Managing the Medicare A Benefit - Amazon S3 it... · Managing the Medicare A Benefit Presented by:...
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Is it Skilled? Managing the Medicare A Benefit Presented by: Judi Kulus, NHA, RN, MAT, RAC-MT, C-NE
Transcript of Managing the Medicare A Benefit - Amazon S3 it... · Managing the Medicare A Benefit Presented by:...
Is it Skilled?Managing the
Medicare A Benefit
Presented by: Judi Kulus, NHA, RN, MAT, RAC-MT, C-NE
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Requirements for Successful Completion
• 1.0 Contact hours will be awarded for this continuing nursing education activity.
The American Association of Nurse Assessment Coordination is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on accreditation (ANCC).
• Criteria for successful completion includes attendance for at least 80% of the entire event.
• Partial credit may not be awarded.
• Approval of this continuing education activity does not imply endorsement by AANAC or ANCC of any commercial products or services.
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Conflict of Interest Disclosure
• There are no conflicts of interest to disclose with this presentation.
Judi Kulus, NHA, RN, MAT, RAC-MT, C-NE Vice President of Curriculum Development American Association of Nurse Assessment
Coordination
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Poll Question
Tell us who you are?
• MDS Coding Nurse
• Other IDT MDS Clinician
• DON
• Nurse Manager
• Administrator
• Corporate Consultants
• Other
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Learning Objectives
• Minimize risk for wrongful coverage of Medicare A beneficiaries with knowledge of the four main requirements for skilled service
• Protect hard earned Medicare reimbursement through appropriate use of the five types of coverage categories
• Audit your own documentation for errors after a thorough review of real-life case studies
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Learning Objectives
• Clear up misconceptions related to the Jimmo vs. Sebelius case by understanding what it means to you
• Protect yourself from skilled coverage compliance violations with detailed information about federal policy and local coverage determinations
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Has
Medicare A
3-Day Qualifying
Hospital Stay
Benefit Days Available
30-Day Transfer
Medical Predictability
FIVE Technical Requirements
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Has Medicare A
• Verify that the resident is on traditional Medicare A
• Medicare card is essential but not enough
• Has he assigned his benefits over to a managed care organization?
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3-Day Qualifying Hospital Stay
• Verify the resident’s hospital status
• Resident was an inpatient of a hospital for a medically necessary stay of at least 3 consecutive calendar days
• Observation stay or in the emergency room prior to (or in lieu of) an inpatient admission to the hospital does not count toward the 3-day qualifying inpatient hospital stay
• Consider contacting the hospital billing office to ask how they will be billing the hospital stay
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Benefit Days Available
• Resident may qualify for up to 100 days IF:
– Technical eligibility requirements met
– Daily skilled coverage requirements met
• Benefit period begins when admitted to a hospital or SNF for skilled level of care
• Benefit period ends when there is ≥ 60 days in which the resident does not receive SNF or higher level of care
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30-Day Transfer
The 30-day transfer requirement:
• The resident is being covered for skilled care within 30 days after discharge from a qualifying hospital stay
or
• Care is being resumed within 30 days of a recent skilled-care episode in a SNF
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Medical Predictability
Unable to Begin Treatment:
• Resident meets the medical predictability for delayed start of treatment
• Predetermined at the hospital that it was medically inappropriate to meet the 30-day transfer requirement by beginning active SNF treatment after a hospital discharge
• This delayed start of skilled services was documented in the hospital transfer record by the physician (MBPM, chap. 8, §§20–20.2.2.4).
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Professionals: Physician Certified
ANDNurse or Therapist
DAILY
Inpatient
Reasonable and Necessary
FOUR General Requirements
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Physician Certification
• Physician must certify that SNF services are required to be given on an inpatient basis
• The resident needs skilled nursing or rehabilitation care on a continuing basis for the condition(s) for which she was receiving inpatient hospital services prior to her transfer to the SNF
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Professional Nurse or Therapist
• The patient requires skilled nursing services or skilled rehabilitation services
• Services that must be performed by or under the supervision of professional or technical personnel (§§30.2 - 30.4)
• Services are ordered by a physician
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Professional Nurse or Therapist
• The resident's condition requires the knowledge, skills and judgment of the professional nurse or therapist
• Professionals are required to safely and effectively perform or supervise the performance of the services
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Skilled Coverage
• Provided 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 he received inpatient hospital services
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Skilled Coverage
Key point:
• Diagnosis alone should never be the sole factor in deciding that a service is or is not skilled
• Prognosis alone should never be the sole factor in deciding that a service is or is not skilled
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Daily
• Resident requires skilled services on a daily basis
– Nursing: 7 days a week
– Rehabilitation: >5 days a week(§30.6)
– Restorative Nursing: at least 6 days a week
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Inpatient
Practical matter
• When considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF (§30.7.)
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Inpatient
Practical Matter Test, Example 1:
• A resident needs skilled PT and can walk only with supervision, but has a reasonable potential to learn to walk independently. Physical therapy is available on a home care basis, but the resident would be at risk for further injury from falling, dehydration, or malnutrition because there was insufficient supervision and assistance at home.– This passes the “practical matter test” as PT can be
provided effectively only in the inpatient setting.
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Inpatient
Practical Matter Test, Example 2:
• Resident admitted to the SNF for BID IV antibiotics every 12 hours. After his morning infusion, he drove himself to the casino for the day. He returned in the evening just in time for his PM infusion. He then left again for the evening, returning just before midnight. – This does not pass the “practical matter test” as
IV’s could be provided using home health care services
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Inpatient
Can a resident ever be gone over midnight during a Medicare stay?
• The MBPM says YES they can!
– The “practical matter” criterion should never be interpreted so strictly that it results in the automatic denial of coverage for patients who meet SNF level of care (LOC) requirements, but are away from the SNF for a brief period of time
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Reasonable and Necessary
• Are the services reasonable and necessary: – For the treatment of a patient’s illness or injury
– Are they consistent with the nature and severity of the individual’s illness or injury?
– Do services match the individual’s particular medical needs?
– Will services meet accepted standards of medical practice?
– Is the anticipated length of stay reasonable in terms of duration and quantity?
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Skilled Nursing
Skilled Rehabilitation
Observation and
Assessment
Management of the Plan of
Care
Teaching and Training
FIVE LOC Requirements
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Presumption of Coverage
Stay is deemed covered from day of admission through the ARD of PPS 5-Day MDS
A PPS 5-Day ARD is appropriately set
then
Correctly assigned into one of top 52 (RUGS IV) payment categories
and
If admitted directly from hospital
and
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“Clinically Complex” or above in RUGs Hierarchy
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Skilled
Nursing
Direct
Skilled
Rehab
Direct
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Observation
And
Assessment
In-Direct
Management and
Evaluation
of the
Care Plan
In-
Direct
Teaching
And
Training
In-Direct
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Skilled
Nursing
Direct
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Direct Skilled Nursing Services
– IV or IM injections and IV feeding
– Enteral feeding with ≥ 26% of calories and ≥ 501 ml fluid per day
– Nasopharyngeal and tracheostomy suctioning
• Not oral suctioning
– Insertion, sterile irrigation and replacement of suprapubic catheters
• Not routine maintenance of stable indwelling bladder catheters, including emptying and cleaning containers and clamping the tubing
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Direct Skilled Nursing Services
– Application of dressings involving prescription medication and aseptic techniques
• Not changes of dressings for uninfected post-operative or chronic conditions
– Treatment of decubitus ulcers, Stage 3 or worse, or a widespread skin disorder
– Heat treatments ordered by MD as part of active treatment which require observation by nurses to adequately evaluate the patient’s progress
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Direct Skilled Nursing Services
– Rehab nursing procedures
• For example, Bowel/bladder programs
– When skilled status is based solely on a restorative nursing program, there must be documented medical evidence to justify the services
• “In most instances, it is expected that a skilled restorative program will be, at most, only a few weeks in duration” (§§30.6)
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Direct Skilled Nursing Services
– Initial phases of treatment involving administration of medical gases
• Not routine administration of oxygen after therapy has been established
– Care of a colostomy during the early post-operative period in the presence of associated complications
• Not general maintenance care of colostomy and ileostomy
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Skilled
Rehab
Direct
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Daily Skilled Rehab
• Therapy services are considered skilled when they are so inherently complex that they can be safely and effectively performed only by, or under the supervision of, a qualified therapist (42CFR §409.32)
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Daily Skilled Rehab
Improvement Standard:
• Be provided with the expectation that the patient’s condition will measurably improve in a generally predictable timeframe
Or
Maintenance Standard:
• Must be necessary for the establishment of a safe & effective maintenance program
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Daily Skilled Rehab
What difference did the Jimmo vs Sebelius case make?
• Resulted in clarification regarding provision of skilled nursing and therapy services necessary to maintain a person's condition
• Simply put, the deciding factor is not the patient’s potential for recovery, but whether the services needed require the skills of a therapist or whether they can be provided by non-skilled personnel
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Daily Skilled Rehab
Improvement does not mean “Cure”• Even with chronic or terminal conditions skilled
therapy may be needed• While full or partial recovery may not be possible,
skilled therapy may be needed to improve the patient’s condition
• For example, in the case of a progressive degenerative disease, service may be intermittently necessary to determine the need for assistive equipment and establish a program to maximize function (MBPM, 15, 220.2)
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Daily Skilled Therapy
Key Point:
• The deciding factors are always A.) whether the services are considered reasonable, effective treatments for the patient’s condition and require the skills of a therapist, or B.) whether they can be safely and effectively carried out by non-skilled personnel without the supervision of qualified professionals.
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Daily Skilled Rehab
• Based on initial evaluation
• Related to an active written treatment plan
• Meet requirements for a qualified therapist involvement and oversight
• Approved by the attending physician
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Observation
And
Assessment
In-Direct
Management and
Evaluation
of the
Care Plan
In-
Direct
Teaching
And
Training
In-Direct
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Indirect Skilled Nursing Services
• May not result in the classification into the upper 52 RUG categories, therefore careful documentation will be required to support the assertion that SNF services were needed and delivered.
– Can be the major source of a “daily skilled need”
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Management and
Evaluation
of the
Care Plan
In-
Direct
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Management and Evaluation of the Care Plan
• SNF Criteria is met when the resident’s physical or mental condition requires the involvement of the technical or professional personnel in order to:
– Meet the residents needs
– Promote recovery
– Ensure medical safety
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Observation
And
Assessment
In-Direct
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Observation and Assessment of Resident’s Condition
• May be coverable when likelihood of adverse change in condition require skilled nursing personnel to identify and evaluate the need for treatment modification or initiation of additional medical procedures until treatment regimen is stable
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Observation and Assessment of Resident’s Condition
• The fact that the resident did not develop an acute episode or complications does not mean that the stay will be denied as long as there was a reasonable probability that it might have occurred
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Observation and Assessment for Psychiatric Condition
• “May be required for patients who have psychiatric conditions”
• “For example, depression, anxiety or agitation, which require skilled observation and assessment such as observing for indications of suicidal or hostile behavior”
– (MBP Manual, Ch. 8)
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Observation and Assessment for Psychiatric Condition
• “However, these conditions often require considerably more specialized, sophisticated nursing techniques and physician attention than is available in most participating SNFs”
• (MBP Manual, Ch. 8)
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Teaching
And
Training
In-Direct
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Teaching and Training
• Teaching and training activities, which require skilled nursing or skilled rehabilitation personnel to teach a patient how to manage their treatment regimen, would constitute skilled services
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Examples
• Self-administration of:
– Injectible meds or a complex range of meds
– Medical gases
– Enteral feedings
• Care of:
– Recent colostomy or ileostomy
– Central venous lines
– Prostheses (includes gait training)
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Examples
• Teaching examples:
– Self catheterization
– Use and care of braces, splints and orthotics, and any associated skin care
– Proper care of any specialized dressings or skin treatments
– New Diabetic care: insulin, diet, foot care, etc
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Key Point
• IT’S NOT THE DIAGNOSIS OR CONDITION, IT’SWHAT YOU ARE DOING ABOUT IT THAT DETERMINES
SNF LEVEL OF CARE!
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Non-Skilled Example
• The primary service needed is oral medication
or• The resident is capable of
independent ambulation, dressing, feeding, and hygiene
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Non-skilled Services
• Routine evaluations of all new admissions without documentation of significant change from prior functional status
• Treatment after hospitalization where it is anticipated prior functional abilities would return spontaneously
• Routine swallow assessments for patients with decreased oral intake, refusing oral intake or weight loss
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Non-skilled Services
• Training multiple caregivers
• Assessment for non-specialized assistive devices or splints without a complicating medical condition
• General strength or endurance training
• Repetitive exercises
• Increasing upright tolerance or sitting times
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Non-Skilled Services
• In general, increasing the quantity of a response is not skilled-service such as goal to increase walking from 50 to 100 feet
• Increasing the quality of a response is skilled such as increasing step length or weight shifting
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Non-Skilled Services
Discharge from Therapy when:
• Achieves therapy goals
• Refuses to continue therapy
• Is transferred to a higher level of care
• Is not making progress and there is no further benefit to continuing
• Is regressing or too ill
• When the physician discontinues treatment
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Non-Skilled Services
• Administration of routine oral medications, eye drops, and ointments
• General maintenance care of colostomy and ileostomy
• Routine care of:– Indwelling catheter
– Incontinence
– Plaster casts
– Braces or other similar devices
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Non-Skilled Services
• Routine administration of medical gases
• Assistance in dressing, eating, and going to the toilet
• Periodic turning and positioning in bed
• General supervision of exercises which have been taught to the patient and the performance of repetitious exercises that do not require skilled rehabilitation personnel for their performance
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Non-Skilled Services
• Prophylactic and palliative skin care, including bathing and application of creams, or treatment of minor skin problems
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Documentation
Skilled Decisions:
• Medical instability or the probability of change in the resident’s condition
• Evidence of risks/potential complications requiring careful supervision
• Evidence skilled licensed personnel are assessing/supervising care
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Documentation
Skilled Decisions
• What is the skilled need?
• Is the documentation sufficient to support skilled need as an inpatient as a practical matter?
• Is there daily charting?
• Are there any chart notes here that may represent any indirect skilled services that may have been captured?
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Critical Thinking
• Documentation should describe your “critical thinking”
– Assessment of resident condition, causative factors, and risk factors
– Analysis of potential outcomes or consequences
– Plan of care
– Action to be taken
– Evaluation of resident response to plan
– Modification and revision of plan
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Critical Thinking
• Don’t assume that another professional will come to the same conclusion as you did –document the connection for them
• Example:– “Res has PVD, diabetes, LE contractures, and has
developed open area on side of foot”• Vascular, Pressure, Diabetic?
• Or is it a skin tear from knocking the foot on the WC?
– Close the loop: Finish the investigation and chart the results. Ask MD to assess as appropriate.
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Critical Thinking
• Assess the clinical condition of the patient
• Prioritizing the patient’s care needs while evaluating effect on functional limitations
• Assessing how these functions affect the resident’s life and discharge plan
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Critical Thinking
• Using professional expertise and training to determine and then carry out interventions
• Analyzing the resident’s performance and responses and then making the necessary adjustments
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Strategies for Success
• During Medicare meetings discuss LOC, PPS Schedule and RUGs
• The clinician closest to the resident should be consulted on skilling decisions
• Avoid undue pressure to skill without detailed analysis of LOC reason(s)
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Local Coverage Determinations
Strategies for Success
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http://www.cms.gov/Medicare/Coverage/DeterminationProcess/LCDs.html
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Local Coverage Determination
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Local Coverage Determination
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Local Coverage Determination
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Strategies for Success
• Post the direct skilled nursing list in a prominent location and refer to it often
• Utilize Medicare resources for coverage decisions
• Know your area’s Local Coverage Determination guidance
• Know why the resident is skilled
• Enhance coordination between therapy and nursing
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Strategies for Success
• Avoid ADR nightmares by managing level of care decisions effectively
• Create cohesive interdisciplinary documentation
• Avoid electronic charting pitfalls :
– Avoid copy and pasting information
– Use narrative boxes effectively
– Don’t rely solely on flow sheets
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References
• Medicare Benefits Policy Manual:– Ch. 8: Coverage of Extended Care (SNF) Services Under
Hospital Insurancehttp://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c08.pdf
– Ch. 15: Covered Medical and Other Health Services, Sections 220-230http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf
• Special Thanks to AANAC Medicare University and its authors
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