FY 2014 Final Rule and MDS 3.0 Updates

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This presentation includes a detailed review of changes and updates discussed to the MDS 3.0 item set effective October 1, 2013. The presentation provides an overview of the most recent MDS 3.0 User’s Manual updates and reviews key elements for MDS coding, which will impact reimbursement based on the Federal Regulations in the FY 2014 Final Rule.

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FY 2014 Final Rule and MDS 3.0 Updates

  1. 1. FY2014 and More HARMONY UNIVERSITY The Provider Unit of Harmony Healthcare International, Inc. (HHI) Presented by: Keri Hart, MS CCC-SLP, RAC-CT, CHHRP-QT Director of Rehabilitation & Reimbursement Education
  2. 2. Speaker Bio Nearly 30 Years Experience in Long-term Care Corporate Director of Clinical Reimbursement Services MDS Corporate Rehab Director Rehab Director SLP Cognition (Dementia and Head Injury) Head and Neck (Dysphagia and Voice) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 2
  3. 3. “It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is the most adaptable to change.” Charles Darwin Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 3
  4. 4. FY 2014 Final Rule: Impact on Providers
  5. 5. Final Rule On August 1, 2013, the Centers for Medicare & Medicaid Services (CMS) published the Final Rule for the Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities (SNF) for FY 2014 Effective October 1st, 2013 for FY 2014 Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 5
  6. 6. New SNF Rates The Final rule provides for a net market basket increase for SNFs of 1.3% beginning October 1, 2013 Full market basket increase of 2.3 percentage points Less a 0.5 percentage point multifactor productivity adjustment required by Section 3401(b) of the Affordable Care Act (ACA) Less 0.5 percentage point reduction to correct for an error in forecasting the market basket in FY 2012 Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 6
  7. 7. Impact on Providers CMS estimates that the net market basket update would increase Medicare SNF payments by approximately $500 million in FY 2014 Nationally projected $7 per Medicare patient day Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 7
  8. 8. Therapy Co-treatment RAI User's Manual reporting requirement for coding co-treatment minutes on the MDS Will not impact RUG calculation at this time Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 8
  9. 9. Therapy Co-treatment Indicator that CMS is concerned about over utilization Applies to Medicare Part A only When two clinicians (therapists or therapy assistants), each from a different discipline, treat one resident at the same time with different treatments, both disciplines may code the treatment session in full Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 9
  10. 10. Impact on Provider MDS Software Update required Rehab Software Update required Rehabilitation Staff reporting required on therapy logs Rehab reporting to MDS Ensure clearly defined Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 10
  11. 11. Distinct Days of Therapy Add MDS Item 00420 (Calendar Days of Therapy) Distinct calendar days of therapy Clarify that classification criteria for the Rehabilitation Medium RUG categories require that the resident receive 5 distinct calendar days of therapy Clarify that classification criteria for the Rehabilitation Low RUG categories require that the resident receive 3 distinct calendar days of therapy If not achieved the RUG would reduce to a Nursing RUG Applies to COT review and ARD Management Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 11
  12. 12. Distinct Days of Therapy Current RUG classification allows classification criteria for the Medium Rehab category without 5 distinct days of therapy Combination of 5 therapy visits Current RUG classification allows classification criteria for the Low Rehab category without 3 distinct days of therapy Combination of 3 Therapy visits plus 6 Days restorative in 2 areas Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 12
  13. 13. Distinct Days of Therapy Safety Net for missed therapy days Potential Nursing RUG despite significant therapy involvement Only 4 Distinct Calendar Days: Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 13 PT 4 X 240 OT 4 X 240 ST 4 X 240 720
  14. 14. Distinct Days of Therapy-Daily Basis The daily basis requirement can be met by furnishing multiple therapy types on different days of the week that collectively add up to "daily" skilled services CMS clarified that to meet this requirement the patient must actually need skilled rehabilitation services to be furnished on different days "It is not sufficient for the scheduling of therapy sessions to be arranged so that some therapy is furnished each day, unless the patient's medical needs indicate that daily therapy is required” Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 14
  15. 15. RAI Manual Updates Released September 2013 Section O: Skilled Procedures Distinct Days of Therapy Reporting Co-Treatment Minutes Section K: Nutrition % Intake Artificial Route While NOT a resident, While a Resident and “During Entire 7 Days” Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 15
  16. 16. Impact on Provider MDS Software Update required Rehab Software Update required Another factor in ARD Management Increase in Change of Therapy (COTs) Rate reduction retroactive 7 days Increase Lower 14 Nursing RUGs Increase audits and denials Increase in use of Short Stay Policy Providers still struggle with this Potential for Rehabilitation Medium patients to not meet Rehab skilled criteria Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 16
  17. 17. SNF Therapy Research Project “Currently, the therapy payment rate component of the SNF PPS is based solely on the amount of therapy provided to a patient during the 7-day look-back period, regardless of the specific patient characteristics” Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 17
  18. 18. SNF Therapy Research Project “As an initial step, the project will review past research studies and policy issues related to SNF PPS therapy payment and options for improving or replacing the current system of paying for SNF therapy services received” CMS has contracted with Acumen, LLC and the Brookings Institution to identify alternatives to the existing methodology used to pay for therapy services received under the SNF PPS CMS invites comments and ideas on the existing methodology Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 18
  19. 19. SNF Therapy Research Project CMS will “regularly” update the public on the progress of this project on the project Web site: http://www.cms.gov/Medicare/Medicare-Fee- forServicePayment/SNFPPS/therapyresearch. html Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 19
  20. 20. Impact on Providers SNF Therapy Research Project could significantly change the reimbursement model for therapy services provided under Medicare Part A Diagnosis may factor in Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 20
  21. 21. Presumption of Coverage “The establishment of the SNF PPS did not change Medicare’s fundamental requirements for SNF coverage” CMS proposes to continue presumption of coverage for beneficiaries correctly assigned to one of the upper 52 groups Automatically classified as meeting the SNF level of care definition up to and including the assessment reference date on the 5-day assessment Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 21
  22. 22. Presumption of Coverage “We note that this administrative presumption policy does not supersede the SNF’s responsibility to ensure that its decisions relating to level of care are appropriate and timely, including a review to confirm that the services prompting the beneficiary’s assignment to one of the upper 52 RUG–IV groups (which, in turn, serves to trigger the administrative presumption) are themselves medically necessary” Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 22
  23. 23. Impact on Providers Warning by CMS to ensure documentation of skilled coverage criteria in the first days of a Patient’s stay Potential increase in audits Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 23
  24. 24. Consolidated Billing Consolidated billing requirements are unchanged Acknowledged certain chemotherapy items, chemotherapy administration services, radioisotope services and customized prosthetic representing recent advances that might meet its criteria for exclusion from SNF Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 24
  25. 25. Consolidated Billing Corrections of error to the annual pricer exclusion files will show that HCPCS codes 11042, 11043, and 11044 (surgical debridement codes) will be corrected to ensure that they are excluded from consolidated billing “Flexibility to revise the list of excluded codes in response to changes of major significance that may occur over time (for example, the development of new medical technologies or other advances in the state of medical practice)’’ (65 FR 46791) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 25
  26. 26. Consolidated Billing-Reminder April 2013 The annual update file contains the complete list of HCPCS codes that are excluded from SNF CB for claims submitted to Fiscal Intermediaries/A/B MACS for payment Effective for claims with dates of service on or after 1/01/2013 unless otherwise noted below Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 26
  27. 27. Swing Beds FYI CMS notes that critical access hospitals (CAHs) will continue to be paid on a reasonable cost basis for SNF level services furnished under a swing bed agreement and that all non CAH swing bed rural hospitals continue to be paid under the SNF PPS Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 27
  28. 28. AIDS Add On 128 percent for SNF residents with Acquired Immune Deficiency Syndrome (AIDS) remains Transition from ICD-9-CM coding system to the ICD- 10-CM coding system starting October 1, 2014 ICD-10-CM diagnosis code of B20 for purposes of defining AIDS Add-On. Includes AIDS, AIDS related complex (ARC) and HIV infection, symptomatic Current code 042 also includes AIDS like syndrome and new Final code B20 does not Impact On Providers May exclude some patients from meeting criteria Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 28
  29. 29. Physician Assistants-Certification CMS finalized revisions to the regulation related to the SNF level of care certification and re-certifications by including Physician Assistants in the provision authorizing nurse practitioners and clinical nurse specialists to sign SNF level of care certifications and re- certifications Impact On Providers Allows additional Physician Extenders to sign Physician Certification Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 29
  30. 30. CMS Review Impact FY2012 Changes CMS concludes that it has found no evidence of possible negative impacts that had been anticipated by SNF providers in comments on the FY 2012 Final Rule, particularly the potential for a “double hit” from the combined impact of the recalibration of the FY 2011 SNF parity adjustment and the FY 2012 policy change Recalibration of the FY 2011 SNF parity adjustment to align with RUG-III Allocation of group therapy Implementation of changes to the MDS 3.0 patient assessment instrument, most notably adding the COT OMRA requirements Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 30
  31. 31. Distribution of MDS Assessments MDS FY2011 % FY2012 % Scheduled PPS 95 84 SOT 2 2 EOT 3 3 EOT/SOT Combined 0 0 EOT-R N/A 0 Combined SOT and EOT-R N/A 0 COT N/A 11 Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 31
  32. 32. FY2014 Transition Memo
  33. 33. FY2014 Transition Memo released September 20th Prior to RAI Manual Release Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 33
  34. 34. FY 2014 Transition An MDS may generate a RUG that bills for days in September 2013 (FY2013) and October 2013 (FY2013) The CMS transition policy dictates payment for these scenarios In short, MDSs with an ARD from October 1st through October 13th will generate a “FY2013 RUG” that will be communicated to billers through the MDS validation report process Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 34
  35. 35. FY 2014 Transition Facilities must ensure MDS/PPS Coordinators communicate with the Business Office to provide the MDS transmission validation reports to accurately bill The FY2013 transition RUG will be based on FY2013 RUG qualifications and the FY2014 will require the new requirements Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 35
  36. 36. Distinct Calendar Days of Therapy MDS Change: For all assessments with an ARD on or after 10/1/2013 must include Item O0420 (Distinct Calendar days) must be coded with the number of distinct calendar days that the resident received therapy services Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 36
  37. 37. Distinct Calendar Days of Therapy RUG IV: Extensive Rehabilitation and Rehabilitation Medium and Low Categories Extensive Rehabilitation and Rehabilitation Medium and Low Categories Criteria Change: Rehabilitation Medium must have greater than 5 Distinct Calendar Days and 150 Minutes of Therapy; Rehabilitation Low must have 3 distinct calendar days and 45 minutes of therapy with 2 rehabilitation/restorative nursing for 6 days Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 37
  38. 38. Distinct Calendar Days of Therapy COT reviews completed on or after October 1st follow FY2014 requirements of Distinct Calendar Days to meet Rehab Medium and Low Criteria Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 38
  39. 39. Swallowing and Nutritional Status Items MDS Change: For all assessments with an ARD on or after 10/1/2013 must include K0710A and item K0710B with the proportion of total calories the resident received through parental or tube feeding and the average fluid intake per day by IV or tube feeding, respectively RUG IV: Special Care High (fever) / Low and Clinically Complex (ADL=0-1) K0710A and item K0710B3 must be coded Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 39
  40. 40. FY2013 Transition RUG September Days Billed October Days Billed ARD on or before 9/30/13 Bill actual RUG for all days of service associated with that assessment even if some of those days of service are on or after 10/1/2013 Bill actual RUG for all days of service associated with that assessment even if some of those days of service are on or after 10/1/2013 ARD 10/1/2013 through 10/13/2013 FY2013 transition RUG should be used to bill any days of service before 10/1/2013 which are associated with that assessment Bill actual RUG for FY2014 for days on or after October 1st 2013 ARD date after 10/13/2013 Not Applicable Bill actual RUG for FY2014 for days on or after October 1st 2013 Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 40
  41. 41. FY2013 RUG An MDS with an ARD after 10/13/13 will not report a transitional RUG as there is not a scenario when a MDS with an ARD on or after 10/14/13 will pay for days both in September and October 2013 Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 41
  42. 42. FY2014 Harmony Healthcare (HHI) recommends implementing FY2014 RUG requirements for ARD planning prior to the implementation date of October 1st Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 42
  43. 43. Co treatment Facilities are also reminded that effective ARD 10/1/13, MDSs must also include of Co- Treatment Minutes Item to MDS 3.0 (items O0400A3A, O0400B3A, and O0400C3A) Co-treatment must also be included in individual minutes to calculate RUG There is no change to the Rehabilitation RUG categorization requirements for co-treatment; therefore, there is no transitional RUG required Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 43
  44. 44. PEPPER: Program for Evaluating Payment Patterns Electronic Report
  45. 45. PEPPER This report will the SNFs detailed Medicare claims data in certain targeted areas and compare he SNF to other SNFs nationally Skilled Nursing Facilities (SNFs) should have received via mail on or about August 30, 2013 Envelope with red print on the outside containing your facility specific PEPPER Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 45
  46. 46. PEPPER PEPPER gives provider-specific Medicare data statistics for services vulnerable to improper payments Allows providers to see how their facility compares to all other SNFs across the state, nation or Medicare Audit Contractors(MAC) jurisdiction. PEPPER data is also shared with both Medicare Audit Contractors (MACs) and the Medicare Recovery Auditor Contractors (RACs). Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 46
  47. 47. PEPPER Targeted areas were derived from two recent Office of Inspector General (OIG) Reports: “Inappropriate Payments to skilled Nursing Facilities Cost Medicare than a Billion Dollars in 2009” (November 2012) “Questionable Billing by Skilled Nursing Facilities” (December 2010) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 47
  48. 48. Claims Data The SNF PEPPER provides SNFs with their jurisdiction, state and national percentile values for each target area with reportable data for the most recent three fiscal years FY 2012 (October 1 2011 through September 30th )is displayed on the first table When the target (numerator) count is less than 11 for a target area for a time period, statistics are not displayed Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 48
  49. 49. Target Areas Therapy RUGs with High ADLs Nontherapy RUGs with High ADLs Change of Therapy Assessment Ultra High RUGs Therapy RUGs 90+ Day Episodes of Care Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 49
  50. 50. Episode of Care Based on episodes of care Defined as a series of claims for a patient where the difference between the “Through Date” of one claim and the “From Date” of the subsequent claim is less than or equal to thirty days Admission through Discharge Considered same Episode of Care if readmission to SNF (billed again) within 30 Days of discharge Data includes episodes of care that end in period reported Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 50
  51. 51. Therapy RUGs with High ADLs Numerator : Count of days billed within episodes of care ending in the report period for Rehabilitation and Rehabilitation Extensive RUGs All Rehab “C” or “X” Days Also includes RLB Denominator : Count of days billed within episodes of care ending in the report period for all Rehabiliattion RUGs Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 51
  52. 52. Nontherapy RUGs with High ADLs Numerator : Count of days billed within episodes of care ending in the report period for Nursing RUGs All Non Therapy “E”Days Also includes BB1 and BB2 (Low ADL) Denominator : Count of days billed within episodes of care ending in the report period for all Nursing RUGs Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 52
  53. 53. Change of Therapy Assessment Numerator: Count of assessments with AI second digit equal to “D” within episodes of care ending in the report period “D” is a Change in Therapy Assessment (COT) Denominator: Count of all assessments within episodes of care ending in the report period COT initiated October 1st 2011 (FY2012) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 53
  54. 54. Ultrahigh Therapy RUGs Numerator: Count of days billed within episodes of care ending in the report period with RUG equal Rehabilitation Ultra High or Ultra High Extensive (RUC,RUB,RUA,RUX,RUL) Denominator: count of days billed within episodes of care ending in the report period for all Rehabilitation RUGs Not Total RUGs Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 54
  55. 55. Therapy RUGs Numerator: Count of days billed within episodes of care ending in the report period for Rehabilitation RUGs Denominator: Count of days billed within episodes of care ending in the report period for all RUGs Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 55
  56. 56. 90+ Day Episodes of Care Numerator: Count of episodes of care ending in the report period with a length of stay of 90+ days Denominator: Count of all episodes of care ending in the report period Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 56
  57. 57. Compare Target Report Page 1 (after introduction) FY2012 only When the SNF’s percent is at or above the national 80th percentile for a target area, the SNF’s percent is printed in red bold When the SNF’s percent is at or below the national 20th percentile for a target area the SNF percent is printed in green italics When the SNF is not an outlier, the SNF’s percent is printed in black Blank if Less than 11 SNFs in group Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 57
  58. 58. Target Count Number of Episodes of Care Shows Volume of Care The “Target Count” can also be used to help prioritize areas for review Areas in which a provider is at/above the 80th percentile that have a large target count may be given higher priority than target areas for which a provider is at/above the 80th percentile that have a smaller target count Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 58
  59. 59. Percentiles Percentiles are calculated for each of the three comparison groups State Medicare Audit Contractor (MAC/FI) jurisdiction Nation SNF are to focus on National Data Given the MAC may potentially use data for Additional Documentation Requests (ADR) reviews, all data is important SNFs whose target percents are at or above the 80th percentile (i.e., in the top 20 percent) are considered at risk for improper Medicare payments with areas at risk for overcoding SNFs whose target percents are at or below the 20th percentile (i.e., in the bottom 20 percent) are considered at risk for improper Medicare payments with areas at risk for undercoding Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 59
  60. 60. Target Area Reports Target area graph provides a visual representation of the SNF’s target area percent over three years Target Area SNF Data Table titled “Your SNF” includes total number of episodes of care for the target area (numerator) and total (denominator) Roughly correlates to Patients Episodes Based on the definition of the target area Comparative Data for National, State and Jurisdiction Some include 80th and 20th Percentile Some only include 80th percentile Average Length of Stay for the numerator and for the denominator Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 60
  61. 61. Target Area Reports CMS has developed “suggested interventions” that SNFs may consider when assessing their risk for improper Medicare payments These are “generalized suggestions and will not apply to all situations” Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 61
  62. 62. Suggested Interventions Therapy or Non-Therapy RUGs with High ADLs greater than 80th Percentile “This could indicate a risk of potential over coding of beneficiaries’ activities of daily living (ADL) status. The SNF should determine whether the amount of assistance beneficiaries need with ADLs as reported on the MDS is supported and consistent with medical record documentation.” Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 62
  63. 63. Suggested Interventions Therapy or NonTherapy RUGs with High ADLs less than 20th Percentile “This could indicate a risk of potential undercoding of beneficiaries’ADL status. The SNF should determine whether the amount of assistance beneficiaries need with ADLs as reported on the MDS is supported and consistent with medical record documentation.” Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 63
  64. 64. Suggested Interventions Ultrahigh Therapy RUGs greater than 80th Percentile “This could indicate that the SNF is improperly billing for therapy services. The SNF should determine whether therapy provided was reasonable and medically necessary, and that the amount of therapy reported on the MDS is supported by documentation in the medical record.” Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 64
  65. 65. RUG Reports SNF Top RUGs Report for all episodes of care lists the top RUGs by number of days SNF Top RUGs Reports episodes of care with 90+ days lists the top RUGs by number of days Jurisdiction-wide Top RUGs Reports Report for all episodes of care lists the top RUGs by number of days Jurisdiction-wide Top RUGs Reports episodes of care with 90+ days lists the top RUGs by number of days Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 65
  66. 66. RUG Reports Each RUG Report Includes Total episodes of care in the report period RUG code and description Number of RUG days billed Percent of RUG days to total days Percent of episodes of care with the RUG billed total episodes of care Average length of stay for the RUG Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 66
  67. 67. PEPPER Impact on Providers: Potential targeted audits in the areas listed on the PEPPER Opportunity to identify risk areas of over utilization to ensure documentation supports Opportunity to Identify areas of underutilization that to ensure facility is properly reimbursed for care provided and ensuring patients have access to Medicare benefits Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 67
  68. 68. Audit Environment: More Changes
  69. 69. Increase in Medicare Documentation Reviews Significant increase in the number of medical review requests from Medicare Administrative Contractors (MACs) Medicare Part A and B Billing inconsistencies ICD-9 Coding triggers Similar pattern to Medical Record Reviews within the nursing facility setting in the early 90's Number of "Help Letters“ was astoundingly high Investigations into potential fraudulent billing practices increased Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 69
  70. 70. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 70Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 70 Zone Program Integrity Contractor (ZPIC) Goal is to identify Fraud CMS launched another major initiative to target providers other than the hospital setting as the RAC auditors have been focusing on hospital audits Southeast, South Central, Midwest, Northeast and West Coast regions of the U.S. are seeing the most ZPIC audits at this time
  71. 71. Unified Program Integrity Contractor (UPIC) CMS is developing a new integrity contractor called a Unified Program Integrity Contractor (UPIC). The previous Medicare Administrative Contractors (MACs) and Zone Program Integrity Contractors (ZPICs) will comprise the new contractor, though MACs will not disappear entirely, they will simply be absorbed by the UPIC. This contractor will focus on both Medicare and Medicaid integrity issues. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 71
  72. 72. Medicare Recovery Auditors (RAs) Recovery Audit Contractors (RACs) are now known as The Medicare Recovery Auditors (RAs) The RAs post what area they are targeting on the web. Providers are able to review their jurisdiction’s website for an update on what the RAs are finding in their data collection. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 72
  73. 73. Medicare Recovery Auditors (RAs) RAs review claims on a post-payment basis There are three types of review: Automated (no medical record needed) Semi-Automated (claims review using data and potential human review of a medical record or other documentation) Complex (medical record required) Look back up to three years from the date the claim was paid Required to employ nurses, therapists, certified coders and a physician CMD Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 73
  74. 74. Be Prepared Give Clinically Appropriate Care Understand Medicare Coverage requirements Technical Clinical Accurately document care provided Bill accurately Respond to documentation requests timely and completely Communicate trends and audit outcomes to staff Get back to Basics !! Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 74
  75. 75. Medicare Part B: Things are Getting Complicated
  76. 76. Overview of the Functional Reporting Medicare Part B Implemented Functional Reporting with a 6- month testing period January 1 through June 30, 2013 Claims will be returned/rejected without applicable G-codes and modifiers for dates of services on or after July 1st 2013 G-Code FAQ released clarifying clinical coding Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 76
  77. 77. Overview of the Functional Reporting Q6) Can therapists use any of the G- Code sets or are they limited to those corresponding to their discipline? A6) The category G-Codes sets are not discipline specific. The G-code set that best describes the functional limitation being treated should be used, regardless of your discipline. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 77
  78. 78. Overview of the Functional Reporting Q10) When I begin reporting on my patient’s second functional limitation, how do I report the severity of its current status? Do I use the severity modifier that reflected the current status at the time of the initial evaluation or the one from the time I began reporting? A10) The severity modifier used to indicate the beneficiary’s current status, reflects the severity of the functional limitation at the time of the visit for which Functional Reporting occurred Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 78
  79. 79. Overview of the Functional Reporting Q12) How do I report the functional information when I provide an evaluation only and determine that the patient does not need further therapy services? A12) For one-time visits, you report all three G-Codes for the functional limitation being evaluated, along with the corresponding severity modifiers for each Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 79
  80. 80. Overview of the Functional Reporting Q14) How do I report an evaluative procedure when it is for a different functional limitation than I am currently reporting? A14) You should report the evaluative procedure furnished for a second/different functional limitation other than the primary functional limitation for which ongoing reporting is occurring as a one-time visit (i.e., report all three (3) G-Codes in the code set for the functional limitation that most closely matches that for which the evaluative procedure was furnished) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 80
  81. 81. Overview of the Functional Reporting A14 (Cont.) The ongoing reporting of a primary functional limitation is not affected by the reporting of a one-time visit with s all three (3) G-Codes in a code set are reported for the secondary functional limitation Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 81
  82. 82. Overview of the Functional Reporting Section 3005(g) of the Middle Class Tax Relief and Jobs Creation Act (MCTRJCA) amended Section 1833(g) of the Social Security Act to require a claims-based data collection system for outpatient therapy services The system will collect clinical data on beneficiaries function during the course of therapy services in order to better understand beneficiary conditions, outcomes, and expenditures. This data will be used in developing an improved payment system. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 82
  83. 83. Overview of the Functional Reporting Implementation will not directly impact reimbursement at this time No actual payment for G Codes billed Data collection process that likely will be used at a later date to reform Medicare Part B Therapy billing and caps Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 83
  84. 84. Impact on Provider Complicates Medicare Part B Billing Complicates documentation requirements for clinicians. Potential denials if documentation requirements to support G Code reporting are not met Increased Medicare Part B billing rejections Data may be used for audits Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 84
  85. 85. Manual Medical Review for Medicare Part B-April 2013 Similar to the therapy cap, there is a threshold of $3,700 for PT and SLP services combined and another threshold of $3,700 for OT services. Such requests for exceptions will be manually medically reviewed. 85Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved
  86. 86. Manual Medicare Reviews for Medicare Part B-April 2013 April 2013: No longer required to submit requests for exceptions to the threshold in advance of furnishing therapy services above the $3700 Recovery Auditors (RAC) will now conduct prepayment review for all claims processed on or after April 1, 2013. The specific process for Manual Medical reviews is based on what state services are provided. 86Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved
  87. 87. Manual Medicare Reviews for Medicare Part B-April 2013 Pre-Payment Review: Claims submitted in the Recovery Audit Prepayment Review Demonstration states will be reviewed on a prepayment basis These states are Florida, California, Michigan, Texas, New York, Louisiana, Illinois, Pennsylvania, Ohio, North Carolina, and Missouri Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 87
  88. 88. Manual Medicare Reviews for Medicare Part B-April 2013 Post-payment Review: In the remaining states, the Recovery Auditors will conduct “immediate post-payment review.” The MAC will flag the claims that meet the criteria, request additional documentation and pay the claim. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 88
  89. 89. Manual Medicare Reviews for Medicare Part B-April 2013 The MAC will send an ADR to the provider requesting the additional documentation be sent to the Recovery Auditor The Recovery Auditor will conduct post payment review and will notify the MAC of the payment decision. The facility’s MAC will then notify the therapy provider of the outcome of the decision. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 89
  90. 90. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 90 http://info.harmony-healthcare.com/symposium2013 Using the Promo code
  91. 91. Questions/Answers Harmony Healthcare International 1 (800) 530 – 4413 Khart@harmony-healthcare.com www.harmony-healthcare.com Harmony Healthcare International, Inc. 9191Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.
  92. 92. Harmony Healthcare International Have you Considered a Customized Complimentary HARMONY(HHI) MEDICARE PROGRAM EVALUATION or CASE MIX ANALYSIS for your Facility? Perhaps your facility has potential for additional revenue Benchmark your facility against key indicators and national norms Email us at for more information RUGS@harmony-healthcare.com Analysis is cost & obligation free Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved 92Harmony Healthcare International, Inc.

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