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PART B

PROGRAMMING

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Part B Programming

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Part B Programming

POST TEST

1. Part B programming should help ensure residents care needs require the skills of a therapist.

a. True b. False

2. Part B certifications and recertifications are due every 30 days. a. True b. False

3. Best practice to identify Part B referrals include the following: a. Limit to quarterly screenings b. Wait for nursing to make referral c. Seek candidates through walking rounds and QM reports d. All of the above

4. Clinical documentation needs to include: a. Nursing documentation must indicate a functional decline b. Prior level of function c. Diagnosis d. All of the above


Part B Programming

POST TEST ANSWERS

1. Part B programming should help ensure resident’s care needs require the skills of a therapist.

a. True b. False

2. Part B certifications and recertifications are due every 30 days. a. True b. False

3. Best practice to identify Part B referrals include the following: a. Limit to quarterly screenings b. Wait for nursing to make referral c. Seek candidates through walking rounds and QM reports d. All of the above

4. Clinical documentation needs to include: a. Nursing documentation must indicate a functional decline b. Prior level of function c. Diagnosis d. All of the above

True

False

C

D


POLARIS GROUP Strategic Solutions For Healthcare www.polaris-group.com©

Part B Programming -Clinical

1


Medicare Part B Therapy Regulations

• Medicare Part B Therapy regulations:

– Medicare Benefit Policy Manual

• Chapter 15

– Covered Medical and Other Health Services

» Section 220-230.6

• CMS Link:

– https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

2



Documentation Requirements

• The services must be furnished according to a written treatment plan determined by the physician/NP/CNS/PA working in collaboration with therapist.

• Payment is dependent on the certification of the plan of care rather than the order, but the use of an order is prudent to determine that a physician is involved in care and available to certify the plan.

3


All Therapy Services (PT, OT, SLP)

– Certification/approval of a plan of care• It indicates the service was provided under the care

of a physician for a resident who needs/needed therapy services.

– Acceptable documentation of certification may be a:• Physicians/CNS/NP/PA progress note

• Physician/CNS/NP/PA detailed clarification order

• Plan of Care signed and dated by Physician/CNS/NP/PA

– There is no specific form or format that is required.4




• Certifications/Re-certification

– Timing of Certifications

• Initial Certification by Physician/NPP

–Should certify the plan “as soon as possible”, or within 30 days of the initial therapy treatment

5



• Certifications/Re-certification

– Timing of Re-certification

• Continued or modified therapy

–Should be signed whenever the need for a significant modification of the plan becomes evident,

–Or at least every 90 days after initiation of treatment under that plan, unless they are delayed.

6



7

Process

1. Documentation of decline, prior to initiation of Medicare Part B services, to justify medical necessity.– Nursing documentation must support decline that triggered

referral

There must be documentation reflecting the actual functional decline/change. Nursing/Therapy discuss.

If no documentation exists, a progress note should be written by nursing to document decline.

“Decline in eating skills, resident had been feeding self, but for last 3 weeks, staff must assist with dining about half the meal.”


Process

• Nursing documentation must support decline that triggered referral.– MDS may reflect decline.

– Weekly or monthly summary notes may reflect decline.

– Nursing restorative documentation may reflect decline.

– Document decline in a progress note if not well reflected in chart; therapy should confirm documentation before starting treatment.

8



9

Process

2. Referral form/process to therapy – May be verbal referral, but ensure Nursing/Therapy

discuss referral and nursing ensures documentation is noted to support decline.

3. Therapy will Screen resident and/or obtain order to Evaluate and Treat as indicated.

4. Plan of Care is written.– Clarification order includes modality, frequency,

duration, and type of therapy using CPT coding terminology.


Plan of Care

• The plan of care shall contain, at minimum:

– Diagnoses,

– Long term treatment goals,

– Type, amount, duration and frequency of therapy services.

• Amount of treatment refers to the number of times in a day that type of treatment will be provided.

• Frequency refers to the number of times in a week that type of treatment is provided.

• Duration is either the number of weeks or the number of treatment sessions.

10



Plan of Care

• Plans of Care

– Services must relate directly and specifically to a written treatment plan

– Must be established by:

• Therapist who will provide the service

• Physician/NP/CNS/PA

– Must be:

• Signed (signature log)

• Dated

• Professional’s identification (e.g. MD, PT, OT) 11


Prior Level of Function

Specific Prior Level of Function is essential.

• See Prior Level of Function guidance

• “Assist in ADL” is vague.

• Be specific: – “Able to dress upper extremities with supervision and

set-up only.”

– “Ambulated to dining room and back with walker, no assistance, and no gait problems”

– “Could sit upright in wheelchair without positioning devices for 1 hour.” 12



Documentation of Therapy Services

Treatment Encounter Note – It is a record of all treatment

• Documentation is required for every treatment day and every therapy service. It must record the following:

– Date of treatment

– Treatment, intervention, or activity

– Total timed code treatment minutes and total treatment time minutes

– Signature and professional identity of the qualified professional furnishing the treatment

– Other information (i.e. response to treatment, changes)13



Progress reports – provides justification for the medical necessity of treatment.

Information required in the progress reports shall be written by the clinician.

• The physician/NP/CNS/PA who provides or supervises the service, or

• The therapist who provides the service and supervises the assistant.

14




Progress reports – provides justification for the medical necessity of treatment.The end of the Progress Reporting Period is:

• A date chosen by the clinician

• The 10th treatment day (revised January 1st, 2013)

• The dates for recertification of plans of care do not affect the dates for required Progress Reports.

15


Ongoing Progress Notes

• Skilled services provided

• Functional Gains.

• Constant relevance to POT/POC.

• Must be clear to the reviewer.

• Testing and Measurement in relation to the improvement in the disabling condition.

What do we mean by that?

16



Testing and Measurement in relation to the improvement in the disabling condition

WHO CARES

If the patient can unzip a zipper on a zipper board

CAN HE

Unzip and get out of his pants timely and with less assist

WHO CARES

If she has 3+/5 Quad Strength

CAN SHE

Pull herself up and stand with better ability than last week

WHO CARES

If the Boston Test of Aphasia was 75 vs. 50

CAN SHE

Ask for a glass of water17


How do I know if the Note is a solid, “audit proof” skilled note?

• Is it objectively compared to your last session?• Did it reference the actual treatment code and is that

code as specific as possible?• Is there an undercurrent of the complexities that

impact the plan?• Can you identify “why are the skills of a therapist

needed?”

• If reads like a note by nursing, it does not reflect therapy skilled services.

18



Demonstrate the Need for a Therapist to Provide Service

– Absence or presence of documentation does not in and of itself determine skilled care

– No certain phraseology is required, however examples included to assist

– Must consider the entirety of the medical record to determine skilled care

19


Supporting Skilled Therapy Services

The services delivered require the skills, knowledge, and judgment of a therapist or the complexity of the patient is such that the treatment can only be safely provided by a skilled clinician.

• Walking a patient to increase distance does not constitute skilled treatment.

• Stacking cones on a table (sitting or standing) does not necessarily require the skills of a therapist and/or improve shoulder range of motion.

• Passively watching a patient consume a meal, does not constitute skill. 20




Examples of Skilled Services

• Gait training addressing specific gait abnormalities with anticipated improvement.

• Therapeutic exercise which leads to an improvement in functional independence and/or quality of movement.

• Document specific degrees of motion, strength grades and levels of assistance.

21




• Designing an individualized treatment plan based on the result of the comprehensive evaluation.

• Caregiver training /education which supports therapeutic intervention.

• Development and training of a program to maintain or prevent further deterioration.

• Progressive therapeutic exercise versus répétition exercise.

22




• Inhibition

• Facilitation

• Observation and Correction of techniques

• Assessment

• Analysis

• Modification

23

• Gait training vs. ambulation

• Neuromuscular facilitation

• Diagnostic treatment

• Teaching and training



Banned Phrases

• Vague phrases

“patient tolerated treatment well,”

“continue with POC,” and

“patient remains stable”

• …insufficiently explanatory to establish coverage

24



Nursing Documentation while Resident is on Part B

• Nursing should document at least weekly on all residents receiving Part B therapy services.

• Progress note to summarize progress on the unit in response to therapy.

• “Resident is making improvements in her ADL status this week, as evidenced by transferring today with one assist as opposed to two assist last week” would be beneficial in supporting Medicare claims.

25


A Comment on Discharge Summaries

• Often used as the key comparative document in making Medical Necessity Determinations.

• What did you say you would do in comparison to the outcome that was actualized?

• The Discharge Summary is the final opportunity to prevent ADR or Denial.

• You know the services were Medically Necessary but did you convey this in a way that the non-clinician reviewer will understand?

26



PART B“When is Enough……Enough”?

• Reaching, Reached, Won’t Reach Goal

• Where is your objective correlation to the functional progress?

• What will it mean for this persons life?

• Are you attaining or maintaining?

• Do they really need a therapist license vs. the same outcome with Nursing or CNA?

27


Components of Successful Program

• Identify potential of Part B residents

– Referrals from nursing

• falls

• change in diet texture

• weight loss

• decline in feeding skill

• skin tears

• contractures28




• Identify potential Part B residents

– Referrals from nursing

• choking or swallowing problems

• change in ADL

• change in gait

• Stage 3 or 4 pressure ulcer

• complex wound

• decline in communication 29



• Identify potential Part B residents – Attend stand-up meetings

• Listen for potential screening opportunities such as new admissions, falls, swallowing difficulties, restraint issues

– Quality Measure Reports

• decline in ADL• pressure ulcers• weight loss

• falls/major injury fall• incontinence• pain

30



Keys to Success

• Facility staff can play a key role in assisting with building a therapy caseload.

• Who can help?– Nursing assistants

– Activities

– Housekeeping/Dietary

– Maintenance

31


Keys to Success

• Nursing Assistants

– Are any of your residents requiring more assistance with dressing, bathing, or grooming?

– Are any of your residents having difficulty finding their room, the dining room, or their way around the facility?

– Do you have residents that you have to pull up in the wheelchair routinely or seem to be slumped over the side of the chair?

32



Keys to Success

• Activities

– Do you have residents who are no longer participating in activities?

– Do you have residents who are needing additional assistance to get to and from activities?

– Do you have residents with in-room activities that look uncomfortable in the bed such as leaning over the side?

33


Keys to Success

• Housekeeping/Dietary

– Are you seeing residents who are going to the bathroom by themselves, but you are being asked to clean the bathroom following?

– Have you noticed anyone choking or coughing while eating in the dining room?

• Maintenance

– Have you been asked to assist a resident?

– Have you seen a near fall with a resident?34




• Identify potential Part B residents – Consider walking rounds weekly by unit/hall

– See Walking Rounds/Resident Questionnaire forms

– Include dining rounds weekly

– Discuss residents with CNAs, nursing, staff and family members, housekeeping, dietary.

– Interview the residents and review the medical record

– Identify residents who could ambulate at time of discharge from therapy that have declined now

– Check splint placement 35


• Dining Rounds

– amount of assistance

– equipment for feeding

– amount of spillage

• Wheelchair/positioning rounds

– restraints

– appropriate cushion/seating

– bed positioning


• Wound Rounds

– positioning for pressure relief

– treatment of the wounds

36




• Weekly review of Part B during Medicare meetings/therapy team meetings

• BOM to check CWF prior to services, then implement tracking systems for therapy amounts– Confirm that Medicare is not secondary payer by asking

questions MSP questions; verify once every 90 days– Meet with the restorative nursing aides on a regular

basis– Discuss/identify any functional changes in LTC

residents37


Decrease Refusals

• Attempt therapy 2-3 times throughout day.

• Try therapy in a different location. For example, if the resident doesn’t want to come to the therapy gym, provide therapy in their room or in the dining room.

• If a resident continues to refuse therapy from a certain therapist, involve another therapist.

• Involve nursing.

• Involve the resident’s family.

• Notify the physician/utilize physician involvement when appropriate.

38



39

Common Part B Challenges

• Often contingent on Part A census flow

• “Part B as a back-up plan” mentality

• Staff understanding of how to identify and interpret subtle changes that justify screen / eval. referral

• The actual Nursing to Therapy referral process

• Team identification strategies (grand rounds, AM meeting, use of QM report to ID needs)

• Therapy Staffing Pattern

• Managing therapy medical necessity documentation


Overview of Covered Services

Outpatient Services – Part B • Only covered if medically necessary and reasonable.• Once annual threshold is met, the KX Modifier must be used on

claim attesting to Medical Necessity – Physical Therapy (PT) and Speech-Language Pathology (SLP)

together and the other is for Occupational Therapy (OT) separately

• CY 2019 = $2,040 PT & SLP CY 2018 = $2,010 PT & SLP

• CY 2019 = $2,040 OT CY 2018 = $2,010 OT

• The dollar amounts are beneficiary-specific • The deductible and the co-pay are included in amounts• Outpatient therapy services billed by hospitals are included in the

amounts 40



Billing for Medically Necessary Services above the Threshold

• Attestation as to medical necessity of services is required when hit the threshold of $2,040 (for 2019), attestation is indicated by KX modifier on claim

• Without further information, assume the diagnosis and CPT codes used in the past to support these claims still applies

41


Billing for Medically Necessary Services above the Threshold

• Proceed with care and bill with KX modifier.

• As tracking system indicates approaching $3,000 threshold, see slides on Manual Review and pre-approval process.– $3,000 threshold is tracked by OT claims or combination

of PT/ST claims just like the Threshold amounts are tracked.

42



RAC Manual Medical Review Update

Post-payment “Targeted” manual reviews of claims over $3,000– MAC will request records for review– The provider will be notified by MAC of any

payment determination and if necessary: • paying back funds by check,• recoupment from future payments,• applying for an extended payment plan, or• appealing the decision.

43


$3,000 Threshold Tracking

• Have a solid process in place to validate the Part B billing for each resident treated. – The BOM should run the CWF for each resident

prior to initiation of care.

– Rehab to track the treatments and dollars billed toward therapy.

44



Reasons for Denials

Services do not need the skills of a therapist

• Documentation does not support the need for the additional services requested

• Documented decline not present

• Lacks established progress toward goals

• More improvement not likely

• Not medically necessary

• Prior Level of Function illegible or PLOF not well defined

45


ABN & Expedited/NOMNC Notices for Part B

Requirement for ABN & Expedited/NOMNC for Part B Services

• The provider billing Medicare has primary responsibility to provide notice.

• Therapy determines Medicare will not continue to pay as medically reasonable and necessary; but resident wants to continue therapy.

– Issue ABN CMS R-131 for one or all therapies they are at risk for liability.

– Issue NOMNC CMS-10123 when all therapies are ending.

46




Example: A resident is receiving one or multiple therapies and therapy determines that ALL services will not continue to meet Medicare criteria for reasonable and necessary service. However, the resident wants to continue to receive therapy; but since Medicare guidelines are not met, the resident would be billed for the services.

– Issue ABN CMS R-131 form as resident is at financial risk and has the right to a demand bill.

– Issue an Expedited Review/NOMNC (CMS-10123) The resident has a right to have the medical necessity reviewed by QIO.

47



Example: Resident is receiving multiple therapies PT and OT, and then PT ends as team feels care is not medically necessary. The resident wants to continue with PT.

• ABN CMS R-131 Form is required for PT

• No Expedited Review/NOMNC (CMS-10123) is required since just a reduction of service; not required until all therapy end.

• If all services were ending, then issue NOMNC

48




Reaching the Threshold and plan to bill using KX modifier to attest to medical necessity.

Example: A resident is receiving PT and will soon reach the threshold. PT is medically necessary, therapy will continue as medically necessary.

– No ABN required (CMS R-131).

– No Expedited Review/NOMNC (CMS-10123) required.

49


Resident Liability

When is resident liable:• Medicare covers medically reasonable and necessary therapy

services up to $2,010 threshold in 2018 ($2040 in 2019).• For services between $2,010 and $3,000 and above, if the

conditions met medical necessity; claim will use KX modifier for attestation; the assumption is claim will be paid.

• For services above the $3,000 threshold, a manual review may be done, and the beneficiary is only financially liable if you have issued an ABN because you did not think the services were medically reasonable and necessary but resident wanted therapy.

50



51


Completing ABN Form for Part B

• Issue ABN CMS R-131– Identifying information

– Body: For therapy; indicate the

modality, frequency, and reason

for service. For example, physical

therapy for 60 minutes, 5 times a week for gait training.

– Indicate last treatment day Medicare will pay, and first treatment day resident would be liable if receive services. 52




Reason Medicare May Not Pay: In this blank, notifier must explain, in beneficiary friendly language, why they believe the items or services described in Blank (D) may not be covered by Medicare.

• Three commonly used reasons for non-coverage are:

• “Medicare will not pay for this service because it does not meet medical necessity requirements for your condition”

• “Medicare does not pay for this test for your condition.”

• “Medicare does not pay for this test as often as this (denied as too frequent).”

• “Medicare does not pay for experimental or research use tests.”53



For therapy: • Estimate the total number of units for a daily or weekly total

charge. Use the dollar amount that will be charged to the resident for each unit for the service. This is not the same as the fee screen.

• Explain and select Options

• Signature and Dates

• Follow procedures for SNF-ABN related to proper notifications, documentation and maintenance of records

• May bill pending review

54



55


Expedited (NOMNC) Review Notice

• EXPEDITED DETERMINATIONS; Notices of right to an expedited review by an independent entity:

• Two Expedited Determination Notices:

1. Notice of Medicare Provider Non-Coverage (NOMNC) CMS-10123

• Required expedited determination notice

56



57


58



Expedited (DENC) Review Notice

2. Detailed Explanation of Non-Coverage Notice (DENC) CMS-10124

• Only issued if an appeal is requested

• Provides information to support the reason for the denial

• QIO uses information included on the notice when making a coverage determination

• No signature by resident is required on this form

59


60



61


Expedited/NOMNC Notices for Part B

• Timing– the notice is to be issued no later than next to last treatment visit before coverage ends.

– If therapy is planned for Tuesday and Thursday, and Tuesday is last covered treatment day, the notice must be issued no later than the preceding Thursday.

• Complete NOMNC (CMS-10123) in same manner as for Part A services.

• Only complete Detailed Notice (CMS-10124) if an appeal is made.

62



SCENARIOS

Resident is receiving Part B therapy, and the resident continues to need therapy, but is about to reach the therapy threshold. The plan is to continue therapy using the KX modifier to attest to medical necessity

Forms:

Team determines therapy is not medically necessary and resident wants to continue to receive therapy.

Forms:

Team determines therapy is not medically necessary and resident agrees.

Forms63


SCENARIOS

Resident is receiving Part B therapy, and the resident continues to need therapy, but is about to reach the therapy threshold. The plan is to continue therapy using the KX modifier to attest to medical necessity.

Forms: No ABN required, no NOMNC is required

Team determines therapy is not medically necessary and resident wants to continue to receive therapy.

Forms: ABN required and NOMNC is required assuming all therapies are ending.

Team determines therapy is not medically necessary and resident agrees.

Forms: NOMNC is required assuming all therapies are ending. 64



Claims-Based Data Collection

• 42 G-Codes for Claims-Based Functional Reporting – 11 G-codes categories that describe categorical functional

limitation, including seven for SLP services.

– 3 G-codes categories that are general G-codes for functional limitations that do not fit within one of the 11categories.

– Each G-Codes category will include the current status, the projected goal status and the status upon discharge.

– See attached handout

65



• Time Frame for Reporting– The functional status reporting with claims submission

required by the therapists will be at 4 distinct time periods:

• Initial service at the outset of a therapy episode

• At least every ten visits (which correlates with the change in progress reporting guidelines)

• Discharge• Re-evaluation - The time the beneficiary’s condition changes

significantly enough to clinically warrant a re-evaluation such that a HCPCS/CPT code for a re-evaluation or a repeat evaluation is billed. 66




• Documentation-Tracking-Implementation– Documentation of the information used for

reporting under this system must be included in the beneficiary’s medical record.

– Therapist will need to track in the medical record the G-codes and the corresponding severity modifiers that were used to report the status of the functional limitations at the time reporting was required.

67



Strategies

• Crosswalk - Functional Outcome Measures (FOM) to G-codes and modifiers – PT/OT– National organizations are evaluating

• Crosswalk - National Outcome Measures (NOM) to G-codes and modifiers – ST– Many ST are certified in NOMs

– ASHA working on crosswalk 68



Summary

• Review practices and procedures for referrals.

• Implement strategies such as walking rounds.

• Identify barriers to increasing caseload.

• Review Part B at Medicare Meetings and triple check QA

• QA Nursing supporting documentation.

69


LONG TERM CARE WALKING ROUNDS FORM

SKIN: Is resident at risk for skin breakdown? Y N NA Is the mattress appropriate to protect from breakdown? Y N NA Does resident currently have skin breakdown? Y N NA Is current treatment appropriate? Y N NA POSITIONING: Is resident upright with good posture in wheelchair? Y N NA Imbalances: _________________________ Does resident have appropriate wheelchair cushion? Y N NA Type: ______________________________ Does the wheelchair have leg rests? Y N NA Are splints/positioning devices prescribed? Y N NA Are they being utilized appropriately? Y N NA Is resident appropriately positioned in bed? Y N NA MOBILITY/ADL’S/CONTINENCE: Is there a change in functional mobility? Y N NA Is there a change in ambulation distance? Y N NA Is there a decline/improvement in functional transfers? Y N NA Specify: ____________________________ Is there a decline/improvement in self-care skills? Y N NA Is there a loss of ROM or an increase in contractures? Y N NA Specify: ____________________________ Is there a current Restorative or Functional Maintenance program? Y N NA Circle all that apply: Positioning/ROM/Splinting/Ambulation/Self-feeding Swallowing/Memory Book/Communication Is program updated appropriately? Y N NA Is there a recent history of falls? Y N NA Is there a change in continence? Y N NA Is resident on a formal bowel and/or bladder program? Y N NA OTHER: Is there a change in swallowing skills or diet? Y N NA Diet change: _________________________ Is there a significant weight loss or gain? Y N NA Is there a change in communication skills? (speech/language/cognition) Y N NA Has there been a recent change in medications? Y N NA Is resident on psychotropic medications? Y N NA Consent form signed? Y N NA Side rail status: _______________________________ Consent form signed? Y N NA Restraints: ___________________________________ Consent form signed? Y N NA FOLLOW UP RECOMMENDED: DATE COMPLETE/INITIALS: Signatures of team members completing form:_________________________________________ _______________________________________________________________________________


Resident Status Questionnaire Ask these questions on observational rounds: Does the resident have the appearance of being uncomfortable in a sitting position? □Yes □No Does the resident have a history of falls?

□Yes □No Does the resident have a type of restraint?

□Yes □No Do you notice difficulty with transfers or moving from place to place?

□Yes □No Do you notice difficulty with ambulating as shuffling, staggering, or requiring more assistance?

□Yes □No Do you notice more difficulty communicating with the resident?

□Yes □No Does the resident need more help with dressing or grooming activities?

□Yes □No Does the resident have a messy dining experience?

□Yes □No Does the resident choke or cough while dining?

□Yes □No Does the resident have a recent weight loss?

□Yes □No Does the newly admitted resident have difficulty with adjustment to the environment?

□Yes □No Does the resident have risks for skin breakdown or have a current skin integrity issue?

□Yes □No Does the resident have limited range of motion in joint(s) or have pain with movement?

□Yes □No


Clinical Justification for the Medical Necessity KX Modifier

□ Physical Therapy □ Occupational Therapy □ Speech Therapy

Patient: ________________________________________ Effective Date: ________________

The item checked below indicates the reason for the Part B therapy:

□ Specific medical condition: Code: _______________ Descriptor: _______________

□ Specific medical complexity: Code: _______________ Descriptor: _______________

□ Discharged from a hospital or SNF within 30 treatment days of starting this episode of therapy Hospital/SNF: __________________________________ D/C Date: ________________

□ Generalized musculoskeletal conditions or conditions affecting multiple sites (not listed as an automatically excepted condition or complexity) that will directly and significantly impact the rate of recovery

□ Mental or cognitive disorder in addition to the condition being treated that will directly and significantly impact the rate of recovery

□ Requires PT and SLP services concurrently

□ Prior episode of outpatient therapy during this calendar year for a different condition

□ Requires treatment in order to return to a pre-morbid living environment which was Prior living environment ______________________________________________________________ Skill(s) required obtaining _____________________________________________________________

□ Requires this treatment plan in order to obtain pre-morbid activities of daily living

Current ADL status: _____________________________________________________________

Pre-morbid ADL status: __________________________________________________________

□ The beneficiary does not have access to the outpatient hospital therapy services, i.e. consolidated billing (dually certified beds, no transportation, and lack of hospital services)

Justification for further treatment provided by the therapist or qualified personnel is supported by the following medical necessity rationale:

□ The patient has the potential to improve secondary to ________________________________________

_____________________________________________________________________________________

□ Maximum improvement is yet to be attained and is related to __________________________________

_____________________________________________________________________________________

□ There is the expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time which is approximately ____________________________________________

_____________________________________________________________________________________

Therapist Signature: _____________________________________________


SNF NOTICES – QUICK REFERENCE

Situation

ABN or Notice of Non-Coverage – liability notice

Expedited Determination/Generic Notice (QIO) - Fast Track

PART B Issue no later than day before last covered treatment/day

Issue on the second to last covered treatment/day.

1 Part B Therapy determines that the services are no longer medically reasonable and necessary and Medicare will no longer continue to pay for any therapy services. The resident does not want to receive any more therapy.

No ABN (CMS R-131) is required

Mandatory When all services are ending-Expedited

Determination/Generic Notice (CMS-10123)

2 Part B – Any time therapy determines that the services are not medically reasonable and necessary and Medicare will not pay for therapy services by one or all disciplines but resident wants to continue to receive therapy, this would make the resident liable for payment for therapy services by one or more disciplines. With any risk for liability for payment, the resident must receive an ABN. An Expedited Review is only required when all therapies are ending.

ABN (CMS R-131) is required for each/all disciplines that will continue

after last covered service.

Mandatory When all services are ending - Expedited

Determination/Generic Notice (CMS-10123)

3 Part B SNF items/services that are not medically reasonable and necessary or never covered under Medicare are expected to be denied under Medicare Part B. For example: Medicare pays for 2 urinary catheters a month but the resident requests the urinary catheter be changed weekly. Medicare Part B never pays for the additional 2 urinary catheters that are not medically reasonable and necessary.

Mandatory - ABN (CMS R-131) is required. Resident will be responsible

for denied charges.

No Expedited Determination/Generic Notice (CMS-10123)

SNFABN = CMS-10055 ABN = CMS-R-131 Updated 02/18 Generic/Expedited Review Notice (Notice of Medicare Provider Non-Coverage) = CMS-10123 (NOMNC)** **Member numbers should not be member’s Medicare number Detailed Explanation Notice = CMS-10124 (DENC) (only issued if an appeal is requested of the QIO) Medicare Advantage/Health Plan Notice of Non-coverage/Expedited QIO review = CMS-10123 (NOMNC) Medicare Advantage/Health Plan Detailed Explanation of Non-Coverage = CMS-10124 (DENC) (issue if an appeal is requested of QIO) Medicare Advantage/Health Plan Notice of Denial of Medicare Coverage CMS-10003NDMCP; Issued by Health Plan


A. Notifier:

B. Patient Name: C. Identification Number:

Advance Beneficiary Notice of Noncoverage (ABN) NOTE: If Medicare doesn’t pay for D. Physical therapy below, you may have to pay.

Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the D.Physical Therapy below.

D. E. Reason Medicare May Not Pay: F. Estimated Cost

Physical Therapy 3 times a week for gait training

Goal has been met, continued skilled therapy is not medically necessary.

$140 per treatment

WHAT YOU NEED TO DO NOW: Read this notice, so you can make an informed decision about your care. Ask us any questions that you may have after you finish reading. Choose an option below about whether to receive the D. listed above.

Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.

G. OPTIONS: Check only one box. We cannot choose a box for you.

□ OPTION 1. I want the D. listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.

□ OPTION 2. I want the D. listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.

□ OPTION 3. I don’t want the D. listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare wouldpay.H. Additional Information:

MUST BE ISSUED THE SECOND TO LAST COVERED TREATMENT/DAY This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048). Signing below means that you have received and understand this notice. You also receive a copy.

I. Signature: J. Date:

CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call: 1-800-MEDICARE or email: [email protected].

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

Form CMS-R-131 (Exp. 03/2020) Form Approved OMB No. 0938-0566


Form Instructions Advance Beneficiary Notice of Noncoverage (ABN)

OMB Approval Number: 0938-0566 Overview

The ABN is a notice given to beneficiaries in Original Medicare to convey that Medicare is not likely to provide coverage in a specific case. “Notifiers” include physicians, providers (including institutional providers like outpatient hospitals), practitioners and suppliers paid under Part B (including independent laboratories), as well as hospice providers and religious non-medical health care institutions (RNHCIs) paid exclusively under Part A. Since 2013, home health agencies (HHAs) providing care under Part A or Part B issue the ABN instead of the Home Health Advance Beneficiary Notice (HHABN) Option Box 1 to inform beneficiaries of potential liability. The HHABN has been discontinued.

All of the aforementioned physicians, suppliers, practitioners, and providers must complete the ABN as described below, and deliver the notice to affected beneficiaries or their representative before providing the items or services that are the subject of the notice. Medicare inpatient hospitals and skilled nursing facilities (SNFs) use other approved notices for Part A items and services when notice is required; however, these facilities must use the ABN for Part B items and services.

The ABN must be reviewed with the beneficiary or his/her representative and any questions raised during that review must be answered before it is signed. The ABN must be delivered far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice. Employees or subcontractors of the notifier may deliver the ABN. ABNs are never required in emergency or urgent care situations. Once all blanks are completed and the form is signed, a copy is given to the beneficiary or representative. In all cases, the notifier must retain a copy of the ABN delivered to the beneficiary on file.

The ABN may also be used to provide voluntary notification of financial liability for items or services that Medicare never covers. When the ABN is used as a voluntary notice, the beneficiary doesn’t choose an option box or sign the notice. CMS has issued detailed instructions on the use of the ABN in its on-line Medicare Claims Processing Manual (MCPM), Publication 100-04, Chapter 30, §50. Related policies on billing and coding of claims, as well as coverage determinations, are found elsewhere in the CMS manual system or website: www.cms.gov.

ABN Changes

The ABN is a formal information collection subject to approval by the Executive Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (PRA). As part of this process, the notice is subject to public comment and re-approval every 3 years. With the 2016 PRA submission, a non-substantive change has been made to the ABN. In accordance with Section 504 of the Rehabilitation Act of 1973 (Section 504), the form has


https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending


https://www.cms.gov/

been revised to include language informing beneficiaries of their rights to CMS nondiscrimination practices and how to request the ABN in an alternative format if needed.

Completing the Notice

ABNs may be downloaded from the CMS website at: http://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html . Notices should be used as is since the ABN is a standardized OMB-approved notice. However, some allowance for customization of format is allowed as mentioned in these instructions and the on-line manual instructions for those choosing to integrate the ABN into other automated business processes. Instructions for completion of the form are set forth below:

ABNs must be reproduced on a single page. The page may be either letter or legal-size, with additional space allowed for each blank needing completion when a legal-size page is used.

Sections and Blanks: There are 10 blanks for completion in this notice, labeled from (A) through (J), with accompanying instructions for each blank below. We recommend that notifiers remove the lettering labels from the blanks before issuing the ABN to beneficiaries. Blanks (A)-(F) and blank (H) may be completed prior to delivering the notice, as appropriate. Entries in the blanks may be typed or hand-written, but should be large enough (i.e., approximately 12-point font) to allow ease in reading. (Note that 10 point font can be used in blanks when detailed information must be given and is otherwise difficult to fit in the allowed space.) The notifier must also insert the blank (D) header information into all of the blanks labeled (D) within the Option Box section, Blank (G). One of the check boxes in the Option Box section, Blank (G), must be selected by the beneficiary or his/her representative. Blank (I) should be a cursive signature, with printed annotation if needed in order to be understood.

Header

Blanks A-C, the header of the notice, must be completed by the notifier prior to delivering the ABN.

Blank (A) Notifier(s): Notifiers must place their name, address, and telephone number (including TTY number when needed) at the top of the notice. This information may be incorporated into a notifier’s logo at the top of the notice by typing, hand-writing, pre- printing, using a label or other means.

If the billing and notifying entities are not the same, the name of more than one entity may be given in the Header as long as it is specified in the Additional Information (H) section who should be contacted for billing questions.

Blank (B) Patient Name: Notifiers must enter the first and last name of the beneficiary receiving the notice, and a middle initial should also be used if there is one on the beneficiary’s Medicare (HICN) card. The ABN will not be invalidated by a misspelling or missing initial, as long as the beneficiary or representative recognizes the name listed on the notice as that of the beneficiary.


http://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html

Blank (C) Identification Number: Use of this field is optional. Notifiers may enter an identification number for the beneficiary that helps to link the notice with a related claim. The absence of an identification number does not invalidate the ABN. An internal filing number created by the notifier, such as a medical record number, may be used. Medicare numbers (HICNs) or Social Security numbers must not appear on the notice.

Body

Blank (D): The following descriptors may be used in the Blank (D) fields:

Item Service Laboratory test Test Procedure Care Equipment

The notifier must list the specific names of the items or services believed to be

noncovered in the column directly under the header of Blank (D). In the case of partial denials, notifiers must list in the column under Blank (D) the

excess component(s) of the item or service for which denial is expected. For repetitive or continuous noncovered care, notifiers must specify the frequency

and/or duration of the item or service. See § 50.7.1 (b) of the MCPM, Chapter 30 for additional information.

General descriptions of specifically grouped supplies are permitted in this column. For example, “wound care supplies” would be a sufficient description of a group of items used to provide this care. An itemized list of each supply is generally not required.

When a reduction in service occurs, notifiers must provide enough additional information so that the beneficiary understands the nature of the reduction. For example, entering “wound care supplies decreased from weekly to monthly” would be appropriate to describe a decrease in frequency for this category of supplies; just writing “wound care supplies decreased” is insufficient.

Please note that there are a total of 7 Blank (D) fields that the notifier must complete on the ABN. Notifiers are encouraged to populate all of the Blank (D) fields in advance when a general descriptor such as “Item(s)/Service(s)” is used. All Blank (D) fields must be completed on the ABN in order for the notice to be considered valid.

Blank (E) Reason Medicare May Not Pay: In the column under this header, notifiers must explain, in beneficiary friendly language, why they believe the items or services listed in the column under Blank (D) may not be covered by Medicare. Three commonly used reasons for noncoverage are:

“Medicare does not pay for this test for your condition.” “Medicare does not pay for this test as often as this (denied as too frequent).”



“Medicare does not pay for experimental or research use tests.” To be a valid ABN, there must be at least one reason applicable to each item or service listed in the column under Blank (D). The same reason for noncoverage may be applied to multiple items in Blank (D) when appropriate.

Blank (F) Estimated Cost: Notifiers must complete the column under Blank (F) to ensure the beneficiary has all available information to make an informed decision about whether or not to obtain potentially noncovered services.

Notifiers must make a good faith effort to insert a reasonable estimate for all of the items or services listed under Blank (D). In general, we would expect that the estimate should be within $100 or 25% of the actual costs, whichever is greater; however, an estimate that exceeds the actual cost substantially would generally still be acceptable, since the beneficiary would not be harmed if the actual costs were less than predicted. Thus, examples of acceptable estimates would include, but not be limited to, the following:

For a service that costs $250: • Any dollar estimate equal to or greater than $150 • “Between $150-300” • “No more than $500”

For a service that costs $500: • Any dollar estimate equal to or greater than $375 • “Between $400-600” • “No more than $700”

Multiple items or services that are routinely grouped can be bundled into a single cost estimate. For example, a single cost estimate can be given for a group of laboratory tests, such as a basic metabolic panel (BMP). An average daily cost estimate is also permissible for long term or complex projections. As noted above, providers may also pre-print a menu of items or services in the column under Blank (D) and include a cost estimate alongside each item or service. If a situation involves the possibility of additional tests or procedures (such as in laboratory reflex testing), and the costs associated with such tests cannot be reasonably estimated by the notifier at the time of ABN delivery, the notifier may enter the initial cost estimate and indicate the possibility of further testing. Finally, if for some reason the notifier is unable to provide a good faith estimate of projected costs at the time of ABN delivery, the notifier may indicate in the cost estimate area that no cost estimate is available. We would not expect either of these last two scenarios to be routine or frequent practices, but the beneficiary would have the option of signing the ABN and accepting liability in these situations.

CMS will work with its contractors to ensure consistency when evaluating cost estimates and determining validity of the ABN in general. In addition, contractors will provide ongoing education to notifiers as needed to ensure proper notice delivery. Notifiers should contact the appropriate CMS regional office if they believe that a contractor inappropriately invalidated an ABN.


Options

Blank (G) Options: Blank (G) contains the following three options:

□ OPTION 1. I want the (D) listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.

This option allows the beneficiary to receive the items and/or services at issue and requires the notifier to submit a claim to Medicare. This will result in a payment decision that can be appealed. See Ch. 30, §50.15.1 of the online Medicare Claims Processing Manual for instructions on the notifier’s obligation to bill Medicare. Suppliers and providers who don’t accept Medicare assignment may make modifications to Option 1 only as specified below under “D. Additional Information.”

Note: Beneficiaries who need to obtain an official Medicare decision in order to file a claim with a secondary insurance should choose Option 1.

□ OPTION 2. I want the (D) listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.

This option allows the beneficiary to receive the noncovered items and/or services and pay for them out of pocket. No claim will be filed and Medicare will not be billed. Thus, there are no appeal rights associated with this option.

□ OPTION 3. I don’t want the (D)listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.

This option means the beneficiary does not want the care in question. By checking this box, the beneficiary understands that no additional care will be provided; thus, there are no appeal rights associated with this option.

The beneficiary or his or her representative must choose only one of the three options listed in Blank (G). Under no circumstances can the notifier decide for the beneficiary which of the 3 checkboxes to select. Pre-selection of an option by the notifier invalidates the notice. However, at the beneficiary’s request, notifiers may enter the beneficiary’s selection if he or she is physically unable to do so. In such cases, notifiers must annotate the notice accordingly.

If there are multiple items or services listed in Blank (D) and the beneficiary wants to receive some, but not all of the items or services, the notifier can accommodate this request by using more than one ABN. The notifier can furnish an additional ABN listing the items/services the beneficiary wishes to receive with the corresponding option.

If the beneficiary cannot or will not make a choice, the notice should be annotated, for



example: “beneficiary refused to choose an option.” Additional Information

Blank (H) Additional Information: Notifiers may use this space to provide additional clarification that they believe will be of use to beneficiaries. For example, notifiers may use this space to include:

A statement advising the beneficiary to notify his or her provider about certain tests

that were ordered, but not received; Information on other insurance coverage for beneficiaries, such as a Medigap policy, if

applicable; An additional dated witness signature; or Other necessary annotations.

Annotations will be assumed to have been made on the same date as that appearing in Blank J, accompanying the signature. If annotations are made on different dates, those dates should be part of the annotations.

Special guidance ONLY for non-participating suppliers and providers (those who don’t accept Medicare assignment):

Strike the last sentence in the Option 1 paragraph with a single line so that it appears like this: If Medicare does pay, you will refund any payments I made to you, less co- pays or deductibles.

This single line strike can be included on ABNs printed specifically for issuance when unassigned items and services are furnished. Alternatively, the line can be hand-penned on an already printed ABN.

The sentence must be stricken and can’t be entirely concealed or deleted. There is no CMS requirement for suppliers or the beneficiary to place initials next

to the stricken sentence or date the annotations when the notifier makes the changes to the ABN before issuing the notice to the beneficiary.

When this sentence is stricken, the supplier shall include the following CMS-approved

unassigned claim statement in the (H) Additional Information section.

“This supplier doesn’t accept payment from Medicare for the item(s) listed in the table above. If I checked Option 1 above, I am responsible for paying the supplier’s charge for the item(s) directly to the supplier. If Medicare does pay, Medicare will pay me the Medicare-approved amount for the item(s), and this payment to me may be less than the supplier’s charge.”

o This statement can be included on ABNs printed for unassigned items and services, or it can be handwritten in a legible 10 point or larger font.

• An ABN with the Option 1 sentence stricken must contain the CMS-approved

unassigned claim statement as written above to be considered valid notice. Similarly, when the unassigned claim statement is included in the “Additional Information” section, the last sentence in Option 1 should be stricken.


B. Signature Box Once the beneficiary reviews and understands the information contained in the ABN, the Signature Box is to be completed by the beneficiary (or representative). This box cannot be completed in advance of the rest of the notice.

Blank (I) Signature: The beneficiary (or representative) must sign the notice to indicate that he or she has received the notice and understands its contents. If a representative signs on behalf of a beneficiary, he or she should write out “representative” in parentheses after his or her signature. The representative’s name should be clearly legible or noted in print.

Blank (J) Date: The beneficiary (or representative) must write the date he or she signed the ABN. If the beneficiary has physical difficulty with writing and requests assistance in completing this blank, the date may be inserted by the notifier.

Disclosure Statement: The disclosure statements in the footer of the notice are required to be included on the document.


SAMPLE

{Insert provider contact information here} Notice of Medicare Non-Coverage

Patient name: John Smith Patient number: XXXXXX

The Effective Date Coverage of Your Current Medicare Part B Physical Therapy Services Will End: May 1 20XX

• Your Medicare provider and/or health plan have determined that Medicare probably will not pay for your current {insert type} services after the effective date indicated above.

• You may have to pay for any services you receive after the above date. State when liability would start if continue with therapy

Your Right to Appeal This Decision

• You have the right to an immediate, independent medical review (appeal) of the decision to end Medicare coverage of these services. Your services will continue during the appeal.

• If you choose to appeal, the independent reviewer will ask for your opinion. The reviewer also will look at your medical records and/or other relevant information. You do not have to prepare anything in writing, but you have the right to do so if you wish.

• If you choose to appeal, you and the independent reviewer will each receive a copy of the detailed explanation about why your coverage for services should not continue. You will receive this detailed notice only after you request an appeal.

• If you choose to appeal, and the independent reviewer agrees services should no longer be covered after the effective date indicated above; o Neither Medicare nor your plan will pay for these services after that date.

• If you stop services no later than the effective date indicated above, you will avoid

financial liability.

How to Ask For an Immediate Appeal

• You must make your request to your Quality Improvement Organization (also known as a QIO). A QIO is the independent reviewer authorized by Medicare to review the decision to end these services.

• Your request for an immediate appeal should be made as soon as possible, but no later than noon of the day before the effective date indicated above.

• The QIO will notify you of its decision as soon as possible, generally no later than two days after the effective date of this notice if you are in Original Medicare. If you are in a Medicare health plan, the QIO generally will notify you of its decision by the effective date of this notice.

• Call your QIO at: INSERT PHONE NUMBER to appeal, or if you have questions.

See page 2 of this notice for more information.


Form CMS 10123-NOMNC (Approved 12/31/2011) OMB approval 0938-0953

If You Miss The Deadline to Request An Immediate Appeal, You May Have Other Appeal Rights: • If you have Original Medicare: Call the QIO listed on page 1.

• If you belong to a Medicare health plan: Call your plan at the number given below.

Plan contact information

Additional Information (Optional): Medicare covers medically necessary skilled care needed on a daily basis. Your goals

have been met.

If reviewed over phone write here: Name of staff, date, time, number called, person spoke to, and indicate “Reviewed last covered treatment day, potential liability, appeal rights and timing, and shared QIO number on this form.”

Please sign below to indicate you received and understood this notice. I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO.

Signature of Patient or Representative Date

Form CMS 10123-NOMNC (Approved 12/31/2011) OMB approval 0938-0953


Detailed Notice for QIO:

Sample ONE

We have reviewed your case and decided that Medicare coverage of your current {insert type} services should end. • The facts used to make this decision: Long Term resident had been ambulatory with walker. Resident had a decline in health, the flu, which resulted

in his inability to ambulate without assistance. On June 1, 20XX, PT started gait training 3xweek. After 3

weeks, the resident is now able to ambulate again without assistance and care is being turned over to nursing

restorative.

• Detailed explanation of why your current services are no longer covered, and the specific Medicare coverage rules and policy used to make this decision:

This resident has met therapy goals to resume prior level of function, requiring the skills of a PT. The therapist

worked on balance and gait.

• Plan policy, provision, or rationale used in making the decision (health plans only): Medicare only covers Part B when the skilled services of a therapist are required.

Provided by Polaris Group


Severity /Complexity Modifiers

Modifier Impairment Limitation Restrictions

CH 0 percent impaired, limited or restricted CI At least 1 percent but less than 20 percent impaired, limited or restricted CJ At least 20 percent but less than 40 percent impaired, limited or restricted CK At least 40 percent but less than 60 percent impaired, limited or restricted CL At least 60 percent but less than 80 percent impaired, limited or restricted CM At least 80 percent but less than 100 percent impaired, limited or restricted CN 100 percent impaired, limited or restricted

HCPCS G‐Codes

Mobility G‐Code Set Function Short Descriptor

G8978 Mobility: walking and moving around functional limitation, current status, at therapy episode outset and at reporting intervals.

Mobility current status

G8979 Mobility: walking & moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting.

Mobility goal status

G8980 Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end reporting.

Mobility D/C status

Changing & Maintaining Body Position G‐code Set Function Short Descriptor

G8981 Changing & maintaining body position functional limitation, current status, at therapy episode outset and at reporting intervals.

Body pos current status

G8982 Changing & maintaining body position functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting

Body pos goal status

G8983 Changing & maintaining body position functional limitation, discharge status, at discharge from therapy or to end reporting.

Body pos D/C status

Carrying, Moving & Handling Objects G‐code Set Function Short Descriptor

G8984 Carrying, moving & handling objects functional limitation, current status, at therapy episode outset and at reporting intervals

Carry current status

G8985 Carrying, moving & handling objects functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting

Carry goal status


G8986 Carrying, moving & handling objects functional limitation, discharge

status, at discharge from therapy or to end reporting

Carry D/C status

Self Care G‐code Set

Function Short Descriptor

G8987 Self care functional limitation, current status, at therapy episode outset and at reporting intervals

Self care current status

G8988 Self care functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting

Self care goal status

G8989 Self care functional limitation, discharge status, at discharge from therapy or to end reporting

Self care D/C status

Other PT/OT Primary G‐code Set

Function Short Descriptor

G8990 Other physical or occupational primary functional limitation, current status, at therapy episode outset and at reporting intervals

Other PT/OT goal status

G8991 Other physical or occupational primary functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting

Other PT/OT goal status

G8992 Other physical or occupational primary functional limitation, discharge status, at discharge from therapy or to end reporting

Other PT/OT D/C status

Other PT/OT Subsequent G‐code Set Function Short Descriptor

G8993

Other physical or occupational subsequent functional limitation, current status, at therapy episode outset and at reporting intervals

Sub PT/OT goal status

G8994 Other physical or occupational subsequent functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting

Sub PT/OT goal status

G8995 Other physical or occupational subsequent functional limitation, discharge status, at discharge from therapy or to end reporting

Sub PT/OT D/C status

Swallowing G‐code Set Function Short Descriptor

G8996 Swallowing functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals

Swallow current status

G8997 Swallowing functional limitation, projected goal status, at initial therapy treatment/outset and at discharge from therapy

Swallow goal status


G8998 Swallowing functional limitation, discharge status, at discharge from

therapy/end of reporting on limitation

Swallow D/C status

Motor Speech G‐code Set: (Note: These codes are not sequentially numbered) Function Short Descriptor

G8999 Motor speech functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals

Motor speech current status

G9186 Motor speech functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy

Motor speech goal status

G9158 Motor speech functional limitation, discharge status at discharge from therapy/end of reporting on limitation

Motor speech D/C status

Spoken Language Comprehension G‐code Set: Function Short Descriptor

G9159 Spoken language comprehension functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals

Language comp current status

G9160 Spoken language comprehension functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy

Language comp goal status

G9161 Spoken language comprehension functional limitation, discharge status at discharge from therapy/end of reporting on limitation

Language comp D/C status

Spoken Language Expressive G‐code Set Function Short Descriptor

G9162 Spoken language expression functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals

Language express current status

G9163 Spoken language expression functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy

Language express goal status

G9164 Spoken language expression functional limitation, discharge status at discharge from therapy/end of reporting on limitation

Language express D/C status

Attention G‐code Set Function Short Descriptor

G9165 Attention functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals

Attention current status

G9166 Attention functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy

Attention goal status

G9167 Attention functional limitation, discharge status at discharge from therapy/end of reporting on limitation

Attention D/C status


Memory G‐code Set Function Short Descriptor

G9168 Memory functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals

Memory current status

G9169 Memory functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy

Memory goal status

G9170 Memory functional limitation, discharge status at discharge from therapy/end of reporting on limitation

Memory D/C status

Voice G‐code Set Function Short Descriptor

G9171 Voice functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals

Voice current status

G9172 Voice functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy

Voice goal status

G9173 Voice functional limitation, discharge status at discharge from therapy/end of reporting on limitation

Voice D/C status

Other Speech Language Pathology G‐code Set Function Short Descriptor

G9174 Other speech language pathology functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals

Speech Language current status

G9175 Other speech language pathology functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy

Speech language goal status

G9176 Other speech language pathology functional limitation, discharge status at discharge from therapy/end of reporting on limitation

Speech language D/C status


Polaris Group - Page 1 of 1

NOTICE TRACKING LOG Initiate LOG at the time an NOMNC and SNFABN or ABN is given. Track to ensure signed copy is in the financial file.

Admit Date Name Room

Bed Notice Type

Date Issued

Issued in person to rep or resident. X if applies

Copy of signed notice in financial file

Issued by certified or registered mail. X if applies

Received signed copy back. Date received

Copy of signed copy in financial file

Original sent back to rep or resident within 30 days of receipt. Date mailed.


Program Development – Identifying the needs of Long-Term Care Residents

Medicare Part B Services:

Facilities must provide continued assessment and observation for changes in the resident’s condition, regardless of payer source.

Skilled therapy may be needed, and improvement in a resident’s condition may occur, even where a chronic or terminal condition exists.

The fact that full or partial recovery is not possible does not necessarily mean that skilled therapy is not needed to improve resident’s condition.

The deciding factor is always whether the services are considered reasonable, effective treatments for the resident’s condition and require the skills of a therapist.

Steps for Implementing a Successful Medicare Part B Therapy Program:

Educate therapists on how to complete a screen. Ensure staff understand the full scope of therapy services available to residents and are proficient in the process of screening.

o Consider discipline specific screens Identify all in-house residents who have access to Part B benefits. Identify the last time each resident with a Part B benefit received therapy. Educate nursing and dietary staff on appropriate resident referrals for Part B therapy.

o Lunch and learns o Small group in-services o All staff presentations o Posters and signs in break room. o Highlight the signs and symptoms staff should look for related to a decline ADL,

mobility, ROM, pain, contractures and cognition. o Educate nursing and CNA staff on how to identify a decline in function when

completing routine ADL. Make certain a referral process is in place.

o Referral forms o Effective communication during stand-up

“Is there anyone that needs to be screened by therapy today?” Take referral forms to stand-up. When a patient is identified, begin the

screen immediately by asking other department heads what they are seeing.

Discuss the results of the previous day screens during stand-up. Ask if the team agrees with the results of the screen.

Initiate routine reviews of key facility reports. o 24-hour report – daily o QM report – monthly o Weight loss – weekly

Review MD orders for new diagnosis or acute conditions that may result in a need for therapy services.


Program Development – Identifying the needs of Long-Term Care Residents

Steps for Implementing a Successful Medicare Part B Therapy Program, continued:

Review residents at RISK for skin issues, weight, pain, behavior, restraint, incontinence and fall risks.

Routinely perform quarterly, annual and significant change in status screens. Review ADL flow sheets for previous months and compart to the current month for

changes. Develop Specialty Programs

o Assign a clinical leader or expert to each specialty program. Clinical leader partners with a nurse leader. Identify signs of a decline in function and reason for referral (i.e. resident

sliding forward in chair or leaning to one side) Strategies for referral (i.e. positioning rounds, interview direct care staff) Provide examples of assessment tools, goals, outcomes and treatment

activities o Facility focus on specialty program for the month or quarter

Educate facility staff based on specialty program Posters or signs in staff areas

o Complete monthly screens based on the specialty program o Round with nursing staff to identify residents who might benefit o Interview direct care staff o Specialty Programs Examples

Pain Management Seating and Positioning Contracture Management Wound Care Dementia Dining Dysphagia Management (Altered consistencies) Falls and Balance Program ADL Continence


part b programming - team tsi university · part b programming post test 1. part b programming...

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