Medicare Forum

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Q Is it acceptable to leave the discharge/re-entry forms only in the electronic file, or must we print, sign and date them and place them in the resident's chart?
A Source: State Operations Manual: Guidance to Surveyors -- Long Term Care Facilities. Tag number: F286

Intent: Facilities are required to maintain 15 months of assessment data in the resident's active clinical record.

Guildelines: The requirement to maintain 15 months of data in the resident's active clinical record applies regardless of form of storage to all MDS forms, RAP Summary forms, Quarterly Assessment forms, Face Sheet Information and Discharge and Reentry Tracking Forms as required during the previous 15 month period.

The information must be kept in a centralized location, accessible to all professional staff members (including consultants) who need to review the information in order to provide care to the resident.

If the facility has a "paperless" system in which each resident's clinical record is entirely electronic, the facility does not need to maintain a hard copy of the forms. to qualify for this exception, the facility's MDS system must meet the following minimum criteria:

  • The system must maintain 15 months' worth of assessment, Discharge and Reentry data and must be able to print all assessments, Discharge and Reentry forms for that period upon request;
  • The facility must have a back-up system to prevent data loss or damage;
  • The information must always be readily available and accessible to staff and surveyors;
  • The system must comply with requirements for safeguarding the confidentiality of clinical records; and,
  • The facility must maintain evidence that identifies the Registered Nurse Assessment Coordinator and other staff members that completed a portion of the assessment.
    (Brian R. Schoeneck, WAHSA)
Q Is it acceptable to leave the discharge/re-entry forms only in the electronic file, or must we print, sign and date them and place them in the resident's chart??
A Check back soon for the answer to this question.(Brian R. Schoeneck, WAHSA)
Q We are admitting a resident on hospice. Do we have to follow PPS procedures for this resident?
A No. A beneficiary who has elected hospice and is currently being treated for the terminal illness is not affected by SNF PPS. The hospice assumes the ongoing responsibility for the beneficiary's comprehensive care needs. (Brian R. Schoeneck, WAHSA)
Q My facility is scheduled to begin PPS on January 1, 1999. With the June 22, 1998 MDS data submission requirement, do we have to complete Section T of the MDS? I thought this was only for use under PPS.
A Completing Section T, therapy supplement for Medicare PPS, will be required for Medicare Part A residents when the nursing facility begins Medicare PPS, which is January 1, 1999 for this facility.

I recommend that nursing facilities, in preparing for the start of Medicare PPS, complete Section T on existing Medicare residents prior to January 1, 1999 so the facility can estimate its facility Medicare case mix and revenues under PPS. (Brian R. Schoeneck, WAHSA)

Q We have to use HCPCS codes for part B therapy billing starting in July. I have a HCPCS book, but where do I find out how much I should bill for each HCPCS code?.
A The Balanced Budget Act requires HCFA Common Procedure Coding System (HCPCS) coding on all SNF Part B bills when Medicare Part A benefits are exhausted or the resident does not have Medicare Part A coverage. HCPCS includes CPT-4 codes. HCFA announced in July that the portion of the original consolidated billing instructions which dealt with the Part B stay (Part A benefits exhausted, post hospital or level of care requirements not met) has been delayed indefinitely. Revised fee schedules for individual items and services are not yet available from HCFA. (Brian R. Schoeneck, WAHSA)
Q Can a facility contract with multiple vendors whereby each vendor does the billing for their particular service using the facility's provider number? The facility would receive payment from Medicare and pay the vendors a contracted amount.
A A SNF may contract with an outside entity to perform on the SNF's behalf the actual tasks involved in completing and submitting the Medicare bill; however, the SNF may not "assign" to any other entity the legal responsibility for the claim or the right to receive Medicare payment. Payment from Medicare must be issued to the SNF itself. HCFA has announced an indefinite delay for the portion of consolidated billing for a Part B stay. (Brian R. Schoeneck, WAHSA)
Q What are the assessment and payment rules for Medicare residents in the SNF prior to July 1, 1998?.
A Let's assume this is a Medicare resident in a Part A covered stay, admitted in the 30 days before the SNF became subject to PPS, and had an MDS completed during those 30 days. The SNF may choose to use the most recent full MS assessment completed within the past 30 days for RUG-III classification. This classification would be effective on the first day the SNF begins PPS and would be used to determine the payment the SNF receives for the Medicare resident for the first 14 days the facility is in the new system. The next assessment must be completed by the 14th calendar day of the month the facility entered the PPS. Another option is for the facility staff to choose to treat the Medicare resident as a "new" admission on the first day of the facility's PPS. In this instance, a Medicare 5-day assessment must be performed as if the day the facility enters the PPS is day 1 of the resident's Part A SNF stay. (Brian R. Schoeneck, WAHSA)
Q What should SNFs report on the MDS 2.0, Section T, #3, case mix group?
A Under the Medicare section, report the RUGs-III alpha code that is generated from the grouper software. Leave the State section blank or report "0." The State section is only for states who have implemented a Medicaid prospective payment system. (Billie March, RAI Coordinator, Wisconsin Bureau of Quality Assurance)
Q MDS 2.0 Section P Special Treatments and Procedures, b. Therapies -- Does evaluation time count as minutes for the various therapies under Section P of the MDS 2.0?
A Evaluation minutes can not be used in completing Section P of the MDS unless actual treatment occurred during the evaluation. An evaluation only can not be recorded as minutes in section P of the MDS. Only minutes of treatment provided post-admission can be included in Section P. To assure that maximum minutes can be obtained, admission orders should read " ___ (OT/PT/SLP) evaluation and treatment per plan of care." This would allow the therapist to begin an active course of treatment immediately instead of waiting for clarification from the physician.(Theresa Lang, SMS Consulting, Milwaukee)
Q As we prepare our budget for 1998 we need to input some number in anticipation of lab, x-ray, and other costs that now are included in the PPS medicare rate. Do you have any information from HCFA as to what this amount is per patient day or by percentage of total PPS rates?
A As a guide in budgeting lab costs, the range we typically see for lab service cost for Part A residents in facilities that have been billing Medicare Part A is $2.50 to $4.00 per patient day. X-ray costs run in the range of $2.00 to $3.50 per patient day. Use the acuity levels of your historical Medicare Part A patients as a guide in determining whether to budget at the lower or higher ends of these ranges. (David Beck, SMS Consulting, Milwaukee)
Q Regarding Section P7 and P8 on the MDS -- For Medicare patients' 14 day assessment, according to the MDS we should answer these questions for the last 14 days. If we do this, we will be including physician orders and visits that already have been counted on the 5-day assessment. Is there a problem with that?
A The five day Medicare PPS assessment will include the MD visits and days of order changes since admission only. Yes, the 14 day Medicare PPS assessment will potentially include some of the same visits and/or order changes. Do not exclude these because they were counted in the first assessment. USE THE REQUIRED NUMBER OF DAYS FOR THE ASSESSMENT without regard to previous assessments and duplication of information.(Theresa Lang, SMS Consulting, Milwaukee)

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Wisconsin Association of Homes and Services for the Aging
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Madison, WI 53703
Telephone: (608)255-7060 FAX:(608)255-7064