Read SNF/Swing Bed Services Manual text version

SNF/Swing Bed Services

Published October 2011

Part A

IMPORTANT

The information provided in this manual was current as of September 2011. Any changes or new information superseding the information in this manual, provided in MLN Matters® articles, eBulletins, listserv notices, Local Coverage Determinations (LCDs) or CMS Internet-Only Manuals with publication dates after September 2011, are available at: http://www.trailblazerhealth.com/Medicare.aspx

© CPT codes, descriptions, and other data only are copyright 2011 American Medical Association. All rights reserved. Applicable FARS/DFARS clauses apply. © CDT codes and descriptions are copyright 2011 American Dental Association. All rights reserved. Applicable FARS/DFARS clauses apply.

Provider Outreach and Education VC

IMPORTANT

MEDICARE PART A

SNF/Swing Bed Services Manual

Table of Contents

INTRODUCTION TO SKILLED NURSING FACILITY/SWING BED SERVICES ........... 1 SNF CARE...................................................................................................................... 2 SNF Overview ............................................................................................................. 2 SNF Eligibility .............................................................................................................. 3 Thirty-Day Transfer...................................................................................................... 3 SNF Coverage............................................................................................................. 4 SWING BED SERVICES ................................................................................................ 6 Introduction.................................................................................................................. 6 Billing ........................................................................................................................... 6 SKILLED NURSING SERVICES AND SKILLED REHABILITATION SERVICES ......... 7 Nursing and/or Rehabilitation Services........................................................................ 7 Determining Whether a Service Is Skilled.................................................................... 7 Moving Out of a Medicare-Certified SNF or Distinct Part Unit ..................................... 8 MEDICAL NECESSITY................................................................................................... 9 Definition of Limited Coverage..................................................................................... 9 Reasons for Non-Coverage ......................................................................................... 9 National Coverage Determinations/Local Coverage Determinations........................... 9 PHYSICIAN CERTIFICATION/RECERTIFICATION..................................................... 11 General...................................................................................................................... 11 Obtaining Certifications.............................................................................................. 11 Initial Certification ...................................................................................................... 11 Delayed Certification and Recertification ................................................................... 12 SNF ADMISSION PROCEDURES................................................................................ 13 Admission Guidelines ................................................................................................ 13 Transfer Agreement................................................................................................... 13 Same-Day Transfer ................................................................................................... 14 Delayed Admission Billing Requirements .................................................................. 14 BENEFIT PERIOD ........................................................................................................ 16 Spell of Illness ........................................................................................................... 16 Starting a Benefit Period............................................................................................ 16 Ending a Benefit Period ............................................................................................. 16 Benefit Period Examples ........................................................................................... 16 Calculating Days in a Benefit Period ......................................................................... 18 SNF PROSPECTIVE PAYMENT SYSTEM .................................................................. 19 General Provisions .................................................................................................... 19

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MEDICARE PART A

SNF/Swing Bed Services Manual

Presumption of Coverage .......................................................................................... 19 SNF Coverage Guidelines ......................................................................................... 20 CMS RAI Manual....................................................................................................... 20 Resident Assessment Instrument (RAI)..................................................................... 23 OBRA-Required Tracking Records and Assessments .............................................. 25 Medicare-Required PPS Assessments...................................................................... 26 Grace Days................................................................................................................ 27 Medicare Short-Stay Assessment ............................................................................. 27 MDS Assessment Schedule ...................................................................................... 29 Combining Assessments ........................................................................................... 29 PPS Scheduled Assessments for a Medicare Part A Stay ........................................ 30 PPS Unscheduled Assessments for a Medicare Part A Stay .................................... 32 RUG Version IV ......................................................................................................... 39 HIPPS Codes ............................................................................................................ 40 RUG-IV Group Code ................................................................................................. 40 AI Codes.................................................................................................................... 41 Adjustment Requests for Corrected Assessments .................................................... 44 MEDICARE SECONDARY PAYER .............................................................................. 46 Billing Claims During an MSP Period ........................................................................ 47 Billing Claims After Other Insurance Ends................................................................. 47 BILLING PART A SNF PPS SERVICES ...................................................................... 48 UB-04 Field Requirements ........................................................................................ 48 Frequency Billing Requirements................................................................................ 49 Provider Liability Billing Instructions .......................................................................... 50 BILLING FOR A CONTINUOUS INPATIENT STAY .................................................... 51 Requirements for Submitting Claims in Sequence .................................................... 51 Reprocessing Inpatient Bills in Sequence.................................................................. 51 ANCILLARY AND PART B OUTPATIENT SERVICES................................................ 52 SNF Part B Items and Services ................................................................................. 52 ANNUAL WELLNESS VISIT (AWV)............................................................................. 55 INFLUENZA, PNEUMOCOCCAL AND HEPATITIS B VACCINES.............................. 56 Influenza .................................................................................................................... 56 PPV ........................................................................................................................... 56 Hepatitis B ................................................................................................................. 56 H1N1 ......................................................................................................................... 56 Billing Requirements.................................................................................................. 56

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Contents

MEDICARE PART A

SNF/Swing Bed Services Manual

PHYSICIAN CERTIFICATION/RECERTIFICATION FOR OUTPATIENT PHYSICAL THERAPY, OCCUPATIONAL THERAPY AND SPEECH-LANGUAGE PATHOLOGY SERVICES .................................................................................................................... 58 Method and Disposition of Certifications ................................................................... 58 Initial Certification of Plan .......................................................................................... 58 Review of Plan and Recertification ............................................................................ 59 PHYSICAL THERAPY, OCCUPATIONAL THERAPY AND SPEECH-LANGUAGE PATHOLOGY SERVICES ............................................................................................ 60 Multiple Procedure Payment Reduction (MPPR) for Selected Therapy Services ...... 60 Physical Therapy ....................................................................................................... 62 Occupational Therapy ............................................................................................... 63 Speech-Language Pathology Services...................................................................... 65 FINANCIAL LIMITATION FOR THERAPY SERVICES................................................ 69 Moratoria on Therapy Claims .................................................................................... 69 Access to Accrued Amount........................................................................................ 70 THERAPY EDITS.......................................................................................................... 71 Therapy Ancillary Charges ........................................................................................ 71 Group Therapy Allocation .......................................................................................... 71 Documentation Requirements ................................................................................... 72 Therapy Student Supervision .................................................................................... 72 Therapy Processing Issues ....................................................................................... 73 Outpatient Therapy Billing Requirements .................................................................. 74 LEAVE OF ABSENCE.................................................................................................. 78 Effect on Benefit Days and Assessment Schedule.................................................... 79 Bed-Hold Policy for SNFs .......................................................................................... 79 SPECIAL BILLING SITUATIONS................................................................................. 81 SNF Discharges Beneficiary or Beneficiary Dies Before Day 8 of Covered Stay ...... 81 Medicare Beneficiaries Enrolled in Medicare Advantage (MA) Plans ........................ 81 Medicare Coverage Rules ......................................................................................... 82 Medicare Beneficiaries in Hospice............................................................................. 82 Processing No-Payment Bills .................................................................................... 83 Hospital Inpatient Qualifying Stay Not Met ................................................................ 85 Benefits Exhausted.................................................................................................... 85 Beneficiary No Longer Requires a Covered Level of Skilled Care............................. 85 Demand Bills (Condition Code 20) ............................................................................ 86 Billing for Denial Notice (Condition Code 21)............................................................. 87 SNF NOTIFICATIONS .................................................................................................. 88

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Contents

MEDICARE PART A

SNF/Swing Bed Services Manual

Prepayment From the Beneficiary ............................................................................. 88 Skilled Nursing Denial Letters.................................................................................... 88 SNF Notice of Exclusion From Medicare Benefits (NEMB) ....................................... 89 Advance Beneficiary Notice of Noncoverage (CMS-R-131) ...................................... 89 Expedited Review Process for Disputed Terminations of Medicare-Covered Services..................................................................................................................... 90 Generic Notice........................................................................................................... 90 Expedited Review Process and the Detailed Notice.................................................. 91 DENIAL OF PAYMENT FOR NEW ADMISSIONS ....................................................... 94 New Admissions ........................................................................................................ 94 Readmissions ............................................................................................................ 94 Current Patients......................................................................................................... 95 CONSOLIDATED BILLING .......................................................................................... 96 Consolidated Billing Requirements Under Part A ...................................................... 96 Services and Treatments Provided `Under Arrangement'.......................................... 96 Services Excluded From Consolidated Billing ........................................................... 97 MEDICAL REVIEW PROCESS UNDER PPS .............................................................. 99 Progressive Corrective Action (PCA)......................................................................... 99 ADDITIONAL DEVELOPMENT REQUEST................................................................ 100 Medical Record Documentation Requirements ....................................................... 100 REIMBURSEMENT..................................................................................................... 101 SNF PPS ................................................................................................................. 101 Payment Adjustment for AIDS ................................................................................. 101 Financial Issues Regarding Payment for Part A Stays ............................................ 101 REVISION HISTORY .................................................................................................. 103

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Contents

MEDICARE PART A

SNF/Swing Bed Services Manual INTRODUCTION TO SKILLED NURSING FACILITY/SWING BED SERVICES

The material contained in this manual provides comprehensive information that was obtained from the CMS Internet-Only Manuals (IOMs) or Change Requests (CRs). Skilled Nursing Facility (SNF) and swing bed policy and billing instructions may be found in the following CMS IOMs: Medicare General Information, Eligibility, and Entitlement Manual, Pub. 100-01, Chapter 4. Benefit Policy Manual, Pub. 100-02, Chapter 8. Claims Processing Manual, Pub. 100-04, Chapters 6, 7 and 30. The CMS IOMs may be found on the CMS Web site at: http://www.cms.gov/Manuals/IOM/list.asp.

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Introduction to SNF/Swing Bed Services

MEDICARE PART A

SNF/Swing Bed Services Manual SNF CARE SNF Overview

SNF services are also known as extended care services. Post-hospital extended care services represent an extension of care for a condition for which the individual received inpatient hospital services. Post-hospital extended care services furnished to inpatients of a SNF or a swing bed hospital are covered under the hospital insurance program. SNF DESCRIPTION A SNF is a specially qualified facility that specializes in skilled care. It has the staff and equipment to provide skilled nursing care or skilled rehabilitation services and other related health services. Skilled nursing care means care that can only be performed by, or under the supervision of, licensed nursing personnel. Skilled rehabilitation services may include such services as physical therapy performed by, or under the supervision of, a professional therapist. Most nursing homes in the United States are not skilled nursing facilities that participate in Medicare. In some facilities, only certain portions participate in Medicare. DISTINCT PART OF AN INSTITUTION AS A SNF The term "distinct part" refers to a portion of an institution or institutional complex (e.g., a nursing home or a hospital) that is Medicare-certified to provide SNF and/or Nursing Facility (NF) services. A distinct part must be physically distinguishable from the larger institution and fiscally separate for cost reporting purposes. An institution or institutional complex can only be certified with one distinct part SNF and/or one distinct part NF. A hospital-based SNF is by definition a distinct part. Multiple certifications within the same institution or institutional complex are strictly prohibited. The distinct part must consist of all beds within the designated area. The distinct part can be a wing, separate building, floor, hallway or one side of a corridor. The beds in the certified distinct part area must be physically separate from (that is, not commingled with) the beds of the institution or institutional complex in which it is located. However, the distinct part need not be confined to a single location within the institution or institutional complex's physical plant. It may, for example, consist of several floors or wards in a single building or floors or wards that are located throughout several different buildings within the institutional complex. In each case, however, all residents of the distinct part would have to be located in units that are physically separate from those units housing other patients of the institution or institutional complex. Where an institution or institutional complex owns and operates a SNF and/or a NF distinct part, that SNF and/or NF distinct part is a single distinct part even if it is operated at various locations throughout the institution or institutional complex. The aggregate of the SNF and/or NF locations represents a single distinct part sub-provider, not multiple sub-providers and is assigned a single CMS Certification Number (CCN).

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SNF Care

MEDICARE PART A

SNF/Swing Bed Services Manual SNF Eligibility

Medicare Part A can help pay for a beneficiary's care in a Medicare-participating SNF if the following conditions are meet: The patient requires skilled nursing services or skilled rehabilitation services, i.e., services that must be performed by or under the supervision of professional or technical personnel: o Services are ordered by a medical professional. And, o The services are rendered for a condition for which the patient received inpatient hospital services or for a condition that arose while receiving care in a SNF for a condition for which the patient received inpatient hospital services. The condition requires daily skilled nursing or skilled rehabilitation services that, as a practical matter, can only be provided on an inpatient basis in a skilled nursing facility. o A patient whose inpatient stay is based solely on the need for skilled rehabilitation services would meet the "daily basis" requirement if the services are reasonable and necessary and received at least five days a week. The patient has been in a hospital at least three days in a row (not counting the day of discharge) before being admitted to a participating SNF. Time spent in observation status or in the emergency room prior to (or in lieu of) an inpatient admission to the hospital does not count toward the three-day qualifying inpatient hospital stay. The patient is admitted to the facility within 30 days after leaving the hospital, except in the case of transfer exceptions.

Thirty-Day Transfer

Extended care services are "post-hospital" if initiated within 30 days after discharge from a hospital stay that included at least three consecutive days of medically necessary inpatient hospital services. In determining the 30-day transfer period, the day of discharge from the hospital is not included in the 30-day period. The 30-day period begins on the day following actual discharge from the hospital and continues until the individual is admitted to a participating SNF, and requires and receives a covered level of care. Thus, an individual who is admitted to a SNF within 30 days after discharge from a hospital, but does not require a covered level of care until more than 30 days after such discharge, does not meet the 30-day requirement.

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SNF Care

MEDICARE PART A

SNF/Swing Bed Services Manual

THIRTY-DAY TRANSFER EXCEPTIONS SNF Bed Not Available The 30-day transfer requirement is waived when admission to the SNF or swing bed is delayed due to bed availability. SNF admissions that meet this criterion are billed with condition code 55. Medical Appropriateness Exception An elapsed period of more than 30 days is permitted for SNF admissions where the patient's condition makes it medically inappropriate to begin an active course of treatment in a SNF immediately after hospital discharge, and it is medically predictable at the time of the hospital discharge that he or she will require covered care within a pre-determinable time period. SNF admissions that meet this criterion are billed with condition code 56. SNF Readmission If an individual who is receiving covered post-hospital extended care, leaves a SNF and is readmitted to the same or any other participating SNF for further covered care within 30 days of the last covered skilled day, the 30-day transfer requirement is considered to be met. Thus, the period of extended care services may be interrupted briefly and then resumed, if necessary, without hospitalization preceding the readmission to a SNF. SNF admissions that meet this criterion are billed with condition code 57.

SNF Coverage

COVERED DAYS In each benefit period, Medicare Part A pays for all covered services for the first 20 days in a SNF. A daily coinsurance amount is assessed to the beneficiary from the 21st through the 100th day. SKILLED LEVEL OF CARE To be considered for Medicare Part A payment, a beneficiary must be receiving daily skilled nursing services or daily skilled rehabilitation services in a Medicare certified bed. Unless skilled care is being rendered, a beneficiary's benefit period will not be affected. The only type of nursing home care Medicare covers is SNF care. Medicare does not cover custodial care when that is the only type of care needed. CUSTODIAL CARE Custodial care is primarily for the purpose of helping the patient with daily living or meeting personal needs, and could be provided safely and reasonably by individuals without professional skills or training. For example, custodial care includes assistance with walking, getting in and out of bed, bathing, dressing, eating and taking medication.

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SNF/Swing Bed Services Manual

COVERED SERVICES Covered SNF services include: Post-hospital SNF services for which benefits are provided under Part A. Items and services (except for excluded services) furnished to a beneficiary during a Part A covered stay in a SNF for which, prior to the Prospective Payment System (PPS), payment was made under Part B. SERVICES NOT COVERED The following services are considered non-covered under the Part A benefit when a patient is in a SNF: Physician services while in a skilled nursing facility are not covered under Part A. These Part B services may be billed on the CMS-1500. Personal convenience items that are requested (such as a television in patient's room). Private duty nurse. Charges for a private room, unless determined to be medically necessary. PROVIDER SERVICES Physician services other than physical, occupational and speech-language therapy services furnished to SNF residents. These Part B services are billed separately on the Electronic Media Claims (EMC)/CMS-1500. Respiratory therapy services are included in the PPS rate except for physician's component. Section 4432(b)(4) of the Balanced Budget Act (BBA) requires bills for these particular services to include the SNFs Medicare CMS Certification Number (CCN). Therefore, the facility must provide the physician with the SNF Medicare CCN. Physician assistants not employed by the SNF, working under a physician's supervision. Nurse practitioners and clinical nurse specialists not employed by the SNF, working in collaboration with a physician. Certified nurse-midwives. Qualified psychologists. Certified registered nurse anesthetists.

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SNF Care

MEDICARE PART A

SNF/Swing Bed Services Manual SWING BED SERVICES Introduction

In order to address the shortage of rural SNF beds for Medicare patients, rural hospitals with fewer than 100 beds may be reimbursed under Medicare for furnishing posthospital extended care services to Medicare beneficiaries. Such a hospital, known as a swing bed facility, can "swing" its beds between the hospital and SNF levels of care, on an as-needed basis, if it has obtained a swing bed approval from the Department of Health and Human Services. SNF PPS applies to short-term hospitals, long-term hospitals and rehabilitation hospitals certified as swing bed hospitals. Critical Access Hospitals (CAHs) with swing beds are exempt from the SNF PPS. Post-hospital extended care services furnished in a swing bed hospital are covered under Part A of Medicare. Beneficiaries with hospital insurance coverage are entitled to have payment made on their behalf for covered extended care services furnished by the provider, by others under arrangement with the provider, or by a hospital with which the provider has a transfer agreement.

Billing

SNF/SWING BED DIFFERENCES The policies for extended care services in a swing bed are the same as a SNF. The only differences are: Type of Bill (TOB) for inpatient is 181. General billing: o When a patient remains in the swing bed unit at a skilled level of care after their SNF benefit days are exhausted, an ancillary claim can be submitted. The ancillary claim is submitted under the acute CMS Certification Number (CCN) as TOB 121. Consolidated billing: o Acute hospitals with a swing bed unit may submit a separate bill for services excluded from consolidated billing using TOB 13X with all appropriate revenue codes, HCPCS codes and line item date of service billing information, and will be paid as outpatient Part B services under the Outpatient Prospective Payment System (OPPS).

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Swing Bed Services

MEDICARE PART A

SNF/Swing Bed Services Manual SKILLED NURSING SERVICES AND SKILLED REHABILITATION SERVICES Nursing and/or Rehabilitation Services

Skilled nursing and/or skilled rehabilitation services are those services furnished based on the orders of a medical professional that: Require the skills of qualified technical or professional health personnel such as registered nurses, licensed practical (vocational) nurses, physical therapists, occupational therapists, and speech pathologists or audiologists. Must be provided directly by or under the general supervision of these skilled nursing or skilled rehabilitation personnel to assure the safety of the patient and to achieve the medically desired result.

Determining Whether a Service Is Skilled

Principles for determining whether a service is skilled include: If the inherent complexity of a service prescribed for a patient is such that it can be performed safely and/or effectively only by or under the general supervision of skilled nursing or skilled rehabilitation personnel, the service is a skilled service. Consider the nature of the service and the skills required for safe and effective delivery of that service in deciding whether a service is a skilled service. While a patient's particular medical condition is a valid factor in deciding if skilled services are needed, a patient's diagnosis or prognosis should never be the sole factor in deciding that a service is not skilled. When rehabilitation services are the primary services, the key issue is whether the skills of a therapist are needed. The deciding factor is not the patient's potential for recovery, but whether the services needed require the skills of a therapist or whether non-skilled personnel can carry out the services. A service that is ordinarily considered non-skilled could be considered a skilled service in cases in which, because of special medical complications, skilled nursing or skilled rehabilitation personnel are required to perform or supervise the service or to observe the patient. In these cases, the complications and special services involved must be documented in the physician's orders and nursing or therapy notes. In determining whether services rendered in a SNF constitute covered care, it is necessary to determine whether individual services are skilled and whether in light of the patient's total condition, skilled management of the services provided is needed even though many or all of the specific services were unskilled. The importance of a particular service to an individual patient, or the frequency, with which it must be performed, does not, by itself, make it a skilled service.

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Skilled Nursing & Skilled Rehab Services

MEDICARE PART A

SNF/Swing Bed Services Manual

The possibility of adverse effects from the improper performance of an otherwise unskilled service does not make it a skilled service unless there is documentation to support the need for skilled nursing or skilled rehabilitation personnel. Teaching and training activities that require skilled nursing or skilled rehabilitation personnel to teach a patient how to manage his treatment regimen would constitute skilled services.

Moving Out of a Medicare-Certified SNF or Distinct Part Unit

There are limited circumstances under which a resident can be involuntarily moved out of a Medicare-certified SNF or Distinct Part Unit (DPU). These circumstances can include situations in which the resident's health has improved to the point where he or she no longer needs SNF care. Once a resident of a Medicare-certified DPU ceases to require SNF care, he may then be moved from the DPU to the Medicare non-certified area of the institution.

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Skilled Nursing & Skilled Rehab Services

MEDICARE PART A

SNF/Swing Bed Services Manual MEDICAL NECESSITY

Medical necessity is defined as services that are reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member and are not excluded under provision of the Medicare program. Medicare notifies the providers of limited coverage and medical necessity on the TrailBlazer Health Enterprises® Web site. The information is posted as notices and can be found on the Local Coverage Determinations (LCD) Web page.

Definition of Limited Coverage

Coverage of certain procedures is limited by the diagnosis. Limited coverage may be the result of an NCD or LCD. Note: Providers are expected to be aware of these policies. TrailBlazer® does not have an LCD for all services/procedures. The service/procedure about which you are trying to obtain information may be covered or non-covered based on other CMS guidelines. Providers may search for National Coverage Determinations (NCDs) on the CMS Medicare Coverage Database

Reasons for Non-Coverage

Services denied by the Medicare program as not medically necessary or reasonable fall into these general categories: Experimental and investigational. Not safe and effective. Limited coverage based on certain criteria. Obsolete tests. Number of services exceeds the norm and no medical necessity demonstrated for the extra number of services.

National Coverage Determinations/Local Coverage Determinations

This section describes the NCDs disseminated from CMS national policy and the Medicare Administrative Contractor's (MAC) LCDs. NATIONAL POLICY CMS creates national policy that provides instruction and guidance on the coverage or non-coverage of medical services or supplies. NCD policy may be accessed through the CMS Web site at: http://www.cms.gov/CoverageGenInfo/.

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Medical Necessity

MEDICARE PART A

SNF/Swing Bed Services Manual

LOCAL POLICY CMS allows MACs to create local policy when the national policy is not clearly defined. LCD policy may be accessed through the TrailBlazer Web site at: http://www.trailblazerhealth.com/Tools/LCDs.aspx. Providers should always review the CMS NCDs, as well as the MAC's LCDs, for coverage limitations and claim adjudication.

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Medical Necessity

MEDICARE PART A

SNF/Swing Bed Services Manual PHYSICIAN CERTIFICATION/RECERTIFICATION General

Payment for covered post-hospital extended care services in a SNF may be made if a physician, Nurse Practitioner (NP) or Clinical Nurse Specialist (CNS) makes the required certification. In swing bed facilities only a physician can make the required certification. When services are furnished over a period of time, recertification is also required.

Obtaining Certifications

Certifications must be obtained at the time of admission, or as soon thereafter as is reasonable and practicable. The routine admission order established by a physician is not a certification of the necessity for post-hospital extended care services for purposes of the program. There must be a separate signed statement indicating that the patient will require a SNF covered level of care on a daily basis. In addition, only physicians may certify outpatient Physical Therapy (PT) and outpatient Speech-Language Pathology (SLP) services. CERTIFICATION/RECERTIFICATION FORMS There is no requirement for a specific procedure or form as long as the approach adopted by the facility permits verification that the certification and recertification requirement is met. Certification or recertification statements may be entered on or included in forms, notes or other records that a physician, NP or CNS normally signs in caring for a patient, or on a separate form. SIGNATURE A certification or recertification statement must be signed by the attending physician or a physician on the staff of the SNF who has knowledge of the case, or by a NP or CNS who does not have a direct or indirect employment relationship with the facility, but who is working in collaboration with the physician. REFUSAL TO CERTIFY If a physician, NP, or CNS refuses to certify, because in his/her opinion, the patient does not need skilled care on a continuing basis for a condition for which he/she was receiving inpatient hospital services, the services are not covered and the facility can bill the patient directly. The reason for the refusal to make the certification must be documented in the SNF's records. Except as otherwise specified, each certification and recertification is to be signed by a physician, NP or CNS.

Initial Certification

The initial certification, a prerequisite to the admission, may meet one of the following:

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Physician Certification/Recertification

MEDICARE PART A

SNF/Swing Bed Services Manual

Certify in the existing context found in 42 CFR 424.20 that the resident meets the existing SNF level of care definition. A statement that the resident's assignment to one of the upper RUG-IV (top 23) group is correct.

The first recertification must be made no later than the 14th day of inpatient extended care services. A SNF can, at its option, provide for the first recertification to be made earlier, or it can vary the timing of the first recertification within the 14-day period by diagnostic or clinical categories. Subsequent recertifications must be made at intervals not exceeding 30 days. Such recertifications may be made at shorter intervals as established by the UR committee and the SNF. At the option of the SNF, review of a stay of extended duration, pursuant to the facility's utilization review plan, may take the place of the second and any subsequent physician recertifications. The SNF should have available in its files a written description of the procedure it adopts with respect to the timing of recertifications. The procedure should specify the intervals at which recertifications are required and whether review of longstay cases by the UR committee serves as an alternative to recertification by a physician in the case of the second or subsequent recertifications. These certification statements have no correlation to requirements specifically related to the plan of treatment for therapy that is required for purposes of coverage.

Delayed Certification and Recertification

SNFs are expected to obtain timely certification and recertification statements. However, delayed certifications and recertifications will be honored where, for example, there has been an oversight or lapse. In addition to complying with the content requirements, delayed certifications and recertifications must include an explanation for the delay and any medical or other evidence which the SNF considers relevant for purposes of explaining the delay. The facility will determine the format of delayed certification and recertification statements and the method by which they are obtained. A delayed certification and recertification may appear in one statement; separately signed statements for each certification and recertification would not be required as they would if timely certification and recertification had been made.

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Physician Certification/Recertification

MEDICARE PART A

SNF/Swing Bed Services Manual SNF ADMISSION PROCEDURES Admission Guidelines

A SNF has no guarantee of payment provision. Therefore, providers should adhere to the following guidelines when admitting a beneficiary: Determine from the transferring hospital if the beneficiary has met the three-day qualifying hospital stay and if the transfer meets the 30-day transfer requirement. If a transfer agreement form is sent from the hospital, use it to determine the qualifying hospital-stay dates and entitlement to Medicare. Ascertain the beneficiary's entitlement to Part A benefits from the transferring hospital if possible. o Two self-service tools available to providers for beneficiary entitlement verification are: The Interactive Voice Response (IVR) system ­ (877) 567-9230. The Direct Data Entry (DDE) Eligibility Detail Inquiry and/or ELGA/HIQA options. Additional information can be found in the TrailBlazer DDE Claims Inquiry manual found at: http://www.trailblazerhealth.com/Publications/Training Manual/GPNet Claims Inquiries.pdf. When only Part B entitlement is available on admission, explain to the beneficiary the liability for payment. When entitlement to Medicare cannot be established from the beneficiary, representative or internal records, contact the Social Security Office (SSO). Determine if the medical appropriateness guidelines are met.

Transfer Agreement

A hospital and a SNF are considered to have a transfer agreement in effect if, by reason of a written agreement between them or (in case the two institutions are under common control) by reason of a written undertaking by the person or body which controls them, there is reasonable assurance that: Transfer of patients will be affected between the hospital and the skilled nursing facility whenever such transfer is medically appropriate as determined by the attending physician. There will be an interchange of medical and other information necessary or useful in the care and treatment of individuals transferred between the institutions, or in determining whether such individuals can be adequately cared for otherwise than in either of such institutions.

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SNF Admission Procedures

MEDICARE PART A

SNF/Swing Bed Services Manual

Same-Day Transfer

The day of admission counts as a utilization day, except in the situation where the patient was admitted with the expectation that he would remain overnight but was transferred to another participating provider before midnight of the same day. In this instance, the first provider completes the bill as follows: Indicate "0" in Covered Days. Insert condition code 40 to indicate the patient was transferred from one participating provider to another before midnight on the day of admission. Admission date and statement "from" and "through" dates are the same. No payment is made to the originating participating provider. Instead, the participating provider to which the patient was transferred counts the admission day as a utilization day that includes the day of admission and may bill the Health Insurance Prospective Payment System (HIPPS) default code. If a patient is transferred from a Medicare-participating facility to a non-participating facility, the day of admission counts as a utilization day and the Medicare-participating facility may bill the HIPPS default code. These general rules apply to transfers between SNFs and between a hospital and an SNF. However, under these same circumstances, if the two providers represent an institution composed of a participating hospital and a distinct part participating SNF, the first provider cannot bill for accommodations, but may bill for ancillary charges.

Delayed Admission Billing Requirements

TRANSFER REQUIREMENT NOT MET OR READMISSION TO SNF WITHIN 30 DAYS The following chart lists the condition codes to report if a SNF admission was delayed more than 30 days after a hospital discharge or a patient is readmitted to a SNF within 30 days of discharge from a SNF. Condition Code 55 Description SNF bed not available Explanation Code indicates the patient's SNF admission was delayed more than 30 days after hospital discharge because a SNF bed was not available.

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SNF Admission Procedures

MEDICARE PART A

SNF/Swing Bed Services Manual

Condition Code 56 Description Medical appropriateness Explanation Code indicates the patient's SNF admission was delayed more than 30 days after hospital discharge because the patient's condition made it inappropriate to begin active care within that period. Code indicates the patient was previously receiving Medicare-covered SNF care within 30 days of this readmission.

57

SNF readmission

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SNF Admission Procedures

MEDICARE PART A

SNF/Swing Bed Services Manual BENEFIT PERIOD Spell of Illness

A benefit period is a period of time for measuring the use of hospital insurance benefits. It is a period of consecutive days during which covered services furnished to a patient can be paid by the hospital insurance plan. A patient is eligible for 100 days of skilled nursing facility services during a benefit period. As long as a person continues to be entitled to hospital insurance, there is no limit on the number of benefit periods he may have. The term "benefit period" is synonymous with spell of illness.

Starting a Benefit Period

A benefit period begins the first day on which a patient is furnished inpatient hospital or SNF services (by a qualified provider) after entitlement to hospital insurance begins. A transfer from one hospital to another is not considered a discharge even if the transfer is considered a discharge under the PPS. A leave of absence is not considered a discharge from the hospital or SNF. Admission to a qualified SNF or to the SNF level of care in a swing bed hospital begins a benefit period even though payment for the services cannot be made because the prior hospitalization or transfer requirement has not been met.

Ending a Benefit Period

A benefit period ends when a beneficiary has not been an inpatient of a hospital or SNF for 60 consecutive days, or has remained an inpatient in a facility but has not been receiving skilled care. To determine the 60-consecutive-day period, begin counting with the day the individual was discharged from an inpatient hospital stay. For discharges from a SNF, begin counting the day after discharge. A benefit period cannot end while a beneficiary is an inpatient of a SNF receiving a skilled level of care. This is when the SNF is defined as a facility which is primarily engaged in providing skilled nursing care and related services to residents who require medical or nursing care, or rehabilitation services for the rehabilitation of injured, disabled or sick persons. An individual may be discharged and readmitted to a hospital or SNF several times during a benefit period and still be in the same benefit period if 60 consecutive days have not elapsed between discharge and readmission. The hospital or SNF stay does not need to be for related physical or mental conditions.

Benefit Period Examples

Example 1: Ms. Jones enters the SNF on October 20. She is discharged on January 24. She has used 20 full SNF and 76 coinsurance days of her first benefit period. Ms. Jones is not hospitalized again until July 20. Since more than 60 days elapsed between

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her hospital or SNF stays, she begins a new benefit period. Her Part A coverage is completely renewed. Example 2: Mr. Greene enters the SNF on December 15. His benefits are exhausted on March 23. His skilled level of care continues until April 10. He is at a non-skilled level of care from April 11 through April 19. On April 20, Mr. Greene's skilled level of care resumes even though benefits are exhausted because Mr. Greene's level of care is now skilled. Mr. Greene is still in his first benefit period. Mr. Greene will not begin a new benefit period until he is out of the hospital (and has not received any skilled care in a SNF for 60 consecutive days). Example 3: Mr. Smith enters the hospital on March 20. He is discharged from the hospital and admitted to the SNF for skilled level of care services on March 22. Although Mr. Smith was not hospitalized for at least three days, the benefit period for utilization purposes will still be extended as long as Mr. Smith remains at a skilled level of care.

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SNF/Swing Bed Services Manual Calculating Days in a Benefit Period

Beginning of Benefits Spell of Illness

Admission Discharge Hospital 1/10/10 1/20/10 Days used = 10 (deductible due) Swing Bed 1/20/10 Days used = 12 Hospital 2/5/10 Days used = 20 Skilled Nursing Facility (SNF) 2/25/10 Days used = 42 Hospital 4/10/10 Days used = 20 Hospital 6/10/10 Days used = 25 SNF 7/5/10 Days used = 4 Hospital 9/1/10 Days used = 20 SNF 9/21/10 Days used = 35 Hospital 10/25/10 Days used = 5 Hospital 11/1/10 Days used = 57 12/28/10 7/5/10 4/7/10 2/1/09

Full ­ Co ­ LTR Days 60 ­ 30 ­ 60

Days Reduced 50 ­ 30 ­ 60 (Remaining benefits)

Full ­ Co Days 20 ­ 80

Days Reduced

8 ­ 80 (Remaining benefits)

2/25/10

30 ­ 30 ­ 60 (Remaining benefits) 0 ­ 46 (Remaining benefits)

4/30/10

10 ­ 30 ­ 60 (Remaining benefits) 0 ­ 15 ­ 60 (Remaining benefits) 0 ­ 42 (Remaining benefits)

7/9/10

9/21/10

0 ­ 0 ­ 60 (5 days non-covered) (Remaining benefits) 0­7 (Remaining benefits)

10/25/10

10/30/10

0 ­ 0 ­ 55 (Remaining benefits) 0­0­0 (Benefits exhausted 12/26/10)

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SNF/Swing Bed Services Manual SNF PROSPECTIVE PAYMENT SYSTEM

General Provisions

Section 4432(a) of the Balanced Budget Act (BBA) of 1997 modified how payment is made for Medicare SNF services. Effective with cost reporting periods beginning on or after July 1, 1998, SNFs are no longer paid on a reasonable cost basis or through lowvolume prospectively determined rates, but rather on the basis of a Prospective Payment System (PPS). The PPS payment rates are adjusted for case mix and geographic variation in wages and cover all costs of furnishing covered SNF services (routine, ancillary and capital-related costs).

Presumption of Coverage

Under the SNF PPS, beneficiaries who are admitted (or readmitted) directly to a SNF after a qualifying hospital stay are considered to meet the level of care requirements of up to and including the assessment reference date for the five-day assessment when assigned to one of the RUGs that is designated as representing the required level of care. In general, Medicare presumes that beneficiaries admitted to a SNF immediately after a hospital stay require a skilled level of care. Therefore, Medicare has developed the presumption of coverage policy. This presumption of coverage policy applies to the Medicare stay from the date of admission to the Assessment Reference Date (ARD) of the five-day Minimum Data Set (MDS). For purposes of this presumption, the assessment reference date must occur no later than the eighth day of post-hospital SNF care. The coverage that arises from this presumption remains in effect for as long as it continues to be supported by the facts of the beneficiary's condition and SNF care needs. However, this administrative presumption does not apply to any of the subsequent assessments. A beneficiary who groups into other than one of the RUGs designated as representing the required level of care on the five-day assessment prescribed is not automatically classified as meeting or not meeting the SNF level of care definition. Instead, the beneficiary must receive an individual level of care determination using existing administrative criteria and procedures. When a beneficiary is assigned correctly to one of the top 23 RUG categories, it is believed that care provided to the beneficiary meets the skilled level of care definition. Nonetheless, there must be supportive documentation in the clinical record addressing the needs of the beneficiary and the skilled services being rendered to the beneficiary by the facility staff. When a beneficiary is assigned to one of the lower 43 categories, he is not automatically classified as meeting or not meeting the definition of skilled services. An individual level of care determination using the administrative criteria should be done.

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These criteria are also used in situations where an MDS is not available (e.g., demand bills or bills submitted at the default rate).

SNF Coverage Guidelines

Coverage determinations (i.e., level of care determinations) were significantly simplified by adopting the system for classifying residents based on resource utilization known as Resource Utilization Group Version IV (RUG-IV). SNFs utilize information from the MDS Version 3.0, Resident Assessment Instrument (RAI), to classify residents into the RUGIV groups. The MDS used by SNFs and swing bed facilities may be obtained from the CMS Web site.

CMS RAI Manual

To locate the CMS RAI manual, refer to the following screenshots of the CMS Web site (http://www.cms.gov):

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SNF/Swing Bed Services Manual Resident Assessment Instrument (RAI)

Providing care to residents with post-acute and long-term care needs is complex and challenging work. It utilizes clinical competence, observational skills, and assessment expertise from all disciplines to develop individualized care plans. The Resident Assessment Instrument (RAI) helps facility staff to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan. It also assists staff to evaluate goal achievement and revise care plans accordingly by enabling the facility to track changes in the resident's status. As the process of problem identification is integrated with sound clinical interventions, the care plan becomes each resident's unique path toward achieving or maintaining his highest practicable level of well-being. The RAI helps facility staff to look at residents holistically, as individuals for whom quality of life and quality of care are mutually significant and necessary. Interdisciplinary use of the RAI promotes this emphasis on quality of care and quality of life. Facilities have found that involving disciplines such as dietary, social work, PT, Occupational Therapy (OT), SLP, pharmacy and activities in the RAI process has fostered a more holistic approach to resident care and strengthened team communication. The long-term care RAI is a three-component document consisting of the following: MDS. o A core set of screening, clinical and functional status elements used in the assessment of all residents in Medicare- or Medicaid-certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. It was developed with certain underlying goals in mind, including: Improved resident input. Improved accuracy and reliability. Increased efficiency. Improved staff satisfaction and perception of clinical utility. The Care Area Assessment (CAA) process. o This process is designed to assist the assessor to systematically interpret the information recorded on the MDS. Once a care area has been triggered, nursing home providers use current, evidence-based clinical resources to conduct an assessment of the potential problem and determine whether to provide a care plan for it. The CAA process helps the clinician to focus on key issues identified during the assessment process so that decisions as to whether and how to intervene can be explored with the resident. Specific components of the CAA process include: Care Area Triggers (CATs) are specific resident responses for one or a combination of MDS elements. The triggers identify residents who have or

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are at risk for developing specific functional problems and require further assessment. CAA Resources is a list of resources that may be helpful in performing the assessment of a triggered care area. These resources are included in Appendix C of the RAI manual and represent neither an all-inclusive list nor government endorsement. CAA Summary (Section V of the MDS 3.0) provides a location for documentation of the care area(s) that were triggered by the MDS and the decisions made during the CAA process regarding whether to proceed to care planning. Utilization guidelines. o The utilization guidelines provide instructions for when and how to use the RAI. These include instructions for completion of the RAI as well as structured frameworks for synthesizing MDS and other clinical information. Information concerning utilization guidelines can be found at the following link: http://cms.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf.

ADDITIONAL RAI INFORMATION While MDS' primary purpose is as an assessment tool used to identify resident care problems that are addressed in an individualized care plan, data collected from MDS assessments is also used for the Medicare reimbursement system, many state Medicaid reimbursement systems, and monitoring the quality of care provided to nursing home residents. Medicare and Medicaid Payment Systems. The MDS contains items that reflect the acuity level of the resident, including diagnoses, treatments and an evaluation of the resident's functional status. The MDS is used as a data collection tool to classify Medicare residents into RUGs. The RUG classification system is used in the PPS for SNFs, hospital swing bed programs, and in many state Medicaid case- mix payment systems to group residents into similar resource usage categories for the purposes of reimbursement. Monitoring the Quality of Care. MDS assessment data is also used to monitor the quality of care in the nation's nursing homes. MDS-based Quality Indicators (QIs) and Quality Measures (QMs) were developed by researchers to assist: o State survey and certification staff in identifying potential care problems in a nursing home. o Nursing home providers with quality improvement activities/efforts. o Nursing home consumers in understanding the quality of care provided by a nursing home. o CMS with long-term quality monitoring and program planning. CMS continuously evaluates the usefulness of the QIs/QMs, which may be modified in the future to enhance their effectiveness.

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Consumer Access to Nursing Home Information. Consumers are also able to access information about every Medicare- and Medicaid-certified nursing home in the country. The Nursing Home Compare tool at http://www.medicare.gov/NHCompare provides public access to nursing home characteristics, staffing and quality of care measures for certified nursing homes.

MDS information is transmitted electronically by nursing homes to the MDS database in their respective states. MDS information from the state databases is captured in the national MDS database at CMS, which is used to determine a RUG-IV. The HIPPS rate code that appears on the claim must match the assessment that has been transmitted and accepted by the state in which the facility operates. The SNF may bill the program only after: An assessment has been completed and submitted to the state RAI database. A final validation report indicates that the assessment has been accepted by the state. And, The covered day has actually been used. SNFs that submit claims that have not completed this process will not be paid. RAI COORDINATOR Each state has an RAI coordinator who can assist and answer questions concerning the requirements for completing the RAI used by facility staff to gather resident's strengths and needs. MDS COORDINATOR Each state has designated staff to assist nursing homes, vendors and professional associations in their efforts to implement the MDS automation requirements. They may be a valuable asset in providing technical assistance and answering questions regarding the MDS system. To find the RAI and MDS coordinators in each state, providers may access: Appendix B of the CMS RAI manual link at: http://www.cms.gov/NursingHomeQualityInits/downloads/MDS30Appendix_B.pdf ASSESSMENTS FOR THE RAI Note: There is no longer a separate Swing Bed MDS Assessment manual.

OBRA-Required Tracking Records and Assessments

Omnibus Budget Reconciliation Act (OBRA)-required tracking records and assessments are federally mandated, and therefore must be performed for all residents of Medicare

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and/or Medicaid certified nursing homes. These assessments are coded on the MDS 3.0 in Item A0310A (Federal OBRA Reason for Assessment) and A0310F (Entry/Discharge reporting). They include: Entry. Death in Facility. Assessments Admission (comprehensive). Quarterly. Annual (comprehensive). Significant Change in Status Assessment (SCSA) (comprehensive). Significant Correction to Prior Comprehensive Assessment (SCPA) (comprehensive). Significant Correction Prior to Quarterly Assessment (SCQA). Discharge (return not anticipated or return anticipated). Note: The above comprehensive assessments are not required for residents in swing bed facilities. However, swing bed providers are required to complete the discharge assessments.

Medicare-Required PPS Assessments

Medicare-required PPS assessments provide information about the clinical condition of beneficiaries receiving Part A SNF-level care in order to be reimbursed under the SNF PPS for both SNFs and swing bed providers. Medicare-required PPS MDSs can be scheduled or unscheduled. These assessments are coded on the MDS 3.0 in Items A0310B (PPS Assessment) and A0310C (PPS OMRA). They include:. 5-day. 14-day. 30-day. 60-day. 90-day. Readmission/return. SCSA. SCPA. Swing Bed Clinical Change (CCA). Start of Therapy (SOT) OMRA. End of Therapy (EOT) OMRA. Both Start and End of Therapy OMRA. Change of Therapy (COT) OMRA.

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ASSESSMENT REFERENCE DATE (ARD) The ARD refers to the last day of the observation (or look-back) period that the assessment covers for the resident. The date is set by the clinical staff. The ARD must be accurately conveyed to the billing staff in order to correctly complete a UB-04 for the service period.

Grace Days

There may be situations when an assessment might be delayed (e.g., illness of RN assessor, a high volume of assessments due at approximately the same time) or additional days are needed to more fully capture therapy or other treatments. Therefore, CMS has allowed for these situations by defining a number of grace days for each Medicare assessment. For example, the Medicare-required five-day ARD can be extended one to three grace days (i.e., days 6 to 8). The use of grace days allows clinical flexibility in setting ARDs. See the chart below for the allowed grace days for each of the scheduled Medicare-required assessments. Grace days are not applied to unscheduled Medicare PPS assessments.

Medicare Short-Stay Assessment

If the beneficiary dies, is discharged from the SNF, or discharged from Part A level of care on or before the eighth day of a covered SNF stay, the resident may be a candidate for the short-stay policy. The short-stay policy allows assignment into a Rehabilitation Plus Extensive Services or Rehabilitation category when a resident received rehabilitation therapy and was not able to receive five days of therapy due to discharge from Medicare Part A. See RAI manual, Chapter 6, Section 6.4 for greater detail.

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Medicare short-stay assessment requirements (all eight must be true): Assessment requirements: 1. Must be SOT OMRA. 2. Five-day or readmission/return assessment must be completed (may be combined with SOT OMRA). ARD requirements: 3. Must be Day eight or earlier of Part A stay. 4. Must be last day of Part A stay (see Item 2400 instructions). 5. Must be no more than three days after the start of therapy. Rehabilitation requirements: 6. Must have started in last four days of Part A stay. 7. Must continue through last day of Part A stay. RUG requirement: 8. Must classify resident in a Rehabilitation Plus Extensive Services or Rehabilitation group Note: When the earliest SOT is the first-day stay, then the Part A stay must be four days or less.

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MDS Assessment Schedule

Effective for all assessments where the ARD is prior to October 1, 2011. Medicare MDS Reason for Assessment Assessment Type (A0310B code) 5-day 14-day 30-day 60-day 90-day 01 02 03 04 05 Applicable Medicare Payment Days 1­14 15­30 31­60 61­90 91­100

ARD Window Days 1­5 Days 11­14 Days 21­29 Days 50­59 Days 80­89

ARD Grace Days 6­8 15­19 30­34 60­64 90­94

Revised Schedule ­ Effective for all assessments where the ARD falls on or after October 1, 2011. Medicare MDS Reason for Assessment Assessment Type (A0310B code) 5-day 14-day 30-day 60-day 90-day 01 02 03 04 05 Applicable Medicare Payment Days 1­14 15­30 31­60 61­90 91­100

ARD Window Days 1­5 Days 13­14 Days 27­29 Days 57­59 Days 87­89

ARD Grace Days 6­8 15­18 30­33 60­63 90­93

Note: When October 1, 2011, is day 19, 34, 64 or 94 of the Medicare Part A SNF stay, assessments should be completed by September 30 or the assessments will be considered late and payment penalties will apply.

Combining Assessments

There may be instances when more than one Medicare-required assessment is due in the same time period. To reduce provider burden, CMS allows the combining of assessments. Two Medicare-required scheduled assessments may never be combined since these assessments have specific ARD windows that do not occur at the same time. However, it is possible that a Medicare-required scheduled assessment and a Medicare unscheduled assessment may be combined or that two Medicare unscheduled assessments may be combined.

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For additional information concerning the combination of assessments, please refer to the CMS RAI manual, Chapter 2.

PPS Scheduled Assessments for a Medicare Part A Stay

MEDICARE-REQUIRED FIVE-DAY SCHEDULED ASSESSMENT

ARD (Item A2300) must be set on days 1­5 of the Part A SNF covered stay. ARD may be extended up to day 8 if using the designated grace days. Must be completed (Item Z0500B) within 14 days after the ARD (ARD plus 14 days). Authorizes payment from days 1­14 of the stay, as long as the resident meets all criteria for Part A SNF-level services. Must be submitted electronically and accepted into the QIES Assessment Submission and Processing (ASAP) system within 14 days after completion (Item Z0500B) (completion plus 14 days). If combined with the OBRA admission assessment, the assessment must be completed by the end of day 14 of admission (admission date plus 13 calendar days). Is the first Medicare-required assessment to be completed when the resident is first admitted for a SNF Part A stay. Is the first Medicare-required assessment to be completed when the Part A resident is readmitted to the facility following a discharge assessment, with return not anticipated, or if the resident returns more than 30 days after a discharge assessment with return anticipated.

MEDICARE-REQUIRED 14-DAY SCHEDULED ASSESSMENT

ARD (Item A2300) must be set on days 13­14 of the Part A SNF covered stay. ARD may be extended up to day 18 if using the designated grace days. Must be completed (Item Z0500B) within 14 days after the ARD (ARD plus 14 days). Authorizes payment from days 15­30 of the stay, as long as all the coverage criteria for Part A SNF-level services continue to be met. Must be submitted electronically and accepted into the QIES ASAP system within 14 days after completion (Item Z0500B) (completion plus 14 days). If combined with the OBRA admission assessment, the assessment must be completed by the end of day 14 of admission and grace days may not be used when setting the ARD.

MEDICARE-REQUIRED 30-DAY SCHEDULED ASSESSMENT

ARD (Item A2300) must be set on days 27­29 of the Part A SNF covered stay. ARD may be extended up to day 33 if using the designated grace days.

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Must be completed (Item Z0500B) within 14 days after the ARD (ARD plus 14 days). Authorizes payment from days 31­60 of the stay, as long as all the coverage criteria for Part A SNF-level services continue to be met. Must be submitted electronically and accepted into the QIES ASAP system within 14 days after completion (Item Z0500B) (completion plus 14 days).

MEDICARE-REQUIRED 60-DAY SCHEDULED ASSESSMENT

ARD (Item A2300) must be set on days 57­59 of the Part A SNF covered stay. ARD may be extended up to day 63 if using the designated grace days. Must be completed (Item Z0500B) within 14 days after the ARD (ARD plus 14 days). Authorizes payment from days 61­90 of the stay, as long as all the coverage criteria for Part A SNF-level services continue to be met. Must be submitted electronically and accepted into the QIES ASAP system within 14 days after completion (Item Z0500B) (completion plus 14 days).

MEDICARE-REQUIRED 90-DAY SCHEDULED ASSESSMENT

ARD (Item A2300) must be set on days 87­89 of the Part A SNF covered stay. ARD may be extended up to day 93 if using the designated grace days. Must be completed (Item Z0500B) within 14 days after the ARD (ARD plus 14 days). Authorizes payment from days 91­100 of the stay, as long as all the coverage criteria for Part A SNF-level services continue to be met. Must be submitted electronically and accepted into the QIES ASAP system within 14 days after completion (Item Z0500B) (completion plus 14 days).

MEDICARE-REQUIRED READMISSION/RETURN ASSESSMENT

Completed when a resident whose SNF stay was being reimbursed by Medicare Part A is hospitalized, discharged return anticipated, and then returns to the SNF from the hospital within 30 days and continues to require and receive Part A SNF-level care services. Under these conditions, the entry tracking record completed upon return to the SNF will be coded as a re-entry with Item A1700 = 2. ARD (Item A2300) must be set on days 1­5 of the Part A SNF covered stay. ARD may be extended up to day 8 if using the designated grace days. Must be completed (Item Z0500B) within 14 days after the ARD (ARD plus 14 days). Authorizes payment from days 1­14 of the stay, as long as all the coverage criteria for Part A SNF-level services continue to be met.

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Must be submitted electronically and accepted into the QIES ASAP system within 14 days after completion (Item Z0500B) (completion plus 14 days). If combined with the OBRA admission assessment, the assessment must be completed by day 14, counting the date of admission as day 1 (admission date plus 13 calendar days).

PPS Unscheduled Assessments for a Medicare Part A Stay

UNSCHEDULED ASSESSMENTS USED FOR PPS

There are several unscheduled assessment types that may be required to be completed during a resident's Part A SNF covered stay.

Start of Therapy (SOT) OMRA

Optional. Completed only to classify a resident into a RUG-IV Rehabilitation Plus Extensive Services or Rehabilitation group. If the RUG-IV classification is not a Rehabilitation Plus Extensive Services or a Rehabilitation (therapy) group, the assessment will not be accepted by CMS and cannot be used for Medicare billing. Completed only if the resident is not already classified into a RUG-IV Rehabilitation Plus Extensive Services or Rehabilitation group. ARD (Item A2300) must be set on days 5­7 after the start of therapy (Item O0400A5 or O0400B5 or O0400C5, whichever is the earliest date) with the exception of the Short-Stay Assessment (see RAI manual, Chapter 6, Section 6.4). The date of the earliest therapy evaluation is counted as day 1 when determining the ARD for the SOT OMRA, regardless if treatment is provided or not on that day. May be combined with scheduled PPS assessments. The ARD may not precede the ARD of the first scheduled PPS assessment of the Medicare stay (five-day or readmission/return assessment). o For example, if the five-day assessment is completed on day 8 and an SOT is completed in that window, the ARD for the SOT would be day 8 as well. Must be completed (Item Z0500B) within 14 days after the ARD (ARD plus 14 days). Establishes a RUG-IV classification and Medicare payment (see RAI manual, Chapter 6, Section 6.4 for policies on determining RUG-IV payment), which begins on the day therapy started. Must be submitted electronically and accepted into the QIES ASAP system within 14 days after completion (Item Z0500B) (completion plus 14 days).

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End of Therapy (EOT) OMRA

Required when the resident was classified in a RUG-IV Rehabilitation Plus Extensive Services or Rehabilitation group and continues to need Part A SNFlevel services after the planned or unplanned discontinuation of all rehabilitation therapies for three or more consecutive days. ARD (Item A2300) must be set on day 1, 2 or 3 after all rehabilitation therapies have been discontinued for any reason (Item O0400A6 or O0400B6 or O0400C6, whichever is the latest). The last day on which therapy treatment was furnished is considered day 0 when determining the ARD for the EOT OMRA. Day 1 is the first day after the last therapy treatment was provided, whether therapy was scheduled or not scheduled for that day. For example: o If the resident was discharged from all therapy services on Tuesday, day 1 would be Wednesday. o If the resident was discharged from all therapy services on Friday, day 1 would be Saturday. o If the resident received therapy Friday, was not scheduled for therapy on Saturday or Sunday and refused therapy on Monday, day 1 would be Saturday. May be combined with any scheduled PPS assessment. In such cases, the item set for the scheduled assessment should be used. The ARD for the EOT OMRA may not precede the ARD of the first scheduled PPS assessment of the Medicare stay (five-day or readmission/return assessment). o For example: if the five-day assessment is completed on day 8 and an EOT is completed in that window, the ARD for the EOT would be day 8 as well. Must be completed (Item Z0500B) within 14 days after the ARD (ARD plus 14 days). Establishes a new non-therapy RUG classification and Medicare payment rate (Item Z0150A), which begins the day after the last day of therapy treatment, regardless of day selected for ARD. Must be submitted electronically to the QIES ASAP system and accepted into the QIES ASAP system within 14 days after completion (Item Z0500B) (completion plus 14 days). If the EOT OMRA is performed because up to three consecutive days of therapy were missed and it is determined that therapy will resume, there are three options for completion: 1. Complete only the EOT OMRA and keep the resident in a non-Rehabilitation RUG category until the next scheduled PPS assessment is completed. For example: o Mr. K was discharged from all therapy services on day 22 of his SNF stay. The EOT OMRA was performed on day 24 of his SNF stay and classified into HD1. Payment continued at HD1 until the 30-day assessment was

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completed. At that point, therapy resumed (with a new therapy evaluation) and the resident was classified into RVB. 2. In cases where therapy resumes after an EOT OMRA is performed and either five or more consecutive calendar days have passed since the last day of therapy provided, or therapy services will not resume at the same RUG-IV therapy classification level that had been in effect prior to the EOT OMRA, an SOT OMRA is required to classify the resident back into a RUG-IV therapy group, and a new therapy evaluation is required as well. For example: o Mr. G, who had been classified into RVX, did not receive therapy on Saturday and Sunday. He also missed therapy on Monday because his family came to visit, missed Tuesday due to a doctor's appointment and refused therapy on Wednesday. An EOT OMRA was performed on Monday classifying him into the ES2 non-therapy RUG. He missed five consecutive calendar days of therapy. A new therapy evaluation was completed and he resumed therapy services on Thursday. An SOT OMRA was then completed and Mr. G was placed back into the RVX therapy RUG category. o Mrs. B, who had been classified into RHC did not receive therapy on Monday, Tuesday and Wednesday because of an infection. It was determined that she would be able to start therapy again on Thursday. An EOT OMRA was completed to pay for the three days she did not have therapy with a non-therapy RUG classification of HC2. It was determined that Mrs. B would not be able to resume therapy at the same RUG-IV therapy classification, and an SOT OMRA was completed to place her into the RMB RUG-IV therapy category. A new therapy evaluation was required. 3. In cases where therapy resumes after the EOT OMRA is performed and the resumption of therapy date is no more than five consecutive calendar days after the last day of therapy provided, and the therapy services have resumed at the same RUG-IV classification level that had been in effect prior to the EOT OMRA, an End of Therapy OMRA with Resumption (EOT-R) may be completed. For example: o Mrs. A, who was in RVL, did not receive therapy on Saturday and Sunday because the facility did not provide weekend services and she missed therapy on Monday because of a doctor's appointment, but resumed therapy Tuesday. The Interdisciplinary Team (IDT) determined that her RUG-IV therapy classification level did not change as she had not had any significant clinical changes during the lapsed therapy days. An EOT-R was completed and Mrs. A was placed into ES3 for the three days she did not receive therapy. On Tuesday, Mrs. A was placed back into RVL, which was the same therapy RUG group she was in prior to the discontinuation of therapy. A new therapy evaluation was not required.

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Note: If the EOT OMRA has not been accepted in the QIES ASAP when therapy resumes, code the EOT-R items (O0450A and O0450B) on the assessment and submit the record. If the EOT OMRA without the EOT-R items has been accepted into the QIES ASAP system, then submit a modification request for that EOT OMRA, with the only changes being the completion of the EOT-R items, and check X0900E to indicate that the reason for modification is the addition of the resumption of therapy date. Note: When an EOT-R is completed, the therapy start date (O0400A5, O0400B5, and O0400C5) on the next PPS assessment is the date of the resumption of therapy on the EOT-R (O0450B). If therapy is ongoing, the therapy end date (O0400A6, O0400B6 and O0400C6) would be filled out with dashes.

Change of Therapy (COT) OMRA

Required when the resident was receiving any amount of skilled therapy services and when the intensity of therapy (as indicated by the total Reimbursable Therapy Minutes (RTM) delivered and other therapy qualifiers such as number of therapy days and disciplines providing therapy) changes to such a degree that it would no longer reflect the RUG-IV classification and payment assigned for a given SNF resident based on the most recent assessment used for Medicare payment. ARD is set for day 7 of a COT observation period. The COT observation periods are successive seven-day windows, with the first observation period beginning on the day following the ARD set for the most recent scheduled or unscheduled PPS assessment, except for an EOT-R assessment (see below). For example: o If the ARD for a patient's 30-day assessment is set for day 30 and there are no intervening assessments, then the COT observation period ends on day 37. o If the ARD for the patient's most recent COT (whether the COT was completed or not) was day 37, the next COT observation period would end on day 44. In cases where the last PPS assessment was an EOT­R, the end of the first COT observation period is day 7 after the resumption of therapy date (O0450B) on the EOT-R, rather than the ARD. For example: o If the ARD for an EOT-R is set for day 35 and the resumption date is the equivalent of day 37, then the COT observation period ends on day 43. An evaluation of the necessity for a COT OMRA (that is, an evaluation of the therapy intensity, as described above) must be completed after the COT observation period is over. The COT would be completed if the patient's therapy intensity, as described above, has changed to classify the resident into a higher or lower RUG category. For example:

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o If a facility sets the ARD for its 14-day assessment to day 14, then day 1, for purposes of the COT period, would be day 15 of the SNF stay, and the facility would be required to review the therapy services provided to the patient for the week consisting of days 15­21. The ARD for the COT OMRA would then be set for day 21 if the facility were to determine that, for example, the total RTM has changed such that the resident's RUG classification would change from that found on the 14-day assessment (assuming no intervening assessments). If the total RTM would not result in a RUG classification change and all other therapy category qualifiers have remained consistent with the patient's current RUG classification, then the COT OMRA would not be completed. If day 7 of the COT observation period falls within the ARD window of a scheduled PPS assessment, the SNF may choose to complete the PPS assessment only, resetting the COT observation period to the seven days following that scheduled PPS assessment ARD. The COT ARD may not precede the ARD of the first scheduled or unscheduled PPS assessment of the Medicare stay used to establish the patient's current RUG-IV therapy classification. Must be completed (Item Z0500B) within 14 days after the ARD (ARD plus 14 days). Establishes a new RUG-IV category. Payment begins on day 1 of that COT observation period and continues for the remainder of the current payment period, unless the payment is modified by a subsequent COT OMRA or other PPS assessment. Must be submitted electronically and accepted into the QIES ASAP system within 14 days after completion (Item Z0500B) (completion plus 14 days).

Significant Change in Status Assessment (SCSA)

Is an OBRA-required assessment. See RAI manual, Chapter 6, Section 2.6 for definition, guidelines in completion, and scheduling. May establish a new RUG-IV classification. When an SCSA for a SNF PPS resident is not combined with a PPS assessment (A0310A = 04 and A0310B = 99), the RUG-IV classification and associated payment rate begin on the ARD. For example, if an SCSA is completed with an ARD of day 20, then the RUG-IV classification begins on day 20. When the SCSA is completed with a scheduled Medicare-required assessment and grace days are not used when setting the ARD, the RUG-IV classification begins on the ARD. For example, if the SCSA is combined with the Medicarerequired 14-day scheduled assessment and the ARD is set on day 13, then the RUG-IV classification begins on day 13. When the SCSA is completed with a scheduled Medicare-required assessment and the ARD is set within the grace days, the RUG-IV classification begins on the

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first day of the payment period of the scheduled Medicare-required assessment standard payment period. For example, if the SCSA is combined with the Medicare-required 30-day scheduled assessment, which pays for days 31 to 60, and the ARD is set at day 33, then the RUG-IV classification begins on day 31.

Swing Bed Clinical Change Assessment

Is a required assessment for swing bed providers. Staff is responsible for determining whether a change (either an improvement or decline) in a patient's condition constitutes a "clinical change" in the patient's status. Is similar to the OBRA SCSA with the exceptions of the CAA process and the timing related to the OBRA admission assessment. See RAI manual, Chapter 6, Section 2.6. May establish a new RUG-IV classification. See previous "Significant Change in Status Assessment" subsection for ARD implications on the payment schedule.

Significant Correction to Prior Comprehensive Assessment

Is an OBRA-required assessment. See RAI manual, Chapter 6, Section 2.6 for definition, guidelines in completio, and scheduling. May establish a new RUG-IV classification. See previous "Significant Change in Status Assessment" subsection for ARD implications on the payment schedule.

EARLY PPS ASSESSMENT

An assessment must be completed according to the designated Medicare PPS assessment schedule. If a scheduled Medicare-required assessment or an OMRA is performed earlier than the schedule indicates (the ARD is not in the defined window), the provider will be paid at the default rate for the number of days the assessment was out of compliance. For example, a Medicare-required 14-day assessment with an ARD of day 12 (one day early) would be paid at the default rate for the first day of the payment period that begins on day 15.

LATE ASSESSMENT

The SNF must complete a late assessment if the SNF fails to set the ARD within the defined ARD window for a scheduled Medicare-required assessment (including the grace days) or an OMRA when the resident is still on Part A coverage. The ARD can be no earlier than the day the omission was identified. If the ARD on the late assessment is set prior to the end of the payment period for the Medicare-required assessment that was missed, the SNF will bill all covered days up to the ARD at the default rate and on and after the ARD at the HIPPS rate code established by the late assessment. For example, a Medicare-required 30-day assessment with an ARD of day 41 would be paid the default rate for days 31­40 and at the HIPPS classification from the assessment beginning on day 41.

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If the ARD of the late assessment is set after the end of the payment period for the Medicare-required assessment that was missed and the resident is still on Part A, the provider must still complete an assessment. The ARD can be no earlier than the day the omission was identified. The SNF must bill all covered days for that payment period at the default rate regardless of the HIPPS code calculated from the late assessment. For example, a Medicare-required 14-day assessment with an ARD of day 32 would be paid at the default rate for days 15­30. A late assessment cannot be used to replace the next regularly scheduled Medicare-required assessment. The SNF would then need to complete the 30-day Medicare-required assessment that covers days 31­60 as long as the beneficiary has SNF days remaining and is eligible for SNF Part A services.

MISSED ASSESSMENT

If the SNF fails to set the ARD prior to the end of the last day of the ARD window, including grace days, and as a result a Medicare-required assessment does not exist in the QIES ASAP for the payment period, the provider may not usually bill for days when an assessment does not exist in the QIES ASAP. When an assessment does not exist in the QIES ASAP, there is not an assessment-based RUG the provider may bill. In order to bill for Medicare SNF Part A services, the provider must submit a valid assessment that is accepted into the QIES ASAP. The provider must bill the RUG category that is verified by the system. If the resident was already discharged from Medicare Part A when this is discovered, an assessment may not be completed. However, there are instances when the SNF may bill the default code when a Medicarerequired assessment does not exist in the QIES ASAP system. These exceptions are: 1. The stay is less than eight days within a spell of illness. 2. The SNF is notified on an untimely basis of or is unaware of a Medicare Secondary Payer (MSP) denial. 3. The SNF is notified on an untimely basis of a beneficiary's enrollment in Medicare Part A. 4. The SNF is notified on an untimely basis of the revocation of a payment ban. 5. The beneficiary requests a demand bill. 6. The SNF is notified on an untimely basis or is unaware of a beneficiary's disenrollment from a Medicare Advantage plan. In situations 2­6, the provider may use the OBRA admission assessment to bill for all days of covered care associated with Medicare-required five-day and 14-day assessments, even if the beneficiary is no longer receiving therapy services that were identified under the most recent clinical assessment. The ARD of the OBRA admission assessment may be before or during the Medicare stay and does not have to fall within the ARD window of the five-day or 14-day assessment. When an OBRA admission assessment does not exist, the SNF must have a valid OBRA assessment (except a stand-alone discharge assessment) in the QIES ASAP system that falls within the ARD window of the five-day or the 14-day assessment

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(including grace days) in order to receive full payment at the RUG category in which the resident was grouped for days 1­14 or days 15­30. This assessment may only cover one payment period. If the ARD of the valid OBRA assessment falls outside the ARD window of the five-day and 14-day PPS assessments (including grace days), the SNF must bill the default code for the applicable payment period. For covered days associated with the Medicare-required 30-day, 60-day or 90-day assessments, the SNF must have a valid OBRA assessment (except a stand-alone discharge assessment) in the QIES ASAP system that falls within the ARD window of the PPS assessment (including grace days) in order to receive full payment at the RUG category in which the resident was grouped. If the ARD of the valid OBRA assessment falls outside the ARD window of the PPS assessment (including grace days), the SNF must bill the default code. Under all situations other than exceptions 1­5, the following apply when the SNF failed to set the ARD prior to the end of the last day of the ARD window (including grace days) or later and the resident was already discharged from Medicare Part A when this was discovered: If a valid OBRA assessment (except a stand-alone discharge assessment) exists in the QIES ASAP system with an ARD that is within the ARD window of the PPS assessment (including grace days), the SNF may bill the RUG category in which the resident classified. If a valid OBRA assessment (except a stand-alone discharge assessment) exists in the QIES ASAP system with an ARD that is outside the ARD window of the Medicare-required assessment (including grace days), the SNF may not bill for any days associated with the missing PPS assessment. If a valid OBRA assessment (except a stand-alone discharge assessment) does not exist in the QIES ASAP system, the SNF may not bill for any days associated with the missing PPS assessment.

ARD OUTSIDE THE MEDICARE PART A SNF BENEFIT

A SNF may not use a date outside the SNF Part A Medicare benefit (i.e., 100 days) as the ARD for a PPS assessment. For example, the resident returns to the SNF on December 11 following a hospital stay, requires and receives SNF skilled services (and meets all other required coverage criteria), and has three days left in his SNF benefit period. The SNF must set the ARD for the PPS assessment on December 11, 12 or 13 to bill for the RUG category associated with the assessment.

RUG Version IV

The MDS assessment data is used to calculate the RUG-IV classification necessary for payment. The MDS contains extensive information on the resident's nursing and therapy needs, Activities of Daily Living (ADL) impairments, cognitive status, behavioral problems and medical diagnoses. This information is used to define RUG-IV groups and form a hierarchy from the greatest to the least resources used.

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For Medicare billing purposes, there is a payment code associated with each of the 66 RUG-IV groups and each assessment applies to specific days within a resident's SNF stay. SNFs that fail to perform assessments timely are paid a default payment for the days of a patient's care for which they are not in compliance with this schedule. The RUG-IV classification system has eight major classification groups: Rehabilitation Plus Extensive Services. Rehabilitation. Extensive Services. Special Care High. Special Care Low. Clinically Complex. Behavioral Symptoms and Cognitive Performance. Reduced Physical Functioning. The eight groups, except for Extensive Services, are further divided by the intensity of the resident's ADL needs. The Special Care High, Special Care Low and Clinically Complex categories are also divided by the presence of depression. The Behavioral Symptoms and Cognitive Performance and the Reduced Physical Function categories are divided by the provision of restorative nursing services. Refer to the RAI manual for a list of detailed RUG classification category characteristics.

HIPPS Codes

Each Medicare claim contains a five-position HIPPS code for the purpose of billing Part A covered days to the Part A/B Medicare Administrative Contractor (A/B MAC). The HIPPS code consists of the RUG-IV code and the Assessment Indicator (AI).

RUG-IV Group Code

The first three positions of the HIPPS code contain the RUG-IV group code to be billed for Medicare reimbursement. The RUG-IV group is calculated from the MDS assessment clinical data. CMS edits and validates the RUG-IV group code of transmitted MDS assessments. SNFs are not permitted to submit Medicare Part A claims until the assessments have been accepted into the CMS database, and they must use the RUG-IV code as validated by CMS when bills are filed, except in cases in which the facility must bill the default code (AAA). The following RUG-IV group codes are used in the billing process.

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Rehabilitation Plus Extensive Services Rehabilitation Extensive Services Special Care High Special Care Low Clinically Complex RUX, RUL, RVX, RVL, RHX, RHL, RMX, RML, RLX RUA, RUB, RUC, RVA, RVB, RVC, RHA, RHB, RHC, RMA, RMB, RMC, RLA, RLB ES3, ES2, ES1 HE2, HE1, HD2, HD1, HC2, HC1, HB2, HB1 LE2, LE1, LD2, LD1, LC2, LC1, LB2, LB1 CE2, CE1, CD2, CD1, CC2, CC1, CB2, CB1, CA2, CA1

Behavioral Symptoms and Cognitive BB2, BB1, BA2, BA1 Performance Reduced Physical Function Default PE2, PE1, PD2, PD1, PC2, PC1, PB2, PB1, PA2, PA1 AAA

There are two different Medicare HIPPS codes that may be recorded on the MDS 3.0 in Item Z0100A (Medicare Part A HIPPS code) and Z0150A (Medicare Part A non-therapy HIPPS code). The Medicare Part A HIPPS code may consist of any RUG-IV group code. The Medicare Part A non-therapy HIPPS code is restricted to the RUG-IV group of extensive services. Which of these HIPPS codes is included on the Medicare claim depends on the specific type of assessments involved. The RUG group codes in Items Z0100A and Z0150A are validated by CMS when the assessment is submitted. If the submitted RUG code is incorrect, the validation report will include a warning giving the correct code, and the facility must use the correct code in the HIPPS code on the bill. The provider must ensure that all Medicare assessment requirements are met. When the provider fails to meet the Medicare assessment requirements, such as when the assessment is late, the provider may be required to bill the default code. In this situation, the provider is responsible for ensuring that the default codes, and not the RUG group validated by CMS in Items Z0100A and Z0150A, are billed for the applicable number of days.

AI Codes

The last two positions of the HIPPS code represent the AI, identifying the assessment type. The AI coding system indicates the different types of assessments that define different PPS payment periods and is based on the coding of Item A0310. The AI code is validated by CMS when the assessment is submitted. If the submitted AI code is incorrect on the assessment, the validation report will include a warning and

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provide the correct code. The facility must use the correct code in the HIPPS code on the bill. In situations when the provider bills the default code, such as a late assessment, the AI provided on the validation report must be used along with the default code AAA on the Medicare claim. FIRST AI DIGIT The first digit identifies scheduled PPS assessments that establish the RUG payment rate for the standard PPS scheduled payment periods. Assessment Indicator First Digit Table First Digit Values 0 1 Assessment Type (abbreviation) Unscheduled PPS assessment (unscheduled). PPS five-day or readmission return (5d or readmission). PPS 14-day (14d) PPS 30-day (30d) PPS 60-day (60d) PPS 90-day (90d) OBRA assessment (not coded as a PPS assessment)** Standard Scheduled Payment Period* Not applicable Days 1­14

2 3 4 5 6

Days 15­30 Days 31­60 Days 61­90 Days 91­100 Not applicable

*These are the payment periods that apply when only the scheduled Medicare-required assessments are completed. These are subject to change when unscheduled assessments used for PPS are completed, e.g., significant change in status or when other requirements must be met. ** In some cases, such an assessment may be used for PPS if it is later determined that qualification for Part A coverage was present at the time of the assessment. For these assessments, A0310A will be 01 to 06 and A0310B will be 99.

SECOND AI DIGIT

The second digit of the AI code identifies unscheduled assessments used for PPS. Unscheduled PPS assessments are conducted in addition to the required standard scheduled PPS assessment and include the following OBRA unscheduled assessments: Significant Change in Status Assessment (SCSA).

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Significant Correction to Comprehensive Assessment (SCPA).

Additional PPS unscheduled assessments include: Start of Therapy (SOT) Other Medicare-Required Assessment (OMRA). End of Therapy (EOT) OMRA Swing Bed Clinical Change Assessment (CCA). Change of Therapy (COT) OMRA. Unscheduled assessments may be required at any time during the resident's Part A stay. They may be completed as separate assessments or combined with other assessments. A stand-alone unscheduled assessment used for PPS will not establish the payment rate for a standard payment period. Rather, a stand-alone unscheduled assessment will modify the payment rate for all or part of a standard payment period, but only when the rate for that standard period has been established by a prior PPS scheduled assessment. For example, if a PPS 14-day scheduled assessment has established the payment rate for the standard Day 15 to Day 30 payment period, then an SCSA with an ARD on Day 20 will modify the payment rate from the ARD (Day 20) to the end of the payment period (Day 30). Special requirements apply when there are multiple assessments within one PPS scheduled assessment window. If an unscheduled PPS assessment (OMRA, SCSA, SCPA or Swing Bed CCA) is required in the assessment window (including grace days) of a scheduled PPS assessment that has not yet been completed, then facilities must combine the scheduled and unscheduled assessments by setting the ARD of the scheduled assessment for the same day that the unscheduled assessment is required. In such cases, facilities should provide the proper response to the A0310 items to indicate which assessments are being combined, as completion of the combined assessment will be taken to fulfill the requirements for both the scheduled and unscheduled assessments. A scheduled PPS assessment cannot occur after an unscheduled assessment in the assessment window ­ the scheduled assessment must be combined with the unscheduled assessment using the appropriate ARD for the unscheduled assessment. The purpose of this policy is to minimize the number of assessments required for SNF PPS payment purposes and to ensure that the assessments used for payment provide the most accurate picture of the resident's clinical condition and service needs. More details about combining PPS assessments are provided in Chapter 2 of the RAI manual and in Chapter 6, Section 30.3 of the Medicare Claims Processing Manual (CMS Pub. 100-04) available on the CMS Web site. Different types of unscheduled assessments start modifying the payment rate on different dates.

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OBRA SCSA, OBRA SCPA and Swing Bed CCA assessments begin modifying the payment rate on the ARD based on the Medicare RUG (Z0100A). The exception is when the ARD of the unscheduled assessment is a grace day of a scheduled PPS assessment. In that case, the Medicare RUG (Z0100A) calculated from the unscheduled assessment takes effect on the first day of the standard payment period for the scheduled assessment. A Start of Therapy OMRA Medicare RUG (item Z0100A) takes effect on the day therapy started. An End of Therapy OMRA Medicare Non-Therapy RUG (Z0150A) takes effect on the day after the last day of therapy provided. A Change of Therapy OMRA Medicare Therapy RUG (item Z0100A) takes effect on day 1 of the Change of Therapy observation period (see RAI manual, Chapter 2 discussion of the Change in Therapy OMRA). Day 1 of the Change of Therapy observation period is the day after the ARD of the last Medicare PPS assessment.

For additional information concerning the second AI digit, please refer to the CMS RAI manual, Chapter 6. HIPPS codes are placed in data element SV202 on the electronic 837 institutional claims transaction or in Form Locator (FL) 44 (HCPCS/rate) on a paper CMS-1450 (UB04) claim form. The associated revenue code is placed in data element SV201 or in FL 42. In certain circumstances, multiple HIPPS codes may appear on separate lines of a single claim. Both components of the HIPPS rate code must be present on a claim or the claim will be rejected. GROUPER SOFTWARE CMS provides standard software and logic for HIPPS code calculation: http://www.cms.gov/NursingHomeQualityInits/30_NHQIMDS30TechnicalInformation.asp

Adjustment Requests for Corrected Assessments

Adjustment requests based on corrected assessments must be submitted within 120 days of the service "through" date. The "through" date indicates the last day of the billing period for which the HIPPS code is billed. An edit is in place to limit the time for submitting this type of adjustment request to 120 days from the service "through" date. CMS expects that most HIPPS code corrections will be made during the course of the beneficiary's Medicare Part A stay. Therefore, providers that routinely submit corrections after the beneficiary's Part A stay has ended may be subject to focused medical review.

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Adjustment requests to change a HIPPS code may not be submitted for any claim that has already been medically reviewed. Such claims are identified in the MAC's system by an indicator on the claim record. This applies whether or not the medical review was performed either pre- or postpayment. All adjustment requests submitted are subject to medical review. For services provided on and after January 1, 2009, SNFs must submit adjustment requests with condition code D2 to reflect changes to the RUG code (i.e., the first three digits of the HIPPS code). Condition code D4 should be used for services prior to January 1, 2009.

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Medicare regulations require SNFs to follow admission practices, which include a survey for coverage by another insurer. If another insurance company is responsible for the payment of the SNF stay, the SNF will bill that insurer according to the rules of the insurance company. Medicare Secondary Payer (MSP) rules will affect the use of the SNF PPS assessment schedule and use of RUG-IV codes. The eight categories of MSP coverage are: Working aged. End Stage Renal Disease (ESRD). Auto/no fault. Liability. Workers' compensation. Disability. Federal black lung. VA benefits. Additional information can be found in the Medicare Secondary Payer manual at: http://www.trailblazerhealth.com/Publications/Training Manual/MSPManual.pdf. Assessments are conducted when: A specific time period is guaranteed by another insurer (usually by an employer group health plan), the assessment schedule begins when the primary insurer's coverage ends. The other insurer is indefinite in the amount of days to be paid. It is recommended that the SNF follow the assessment schedule from the day of admission. When the time paid by another insurer is based on dollars available on the policy or medical limitations of the policy, it is recommended (but not required) that the SNF follow the required Medicare assessment schedule during the period of coverage by another insurer to insure correct billing to Medicare if the other insurer denies payment. If the SNF does not follow the required Medicare schedule and payment is retroactively denied by the primary insurer, the SNF may use the most recent assessment that was completed in accordance with the schedule outlined in 42 CFR 483.20(b)(4) in order to receive payment under the Medicare program for those days that were denied by the secondary insurer, as long as the beneficiary meets all applicable eligibility and coverage requirements.

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SNF/Swing Bed Services Manual Billing Claims During an MSP Period

All Part A MSP claims must be submitted to the MAC to satisfy the sequential claims processing requirements prior to billing Medicare days: Bill claims with covered days and charges. Use value code 44 if payment is accepted as payment in full. SNF PPS coding must be present on the claim including HIPPS codes and ARD. Default code AAA00 may be used if no Medicare secondary payment is sought. All applicable MSP billing requirements must be met.

Billing Claims After Other Insurance Ends

Billing instructions: Part A Medicare primary claims follow the MSP period if the beneficiary continues to meet skilled level of care criteria. Begin the MDS schedule on first day that Medicare becomes primary. o First day of Medicare coverage is day 1 of the Medicare schedule. o First assessment would use the 01 modifier for Medicare billing (five-day assessment). o Use modifier 01 (five-day assessment) regardless of where the patient was in the schedule and bill for all of the days until the next assessment is scheduled. o If the primary insurance file is still "open," code the claim with occurrence code 24 and the date the other insurance company denied payment.

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UB-04 Field Requirements

The MAC makes payment to the SNF using the HIPPS rate code(s), the units of service (covered days) and the assessment reference date that is transmitted by the SNF on the UB-04. Billing requirements for revenue code (Form Locator (FL) 42): Revenue code 0022 is required on all inpatient (21X bill types). Revenue code 0120 is used to reflect the accommodations. Billing requirements for HCPCS/rate (FL 44): When billing for accommodations, code the customary charge in the FL 44. When billing revenue code 0022, code the HIPPS rate code in FL 44. Part A claims do not require HCPCS codes for ancillary services.

BILLING REQUIREMENTS FOR SERVICE DATE (FL 45):

Required field on revenue code 0022 line for reporting ARD. Effective for dates of service on or after January 1, 2011, there must be an occurrence code 50 with the Assessment Reference Date (ARD) for each assessment period represented on the claim with revenue code 0022. The date of service reported with occurrence code 50 must contain the ARD. HIPPS code AAAxx (where "xx" is varying digits) does not need an accompanying occurrence code 50. SNF providers must ensure that each HIPPS code reported on the claim is billed in the order in which that level of care is received for the month. In addition, for the following OMRA-related AIs where two HIPPS codes may be produced by one assessment, providers need only report one occurrence code 50 to cover both HIPPS codes: xxx05 xxx06 xxx12 xxx13 xxx14 xxx15 xxx16 xxx17 xxx24 xxx25 xxx26 xxx34 xxx35 xxx36 xxx44 xxx45 xxx46 xxx54 xxx55 xxx56

Billing requirements for units (FL 46): When billing accommodations, units are days. When billing HIPPS codes, units represent days covered by a specific assessment.

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When billing therapy ancillary services, units represent number of times therapy procedures were performed. When there is no specific time frame to be reported, the number one must be coded in the unit field.

Billing requirements for charges (FL 47): Required on all revenue code lines except 0022 (PPS code) and 0180 (LOA). Note: The HIPPS rate will also be saved for each HIPPS rate code. The MAC will send the claim including the HIPPS rate code(s) and rate(s), all ancillary revenue codes and the SNF's total charges reported in FL 47 to the Common Working file (CWF) for eligibility utilization information. A remittance advice (RA) will be sent to the SNF. The MAC will determine if a copay amount is due and deduct the applicable amount from the reimbursement amount calculated. The MAC will retain the original customary accommodation rate for each HIPPS rate code on the system's master claim history file for audit trail monitoring and/or adjustment bill processing.

Frequency Billing Requirements

Inpatient services in SNFs may be billed: Upon discharge of the beneficiary. When the beneficiary's benefits are exhausted. When the beneficiary's need for care changes. On a monthly basis. Providers may only submit a split bill to the MAC when a beneficiary in a SNF ceases to need active care (occurrence code 22) or the beneficiary exhausts benefit days (occurrence code A3). In cases where the facility chooses to split the claim during the month, if the appropriate occurrence code is not on the claim for the first portion of the month, the claim for the second portion of the month will be returned to the provider. Split billing requirements for fiscal year-end cost reporting purposes and calendar year do not apply to SNFs under PPS. It is necessary, however, to report the coinsurance days in each calendar year (value code 09 for first year and value code 11 for second year) on the UB-04. Note: Claims submitted for payment may not cross Medicare's fiscal year. These claims cannot span September to October; they must be split. This does not apply to nopayment claims.

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SNF/Swing Bed Services Manual Provider Liability Billing Instructions

In situations where the services rendered are not considered medically necessary and the provider fails to notify the patient prior to the services being rendered, the claim should be submitted as provider liable. The SNF must file a covered bill with the MAC using occurrence span code 77 that indicates the facility is liable for the services but any applicable copayments will be charged to the beneficiary's Part A benefit period. Furthermore, for types of bill 21X (SNF inpatient) and 18X (swing bed inpatient) the sum of all covered units reported on all revenue code 0022 lines should be equal to the covered days field less the number of provider liable days reported in the occurrence span code 77. When the SNF is liable for the Part A stay, the SNF is required to provide all necessary covered Part A services, including those services such as therapies and radiology mandated under consolidated billing. For example, if the beneficiary goes to the hospital for a non-emergency chest X-ray, the SNF will be responsible for the outpatient hospital radiology and any ambulance charges. In this case, the SNF may not charge the beneficiary or family members for any services that, in the absence of a payment sanction, would have been covered under the Part A PPS payment.

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SNF/Swing Bed Services Manual BILLING FOR A CONTINUOUS INPATIENT STAY Requirements for Submitting Claims in Sequence

CMS requires bills to be submitted in sequence for a continuous inpatient stay. The insequence requirements apply to each separate admission the beneficiary has. When a patient remains an inpatient of a SNF or swing bed for more than 30 days, providers are permitted to bill monthly. However, providers must submit their claims in sequence for each beneficiary stay. Medicare will not process a continuing stay claim until the prior bill has been processed.

Reprocessing Inpatient Bills in Sequence

When a beneficiary experiences multiple admissions (to the same or different facilities) during a benefit period, claims are processed by CWF in the same order that they are received, regardless of the dates on which expenses were incurred. This first-in/first-out method of processing requests for payment facilitates prompt handling of claims. If a SNF, any beneficiary or secondary insurer has increased liability as a result of CWF's first-in/first-out processing, the SNF must notify the Fiscal Intermediary (FI)/Medicare Administrative Contractor (MAC) to arrange reprocessing of all affected claims. This approach is not applicable if the liability stays the same, e.g., if the coinsurance or deductible amounts are applied on the second stay instead of the first, but there is no issue with regard to the effective date of supplementary coverage or if the beneficiary is responsible for payment of the first claim instead of the second. The FI/MAC will verify and cancel any bills posted out of sequence and request that any other FI/MAC involved also cancel any affected bills. The FI/MAC will reprocess all bills in the benefit period in the sequence of the beneficiary's stays to properly allocate days where payment is made in full by Medicare and to identify those days where the beneficiary is required to pay coinsurance.

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SNF Part B Items and Services

The SNF may not bill excluded services separately under Part B for its inpatients entitled to Part A benefits. They are billed separately by the rendering provider/supplier to Part B. The following services are beyond the scope of the SNF Part A benefit and excluded from SNF PPS: Diagnostic X-ray tests, diagnostic laboratory and other diagnostic tests. X-ray, radium and radioactive isotope therapy, including materials and services of technicians (revenue code 0320). Surgical dressings, splints, cast and other devices used for the reduction of fractures and dislocations (revenue code 0623). Prosthetic devices (other than dental) which replace all or part of an internal body organ (including contiguous tissue) or replace all or part of the functions of a permanently inoperative or malfunctioning internal body organ, including replacement or repair of such devices (revenue code 0274). Leg, arm, back and neck braces, trusses, artificial legs, arms and eyes, including adjustments, repairs and replacements required because of breakage, wear, loss, or change in the patient's physical condition (revenue code 027X). Outpatient PT, outpatient OT and outpatient speech-language-pathology furnished to inpatients (revenue code 0420, 0430 or 0440). Screening mammography services (revenue code 0403). Screening Pap smears (revenue code 0311) and pelvic exams (revenue code 0770). Influenza, pneumococcal pneumonia and hepatitis B vaccines (revenue code 0636). Colorectal screening (revenue code as appropriate depending on procedure/test performed). Diabetes self-management (revenue code 0942). Prostate screening (revenue codes 030X or 0770). Some ambulance services (revenue code 0540). Hemophilia clotting factors for hemophilia patients competent to use these factors without supervision) (revenue code 0636). Immunosuppressive drugs (revenue code 0636). Oral anti-cancer drugs (revenue code 0636). Oral drug prescribed for use as an acute anti-emetic used as part of an anticancer chemotherapeutic regimen (revenue code 0636). Epoetin Alfa (EPO) (revenue code 0636).

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ROUTINE SERVICES Items such as IVs, infusion and feeding pumps provided in a SNF/swing bed are considered routine care for inpatient swing bed services and Part B services in SNFs. The cost of these items under Part A is included in the SNF PPS payment or the swing bed reimbursement rate. The following types of items and services, in addition to room, dietary, medical social services and psychiatric social services, are considered routine services in a SNF/swing bed: All general nursing services, including administration of oxygen and related medications, hand feeding, incontinency care, tray service and enemas. Items that are furnished routinely and relatively uniformly to all patients (e.g., patient gowns, paper tissues, water pitchers, basins, bed pans, deodorants and mouthwashes). Items stocked at nursing stations or on the floor in gross supply and distributed or used individually in small quantities, e.g., alcohol, applicators, cotton balls, bandages and tongue depressors. Items that are used by individual patients but are reusable and expected to be available in an institution providing a SNF level of care, e.g., ice bags, bed rails, canes, crutches, walkers, wheelchairs, traction equipment and other Durable Medical Equipment (DME) that does not meet the criteria for ancillary services in a SNF/swing bed. DME, which does not meet the criteria for ancillary charges, must be classified as routine. Special dietary supplements used for tube feeding or oral feeding, such as elemental high nitrogen diet, even if written as a prescription item by a physician, because the Food and Drug Administration (FDA) has classified these supplements as a food rather than a drug. Items and services may be considered ancillary for inpatient swing bed services and for Part B services in SNFs if items and services meet the requirements of recognition of ancillary charges and meet the following requirements. The cost of these items under Part A is included in the SNF PPS payment: Direct identifiable services to individual patients. Furnished at the direction of a physician because of specific medical needs: o Not reusable ­ Artificial limbs and organs, braces, intravenous fluids or solutions, oxygen (including medications) and disposable catheters. o Represent a cost for each preparation ­ Catheters and related equipment, colostomy bags, drainage equipment, trays and tubing. Complex medical equipment ­ Ventilators, Intermittent Positive Pressure Breathing (IPPB) machines, nebulizers, suction pumps, Continuous Positive Airway Pressure (CPAP) devices and specialty beds (revenue code 0947).

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ANCILLARY/PART B SERVICES Payment may be made under Medicare Part B using TOB 22X for certain medical items and services when furnished by a participating SNF (either directly or under arrangements) to an inpatient of the SNF, if payment for these services cannot be made under Medicare Part A in any of the following situations: The beneficiary does not have Part A eligibility. The beneficiary has exhausted 100 days of inpatient SNF coverage under Part A in his current spell of illness. He is determined to be receiving a non-covered level of care. The three-day prior hospitalization or the transfer requirement is not met. TOB 221 ­ Medically necessary inpatient ancillary services may be billed when benefits are exhausted if a beneficiary is at a skilled level of care and remains in a Medicare certified bed (1819 (a)(1)), or a resident in any bed in the facility. TOB 231 ­ Non-residents (beneficiaries living in the community or in a non-certified unit of the SNF) who come to the SNF for Part B services.

CLARIFICATION OF TOB 22X AND 23X

When the institution limits its Medicare SNF participation to a distinct part SNF, and moves a beneficiary from the Medicare/Medicaid-certified distinct part SNF to a noncertified area of the institution, the beneficiary is no longer considered a resident of the SNF. Thus, it is appropriate to bill services rendered to the beneficiary as a non-resident of the SNF using TOB 23X (non-resident) as opposed to TOB 22X (resident). Note: If the patient is receiving services that will be billed using TOB 22X, the Part A claim must be submitted and complete processing before the Part B claim can be submitted.

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SNF/Swing Bed Services Manual ANNUAL WELLNESS VISIT (AWV)

Effective on or after January 1, 2011, the Affordable Care Act (ACA) allows for a preventive physical exam called the Annual Wellness Visit (AWV) and includes Personal Prevention Plan Services (PPPS). Information concerning this benefit can be found on the TrailBlazer Web site at: http://www.trailblazerhealth.com/Specialty Services/Preventive Services/default.aspx.

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SNF/Swing Bed Services Manual INFLUENZA, PNEUMOCOCCAL AND HEPATITIS B VACCINES

Medicare Part B pays 100 percent for Pneumococcal Pneumonia Vaccine (PPV) and influenza virus vaccine and their administration. Part B deductible and coinsurance do not apply for PPV and influenza virus vaccine. Medicare Part B also covers the hepatitis B vaccine and its administration. Part B deductible and coinsurance do apply for the hepatitis B vaccine.

Influenza

Typically, this vaccine is administered once a year in the fall or winter. Medicare does not require for coverage purposes that a doctor of medicine or osteopathy order the vaccine.

PPV

Typically, PPV is administered once in a lifetime. An initial PPV may be administered only to persons at high risk of pneumococcal disease. Revaccination may be administered only to persons at highest risk of serious pneumococcal infection and those likely to have a rapid decline in pneumococcal antibody levels, provided that at least five years have passed since receipt of a previous dose of pneumococcal vaccine.

Hepatitis B

The hepatitis B vaccine and its administration is covered if it is ordered by a doctor of medicine or osteopathy and is available to Medicare beneficiaries who are at high or intermediate risk of contracting hepatitis B (e.g., exposed to hepatitis B).

H1N1

Medicare Part B provides coverage for seasonal influenza virus vaccine and its administration as part of its preventive immunization services. The Influenza A (H1N1) virus has been identified as an additional type of influenza. Medicare will pay for the administration of the H1N1 vaccine. The H1N1 vaccine will be made available at no cost to providers; therefore, Medicare will not pay for the vaccine.

Billing Requirements

REVENUE CODES 0636 Vaccine (pharmacy, drugs requiring detailed coding) 0771 Administration

VACCINE HCPCS CODES

90655© 90656© 90657© Flu vaccine no preserv 6-35m Flu vaccine no preserv 3 & > Flu vaccine, 6-35 mo, im

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90658© Flu vaccine age 3 & over, im. (discontinued December 31, 2010) 90660© Flu vaccine nasal 90662© Flu vacc prsv free inc antig 90669© Pneumococcal vacc 7 val im 90670© Pneumococcal vacc 13 val im Q2035 Afluria® Q2036 Flulaval® Q2037 Fluvirin® Q2038 Fluzone® Q2039 (Not Otherwise Specified (NOS) flu vaccine The following information must be submitted: o Name of vaccine. o National Drug Code (NDC) number. o Route of administration. o Dosage. 90732© Pneumococcal vaccine 90740© HepB vacc, ill pat 3 dose im 90743© Hep B vacc, adol, 2 dose, im 90744© HepB vacc ped/adol 3 dose im 90746© Hep B vaccine, adult, im G9142 Flu vaccine (H1N1) any route of administration (HCPCS code need not be included on claim).

ADMINISTRATION HCPCS CODES The following codes are for reporting administration of the vaccines only. The administration of the vaccines is billed using: G0008 Administration of influenza virus vaccine. G0009 Administration of pneumococcal vaccine. G0010 Administration of hepatitis B vaccine. G9141 Administration of influenza (H1N1) vaccine. DIAGNOSIS One of the following diagnosis codes must be reported as appropriate: V03.82 PPV. V04.81 Influenza/H1N1. V05.3 Hepatitis B. V06.6 PPV and influenza.

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SNF/Swing Bed Services Manual PHYSICIAN CERTIFICATION/RECERTIFICATION FOR OUTPATIENT PHYSICAL THERAPY, OCCUPATIONAL THERAPY AND SPEECHLANGUAGE PATHOLOGY SERVICES Method and Disposition of Certifications

Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care. It is not appropriate for the physician/Non-Physician Practitioner (NPP) to certify a plan of care if the patient was not under the care of some physician/NPP at the time of the treatment or if the patient did not need the treatment. Since delayed certification is allowed, the date the certification is signed is important only to determine if it is timely or delayed. The certification must relate to treatment during the interval on the claim. Unless there is reason to believe the plan was not signed appropriately, or it is not timely, no further evidence that the patient was under the care of a physician/NPP and that the patient needed the care is required. The individual facility and/or practitioner determine the format of all certifications and recertifications and the method by which they are obtained. Acceptable documentation of certification may be, for example, a physician progress note, a physician/NPP order, or a plan of care that is signed and dated during the interval of treatment by a physician/NPP, and indicates the physician/NPP is aware that therapy service is or was in progress and the physician/NPP makes no record of disagreement with the plan when there is evidence the plan was sent (e.g., to the office) or is available in the record (e.g., of the institution that employs the physician/NPP) for the physician/NPP to review. The certification should be retained in the clinical record and available if requested by the MAC.

Initial Certification of Plan

The physician's/NPP's certification of the plan (with or without an order) satisfies all of the certification requirements noted in IOM Pub. 100-02, Chapter 15, Section 220.1, for the duration of the plan of care, or 90 calendar days from the date of the initial treatment, whichever is less. The initial treatment includes the evaluation that resulted in the plan.

TIMING OF INITIAL CERTIFICATION

The provider or supplier (e.g., facility, physician/NPP, or therapist) should obtain certification as soon as possible after the plan of care is established, unless the requirements of delayed certification are met. "As soon as possible" means that the physician/NPP shall certify the plan as soon as it is obtained, or within 30 days of the initial therapy treatment. Since payment may be denied if a physician does not certify the plan, the therapist should forward the plan to the physician as soon as it is

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established. Medicare may consider evidence of diligence in providing the plan to the physician during review in the event of a delayed certification. Timely certification of the first interval of treatment is met when physician/NPP certification of the plan for the first interval of treatment is documented, by signature or verbal order, and dated before the end of the interval. If the order to certify is verbal, it must be followed within 14 days by a signature to be timely. A dated notation of the order to certify the plan should be made in the patient's medical record.

Review of Plan and Recertification

Payment and coverage conditions require that the plan must be reviewed, dated and signed by a physician/NPP every 30 days to complete the certification requirements in unless delayed certification requirements are met. When therapy services are continued for longer than one month, the physician/NPP who is responsible for the patient's care at that time should review and certify the plan for each interval of therapy. It is not required that the same physician/NPP order, certify and/or recertify the plans. Recertifications that document the need for continued therapy in subsequent intervals should be signed before or during the subsequent intervals of treatment (when they are timely) or later, when they are delayed. Subsequent recertifications should be completed before or during the next interval, unless they are delayed.

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SNF/Swing Bed Services Manual PHYSICAL THERAPY, OCCUPATIONAL THERAPY AND SPEECHLANGUAGE PATHOLOGY SERVICES

The information contained in this section of the manual provides guidance for PT, OT, and SLP. Although the information in this section was disseminated from CMS in Change Request (CR) 3648, Transmittal 36, dated June 24, 2005, providers should also access TrailBlazer local policy.

Multiple Procedure Payment Reduction (MPPR) for Selected Therapy Services

Section 3134 of the ACA added Section 1848(c)(2)(K) of the Social Security Act, which specifies that the Secretary of Health and Human Services (HHS) shall identify potentially misvalued codes by examining multiple codes that are frequently billed in conjunction with furnishing a single service. As a step in implementing this provision, Medicare is applying a new Multiple Procedure Payment Reduction (MPPR) to the Practice Expense (PE) payment of select therapy services paid under the physician fee schedule. The reduction is similar to that currently applied to multiple surgical procedures and to diagnostic imaging procedures. This policy is discussed in the Calendar Year (CY) 2011 physician fee schedule proposed rule published July 13, 2010. This policy was implemented effective January 1, 2011. POLICY Many therapy services are time-based codes, i.e., multiple units may be billed for a single procedure. The MPPR is being applied to the PE payment when more than one unit or procedure is provided to the same patient on the same day, i.e., the MPPR applies to multiple units as well as multiple procedures. Full payment is made for the unit or procedure with the highest PE payment. For subsequent units and procedures furnished to the same patient on the same day, full payment is made for work and malpractice, and 80 percent payment for the PE for services furnished in office settings and other non-institutional settings (services paid under Section 1848 of the Social Security Act), and 75 percent payment for the PE for services furnished in institutional settings. For therapy services furnished by a group practice or "incident to" a physician's service, the MPPR applies to all services furnished to a patient on the same day, regardless of whether the services are provided in one therapy discipline or multiple disciplines, for example, PT, OT or SLP. The reduction applies to the HCPCS codes contained on the list of "always therapy" services that are paid under the physician fee schedule, regardless of the type of provider or supplier that furnishes the services (e.g., hospitals, home health agencies and Comprehensive Outpatient Rehabilitation Facilities (CORFs)).

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LIST OF THERAPY PROCEDURES SUBJECT TO MPPR The therapy procedures subject to the MPPR are listed below. CPT Code 92506© 92507© 92508© 92526© 92597© 92607© 92609© 96125© 97001© 97002© 97003© 97004© 97012© 97016© 97018© 97022© 97024© 97026© 97028© 97032© 97033© 97034© 97035© 97036© 97110© 97112© 97113© 97116© 97124© 97140© 97150© 97530© Short Descriptor Speech/hearing evaluation Speech/hearing therapy Speech/hearing therapy Oral function therapy Oral speech device eval Ex for speech device rx, 1hr Use of speech device service Cognitive test by hc pro Pt evaluation Pt re-evaluation Ot evaluation Ot re-evaluation Mechanical traction therapy Vasopneumatic device therapy Paraffin bath therapy Whirlpool therapy Diathermy eg, microwave Infrared therapy Ultraviolet therapy Electrical stimulation Electric current therapy Contrast bath therapy Ultrasound therapy Hydrotherapy Therapeutic exercises Neuromuscular reeducation Aquatic therapy/exercises Gait training therapy Massage therapy Manual therapy Group therapeutic procedures Therapeutic activities

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CPT Code 97533© 97535© 97537© 97542© Short Descriptor Sensory integration Self care mngment training Community/work reintegration Wheelchair mngment training

FEE SCHEDULE CHANGES

To accommodate implementation of this new policy for professional claims, the 2011 Medicare Physician Fee Schedule layout will have some additional changes. To view the fee schedule and changes, refer to: http://www.trailblazerhealth.com/Tools/Fee Schedule/MedicareFeeSchedule.aspx. The MPPR Rate File, which includes the fee amount, reduction amounts and Practice Expense (PE) for each selected therapy service is found on the CMS Web site at: http://www.cms.gov/TherapyServices/.

Physical Therapy

Physical Therapy (PT) services are those services provided within the scope of practice of physical therapists and necessary for the diagnosis and treatment of impairments, functional limitations, disabilities or changes in physical function and health status. DEFINITION OF A QUALIFIED PHYSICAL THERAPIST A qualified physical therapist for program coverage purposes is a person who is licensed as a physical therapist by the state in which he is practicing. Credentials may be found in IOM Pub. 100-02, Chapter 15, Section 230.1. SERVICES OF PHYSICAL THERAPY SUPPORT PERSONNEL A Physical Therapist Assistant (PTA) is a person who is licensed as a physical therapist assistant, if applicable, by the state in which he or she is practicing. Credentials may be found in IOM Pub. 100-02, Chapter 15, Section 230.1. The services of PTAs used when providing covered therapy benefits are included as part of the covered service. These services are billed by the supervising physical therapist. PTAs may not provide evaluation services, make clinical judgments or decisions or take responsibility for the service. They act at the direction and under the supervision of the treating physical therapist and in accordance with state laws. A physical therapist must supervise PTAs. The level and frequency of supervision differs by setting (and by state or local law). General supervision is required for PTAs in all settings except private practice (which requires direct supervision) unless state

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practice requirements are more stringent, in which case state or local requirements must be followed. The services of a PTA should not be billed as services incident to a physician/NPP's service, because they do not meet the qualifications of a therapist. The cost of supplies (e.g., Theraband, hand putty, electrodes) used in furnishing covered therapy care is included in the payment for the HCPCS codes billed by the physical therapist, and are not separately billable. Separate coverage and billing provisions apply to items that meet the definition of a brace. Services provided by aides, even if under the supervision of a therapist, are not therapy services in the outpatient setting and are not covered by Medicare. Although an aide may help the therapist by providing unskilled services, those services that are unskilled are not covered by Medicare and shall be denied as not reasonable and necessary if they are billed as therapy services.

Occupational Therapy

Occupational Therapy (OT) services are those services provided within the scope of practice of occupational therapists and necessary for the diagnosis and treatment of impairments, functional disabilities or changes in physical function and health status. OT is medically prescribed treatment concerned with improving or restoring functions, which have been impaired, by illness or injury or, where function has been permanently lost or reduced by illness or injury, to improve the individual's ability to perform those tasks required for independent functioning. Such therapy may involve: The evaluation and re-evaluation, as required, of a patient's level of function by administering diagnostic and prognostic tests. The selection and teaching of task-oriented therapeutic activities designed to restore physical function; e.g., use of woodworking activities on an inclined table to restore shoulder, elbow, and wrist range of motion lost as a result of burns. The planning, implementing and supervising of individualized therapeutic activity programs as part of an overall active treatment program for a patient with a diagnosed psychiatric illness; e.g., the use of sewing activities which require following a pattern to reduce confusion and restore reality orientation in a schizophrenic patient. The planning and implementing of therapeutic tasks and activities to restore sensory-integrative function; e.g., providing motor and tactile activities to increase sensory input and improve response for a stroke patient with functional loss resulting in a distorted body image. The teaching of compensatory techniques to improve the level of independence in the activities of daily living, such as: o Teaching a patient who has lost the use of an arm how to pare potatoes and chop vegetables with one hand.

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o Teaching an upper extremity amputee how to functionally utilize a prosthesis. o Teaching a stroke patient new techniques to enable the patient to perform feeding, dressing and other activities as independently as possible. o Teaching a patient with a hip fracture or hip replacement techniques of standing tolerance and balance to enable the patient to perform such functional activities as dressing and homemaking tasks. The design, fabrication and fitting of orthotics and self-help devices (e.g., making a hand splint for a patient with rheumatoid arthritis to maintain the hand in a functional position or constructing a device that would enable an individual to hold a utensil and feed independently). Vocational and prevocational assessment and training, subject to the limitations specified below.

Only a qualified occupational therapist has the knowledge, training and experience required to evaluate and, as necessary, re-evaluate a patient's level of function, determine whether an OT program could reasonably be expected to improve, restore or compensate for lost function and, where appropriate, recommend to the physician/NPP a plan of treatment. Credentials may be found in IOM Pub. 100-02, Chapter 15, Section 230.2. SERVICES OF OT SUPPORT PERSONNEL The services of Occupational Therapy Assistants (OTAs) used when providing covered therapy benefits are included as part of the covered service. These services are billed by the supervising occupational therapist. OTAs may not provide evaluation services, make clinical judgments or decisions or take responsibility for the service. They act at the direction and under the supervision of the treating occupational therapist and in accordance with state laws. Credentials may be found in IOM Pub. 100-02, Chapter 15, Section 230.2. An occupational therapist must supervise OTAs. The level and frequency of supervision differs by setting (and by state or local law). General supervision is required for OTAs in all settings except private practice (which requires direct supervision) unless state practice requirements are more stringent, in which case state or local requirements must be followed. See specific settings for details. For example, in clinics, rehabilitation agencies, and public health agencies, 42CFR485.713 indicates that when an OTA provides services, either on or off the organization's premises, those services are supervised by a qualified occupational therapist who makes an onsite supervisory visit at least once every 30 days or more frequently if required by state or local laws or regulation. The services of an OTA should not be billed as services incident to a physician/NPP's service, because they do not meet the qualifications of a therapist.

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The cost of supplies (e.g., looms, ceramic tiles or leather) used in furnishing covered therapy care is included in the payment for the HCPCS codes billed by the occupational therapist and are, therefore, not separately billable. Services provided by aides, even if under the supervision of a therapist, are not therapy services in the outpatient setting and are not covered by Medicare. Although an aide may help the therapist by providing unskilled services, those services that are unskilled are not covered by Medicare and shall be denied as not reasonable and necessary if they are billed as therapy services. APPLICATION OF MEDICARE GUIDELINES TO OT SERVICES OT may be required for a patient with a specific diagnosed psychiatric illness. If such services are required, they are covered assuming the coverage criteria are met. However, where an individual's motivational needs are not related to a specific diagnosed psychiatric illness, the meeting of such needs does not usually require an individualized therapeutic program. Such needs can be met through general activity programs or the efforts of other professional personnel involved in the care of the patient. Patient motivation is an appropriate and inherent function of all health disciplines, which is interwoven with other functions performed by such personnel for the patient. Accordingly, since the special skills of an occupational therapist are not required, an OT program for individuals who do not have a specific diagnosed psychiatric illness is not to be considered reasonable and necessary for the treatment of an illness or injury. Services furnished under such a program are not covered. OT may include vocational and prevocational assessment and training. When services provided by an occupational therapist are related solely to specific employment opportunities, work skills, or work settings, they are not reasonable or necessary for the diagnosis or treatment of an illness or injury and are not covered. However, an assessment of sitting and standing tolerance might be non-vocational for a mother of young children or a retired individual living alone, but could also be a vocational test for a sales clerk. Training an amputee in the use of prosthesis for telephoning is necessary for everyday activities as well as for employment purposes. Major changes in life style may be mandatory for an individual with a substantial disability. The techniques of adjustment cannot be considered exclusively vocational or non-vocational.

Speech-Language Pathology Services

Speech-Language Pathology (SLP) services are those services provided within the scope of practice of speech-language pathologists and necessary for the diagnosis and treatment of speech and language disorders, which result in communication disabilities and for the diagnosis and treatment of swallowing disorders (dysphagia), regardless of the presence of a communication disability.

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QUALIFIED SPEECH-LANGUAGE PATHOLOGIST A qualified speech-language pathologist, for program coverage purposes, must meet one of the following requirements: The education and experience requirements for a certificate of clinical competence in SLP or audiology granted by the American Speech-Language Hearing Association. The educational requirements for certification and is in the process of accumulating the supervised experience required for certification. Speech-language pathologists may not enroll and submit claims directly to Medicare. Providers such as rehabilitation agencies and Comprehensive Outpatient Rehabilitation Facilities (CORFs) may bill the services of speech-language pathologists. SERVICES OF SLP SUPPORT PERSONNEL Services of SLP assistants are not recognized for Medicare coverage. Services provided by SLP assistants, even if they are licensed to provide services in their states, will be considered unskilled services and denied as not reasonable and necessary if they are billed as therapy services. Services provided by aides, even if under the supervision of a therapist, are not therapy services and are not covered by Medicare. Although an aide may help the therapist by providing unskilled services, those services are not covered by Medicare and shall be denied as not reasonable and necessary if they are billed as therapy services. APPLICATION OF MEDICARE GUIDELINES TO SLP SERVICES Evaluation Services SLP evaluation services are covered if they are reasonable and necessary and not excluded as routine screening by Section 1862(a)(7) of the Social Security Act. The speech-language pathologist employs a variety of formal and informal speech, language, and dysphagia assessment tests to ascertain the type, causal factor(s), and severity of the speech and language or swallowing disorders. Reevaluation of patients for whom speech, language and swallowing were previously contraindicated is covered only if the patient exhibits a change in medical condition. However, monthly reevaluations; e.g., a Western Aphasia Battery, for a patient undergoing a rehabilitative SLP program, are considered a part of the treatment session and shall not be covered as a separate evaluation for billing purposes. Although hearing screening by the speech-language pathologist may be part of an evaluation, it is not billable as a separate service. Therapeutic Services The following are examples of common medical disorders and resulting communication deficits, which may necessitate active rehabilitative therapy. This list is not all-inclusive.

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Cerebrovascular disease such as cerebral vascular accidents presenting with dysphagia, aphasia/dysphasia, apraxia and dysarthria. Neurological disease such as parkinsonism or multiple sclerosis with dysarthria, dysphagia, inadequate respiratory volume/control or voice disorder. Laryngeal carcinoma requiring laryngectomy, resulting in aphonia.

Aural Rehabilitation Aural rehabilitation may be covered and medically necessary when it has been determined by a speech-language pathologist in collaboration with an audiologist that the beneficiary's current amplification options (hearing aid, other amplification device or cochlear implant) will not sufficiently meet the patient's functional communication needs. Assessment for the need for aural rehabilitation may be done by a speech language pathologist and includes evaluation of comprehension and production of language in oral, signed or written modalities, speech and voice production, listening skills, speech reading, communications strategies, and the impact of the hearing loss on the patient/client and family. Aural rehabilitation consists of treatment that focuses on comprehension, and production of language in oral, signed or written modalities; speech and voice production, auditory training, speech reading, multimodal (e.g., visual, auditory visual, and tactile) training, communication strategies, education and counseling. In determining the necessity for treatment, the beneficiary's performance in both clinical and natural environment should be considered. Dysphagia Dysphagia, or difficulty in swallowing, can cause food to enter the airway, resulting in coughing, choking, pulmonary problems, aspiration or inadequate nutrition and hydration with resultant weight loss, failure to thrive, pneumonia and death. It is most often due to complex neurological and/or structural impairments including head and neck trauma, cerebrovascular accident, neuromuscular degenerative diseases, head and neck cancer, dementias, and encephalopathies. For these reasons, it is important that only qualified professionals with specific training and experience in this disorder provide evaluation and treatment. The speech-language pathologist performs clinical and instrumental assessments and analyzes and integrates the diagnostic information to determine candidacy for intervention as well as appropriate compensations and rehabilitative therapy techniques. The equipment that is used in the examination may be fixed, mobile or portable. Professional guidelines recommend that the service be provided in a team setting with a physician/NPP who provides supervision of the radiological examination and interpretation of medical conditions revealed in it.

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Swallowing assessment and rehabilitation are highly specialized services. The professional rendering care must have education, experience and demonstrated competencies. Competencies include but are not limited to: identifying abnormal upper aerodigestive tract structure and function; conducting an oral, pharyngeal, laryngeal and respiratory function examination as it relates to the functional assessment of swallowing; recommending methods of oral intake and risk precautions; and developing a treatment plan employing appropriate compensations and therapy techniques.

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SNF/Swing Bed Services Manual FINANCIAL LIMITATION FOR THERAPY SERVICES

The BBA of 1997 required payment under a PPS for outpatient rehabilitation services. Outpatient rehabilitation services include the following services: PT (which includes outpatient SLP). OT. Section 4541(c) of the BBA required application of a financial limitation to all outpatient rehabilitation services (except those furnished by or under arrangements with a hospital). In 1999, an annual per beneficiary limit of $1,500 applied to all outpatient PT services (including SLP services). A separate limit applied to all OT services. The limit is based on incurred expenses and includes applicable deductible and coinsurance. The BBA provided that the limits be indexed by the Medicare Economic Index (MEI) each year beginning in 2002. The limitation is based on the services the Medicare beneficiary receives, not the type of practitioner who provides the service. Therefore, physical therapists, speechlanguage pathologists, occupational therapists, physicians and certain non-physician practitioners could render a therapy service. As a transitional measure, effective in 1999, providers/suppliers were instructed to keep track of the allowed incurred expenses. This process was put in place to assure providers/suppliers did not bill Medicare for patients who exceeded the annual limitations for PT or for OT services rendered by individual providers/suppliers. In 2003 and later, the limitation was applied through CMS systems.

Moratoria on Therapy Claims

Section 221 of the Balanced Budget Refinement Act (BBRA) of 1999 placed a two-year moratorium on the application of the financial limitation for claims for therapy services with dates of service January 1, 2000, through December 31, 2001. Section 421 of the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000 extended the moratorium on application of the financial limitation to claims for outpatient rehabilitation services with dates of service January 1, 2002, through December 31, 2002. Therefore, the moratorium was for a three-year period and applied to outpatient rehabilitation claims with dates of service January 1, 2000, through December 31, 2002. In 2003, there was not a moratorium on therapy caps. Implementation was delayed until September 1, 2003. Therapy caps were in effect for services rendered on September 1, 2003, through December 7, 2003. Congress re-enacted a moratorium on financial limitations on outpatient therapy services on December 8, 2003, that extended through December 31, 2005.

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Caps were implemented again on January 1, 2006, and policies were modified to allow exceptions as directed by the Deficit Reduction Act of 2005 (DRA), only for Calendar Year (CY) 2006. The Tax Relief and Health Care Act of 2006 (TRHCA) extended the cap exception process through CY 2007. The Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA) extended the cap exception process for services furnished through June 30, 2008. The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) extended the exception process from July 1, 2008, through December 31, 2009. The Temporary Extension Act of 2010 extended the exception process through March 31, 2010. Annual therapy limits: The 2008 annual limit on the amount for outpatient PT and SLP combined was $1,810; the limit for OT was $1,810. The 2009 annual limit on the amount for outpatient PT and SLP combined was $1,840; the limit for OT was $1,840. The 2010 annual limit on the amount for outpatient PT and SLP combined is $1,860; the limit for OT is $1,860. The 2011 annual limit on the amount for outpatient PT and SLP combined is $1,870; the limit for OT is $1,870. Limits apply to outpatient Part B therapy services from all settings except outpatient hospital and hospital emergency room. Medicare will apply the financial limitations to the allowed amount for therapy services for each beneficiary. The CWF tracks utilization and therapy limits. For more information regarding therapy services, please refer to TrailBlazer's "Therapy Services" LCD at: http://www.trailblazerhealth.com/Tools/LCDs.aspx.

Access to Accrued Amount

All providers may access the accrued amount of therapy services through the DDE system. For further information, please refer to the DDE Claims Inquiries manual at: http://www.trailblazerhealth.com/Publications/Training Manual/GPNet Claims Inquiries.pdf.

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SNF/Swing Bed Services Manual THERAPY EDITS Therapy Ancillary Charges

SNF PPS requires the billing of ancillary charges for residents who score in a RUG rehabilitation group. System edits have been developed to ensure that the rehabilitation RUG groups are not billed unless therapy ancillaries appear on the claim. When a HIPPS rate code of RUAxx, RUBxx, RUCxx, RULxx and/or RUXxx is present, a minimum of two rehabilitation therapy ancillary codes are required (revenue code 042X, 043X and/or 044X). When a HIPPS rate code of RHAxx, RHBxx, RHCxx, RHLxx, RHXxx, RLAxx, RLBxx, RLXxx, RMAxx, RMBxx, RMCxx, RMLxx, RMXxx, RVAxx, RVBxx, RVCxx, RVLxx and/or RVXxx is present, a minimum of one rehabilitation therapy ancillary revenue code is required (revenue code 042X, 043X or 044X. Claims that fail system edits will be returned to the provider for corrected submission.

Group Therapy Allocation

Group therapy is defined as therapy provided simultaneously for four patients (regardless of payer source) who are performing the same or similar activities. Facilities must plan group therapy sessions to include no more or less than four participants. Effective for assessments with an ARD set on or after October 1, 2011, all group time reported on the MDS will be divided by four when determining each resident's appropriate RUG classification. If one participant gets sick or refuses to participate, as long as the facility originally planned the session for four participants, then the group session can still be counted for the other group members. Note: In this case minutes will still be divided by four for each remaining participant. Unallocated group time reported on the MDS 3.0 is divided by four by the RUG-IV grouper and used for RUG classification. Example: Four residents in a SNF participate in a group session for a total of 60 minutes. Facility records 60 minutes of group therapy for each resident on each MDS. The unallocated group time is divided by four by the RUG-IV grouper. Allocated group therapy minutes (15 minutes) are then used to determine each patient's RUG classification.

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The group therapy cap (i.e., that a resident's group minutes cannot constitute more than 25 percent of their total therapy time) still applies. The cap will apply to the resident's reimbursable therapy minutes after allocation.

Documentation Requirements

SNFs must ensure that patient care follows a prescribed and documented plan of care. Relevant regulatory guidelines are found at: o Code of Federal Regulations: Section 409.23. Section 409.17(b) through (d). Documentation in the patient's medical record should be sufficient to justify plan of care and to identify potential changes in the patient's medical condition. Skilled services, particularly therapy services, should be properly tailored to the individualized goals of the patient. Medical record and plan of care should include descriptions of prescribed therapy type (individual, concurrent, group), discipline's (PT, OT, SLP) rationale for a particular therapy regimen, and who is providing the therapy (therapist or student).

Therapy Student Supervision

Effective October 1, 2011, students are no longer required to be under line-of-sight supervision. The SNF's supervising therapists are expected to exercise their own judgment regarding the level of supervision a particular student may require. Recommended skilled nursing facility therapy student supervision guidelines have been submitted to CMS by the following associations: American Physical Therapy Association (APTA). American Occupational Therapy Association (AOTA). American Speech Language Hearing Association (ASHA). The guidelines can be found on the CMS SNF PPS Web site at: https://www.cms.gov/SNFPPS/02_Spotlight.asp. When billing for supervising a student, for billing purposes the student is considered an extension of the therapist.

INDIVIDUAL THERAPY AND STUDENT SUPERVISION

Code as individual therapy when the therapist or student is treating one resident, while the other is not treating/supervising any other residents/therapists.

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CONCURRENT THERAPY AND STUDENT SUPERVISION

Code as concurrent therapy when the therapist and student are treating one resident each, while not treating/supervising any other resident/therapists. Code as concurrent therapy: If the therapist: is treating two residents while the student is not treating any residents. Or, If the student is treating two residents while the therapist is not treating any residents. The time for a group session may only be counted if the full group of four participants is being run by either the supervising therapist or the student, while the other may not be supervising any other therapists or treating residents. May Not Be Counted May Be Counted

Student treats two residents while the Supervising therapist treats four supervising therapist treats two residents, residents doing the same activity, while all doing the same activity. the student does not treat any residents.

Therapy Processing Issues

An OMRA must be completed when all therapy has ended and the patient remains at a skilled level of care for another condition. When a resident in an ultra-high therapy RUG-IV group decreases therapy, but does not end all therapy, there is no mechanism to obtain a new HIPPS code for continued billing. SNFs are permitted to code the existing HIPPS code from the last assessment until the next assessment is due. WORKAROUND FOR THERAPY EDIT At times, the resident is in an ultra-high therapy RUG-IV group and discontinues one of the therapies. The claim for the month in which the therapy is discontinued will process without a problem. However, when the claim for the next month is submitted with only one therapy revenue code, the claim will receive an edit. CMS has approved the following workaround: Enter a single line of coding to represent the therapy that has been discontinued. o 0429 for discontinued PT. o 0439 for discontinued OT. o 0449 for discontinued speech therapy. o Enter a unit of 1. o Enter charges of 0.01.

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Providers should not be using this workaround for the purpose of getting claims through the system when they have failed to do an OMRA. This workaround is only appropriate when there has been a decrease in the level of therapy services and the next regularly scheduled assessment is more than 10 days away.

Outpatient Therapy Billing Requirements

Section 4541(a)(2) of the BBA requires that claims for outpatient rehabilitation services be reported using a uniform coding system. Outpatient rehabilitation services that require HCPCS coding are outpatient PT services, outpatient SLP services and outpatient OT services. SNFs providing outpatient rehabilitation services to their inpatients who are entitled to benefits under Part A, but who have exhausted benefits for inpatient services during a spell of illness, or to their inpatients who are not entitled to benefits under Part A, are also required to report HCPCS codes.

CODING REQUIREMENTS

If more than one therapy is billed, the occurrence code 11 (FLs 31­34) (onset of symptoms/illness) should be reported only once with the date of the earliest onset. Therapy services should be billed on a monthly basis (calendar month to calendar month), not on a daily or weekly basis. The following table lists the applicable codes required when billing Medicare outpatient therapy services. Physical Therapy Occurrence codes/dates: 11 ­ Onset symptom/illness. 29 ­ Date PT plan of care was established or last reviewed. 35 ­ Date PT began. Revenue codes: 0420. HCPCS: Required. Occupational Therapy Occurrence codes/dates: 11 ­ Onset symptom/illness. 17 ­ Date OT plan of care was established or last reviewed. 44 ­ Date OT began. Revenue codes: 0430. HCPCS: Required. Speech-Language Pathology Occurrence codes/dates: 11 ­ Onset symptom/illness. 30 ­ Date SP plan of care was established or last reviewed. 45 ­ Date SP began. Revenue codes: 0440. HCPCS: Required.

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Physical Therapy Units/line item date of service: Required. Modifiers: GP ­ PT plan of treatment. Occupational Therapy Units/line item date of service: Required. Modifiers: GO ­ OT plan of treatment. Speech-Language Pathology Units/line item date of service: Required. Modifiers: GN ­ SP plan of treatment.

Note: In all cases where the EOT is completed, SNFs must submit occurrence code 16, date of last therapy, to indicate the last day of therapy services (e.g., PT, OT and SLP) for the beneficiary. HCPCS CODING REQUIREMENTS HCPCS codes include CPT-4 codes. HCPCS codes should be reported in FL 44, HCPCS/Rate field. The matching of outpatient rehabilitation HCPCS codes to revenue codes has been eliminated because many therapy services, for example PT modalities or therapy procedures described by HCPCS codes, are commonly delivered by both physical and occupational therapists. Either occupational therapists or speech-language pathologists may deliver other services. Therefore, providers should report outpatient rehabilitation HCPCS codes in conjunction with the appropriate outpatient rehabilitation revenue code based on the type of therapy plan of care for which the service is delivered.

COUNTING MINUTES FOR TIMED CODES IN 15-MINUTE UNITS

When only one service is provided in a day, providers should not bill for services performed for less than eight minutes. For any single timed CPT code in the same day measured in 15-minute units, providers bill a single 15-minute unit for treatment greater than or equal to eight minutes, through and including 22 minutes. If the duration of a single modality or procedure in a day is greater than or equal to 23 minutes, through and including 37 minutes, then two units should be billed. Time intervals for one through eight units are as follows: 1 unit > 8 minutes through 22 minutes. 2 units > 23 minutes through 37 minutes. 3 units > 38 minutes through 52 minutes. 4 units > 53 minutes through 67 minutes. 5 units > 68 minutes through 82 minutes. 6 units > 83 minutes through 97 minutes. 7 units > 98 minutes through 112 minutes. 8 units > 113 minutes through127 minutes.

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The pattern remains the same for treatment times in excess of two hours. If a service represented by a 15-minute timed code is performed in a single day for at least 15 minutes, that service will be billed for at least one unit. If the service is performed for at least 30 minutes, that service will be billed for at least two units, etc. It is not appropriate to count all minutes of treatment in a day toward the units for one code if other services were performed for more than 15 minutes. When more than one service represented by 15-minute timed codes is performed in a single day, the total number of minutes of service (as noted on the chart above) determines the number of timed units billed. If any 15-minute timed service that is performed for seven minutes or less on the same day as another 15-minute timed service that was also performed for seven minutes or less and the total time of the two is eight minutes or greater, then bill one unit for the service performed for the most minutes. This is correct because the total time is greater than the minimum time for one unit. The same logic is applied when three or more different services are provided for seven minutes or less. The expectation (based on the work values for these codes) is that a provider's direct patient contact time for each unit will average 15 minutes in length. If a provider has a consistent practice of billing less than 15 minutes for a unit, these situations should be highlighted for review.

CODING PPS BILLS FOR ANCILLARY SERVICES

When coding PPS bills for ancillary services associated with a Part A inpatient stay, the traditional revenue codes will continue to be shown (e.g., 0250 ­ Pharmacy, 042X ­ Physical Therapy) in conjunction with the appropriate entries in Service Units and Total Charges. SNFs are required to report the number of units based on the procedure or service. For therapy services (that is, revenue codes 042X, 043X and 044X), units represent the number of calendar days of therapy provided. For example, if the beneficiary received physical therapy, occupational therapy or speech-language pathology on May 1, that would be considered one calendar day and would be billed as one unit. SNFs are required to report the actual charge for each line item in Total Charges. DISCIPLINE-SPECIFIC OUTPATIENT REHABILITATION MODIFIERS Providers are required to report one of the following modifiers to distinguish the type of therapist who performed the outpatient rehabilitation service. If a therapist did not deliver the services, then the discipline of the plan of treatment/care under which the service is delivered should be reported using one of the following:

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GN ­ Service rendered under outpatient SLP plan of care. GO ­ Service rendered under outpatient OT plan of care. GP ­ Service rendered under outpatient PT plan of care.

As a transitional measure, reporting of the above modifiers is for data collection purposes and for provider tracking of the financial limitation.

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SNF/Swing Bed Services Manual LEAVE OF ABSENCE

While most beneficiaries requiring a SNF level of care find that they are unable to leave the facility, the fact that a patient may leave for a short leave of absence (e.g., for the purpose of attending a special religious service, holiday meal, family occasion, going on a car ride or for a trial visit home) is not, by itself, evidence that the individual no longer needs to be in a SNF for the receipt of required skilled care. Whenever a Medicare beneficiary is absent at midnight census-taking, the resident is considered to be on a Leave of Absence (LOA). The effect on the Medicare assessment schedule and on Medicare billing makes no distinction between an absence for medical or social reasons. No Part A benefit day is applied when the beneficiary is absent at midnight. Where frequent or prolonged periods away from the SNF become possible, the MAC may question whether the patient's care can, as a practical matter, only be furnished on an inpatient basis in a SNF. Decisions in these cases should be based on information reflecting the care needed and received by the patient while in the SNF and on the arrangements needed for the provision, if any, of this care during any absences. A conservative approach to retain the presumption for limitation of liability may lead a facility to notify patients that leaving the facility will result in denial of coverage. Such a notice is not appropriate. If the absence exceeds 30 consecutive days, the three-day prior stay and 30-day transfer requirements, as appropriate, must again be met to establish re-entitlement to SNF benefits. Where the patient does not return from a leave of absence, regardless of the reason, the SNF must submit a discharge bill showing the date of discharge as the date the individual actually left. If the patient status was reported as "30" (still patient) on an interim bill and the patient failed to return from a leave of absence within 30 days (including the day leave began) or has been admitted to another institution at any time during the leave of absence, the SNF must submit an adjustment request to correctly indicate the day the patient left as the date of discharge. (A beneficiary cannot be an inpatient in two institutions at the same time.) This closes the open admission on the patient's utilization record. The following data elements are required for reporting leave of absence: Revenue code 018X. Revenue code units and charges. Occurrence span code 74 and associated dates. Patient status code.

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The effect of LOA on benefit days and the assessment schedule includes the following: Medicare Part A benefit days are not taken. Do not code non-covered charges on LOA days. LOA days do not interrupt the assessment schedule. Outside services rendered to the SNF patient on an LOA day are not bundled to the SNF, but may be billed directly to Medicare by the entity performing the service. Claim coding: Report occurrence span code 74 and dates the patient was absent at midnight (FLs 35­36). Report days as non-covered. Report revenue code 0180 (FL 42). Report units equal to the number of days the beneficiary was gone at midnight (FL 45). Report zero (0) total charges in the Total Charge field (FL 47). Do not report charges as non-covered (FL 48). Bill existing HIPPS code for all days of the payment block not included in the LOA days. Report all ancillary charges rendered to the patient in the facility before the patient leaves on an LOA day. These ancillary services cannot be separately billed to Part B.

Bed-Hold Policy for SNFs

Medicare regulations do not include any provisions authorizing the program to make bed-hold payments. A SNF is required to inform each resident, upon admission and periodically thereafter, of services for which the resident can be charged, as well as the amount of the charges. Under the Medicare provider agreement, a SNF may charge a resident for services in excess of covered services only when the services are furnished at the resident's request. Medicare does not make bed-hold payments prior to a prospective resident's initial admission to a facility. A SNF may not accept preadmission bed-hold payments from or on behalf of a person in return for admitting that person on some specified future date for covered inpatient services. However, a SNF would be able to accept a preadmission bed-hold payment from or on behalf of a person who would clearly be denied Part A payment.

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For SNFs, the Medicare prohibition applies only to admissions or readmissions for covered inpatient services. Medicare prohibitions on preadmission payments do not apply to private pay SNF residents, or to those Medicare beneficiaries who are not Medicare eligible or do not meet the requirements for Part A SNF coverage. When temporarily leaving a SNF, a resident can choose to make bed-hold payments to the SNF, as long as the SNF's acceptance of these payments does not represent a prohibited provider practice. This means that payment to the SNF is solely for the purpose of reserving the bed during the resident's absence and does not represent a payment for the act of readmission on some future date for covered inpatient services. SNFs must inform a resident in advance of their option to made bed-hold payments, as well as the amount of the facility's charge. The facility should make clear that the resident must elect to make arrangements prior to being billed. A facility cannot simply consider a resident to have selected to make bed-hold payments and then automatically bill for them upon the resident's departure from the facility. When a Medicare eligible resident leaves a facility temporarily, it is possible to distinguish between prohibited payments made for the act of admissions or readmission itself and permissible payment made for holding a resident's bed during the resident's temporary absence as follows: Bed-hold payments are distinguishable from payments made prior to initial admission, in that the absent individual has already been admitted to the facility and established residence in a particular living space within it. Similarly, bed-hold payments are distinguishable from payment for readmission. The payment for readmission compensates the facility merely for agreeing in advance to allow a departing resident to re-enter the facility upon return. Bedhold payments represent payment to the facility for the privilege of actually maintaining the resident's personal effects in the particular living space that the resident has temporarily vacated. One indicator that post-admission payments do represent permissible bed-hold charges, related to maintaining personal effects in a particular living space, would be that the charges are calculated on the basis of a per diem bed-hold payment rate multiplied by however many days the resident is absent. This is opposed to assessing the resident a fixed sum at the time of departure from the facility.

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SNF/Swing Bed Services Manual SPECIAL BILLING SITUATIONS SNF Discharges Beneficiary or Beneficiary Dies Before Day 8 of Covered Stay

A SNF must prepare an MDS as completely as possible to assign a HIPPS rate code for Medicare payment purposes within the required assessment schedule, for a beneficiary who is discharged or dies before day 8 of the covered stay. If no MDS is completed or the MDS is submitted on an untimely basis, the claim is submitted reporting the HIPPS default rate code (AAA00) in FL 44. The HIPPS default rate is at a level that may be lower than the federal rate or transition rate paid for a beneficiary, had the SNF submitted an MDS in accordance with the prescribed assessment schedule. When the default code is reported in lieu of the completed assessment, documentation to determine coverage under the existing administrative criteria may be requested. When a beneficiary is discharged from the SNF after day 8 of a covered stay, exhausts benefits or dies, the SNF bills for up to the number of days in between the last assessment completed (either a Medicare required or an off-cycle assessment). This includes the date of discharge, date of death or date that benefits were exhausted, whichever applies, so long as the beneficiary required covered care.

Medicare Beneficiaries Enrolled in Medicare Advantage (MA) Plans

If a beneficiary chooses an MA plan as his form of Medicare, he cannot look to traditional Fee-for-Service (FFS) Medicare to pay the claim if the MA plan denies coverage. SNF providers shall apply the following policies to MA beneficiaries who are admitted to a SNF: If the SNF is non-participating with the plan, the beneficiary must be notified of his status because he may be private pay in this circumstance, depending upon the type of MA plan in which he is enrolled. If the SNF is participating with the plan, pre-approve the SNF stay with the plan. If the plan denies coverage, appeal to the plan, not to the FFS MAC. Count the number of days paid by the plan as Part A days used (this is the beneficiary's 100 days of Medicare SNF benefits). Submit a claim to the FFS MAC to subtract benefit days from the CWF records. Submit covered claims and include a HIPPS code (use default code AAA00 if no assessment was done), room and board charges, and condition code 04. Failure to send a claim to the MAC will inaccurately show days available.

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If a beneficiary no longer requires skilled care under the MA plan, the SNF may discharge the patient using patient status code 04. No-payment bills are not required for beneficiaries that are receiving non-skilled care and are enrolled in an MA plan. If the beneficiary again requires skilled care after a period of nonskilled care, the provider should begin a new admission claim for Medicare to continue the spell of illness.

Note: If the beneficiary drops his MA plan participation during his SNF stay, the beneficiary is entitled to coverage under Medicare FFS for the number of days available that remain out of the 100 days available under the SNF benefit.

PAYMENT OF SNF CLAIMS FOR BENEFICIARIES TERMINATING MA PLANS WHO HAVE NOT MET THE THREE-DAY STAY REQUIREMENT

If a beneficiary voluntarily or involuntarily disenrolls from a risk MA plan while an inpatient of an SNF and converts to original Medicare (i.e., FFS), the requirement for a three-day hospital stay will be waived if the beneficiary meets the level of care criteria found in 42 CFR 409, Subpart D, up through the effective date of disenrollment. The beneficiary will then be eligible for the number of days that remain out of the 100-day SNF benefit for that particular SNF stay minus those days that would have been covered by the program under original Medicare while the beneficiary was enrolled in the risk MA plan. However, in cases where the beneficiary disenrolls from a risk MA plan after discharge from the SNF and then is readmitted to the SNF under the 30-day rule, all requirements for original Medicare (i.e., FFS), including the three-day hospital stay, must be met. Rules regarding cost sharing apply to these cases; that is, providers may only charge beneficiaries for SNF coinsurance amounts. If the beneficiary voluntarily disenrolls from a risk MA plan and converts to original Medicare (i.e., FFS) before admission to a SNF, then the beneficiary must meet all original Medicare requirements for a SNF stay, including that of a three-day inpatient hospital stay.

Medicare Coverage Rules

Providers are reminded that Medicare will only pay for claims submitted for beneficiaries in certified SNF beds. Original Medicare coverage rules regarding the skilled level of care requirements apply; therefore, SNFs will need to assign these beneficiaries to a resource utilization group. In addition, original Medicare FFS rules regarding beneficiary cost sharing apply to these cases; consequently providers may only charge beneficiaries for SNF coinsurance amounts.

Medicare Beneficiaries in Hospice

Medicare beneficiaries enrolled in the hospice program who are admitted to the SNF for their terminal illness are not covered by the inpatient Part A SNF benefit.

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Medicare beneficiaries enrolled in hospice who are admitted to a SNF for a condition unrelated to their terminal illness are governed by PPS regulations. Providers are to apply the following: Follow the PPS assessment schedule. Bill covered claims with a valid HIPPS codes. Condition code 07 must be present on the claim.

Processing No-Payment Bills

The benefit days available to a beneficiary depends upon the status of his utilization of services during the "spell of illness." Submission of bills by providers for all stays at a skilled level of care, including those for which no payment can be made, is required to enable the MAC and CMS to maintain utilization records and determine remaining eligibility on subsequent claims. BILLS COVERING INPATIENT SERVICES Hospitals and SNFs must prepare bills covering inpatient services in situations for which no payment can be made. One bill is required for the no-payment period for which providers are liable. Submit provider-liable no-payment bills before discharge to assure that utilization chargeable and no utilization chargeable billing periods are clearly identified for record posting. A separate bill is required for the following no-payment periods for which the beneficiary is liable: If bills have been submitted for Part B inpatient services as TOB 22X, a nopayment bill is still required. This is necessary to maintain the beneficiary's utilization record. Do not send a no-payment discharge bill when the beneficiary has been notified by the MAC that the patient has Part B entitlement only. SUBMISSION OF NO-PAYMENT BILLS SNFs are required to submit a no-payment UB-04 bill for any of the following situations: No program payment can be made when the patient remains at a skilled level of care after benefits are exhausted. The beneficiary requests that a bill be submitted when the Utilization Review Committee URC) or the provider determines care to be non-covered (demand bill ­ condition code 20). The period after the date benefits were exhausted. The period beginning with the third day after a URC finding precludes further payment. The period for which payment was made by a National Institutes of Health grant, the Public Health Service, Veterans Affairs (VA) or other governmental entity. The period covered in full by Workers' Compensation (WC).

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The period covered in full by no-fault or liability insurance. The period covered in full by an Employer Group Health Plan (EGHP) for entitled individuals during a Medicare coordination period. The period covered in full by an EGHP for employed beneficiaries and spouses. The period covered in full by a Large Group Health Plan (LGHP) for active individuals under age 65 entitled to Medicare on the basis of disability. Services are not covered under Part A (e.g., when the three-day prior hospital stay or the 30-day transfer requirement is not met). A limitation of liability decision finds the beneficiary liable. For final no-payment bills when the beneficiary is admitted prior to termination of the provider agreement.

Complete all items on a no-payment bill in accordance with instructions for completing payment bills. CHARGING UTILIZATION TO THE PATIENT Submit a claim in the following situations where utilization is charged to the patient, even though no program payment can be made: The patient or his representative refuses to request that payment be made on his behalf. The physician refuses to make an otherwise required certification for a reason other than lack of medical necessity. The time limitation on filing for covered services expires before the provider files a claim for payment and is responsible for the late filing. A bill must be submitted to record utilization and applicable deductibles. The provider fails to submit needed information. The MAC has notified the provider that a limitation of liability decision finds the provider at fault. If the patient or his representative refuses to sign a request for payment, submit a bill upon discharge or death so that utilization days will be charged. The provider may bill the patient for the services. If a physician refuses to sign a certification, even though he agrees that extended care services are required, no program payment can be made, but providers should submit a bill upon discharge or date of death so that utilization days can be charged. However, the patient cannot be billed for any covered services. If needed information is not submitted, or if an adverse limitation of liability decision was made finding only the provider at fault under the limitation of liability provisions, providers are required to submit a bill upon discharge or date of death so utilization days may be charged. Do not bill the patient for Medicare services.

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Admission to a qualified SNF or to the SNF level of care affects a benefit period even though payment cannot be made because the prior hospitalization or transfer requirement has not been met. If the beneficiary is receiving a skilled level of care, but the inpatient hospital stay was less than three days, enter occurrence span code 70 and the dates of the inpatient stay in FLs 35­36. If there was no qualifying stay, do not report occurrence span code 70 on the claim. These claims should be submitted as covered claims. After the Part A claim has been rejected due to lack of a qualifying stay, the SNF may then file a TOB 22X in FL 4 for covered ancillary charges.

Benefits Exhausted

When Part A benefits are exhausted during a skilled level of inpatient care, the SNF will submit a covered bill reporting occurrence code A3, B3 or C3 (Medicare payer code) in FLs 31-34, the last date benefits were payable, the patient status code in FL 17 and appropriate covered/non-covered days. When Part A benefits are fully exhausted and the patient remains at a skilled level of inpatient care, the SNF will submit a bill with all days and charges as covered. TOB 21X with a patient status code 30 will allow the SNF to begin submitting subsequent benefits-exhausted bills. No occurrence code reflecting the last day benefits were exhausted is necessary. After the Part A claim has been rejected due to benefits exhausted, the SNF may then file a TOB 22X in FL 4 for covered ancillary charges. When benefits are exhausted and the patient remains at a skilled level of care, all SNFs (PIP and non-PIP) must submit a covered claim to Medicare to correctly extend the benefit period. No payment will be made if all 100 benefit days have been used. After benefits have exhausted and the patient is no longer receiving skilled care, if the patient remains in a bed certified for Medicare or Medicaid, a claim indicating the level of care change must be submitted.

Beneficiary No Longer Requires a Covered Level of Skilled Care

A SNF must determine if a beneficiary continues to require a covered level of care during the entire course of the stay. The SNF must issue a written notice of noncoverage at any time that it determines that the beneficiary no longer requires a covered level of care. An assessment is not required to determine non-covered status. Where the SNF fails to give the beneficiary such timely notice, the beneficiary is protected from liability until he receives this notice. The SNF is entitled to program payment only through the date on which it gave notice.

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If the skilled level of care has ended and the patient is transferred to a bed not certified for Medicare or Medicaid in the same or different facility, the provider will file a discharge claim with patient status code of 70. If the skilled level of care has ended and the patient remains in a Medicare or Medicaid certified bed, the provider will file the claim with a patient status code of 30 (still a patient) and an occurrence code 22 (date active care ended). A single discharge claim is all that is required from the first day of non-coverage until the date of discharge. Note: A final no-pay bill must be submitted if the beneficiary is discharged, transferred back to skilled level of care or dies. Failure to submit discharge bills creates an artificial gap in service on the CWF and establishes a new benefit period inappropriately. Intentional failure to submit discharge bills for the purpose of creating a new benefit period is fraud.

Demand Bills (Condition Code 20)

A demand bill is submitted with a condition code 20 indicating the beneficiary has requested a medical determination from Medicare that the services are non-covered. Note: Demand bills (condition code 20) are not acceptable when benefits have exhausted, the patient does not meet the qualifying hospital stay requirement or the physician has discontinued the order for skilled care. A HIPPS rate code must be present on the demand bill; the default code AAA00 can be used in the absence of a valid MDS. Claims submitted with condition code 20 will generate an Additional Development Request (ADR) to the provider. The ADR should be returned with the notice of non-coverage issued to the patient, the medical documentation for the services rendered during the time in question, and a copy of the MDS. The MAC will review the documentation and advise the SNF and the beneficiary of its decision. Until a decision is made, the facility may only bill the beneficiary for charges normally non-covered by Medicare. When disposition of the demand bill has been completed, and if the demand bill is approved, it will be paid based on the HIPPS code submitted on the demand bill.

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If it is determined the services rendered were not skilled services, the demand bill will be denied. If the beneficiary disagrees with the denial of the demand bill, the beneficiary can appeal the determination. Claim coding for demand bills: TOB 210 (FL 4). Non-covered days. Condition code 20 (FLs 18­28). Non-covered charge field (FL 48) reports charges as non-covered.

Billing for Denial Notice (Condition Code 21)

A facility that is requesting a denial notice for Medicaid or other insurer can submit a non-covered claim to Medicare for a denial notification. Claim coding for denial notices: TOB 210 (FL 4). Non-covered days. Condition code 21 (FLs 18­28). Non-covered charge field (FL 48) reports charges as non-covered. This is not a request for a medical determination. Condition code 21 is applicable for all bill types (both inpatient and outpatient). For inpatient bills, report occurrence span code 76 and the non-covered dates of service on the bill along with occurrence span code 70 and the qualifying inpatient hospital stay dates.

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SNF/Swing Bed Services Manual SNF NOTIFICATIONS Prepayment From the Beneficiary

SNF REGULATIONS A SNF may not require a beneficiary to pay a deposit as a condition of admission unless it is clear that Medicare will not cover the stay. If the provider believes that a beneficiary's stay will not be covered, but the beneficiary disagrees and asks the provider to submit a demand bill (condition code 20), the SNF may not charge a deposit for the stay until it has been determined that the stay is not covered. The SNF may require prepayment of non-covered services, if this is its practice with non-Medicare patients. However, it may not require the Medicare patient to request non-covered services as a condition of admission. Medicare regulations contain several other special limitations that are implications of the provider agreement. These include a prohibition against: Evicting or threatening to evict a beneficiary for inability to pay a deductible or coinsurance amount required under Medicare. Charging a beneficiary for an agreement to readmit him for inpatient services covered by Medicare (as distinguished from holding a bed for him). Charging a beneficiary for failure to remain in the facility for a certain period of time or for failure to give advance notice of departure. APPROPRIATE REFUNDS Appropriate refunds must be made where any advance payment made by a patient after admission toward the coinsurance or toward non-covered service is greater than the amount due for the coinsurance or non-covered services furnished. Funds advanced by a patient may not be retained by the SNF as damages for the patient's failure to remain in the facility for any agreed upon length of time or for failure to give advance notice of the date he will leave the facility.

Skilled Nursing Denial Letters

If SNFs are aware that the services to be furnished to a patient are not covered under Part A, they must advise the patient (or representative) in writing prior to, or at admission (or when the type of care changes during a stay) that the care is non-covered and why. Also, no claim for Medicare reimbursement is being submitted. The written notice should be clear and state that the beneficiary has the right to request that a claim be filed for Medicare benefits if he believes a covered level of service is required. The written notice could state: "We are placing you in a part of this facility that is not appropriately certified by Medicare because (state any reasons for the noncertified bed placement here). However, you (or someone acting on your behalf) may

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request us to file a claim for Medicare benefits. Based on this claim, Medicare will make a formal determination and advise whether any benefits are payable to you." SNFs are required to issue a liability notice before extended care item(s) and/or service(s) are initiated, reduced or terminated and Medicare is not expected to pay. SNFs may use either the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) or one of the five SNF denial letters. These notices can be found at: http://www.cms.gov/BNI/04_FFSSNFABNandSNFDenialLetters.asp. A SNF should issue a written notice to the beneficiary if the services are expected to be denied as "not reasonable or necessary" ("medical necessity") under Section 1862(a)(1) of the Social Security Act, or "custodial care" under Section 1862(a)(9) if the extended care service or item is not a Medicare benefit (e.g., personal comfort items excluded under Section 1862(a)(6)).

SNF Notice of Exclusion From Medicare Benefits (NEMB)

It is not appropriate to issue the SNFABN or one of the denial letters when the reason for non-coverage is not based on medical necessity. Instead, the SNF NEMB should be issued for: No qualifying three-day inpatient hospital stay. No days left in this benefit period. Care not ordered or certified by a physician. Daily skilled care not needed. SNF transfer requirement not met. Facility/bed not certified by Medicare. Care not given by, nor supervised by, skilled nursing or rehabilitation staff. Items or services not furnished under arrangements by the SNF. The SNF NEMB can be found on the CMS Web site at: http://www.cms.gov/BNI/13_FFS NEMB SNF.asp.

Advance Beneficiary Notice of Noncoverage (CMS-R-131)

When a SNF determines that the services are to be furnished to a patient under Part B, it must advise the patient (or representative) in writing prior to the services being rendered by issuing CMS-R-131. Information regarding this notice can be found the Advance Beneficiary Notice of Noncoverage manual available at: http://www.trailblazerhealth.com/Publications/Training Manual/abn.pdf.

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SNF/Swing Bed Services Manual Expedited Review Process for Disputed Terminations of MedicareCovered Services

Section 1869(b)(1)(F) of the Social Security Act, as amended by Section 521 of the BIPA, Public Law 106-554, requires SNFs, home health agencies, comprehensive outpatient rehabilitation facilities and hospice agencies to issue expedited review notices to beneficiaries when covered SNF services are ending. The provider is responsible for delivering the generic notice to all beneficiaries no later than two days before their covered services end. The beneficiary (or authorized representative) is responsible for acknowledging receipt of the generic notice and for contacting the Quality Improvement Organization (QIO) by noon the day after the notice is issued. If the beneficiary requests a review, the SNF is responsible for issuing the detailed notice to the beneficiary by the close of business on the same day that the QIO notifies the provider that the beneficiary has requested an expedited review. The QIO is responsible for conducting the review and making a decision no later than 72 hours after receipt of the beneficiary's request.

Generic Notice

The Generic Notice is a short and straightforward notice that simply informs the beneficiary of the date that coverage of services is going to end and describes what should be done if the beneficiary wants the decision to be reviewed or if the beneficiary needs more information about the decision. CMS has designed the Generic Notice so that its delivery is as simple as possible for the provider. WHEN TO DELIVER THE GENERIC NOTICE Generally, the provider is responsible for delivering the Generic Notice no later than two days before covered services will end. If services are expected to last less than two days, the Generic Notice should be delivered upon admission. If there is more than a two-day span between services (e.g., in the home health setting), the Generic Notice should be issued the next to last time services are furnished. HOW TO DELIVER THE GENERIC NOTICE To ensure valid delivery of the Generic Notice, the provider must provide the completed notice to the beneficiary (or authorized representative) so that the beneficiary can sign and date the notice. If the beneficiary refuses to sign the notice, the provider must make a notation on the Generic Notice that the beneficiary was provided with the notice but did not sign it. An authorized representative may be notified by telephone if personal delivery is not immediately available. In this case, the authorized representative must be informed of the content of the notice, and the provider must document the call and then mail the notice to the representative. Providers that deliver the Generic Notice must insert the following patient-specific information:

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The beneficiary's name and Medicare number. The date that coverage of services ends.

The Generic Notice also should identify the appropriate QIO. It also includes space for additional information as necessary or required.

Expedited Review Process and the Detailed Notice

If the beneficiary decides to appeal the provider's decision that Medicare coverage should end, he must contact the QIO by no later than noon of the day before services are to end (as indicated in the Generic Notice) to request a review. The QIO will inform the provider of the request for a review. The provider is responsible for providing the QIO and the beneficiary with a detailed explanation of why coverage is ending. The provider may need to present additional information to the QIO for the QIO to use in making a decision. Based on the time frames associated with the expedited review process, the QIO decision should take place 72 hours after receipt of the beneficiary's request for a review. IMPORTANCE OF TIMING AND NEED FOR FLEXIBILITY Although the regulations and accompanying instructions do not require action until two days before the planned termination of covered services, the Generic Notice may be given as soon as the provider can reasonably determine the discharge date. This will provide beneficiaries with more time to consider their options, including whether to pursue an expedited review of the decision. This also would allow more time for the review process to occur while Medicare coverage is still in place. Similarly, SNF providers may want to consider how they can assist patients who wish to be discharged in the evening or on weekends in the event that they receive an unfavorable decision from the QIO review process and want to minimize any additional liability. Tasks such as ensuring that arrangements for follow-up care are in place, scheduling equipment to be delivered (if needed), and writing orders or instructions can be done in advance to facilitate a more efficient discharge. Providers are strongly encouraged to structure their notice delivery and discharge patterns to make the process work as smoothly as possible. CMS intends to continue to work together with all involved parties to identify problems, publicize best practices and implement needed refinements to these procedures and welcomes all suggestions for fine-tuning the expedited review process. PLACEMENT IN A NON-CERTIFIED BED Payment for SNF claims may not be denied solely on the basis of a beneficiary's placement in a non-certified bed of a participating SNF. When requested by the beneficiary or his representative, a SNF will submit a claim for services rendered in a non-certified bed. When a claim is reviewed for services rendered in a non-certified bed, a determination is made on whether the beneficiary consented to the placement. If the beneficiary consented, the claim is denied. If the beneficiary did not consent, it is

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determined whether there are any other reasons for denying the claim. If there is another basis for denying the claim, it is denied. However, if none of the reasons for denial exist, beneficiary liability is waived and a further determination is made as to whether the SNF, rather than the Medicare program, must accept liability for the services in question. DETERMINING BENEFICIARY CONSENT The SNF may submit evidence to rebut the presumption that the beneficiary did not consent to placement in a non-certified bed. However, under this policy, beneficiaries are still not viewed as having given their consent to placement in a non-certified bed if their consent is based on erroneous or incomplete information. A beneficiary may knowingly and voluntarily consent to placement in a non-certified bed for either of several reasons, such as: Only requires a short stay. Wishes to be placed in a facility that is near a close relative. Believes the care is being paid for by a third-party payer (other than Medicare). For any other reason. In these situations, Medicare payment is not made, even though the beneficiary may have needed and received an otherwise covered level of care. CONSENT STATEMENT LANGUAGE To be considered valid, the consent statement must include language to the effect that the beneficiary understands that his voluntary placement in a non-certified portion of a facility disqualifies the beneficiary from eligibility for Medicare payments for services received while in the non-certified bed. The statement must assert that the beneficiary's consent to being placed in a non-certified bed is voluntary. The consent statement must be signed by the beneficiary (provided he is competent to give such consent) or by the beneficiary's legal representative and must be accompanied by a physician's statement attesting to the beneficiary's competence or incompetence. If any of these requirements are not met, a consent statement is automatically determined to be invalid. DETERMINING THE DATE OF NOTICE OF NON-COVERAGE In determining when the beneficiary received knowledge of non-coverage, the date of the written notice is used when the beneficiary is an inpatient and is capable of handling his own affairs (e.g., able to sign and negotiate checks). When direct phone contact cannot be made, the provider should send the notice to the representative by certified mail and request a return receipt. The date that someone at the representative's address signs (or refuses to sign) for the notice is the date of receipt.

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NOTIFICATION DATES If a MAC notifies the provider of non-coverage, use the date indicated in the letter. When the provider is notified of non-coverage by a URC, the MAC uses the notice date reported on the UB-04 (occurrence code 22/date), unless there is evidence of an earlier notification. When the provider determines that covered care is no longer required, the MAC uses the date of the written notice to the beneficiary. DOCUMENTATION OF THE NOTICE Providers should retain copies of all notices of non-coverage given to beneficiaries as part of the patient's medical record. The date of notification is an essential element in an appeal on the issue of limitation of liability and as evidence of notice for verification of resident's rights.

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SNF/Swing Bed Services Manual DENIAL OF PAYMENT FOR NEW ADMISSIONS

Under Sections 1819(h) and 1919(h) of the Social Security Act and CMS' regulations at 42 CFR 488.417, CMS may impose a Denial of Payment for New Admissions (DPNA) against a SNF when a facility is not in substantial compliance with requirements of participation. MACs are responsible for applying these payment sanctions to new SNF admissions resulting from adverse survey findings.

New Admissions

A new admission occurs when a patient is admitted to a SNF where he has not received services before. The provider is liable for services rendered during a sanction period unless a notice of non-coverage was issued to the beneficiary prior to admission. The notice of non-coverage should indicate that Medicare would not be making payment for the stay due to the DPNA. If the patient elects to receive services at the sanctioned facility, the patient assumes financial responsibility for the days the facility was sanctioned. These days are billed as non-covered, with occurrence span code 76, and are not deducted from the patient's 100 skilled days. If a notice of non-coverage was not issued to the beneficiary, the SNF assumes responsibility for the costs incurred during the sanction period. Payment sanctions are applied to days that would normally be paid, or days that the beneficiary was receiving skilled care in a Medicare bed. Since the patient is receiving skilled care, the days during the sanction period are counted as benefit days, and are deducted from the patient's 100 skilled days. The claim should be filed as a covered stay (covered days and covered charges) with occurrence span code 77 for the days the facility was under sanction. The covered units reported under revenue code 0022 should be the number of covered days minus the number of days reported under occurrence span code 77. Billing with occurrence span code 77 indicates that the provider should not be paid, but benefit days should be used.

Readmissions

Medicare will pay for services rendered to a patient who is readmitted to a facility that is under a DPNA. A readmission occurs when the patient is admitted to a facility from which they have previously received services. It does not matter what type of service (skilled or non-skilled) the patient received or what type of bed they were in when they were previously at the facility. If the patient was receiving services at the facility and leaves (such as admission to the hospital, goes home, or is discharged to another type of facility), then returns to the same facility that is now under a DPNA, Medicare payment can be made as long as the patient meets all other coverage requirements.

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Claims for readmissions that are not subject to the payment ban should be submitted with occurrence span code 80 and the dates of the prior stay.

Current Patients

Patients receiving services at the facility when the sanction is put into effect are not affected by the payment ban. The payment ban only applies to patients admitted during the sanction period. The billing requirements for these claims do not change.

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SNF/Swing Bed Services Manual CONSOLIDATED BILLING

Under the consolidated billing requirement, the SNF must submit all Medicare claims for all the services that its residents receive under Part A, except for certain excluded services, and for all physical, occupational and SLP services received by residents under Part B. When a beneficiary leaves the facility (or the DPU), the beneficiary's status as a SNF resident for consolidated billing purposes (along with the SNF's responsibility to furnish or make arrangements for needed services) ends. It may be triggered by any one of the following events: The beneficiary is admitted as an inpatient to another facility. The beneficiary is moved from the DPU to a non-certified area within the same institution. The CWF has installed edits to prevent duplicate payment of services governed by consolidated billing for both SNF Part A and Part B beneficiaries.

Consolidated Billing Requirements Under Part A

Consolidated billing applies to services and supplies that a SNF resident receives while in a SNF PPS Part A inpatient stay. Consolidated billing requires that charges for outside services must be charged back to the SNF if the beneficiary is covered under Medicare Part A and the SNF is receiving SNF PPS payment for that day. Services provided outside the SNF on the day of discharge or on Leave of Absence days do not have to be charged back to the SNF since the SNF is not receiving Part A reimbursement.

Services and Treatments Provided `Under Arrangement'

For any Part A or Part B service that is subject to SNF consolidated billing, the SNF must either furnish the service directly with its own resources, or obtain the service from an outside entity (such as a supplier) under an "arrangement." Medicare does not prescribe the actual terms of the SNF's relationship with its suppliers (such as the specific amount or timing of payment by the SNF), which are to be arrived at through direct negotiation between the parties to the agreement. However, in order for a valid arrangement to exist, the SNF must reach a mutual understanding with its supplier as to how the supplier is to be paid for its services. Documenting the terms of the arrangement confers the added benefit of providing both parties with a ready means of resolution in the event that a dispute arises over a particular service. This type of arrangement has proven to be effective in situations where suppliers regularly provide

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services to facility residents on an ongoing basis (e.g., laboratory, X-ray or DME suppliers). If a SNF elects to use an outside supplier to furnish medically appropriate services that are subject to consolidated billing, but then refuses to reimburse that supplier for the services, there is no valid arrangement as contemplated under Section 1862(a)(18) of the Social Security Act. Not only would this potentially result in Medicare's noncoverage of the particular services at issue, but a SNF demonstrating a pattern of nonpayment would also risk being found in violation of the terms of its provider agreement. Consolidated billing requires that services provided by individuals or companies other than the employees of the SNF must be billed to the MAC on the UB-04 for Medicare beneficiaries covered under Part A (and Part B beneficiaries receiving covered therapy services). The SNF must do the billing. Under such an arrangement, the SNF must reimburse the outside entity for those Medicare-covered services that are subject to consolidated billing.

Services Excluded From Consolidated Billing

CMS has provided a list of those exceptionally intensive and costly services that lie well beyond the scope of the care plans and services that SNFs would ordinarily furnish and, therefore are not bound by consolidated billing rules. This exclusion is not invoked merely because a particular outpatient hospital service does not appear in the individual SNF care plan of the person receiving the service. Physicians (professional component of physician services). Physician assistants working under a physician's supervision. Nurse practitioners and clinical nurse specialists working in collaboration with a physician. Certified nurse-midwives. Qualified psychologists. Certified registered nurse anesthetists. Home dialysis supplies and equipment, self-care home dialysis support services and institutional dialysis services and supplies. Erythropoietin (EPO) for certain dialysis patients. Hospice care related to a beneficiary's terminal condition. An ambulance trip that transports a beneficiary to the SNF for the initial admission or from the SNF following a final discharge. Cardiac catheterization (provided by a hospital or Critical Access Hospital (CAH)). Computerized Axial Tomography (CT) scans (provided by a hospital or CAH). Magnetic Resonance Imaging (MRI) (provided by a hospital or CAH).

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Ambulatory surgery involving the use of an operating room. Emergency room services billed to the Part A contractor under revenue code 045X. Radiation therapy. Angiography codes. Lymphatic procedures and venous procedures. Chemotherapy items (some chemotherapy is included in SNF PPS). Chemotherapy administration services. Radioisotope services. Customized prosthetic devices. Ambulance transport for renal dialysis services.

A listing of specific services excluded from consolidated billing is maintained by CMS. This listing, the annual updates to the listing and a help file associated with consolidated billing can be located at: http://www.cms.gov/SNFConsolidatedBilling/01_Overview.asp.

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SNF/Swing Bed Services Manual MEDICAL REVIEW PROCESS UNDER PPS

Medical Review (MR) is an important part of the Medicare Integrity Program that requires contractors to verify inappropriate billing and develop interventions to correct the problem. MR is defined as a review of claims to determine whether services provided are medically reasonable and necessary, as well as to follow up on the effectiveness of previous corrective actions. Medical staff reviews selected medical records to determine if the documentation supports the medical necessity of the services billed. Its purpose is to ensure the correct amount is paid to legitimate providers for covered, reasonable and necessary services provided to eligible beneficiaries. Benefits to providers include: Reduced Medicare claims payment error. Decreased denials. Increased educational opportunities.

Progressive Corrective Action (PCA)

CMS has instructed the MACs to educate and initiate PCA for services that receive high reimbursement and may not be compliant with Medicare guidelines. The six phases of PCA include: 1. Problem identification. o The MAC identifies problems by analyzing billing data. o The results of the data determine which services or facilities will be medically reviewed. 2. Problem validation. o The MAC conducts widespread and limited probe reviews to validate billing of the services in question. 3. Intervention. o Medical review identifies services paid in error and calculates a payment error rate. 4. Monitoring. o Billing patterns are monitored for those services identified in Phase 3. 5. Problem closure. o Close the issue if data reveals significant improvement. 6. Effectiveness. o Keep monitoring the problem if no significant improvement can be seen. Or, o Refer providers with significant aberrancies to Health Integrity, LLC.

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SNF/Swing Bed Services Manual ADDITIONAL DEVELOPMENT REQUEST Medical Record Documentation Requirements

The purpose of the Additional Development Request (ADR) is to obtain additional information from the provider while the claim is still active. MR will read the documentation in the medical record to ensure the service in question was medically reasonable and necessary for the patient. In response to an ADR, the following documentation is required: All applicable MDS for the claim period billed. All medical records for 30 days prior to each ARD applicable to this billing period, including, but not limited to, the following: o Hospital discharge summary. o History and physical. o Admission assessment. o Hospital documentation to support five-day MDS assessment. o Physician certification/rectification. o Physician orders specifying need for SNF care. o Care plans. o Progress notes (nursing, rehabilitation), including: Physician progress notes. Therapy evaluation/re-evaluation. Intake and output log. Vital sign log. Weight records. Treatment and medication sheets. o Provider's written notice(s) of denial to the beneficiary and any reinstatement notices. Include dated verification that the beneficiary or representative received notification or documentation that telephone contact was attempted. After the review is completed, any payment identified by the MR department as being made in error is recouped, including claims that were requested but for which no documentation was received. If the provider disagrees with the review results, a redetermination will be the next level of review for these claims.

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SNF/Swing Bed Services Manual REIMBURSEMENT SNF PPS

CALCULATION OF THE RUG-III AND RUG-IV REIMBURSEMENT RATES CMS publishes updates to the SNF PPS payment rates in the Federal Register each year, prior to August 1. TrailBlazer publishes these rates on the SNF page of its Web site: http://www.trailblazerhealth.com/Facility Types/SNF/default.aspx. The payment rates are national rates, which are adjusted by wage index based on the facility's location in the country. Beginning fiscal year 2007, the wage index is based on the Core Based Statistical Area (CBSA). The federal rates are published as total rates, which are also split into labor and non-labor amounts. If a facility is unsure of the wage index used to calculate its payment rates, contact the TrailBlazer Part A Provider Contact Center at (866) 640-9202. To calculate SNF PPS payment: Multiply the labor portion by the wage index. Add the non-labor portion. Multiply the result by the number of days billed under that RUG-III category. Each RUG-III group on the claim will be calculated separately, and then totaled to determine total reimbursement. Beneficiary coinsurance responsibility is calculated and subtracted from the total reimbursement to establish the payment amount. Payment includes all reimbursement for services: routine, capital and ancillary.

Payment Adjustment for AIDS

Due to the high cost of caring for patients with AIDS, Section 511 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) amended paragraph (12) of Section 1888(e) (42 USC 1395yy(e)) by providing a special payment adjustment that specifically reflects the increased costs associated with the care of these residents. Effective for discharges October 1, 2004, claims with ICD-9-CM 042 will receive a payment adjustment of 128 percent.

Financial Issues Regarding Payment for Part A Stays

Based on their participating agreements, SNFs may not charge the beneficiary the difference between the Medicare payment and the charges on the claim. Beneficiaries are financially responsible only for coinsurance amounts and services non-covered by Medicare for which a written notice of non-coverage has been issued.

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SNFs will be in violation of their participation agreements if they discriminate against the Medicare beneficiary in their admission practices or in delivery of medically necessary services due to the level of payment.

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SNF/Swing Bed Services Manual REVISION HISTORY

Date February 2010 All SNF Eligibility Swing Bed Services Calculating Days in a Benefit Period SNF PPS Overview Adjustment Request for Corrected Assessments Frequency Billing Requirements Influenza, Pneumococcal and Hepatitis B Vaccines Annual Therapy Limits Therapy Ancillary Charges Leave of Absence Section Revision Deleted references in text. Updated eligibility conditions. Added additional swing bed overview. Updated table. Verbiage added concerning HIPPS rate code/ assessment. D2 on or after January 1, 2009. D4 prior to January 1, 2009. Updated information concerning split billing. Added H1N1 information. Added information concerning annual cap limits. Updated ancillary charges for RUG-III rehabilitation groups. Updated to include SNF bed-hold policy per IOM Pub. 100-4, Chapter 6, Section 30.1.1.1.

Advance Beneficiary Notice Added instructions regarding CMS-131-R for of Noncoverage non-covered Part B services. Denial of Payment for New Admissions Exhibit B August 2010 October 2010 Leave of Absence UB-04 Field Requirements Updated to include billing instructions effective January 1, 2009, per IOM Pub. 100-04, Chapter 6, Section 50.2. Updated SNF HIPPS Modifiers. Updated Swing-Bed HIPPS Modifiers. Updated information concerning LOA in excess of 30 days. Updated ARD for each HIPPS reported on claim with occurrence code 50 requirement per CR 7019. Removed value codes 50­53 information per CR 6899.

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Date February 2011 Section Revision

SNF Admission Procedures Added IVR and DDE ELGA/HIQA information. CMS RAI Manual Resident Assessment Instrument (RAI) Types of Assessments Grace Days RUG Version III RUG-IV Group Code AI Codes Medicare Short-Stay Assessment Timeliness Requirements for Setting the ARD Annual Wellness Visit Influenza, Pneumococcal and Hepatitis B Vaccines New section with screenshots on how to locate manual on CMS Web site. Updated MDS information. Updated assessment information. Updated information. Replaced with "RUG Version IV" section. Added RUG-IV group code information. Added AI code information. Added Medicare short-stay assessment information and flowchart. Added information concerning PPS early and late assessments. Added information on new preventive service. Added new "Q" codes for influenza vaccines.

MPPR for Selected Therapy Added section on MPPR. Services Financial Limitation for Therapy Services Outpatient Therapy Billing Requirements Added the 2011 annual therapy limits. Updated time intervals for reporting of service units.

Exhibit A: Crosswalk of Removed from manual. MDS 2.0 Items and RUG-III Groups Exhibit B: HIPPS Modifiers October 2011 Medical Necessity Removed from manual. Added medical necessity and limited coverage information.

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SNF/Swing Bed Services Manual

SNF Admission Procedures Added same-day transfer information. SNF Prospective Payment System Updated screenshots on how to locate the CMS RAI manual. Updated assessments for the RAI (information taken from the RAI manual. Billing for Continuous Inpatient Stay Influenza, Pneumococcal and Hepatitis B Vaccines Therapy Edits Added reprocessing inpatient bills in sequence information. Added new codes for influenza and pneumococcal vaccines. Added CMS group therapy allocation information based on CMS 08/24/2011 and 09/01/2011 presentations. Added CMS therapy student supervision information based on CMS 08/24/2011 and 09/01/2011 presentations. Added occurrence code 16 requirement when EOT is completed. Updated counting therapy minutes information. Added coding PPS bills for ancillary service information. Special Billing Situations Updated information concerning beneficiary's termination of MA plan when three-day qualifying stay has not been met.

Rev. 10/2011

105

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SNF/Swing Bed Services Manual

111 pages

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