverage for beneficiaries correctly assigned to one of the upper 52 groups

Automatically classified as meeting the SNF level of care definition up to and including the Assessment Reference Date on the 5-day assessment


Presumption of Coverage“We note that this administrative presumption policy does not supersede the SNF’s responsibility to ensure that its decisions relating to level of care are appropriate and timely, including a review to confirm that the services prompting the beneficiary’s assignment to one of the upper 52 RUG–IV groups (which, in turn, serves to trigger the administrative presumption) are themselves medically necessary”


Impact on Providers

Warning by CMS to ensure documentation of skilled coverage criteria in the first days of a patient’s stayPotential increase in audits


Consolidated Billing

Consolidated billing requirements are unchanged

Acknowledged certain chemotherapy items, chemotherapy administration services, radioisotope services and customized prosthetic representing recent advances that might meet its criteria for exclusion from SNF


Consolidated Billing

Corrections of error to the annual priced exclusion files will show that HCPCS Codes 11042, 11043, and 11044 (surgical debridement codes) will be corrected to ensure that they are excluded from consolidated billing“Flexibility to revise the list of excluded codes in response to changes of major significance that may occur over time (for example, the development of new medical technologies or other advances in the state of medical practice)’’ (65 FR 46791)


Consolidated Billing-Reminder

April 2013The annual update file contains the complete list of HCPCS Codes that are excluded from SNF CB for claims submitted to Fiscal Intermediaries/A/B MACS for payment Effective for claims with dates of service on or after 1/01/2013 unless otherwise noted belowCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 82

Swing Beds FYI

CMS notes that critical access hospitals (CAHs) will continue to be paid on a reasonable cost basis for SNF level services furnished under a swing bed agreement and that all non-CAH swing bed rural hospitals continue to be paid under the SNF PPS


AIDS Add On

128 percent for SNF residents with Acquired Immune Deficiency Syndrome (AIDS) remains Transition from ICD-9-CM coding system to the ICD-10-CM coding system, starting October 1, 2014.

ICD-10-CM diagnosis code of B20 for purposes of defining AIDS Add-On. Includes AIDS, AIDS related complex (ARC) and HIV infection, symptomatic. Current code 042 also includes AIDS like syndrome and new Final code B20 does not

Impact On ProvidersMay exclude some patients from meeting criteria


Physician Assistants-Certification

CMS finalized revisions to the regulation related to the SNF level of care certification and re-certifications by including Physician Assistants in the provision authorizing Nurse Practitioners and Clinical Nurse Specialists to sign SNF level of care certifications and re-certificationsImpact On Providers

Allows additional Physician Extenders to sign Physician Certification


CMS Review Impact FY2012 Changes

CMS concludes that it has found no evidence of possible negative impacts that had been anticipated by SNF providers in comments on the FY 2012 Final Rule, particularly the potential for a “double hit” from the combined impact of the recalibration of the FY 2011 SNF parity adjustment and the FY 2012 policy change

Recalibration of the FY 2011 SNF parity adjustment to align with RUG-IIIAllocation of group therapyImplementation of changes to the MDS 3.0 patient assessment instrument, most notably adding the COT OMRA requirementsCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 86

Distribution of MDS Assessments

MDS FY2011 % FY2012 %

Scheduled PPS 95 84

SOT 2 2

EOT 3 3

EOT/SOT Combined

0 0

EOT-R N/A 0

Combined SOT and EOT-R

N/A 0

COT N/A 11


FY2014 Transition Memo

FY2014

Transition Memo released September 20Prior to RAI Manual ReleaseImpacts Days billed in September

Review for accuracy


FY 2014 Transition

An MDS may generate a RUG that bills for days in September 2013 (FY2013) and October 2013 (FY2014) The CMS transition policy dictates payment for these scenarios In short, MDSs with an ARD from October 1 through October 13 will generate a “FY2013 RUG” that will be communicated to billers through the MDS validation report process


FY 2014 Transition

Facilities must ensure MDS/PPS Coordinators communicate with the Business Office to provide the MDS transmission validation reports to accurately bill The FY2013 transition RUG will be based on FY2013 RUG qualifications and the FY2014 will require the new requirements


Distinct Calendar Days of Therapy

MDS Change: For all assessments with an ARD on or after 10/1/2013, must include Item O0420 (Distinct Calendar days) must be coded with the number of distinct calendar days that the resident received therapy services



RUG-IV: Extensive Rehabilitation and Rehabilitation Medium and Low Categories Extensive Rehabilitation and Rehabilitation Medium and Low Categories Criteria Change: Rehabilitation Medium must have greater than 5 Distinct Calendar Days and 150 Minutes of Therapy; Rehabilitation Low must have 3 distinct calendar days and 45 minutes of therapy with 2 rehabilitation/restorative nursing for 6 days



COT reviews completed on or after October 1, follow FY2014 requirements of Distinct Calendar Days to meet Rehab Medium and Low Criteria


Swallowing and Nutritional Status Items

MDS Change: For all assessments with an ARD on or after 10/1/2013, must include K0710A and item K0710B with the proportion of total calories the resident received through parental or tube feeding and the average fluid intake per day by IV or tube feeding, respectively RUG IV: Special Care High (fever) / Low and Clinically Complex (ADL=0-1) K0710A and item K0710B3 must be codedCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 95

FY2013 Transition RUG

September Days Billed October Days Billed

ARD on or before 9/30/13

Bill actual RUG for all days of service associated with that assessment even if some of those days of service are on or after 10/1/2013

Bill actual RUG for all days of service associated with that assessment even if some of those days of service are on or after 10/1/2013

ARD 10/1/2013 through 10/13/2013

FY2013 transition RUG should be used to bill any days of service before 10/1/2013 which are associated with that assessment

Bill actual RUG for FY2014 for days on or after October 1, 2013

ARD date after 10/13/2013

Not Applicable Bill actual RUG for FY2014 for days on or after October 1, 2013


FY2013 RUG

An MDS with an ARD after 10/13/13 will not report a transitional RUG as there is not a scenario when a MDS with an ARD on or after 10/14/13 will pay for days both in September and October 2013


Audit Environment: More Changes

Increase in Medicare Documentation Reviews

Significant increase in the number of medical review requests from Medicare Administrative Contractors (MACs)

Medicare Part A and BBilling inconsistenciesICD-9 Coding triggers

Similar pattern to Medical Record Reviews within the nursing facility setting in the early 90's

Number of "Help Letters“ was astoundingly highInvestigations into potential fraudulent billing practices increasedCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 99

Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 100Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 100

Zone Program Integrity Contractor (ZPIC)

Goal is to identify FraudCMS launched another major initiative to target providers other than the hospital setting as the RAC auditors have been focusing on hospital auditsSoutheast, South Central, Midwest, Northeast and West Coast regions of the U.S. are seeing the most ZPIC audits at this time

Unified Program Integrity Contractor (UPIC)

CMS is developing a new integrity contractor called a Unified Program Integrity Contractor (UPIC). The previous Medicare Administrative Contractors (MACs) and Zone Program Integrity Contractors (ZPICs) will comprise the new contractor, though MACs will not disappear entirely, they will simply be absorbed by the UPIC. This contractor will focus on both Medicare and Medicaid integrity issues. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 101

Medicare Recovery Auditors (RAs)

Recovery Audit Contractors (RACs) are now known as The Medicare Recovery Auditors (RAs)The RAs post what area they are targeting on the web. Providers are able to review their jurisdiction’s website for an update on what the RAs are finding in their data collection.


Medicare Recovery Auditors (RAs)

RAs review claims on a post-payment basis There are three types of review:

Automated (no medical record needed)Semi-Automated (claims review using data and potential human review of a medical record or other documentation)Complex (medical record required)

Look-back up to three years from the date the claim was paid Required to employ nurses, therapists, certified coders and a physician CMD


Be Prepared

Give Clinically Appropriate CareUnderstand Medicare Coverage requirements

TechnicalClinical

Accurately document care providedBill accuratelyRespond to documentation requests timely and completely

Communicate trends and audit outcomes to staff

Get back to Basics !!Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 104

Questions/Answers

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