NEWS & REFERENCE - MEDICARE PPS

HCFA asked for comments on its rules regarding Medicare Prospective Payment System and it received 500. In its Final Rule, published in the Federal Register, July 30, 1999, HCFA addresses those comments, clarifies intentions, and makes changes.

The quotes here are directly from the Final Rule, although some wording has been deleted. The Final Rule is worth reading in full; it includes HCFA’s reasoning on many regulations and it covers broad policy issues as well as nitty-gritty MDS timing points.

Page numbers are shown for reference to the complete text of the excerpts printed here.

Guaranteed Coverage – page 41646

"We believe that an initial 5-day assessment, properly completed, that places the resident in one of the upper 26 RUG-III classifications, provides the basis for us to assume that the resident needed a covered level of SNF care upon admission and at least up until the assessment reference date (ARD) of the Medicare-required 5-day assessment."

HCFA addresss this issue again on page 41667: "the continuation of SNF coverage (once it has been initiated by the RUG-III presumption) must be supported by the resident’s actual condition and care needs, and is not guaranteed for some predetermined block of time."

Revision Per the Budget regarding Rates Transition – page 41654

The Budget signed into law on November 29, 1999, allows providers to elect either a PPS-transition-based payment or the full Federal rate. Whichever rate the provider chooses must be used for all the years of the transition period.

HCFA had not announced an implementation schedule as of press time.

Other Medicare Required Assessment (OMRA) - page 41656

"An OMRA is required 8 to 10 days after rehabilitation therapy is discontinued for Medicare beneficiaries…. the OMRA is not required to be a comprehensive assessment… (that is, those including RAPS). Comprehensive assessments are only required for clinical reasons.

"An SNF must perform an OMRA only for beneficiaries who continue to have skilled care requirements after their rehabilitation therapy services have been discontinued…"

"The assessment reference date (ARD) of the OMRA must be set on day 8, 9 or 10 after the last day any rehabilitation therapy services were provided. This timing ensures that no therapy minutes are captured on the OMRA…"

"For the days between the cessation of rehabilitation therapy and the ARD of the OMRA, the beneficiary continues to be covered at the therapy RUG-III to which he or she was classified before cessation."

Grace Days – page 41657

"Days six, seven, and eight of the Medicare-covered stay were provided as grace days for setting the ARD for the Medicare 5-day assessment. This assessment is to have an ARD (MDS 2.0 Item A3a) of any day one through eight of the Medicare Part A stay. Days one through five are optimal but days six through eight are also acceptable, and for some residents may be more appropriate."

"The grace days for the 5-day allow maximum flexibility for nurses to determine when to set the ARD…

"However, we discourage the routine use of grace days for assessing every Medicare admission. We plan to identify patterns of inappropriate use as we gain a better understanding of facilities’ practice patterns. When a facility routinely uses a grace day as the ARD for the 5-day assessment, it loses the cushion these days provide against performing the MDS later than day eight and, thus, risks payment at the default rate.

"… grace days are also provided to offset any incentive facilities may have to initiate therapy services before the beneficiary is able to tolerate that level of activity."

MDS Completion and Locking Dates - page 41658

"For Medicare payment, we are requiring that any assessment, including the 5-day, must be ‘completed’ (that is, signed by all members of the care team) within 14 days of the ARD (MDS item A3a). That is, the completion date at MDS item R2b, must be a date within 14 days of the date at A3a.

"Then the assessment must be ‘locked’ within seven days of the date at R2b, and transmitted to the State within 31 days of the final lock date (State Operations Manual, HCFA Pub. 7)."

5-day, 14-day, and Initial Assessments – page 41658

"There is still the clinical requirement that an Initial Admission Assessment must be ‘completed’ by the 14th day of the nursing home stay. This means that for a Medicare beneficiary who is newly admitted to the SNF for a covered Part A stay, the SNF must complete a comprehensive MDS by day 14, regardless of the ARDs on the Medicare-required 5-day and 14-day assessments.

"In addition, for Medicare beneficiaries in a covered Part A stay, a 5-day assessment must be performed, with an ARD on any day one through eight of the Medicare Part A covered stay, and must be completed within 14 days of the ARD."

Also, the Medicare 14-day assessment must have "an ARD of any day 11 through 19 (including the 5-day grace period provided for this assessment).

"…we believe that in many cases facilities will opt to complete a single assessment to satisfy requirements for both the 5-day (or 14-day) assessment and the Initial Admission Assessment. In this example, the Medicare 5-day, with an ARD of any day, one through eight of the stay, will be a comprehensive assessment (with RAPS) and must be completed within 14 days of admission. The day of admission is counted as day one.

"When the Medicare 5-day assessment is also used to fulfill the requirement for the Initial Admission Assessment, the Medicare 14-day assessment may use any day, 11 through 14 of the stay, as the ARD (MDS item A3a). In addition, the SNF may use the five available grace days (through day 19), if necessary.

"The Medicare 14-day assessment must then be completed (dated at item R2b) 14 days after the ARD, and locked in seven days… no grace days for completion of the Initial Admission Assessment and it must be completed by day 14.

"Another factor to consider in timing completion and locking is that bills may only be sent for locked assessments."

Leaves of Absence and the Midnight Rule – page 41658

The reasons for a leave of absence include a "temporary home visit, a temporary therapeutic leave, or a hospital observational stay of less than 24 hours in which the beneficiary is not formally admitted to the hospital and is not discharged from the SNF. In each example, the SNF is not required to complete a Discharge or a Re-Entry Tracking form. …A leave of absence does not affect the ‘clock’ for clinical assessments."

Here is the "midnight rule": when a beneficiary, during an SNF stay, "goes to a hospital emergency room (ER) and is in the ER at midnight…the day preceding the midnight on which the beneficiary was absent becomes a day for which the SNF may not bill Medicare Part A."

For "Medicare payment under PPS, no additional assessment is required. The day preceding the midnight is not a covered Part A day and, therefore, the Medicare assessment ‘clock’ is altered by skipping that day in calculating when the next Medicare assessment is due.

"A beneficiary who must be in the ER at midnight may well have experienced significant change. In that case…a Significant Change in Status Assessment must be completed when the beneficiary returns to the SNF.

"Alternatively, if the beneficiary is in the ER for more than 24 hours, is admitted to the hospital, or discharged from the SNF, a Discharge Tracking form is required.

"In addition, when the beneficiary returns to the SNF, a Re-Entry Tracking form is required, and a Return/Readmission Assessment (MDS item A8b=-5) must be performed to restart the Medicare assessment schedule. The Readmission Assessment fulfills the requirement for a 5-day assessment in this situation, and the next required assessment would be the Medicare 14-day assessment."

Rehabilitation Therapy Assistants, Aides, Students - page 41661

"An appropriately licensed or certified individual must provide or supervise the therapeutic service and coordinate the intervention with nursing services.

"Physical and occupational therapy assistants may provide rehabilitation therapy services under the supervision of the professional therapist who is accessible while the assistant is providing services to the beneficiary. The therapy assistant cannot supervise a therapy aide."

"A therapy aide must be supervised personally by the professional therapist in such a way that the therapist has visual contact with the aide at all times. Therapy aides are not to perform any services without ‘line-of-sight’ supervision. Similarly, a therapy aide must never be responsible for provision of group therapy services."

"A therapy student who is participating in field experience must also be under the ‘line-of-sight’ level of supervision of the professional therapist."

Retraction Re: Therapy Students

The Correction notice effective September 28, 1999 retracted HCFA’s statement of "none of the minutes of therapy services provided by the students may be recorded on the MDS as minutes of therapy received by the beneficiary."

The correction states "Providers should record the minutes of therapy provided by therapy students in accordance with the past practice…"

Physicians’ Role - p. 41660 - 61

"The rehabilitation therapy service must be ordered by a physician. The Medicare policy regarding the requirement for the physician signature on the therapy plan of treatment has not changed."

"We realize, however, that in the SNF setting there may not be a physician on the premises every day. Therefore, Medicare allows the professional therapist to develop a suggested plan of treatment and to begin providing services based on that plan prior to obtaining the physician’s signature on the plan…A physician signature must be obtained before the facility bills Medicare…"

"We understand many physicians use the fax to participate actively in the review of written plans of care and so believe that it is appropriate to accept physicians’ faxed signatures for the treatment plan."

Counting and Recording Minutes in the MDS – page 41661

The directions for section P state "to look back over the ‘last 7 calendar days,’ counting only post-admission days and minutes of therapy…The number of minutes recorded here must be the actual (not rounded) number received. Seven calendar days are, by definition, consecutive days.

"In the case of a Medicare 5-day assessment, the assessor will choose as the ARD (A3a), any day one through eight of the covered stay, and will look back over the prior seven calendar days (or over the days since admission, if fewer than seven days) to count the days that more than 15 minutes of therapy were received and the number of minutes…It is irrelevant if a break occurs in therapy (such as a weekend or holiday) during that time.

"For example, if day five of the stay is chosen as the ARD, the assessor would look back to admission to count the PT, OT, and ST time. If the beneficiary received PT for 50 minutes on both the second and fifth days of the Part A stay, it would be recorded as two days of PT and 100 total minutes. The actual number (not rounded) of minutes must be recorded."

Initial Evaluation – page 41661

"Whether the time spent evaluating the beneficiary is counted depends on whether it is the formal initial evaluation or an evaluation performed after the course of therapy has begun. The time it takes to perform the formal initial evaluation and develop the treatment goals and the plan of treatment may not be counted as minutes of therapy received by the beneficiary."

"However, a reevaluation—a hands-on examination of the beneficiary—not simply an update to the documentation and care plan revision, performed once a therapy regimen is underway…may be counted as minutes of therapy received."

Consolidated Billing for Medicare Part B – pages 41670-71

"Consolidated billing implementation with regard to SNF residents in noncovered stays is postponed, because it requires far more extensive systems modifications than those needed for the PPS under Part A… We plan to publish a notice in the Federal Register of the implementation date for this aspect of consolidated billing at least 90 days in advance.

Ambulances - page 41673

"An ambulance trip from the SNF is not subject to PPS consolidated billing when it is in connection with one of the events that ends the beneficiary’s SNF ‘resident’ status." These events include a "trip to a Medicare-participating hospital for the specific purpose of receiving emergency services or certain other intensive outpatient services not included in the SNF’s comprehensive care plan."

"This means the beneficiary ceases to be a ‘resident’ of the SNF for consolidated billing purposes (PPS), thus, ambulance transportation to the hospital is also excluded from consolidated billing…" [The ambulance company can bill Medicare.] "…this exclusion applies to the return trip from the hospital to the SNF as well."

Revision per the Budget regarding Ambulance & Dialysis – page 41673

The Budget Agreement signed on November 29, 1999 excludes ambulance service to and from dialysis from the consolidated PPS rate.

Dialysis - page 41675

"An SNF is not itself required to furnish or arrange for this service. However, if an SNF nonetheless elects to do so, the dialysis is included within the scope of the Part A extended care benefit, as well as in the PPS per diem payment.

"Alternatively, since a SNF has the option of declining to furnish or make arrangements for dialysis, those services that meet the following coverage requirement for the Part B dialysis benefit could be furnished and billed to Medicare directly by an outside dialysis supplier."