Skilled Nursing Facility
Lower 14 RUGs
Presented by
Provider Outreach & Education
July 13, 2016
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Disclaimer
Information provided in this webcast is
current as of July 5, 2016. Any changes or
new information superseding this
information is provided in articles with
publication dates after July 5, 2016 on our
website at: www.palmettogba.com/jma
CPT only copyright 2016 American Medical Association.
All rights reserved.
The Code on Dental Procedures and Nomenclature is published in Current
Dental Terminology (CDT), Copyright © 2012 American Dental Association
(ADA). All rights reserved.
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Objective
□ To allow SNF providers to increase
knowledge & understanding of Medicare
guidelines for successful billing
□ To apply given information in a way to
positively affect provider billing practices
3
Agenda
□ Overview
□ Assessments & MDS Levels
□ RUGs & the Lower 14
□ Documentation &Tips
□ Resources
4
BASIC OVERVIEW
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Basic Overview
□ Medicare covers skilled nursing facility
(SNF) care after an inpatient hospital
stay of 3 or more days, admit is within
30 days & certified medically necessary
□ Medicare does not cover nursing facility
care if a patient does not require skilled
nursing or skilled rehabilitation services
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Coverage
□ Medicare provides 100 calendar days
starting from day of admission.
□ To receive these skilled days a
beneficiary must qualify & receive
skilled nursing or rehabilitation services
□ Benefits are only provided in a
Medicare-certified facility or hospital
swing bed, & only subsequent to a 3day qualifying hospital stay
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Re-establishing Skilled Days
30 Day Rule
OR
Resident requires
skilled services within
30 days of the last
billable Medicare day
Resident requires
skilled services within
30 days of 3-day
qualifying hospital
stay
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Termination of Skilled Days
1. Re-hospitalization
2. Hospice
3. Skilled therapy or nursing no longer
needed
4. Discharge from facility (home, another
facility, hospital, etc.)
5. Ending of 100 days
6. Expiration
9
Re-establishing Skilled Days
□ A break of at least 60 consecutive
days since inpatient hospital or SNF
services was provided
□ Benefit period includes all inpatient days
10
Reimbursement Based on RUG
□ Skilled coverage reimburses at a per
diem rate based on Resource Utilization
Group (RUG) category captured; all
services are included in per diem rate:
□ Routine Services - room/board, general
nursing care & administrative overhead
□ Ancillary Services - physical, occupational
therapies (PT, OT) and speech language
pathology (SLP) services
□ Capital - Certain DME while inpatient
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Resource Utilization Groups
RUGs
12
Minimum Data Set (MDS)
□ MDS is a federally mandated process
for clinical assessment of all residents
in Medicare certified nursing homes
□ Process provides a comprehensive
assessment of each resident's
functional capabilities & helps nursing
home staff identify health issues
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Resource Utilization Groups
□ RUGs are a number of groups into
which a nursing home resident is
categorized, based on functional
status and anticipated use of services
and resources
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RUG Categories
□ There are five RUG categories to
capture rehabilitation services:
1.
2.
3.
4.
5.
Ultra High
Very High
High
Medium
Low
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RUG Categories
Ultra High
Must receive minimum
total of 720 minutes & at
least 1 discipline for 5x a
week and 1 discipline for
3x a week
Very High
Must receive
minimum total of
500 minutes & at
least 1 discipline
for 5x a week
High
Must receive minimum total of 325 minutes &
at least 1 discipline for 5x a week
16
RUG Categories
Medium
Must receive
minimum total
of 150 minutes &
any discipline
combination for
5x a week
Low
Must receive minimum
total of 45 minutes & any
discipline combination for
3x week and 2 rehab
nursing programs for 6x
week (15 minutes each)
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Assessment Reference Periods
□ The gathering of information & services
over seven consecutive days
□ This information is reported on the MDS
□ Assessments are required for Medicare
Part A patients for initial 5-day, 14-day,
30-day, 60-day, & 90-day timeframes
□ Additional assessments may be required
due to various circumstances
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Assessment Reference Date
□ ARD = date that signifies the end of
the look-back period
□ This date is used to base responses to all
MDS coding items
□ Starts the clock: all assessment items refer
to patient's objective performance &
health status during same period of time
19
Part A Required MDS
These 5 assessment periods
Assessments capture all services rendered
over entire 100 skilled days
5 day
14 day
If skilled services terminated
30 day
prior to using all 100 days; future
60 day
pending assessments will not be
90 day
required for completion
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Evaluations
□ Medicare Part A does NOT reimburse
for PT, OT, & SLP evaluations
□ Time billed for evaluation codes may
NOT be included when adding total
treatment minutes for MDS
□ Perform an evaluation & treatment on
patient’s first day of rehabilitation
21
5 Day Assessment
□ This assessment is the first assessment
that must be completed if a patient
is admitted with Medicare Part A
□ RUG category captured for this
assessment will reimburse for the first
14 days of the patient’s length of stay
□ ARDs may be picked from Day 1 – 8
(days 6, 7, & 8 are grace days)
22
14 Day Assessment
□ RUG category captured for this
assessment will reimburse for days 15
through 30 of patient’s length of stay
□ ARDs may be from Day 13 – 18
□ Days 15 – 18 are grace days
□ Payment for days 15 – 30
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30 Day Assessment
□ RUG category captured for this
assessment will reimburse for days
31- 60 of patient’s length of stay
□ ARDs may be from Day 27 – Day 33
□ Days 30 – 33 are grace days
□ Payment for days 31 – 60
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60 Day Assessment
□ RUG category captured for this
assessment will reimburse for the days
61 - 90 of patient’s length of stay
□ ARDs may be from Day 57 – Day 63
□ Days 60 – 63 are grace days
□ Payment for days 61 – 90
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90 Day Assessment
□ RUG category captured for this
assessment will reimburse for the days
91-100 of the patient’s length of stay
□ ARDs may be from Day 87 – Day 93
□ Days 90 – 93 are grace days
□ Payment for days 91 – 100
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MDS RUG Levels
Lower 14 RUGs
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RUG Levels
□ Total of 66 RUG-IV levels - four levels
fall into lower category
□ When a patient is accessed for
Medicare benefits; there is an
associated RUG score
□ RUG score must have a relationship to
the rationale for skilled services
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Lower 14 RUG Example
□ Patient = behavioral RUG score of BB1
□ Experiencing delusions, is verbally
abusive & wanders more than usual
□ Medicare team feels patient requires
daily oversight of licensed nursing
staff, despite the lower level score
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Importance of RUG level
Reviews
□ Assessment reveals PRN oxygen required
two out of three evenings within
assessment window
□ Application of oxygen & associated care
provided changes MDS coding from
behavioral category - BB1 to clinically
complex level - CB1
□ RUG level is now in an upper category
level that more clearly represents
patient’s clinical picture
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SNF Level of Care Administrative Presumption
□ Patients correctly assigned to one of
the upper 52 RUG groups on initial 5day assessment are automatically
classified as meeting SNF level of care
definition up to & including the ARD
31
SNF Level of Care Administrative Presumption
□ Patient assigned to any of the lower
14 RUG groups is not automatically
classified as either meeting or not
meeting SNF level of care
□ Instead receives an individual level of
care determination using existing
administrative criteria
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PALMETTO GBA
MEDICAL REVIEW RESULTS
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Palmetto GBA
Medical Review Results
□ Prepayment service specific targeted
medical review performed for SNF 14
lower RUG code
□ Claims processed 10/1/15 - 12/31/15
□ Medical Review 10th quarter results at:
□ www.palmettogba.com/medicare
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Results
Denial
Code
Description
NC SC
VA WV
5D504/5H504 Information does not support
medical necessity for services
5DOWN
MR Down Code
86.8 73.3 85.1 80.2
4.0
2.5
2.7
3.3
56900
Requested records not
submitted
5D507/5H507 MDS not in National Repository
3.8
15.1 6.9
5.6
3.4
-
1.9
-
5D501/5H501 Billed in Error
1.5
-
1.9
5.2
5D508/5H508 Benefits Exhausted
-
6.3
-
-
SNF benefits only available after eligible covered hospital stay ≥ 3
days
1.9
-
5.7
5D510
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Charge Denial Rates
NC
SC
VA
WV
53.5%
49.6%
60.4%
61.4%
How can SNF providers avoid these errors
and improve CDR?
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Documentation
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Nursing Admission
Documentation
□ Why? = skilled related to qualifying
hospital stay
□ i.e. rehabilitation & skilled nursing
following surgical repair to fractured hip
□ What? = skilled services anticipated
□ Daily surgical wound care; PT/OT
services
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Nursing Admission
Documentation
□ Patient goals for skilled stay
□ Psychosocial condition & support systems
□ Patient motivation; family involvement
□ Risks, impairments or disabilities that may
impact required services
□ Patient assessment & functional abilities
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Daily Nursing Documentation
□ Required once every 24 hours,
recommended every shift
□ Why patient continues to be skilled
related to qualifying hospital stay
□ What skilled services are provided
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Daily Nursing Documentation
□ Patient’s tolerance of services
□ Ask patient, document their response
□ Barriers that may be preventing patient
from reaching goals
□ When there are no longer any issues to
document, discuss discharge
41
Physician Documentation
□ Supports medical necessity of SNF
level of care
□ Physical condition & functional abilities
□ Psychosocial condition & support
□ Risks, impairments & disabilities
□ Cause of patient’s condition
□ Ability to benefit from skilled services
□ Tolerance & risks of therapy services
42
Physician Documentation
□ Tip to assist in obtaining all elements
from physician:
□ Develop a note at first interdisciplinary
team meeting that includes all required
elements to support medical necessity
□ Present it to physician for review and if
agrees; he/she may sign & it can be
added to patient’s medical record
43
Physician Certification
□ Submit physician’s certification &
subsequent recertifications of need for
continuing daily skilled SNF services
□ Submit dated physician’s orders for all
services billed, including those during
look back period
□ If orders for services rendered during look
back period were written prior to it, they
must be submitted with the documentation
44
Separate Forms
□ Include any separate forms used for
documentation of:
□ Medication, wound care, staging of
wounds, therapy minutes, weights, vital
signs, intake & output, enteral feedings,
nutritional consults, percentage of meals
consumed, bladder & bowel function
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MDS for each RUG
□ Submit corresponding MDS for each
RUG; If more than one billed = MDS for
each RUG code must be submitted
□ May include all MDS from start of care
through the dates of service billed
□ Submit all documentation used to
complete each MDS
□ Includes documentation to cover relevant
look back periods for each MDS submitted
46
Double Check
□ Prior to any planned discharge from
skilled care - MDS, therapy & billing
should review the Medicare claim
□ Make sure all required MDS
assessments completed as required &
documentation supports RUG
calculated by each MDS assessment
47
Double Check
□ Is Medicare primary?
□ Is beneficiary information correct?
□ Are benefit days available per CWF?
□ Qualified hospital stay dates confirmed?
□ Is cert/re-cert timely & complete?
□ Doctor orders to admit skilled included?
□ Are the dates of service correct?
48
Double Check
□ MDS assessments transmitted/accepted?
□ Does ARD match service date & within
allowed assessment window?
□ Does number of units/days agree with
assessment type?
□ Do RUGs & modifiers agree with MDS?
□ Is therapy plan of care signed & dated
by physician?
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Double Check
□ Check reported diagnoses to make sure:
□ Primary diagnosis is related to qualifying stay
□ Diagnoses are sequenced appropriately
□ Have all ancillary services been reported?
□ Did patient drop to a lower level of care?
□ Occurrence Code 22
□ Are therapy treatment codes on claim?
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POTENTIAL RISK &
BENCHMARKS
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Indicators of Potential Risk
□ Above average therapy & length of stay
□ High percentage of RU & RV categories
□ Long duration - ADL index shows low,
fluctuating or no improvement;
□ MDS validation reports - late completion
or transmission warnings may indicate:
□ Late/missed assessments; backdated
ARDs on assessments
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Benchmarks
□ Benchmarks provided by:
□ Centers for Medicare & Medicaid
Services
□ Office of Inspector General (OIG)
□ General Accountability Office (GAO)
□ Comparative Billing Report Contractor
□ PEPPER Report
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PEPPER
□ Administrator or CEO may access at:
http://pepperresources.org
□ Statistics for discharges/services
vulnerable to improper payments
□ Assists compliance efforts by identifying
outlier for risk areas & potential
overpayments/underpayments
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