Centers for Medicare & Medicaid Services (CMS) plans to closely scrutinize facility discharge practices to ensure safe and appropriate discharges. Released by CMS on December 26, 2017,
Survey and Certification (S&C) Letter,
, calls for greater scrutiny of Skilled Nursing Facility (SNF) discharges. CMS states that discharges violating federal regulations continue to be one of the most frequent complaints made to the State Long Term Care Ombudsman Program. CMS is encouraging survey agencies to send deficiencies "precipitated by facility-initiated discharges" to their Regional Office for review.
CMS has taken the position that facilities should "determine their capacity and capability of caring for the residents they admit" prior to admission. This would include having knowledge about the conditions of individuals they admit, including "behavioral, mental, and/or emotional expressions or indications of resident distress." In reality, information about the conditions and behaviors of the individuals admitted is often not available to the facility prior to admission. This is frequently due to limited knowledge of the referral source or withholding of information, and the pressing need for time sensitive admission acceptance decisions. The memo states "it should be rare that facilities who properly assess their capacity and capability of caring for a resident then discharge the resident based on the inability to meet their needs."
This provides yet another reason to believe that documentation will be paramount in telling the facility's side of the story. Information received before admission, information noted upon admission, and incidents that may lead to transfer or discharge need to be well represented in the resident's record. Facility response, changes to the plan of care, interventions and outcomes, and any support provided to promote the individual's highest level of functioning and attempts to meet their needs within the facility should be captured. Transfers and discharges, as always, must be considered carefully for each individual.
Therapy Code Update
Have you checked the updated therapy code list? One of the changes made related to therapy billing in the Healthcare Common Procedure Coding System (HCPCS) is deletion of code 97532, which is commonly used for Part B therapy services. For more information, visit the
2018 Medicare Learning Network MLN Annual Update
for the Therapy Code List. Remember to share this information with therapy and billing staff.
Coming Down the Pike
Bundled Payment Incentive...
CMS Innovation (Innovation Center) announced the launch of a new voluntary bundled payment model called Bundled Payments for Care Improvement Advanced (BPCI Advanced). Under traditional fee-for-service payment, Medicare pays providers for each individual service they perform. Under this bundled payment model, participants can earn additional payment if all expenditures for a beneficiary’s episode of care are under a spending target that factors in quality.
Bundled payments are intended to create incentives for providers and practitioners to work together to coordinate care and engage in continuous improvement and to keep spending under a target amount. BPCI Advanced Participants may receive payments for performance on 32 different clinical episodes, such as major joint replacement of the lower extremity (inpatient) and percutaneous coronary intervention (inpatient or outpatient). An episode model such as BPCI Advanced supports healthcare providers who invest in practice innovation and care redesign to improve quality and reduce expenditures.
Of note, BPCI Advanced will qualify as an Advanced Alternative Payment Model (Advanced APM) under the Quality Payment Program. In 2015, Congress passed the Medicare Access and CHIP Reauthorization Act or MACRA. MACRA requires CMS to implement a program called the Quality Payment Program or QPP, which changes the way physicians are paid in Medicare. QPP creates two tracks for physician payment – the Merit-Based Incentive Payment System, or MIPS, track and the Advanced APM track. Under MIPS, providers have to report a range of performance metrics and then have their payment amount adjusted based on their performance. Under Advanced APM, providers take on financial risk to earn the Advanced APM incentive payment.
In BPCI Advanced, participants will be expected to redesign care delivery to keep Medicare expenditures within a defined budget while maintaining or improving performance on specific quality measures. Participants bear financial risk, have payments under the model tied to quality performance, and are required to use Certified Electronic Health Record Technology. By meeting these requirements, the model qualifies as an Advanced APM. The 32 types of clinical episodes in BPCI Advanced add outpatient episodes to the inpatient episodes that were offered in the Innovation Center’s previous bundled payment model (the Bundled Payments for Care Improvement initiative), including percutaneous coronary intervention, cardiac defibrillator, and back and neck except spinal fusion.
The Model Performance Period for BPCI Advanced starts on October 1, 2018, and runs through December 31, 2023. Like all models tested by CMS, there will be a formal, independent evaluation to assess the quality of care and changes in spending under the model.
Applications must be submitted via the
, which will close on 11:59 pm EST on March 12, 2018. Applications submitted via email will not be accepted.
Follow-up to December
New SNF Survey Process Results
The new survey process was implemented on
November 28, 2017. With goals of achieving more efficiency and effectiveness, as well as focusing centrally on the resident, will the new nationwide process bring the desired results? Time will tell. While surveyors appear to be optimistic, they are still in their learning curve and are frequently referring to their guiding documents and online resources. We will bring you the November 28, 2017, to December 31, 2017, deficiency information in the February newsletter. In the meantime, collaboration, attention to detail, and the provision of resident centered care are the minimum expectations. Don't forget to incorporate the new
CMS survey pathways and other tools
in your routine through your Quality Assurance Performance Improvement (QAPI) program.
ACT Senior Living Consulting Services
The ACT Senior Living Consulting team can help you review reimbursement and billing practices to ensure you are accurately capturing services and optimizing reimbursement. The following are only a few of the services we offer:
- MDS/RAI and RUG system reviews
- Therapy service, documentation, coding, and billing reviews
- ADL coding review and education
- Restorative nursing program review, development, and assistance in implementation
- Clinical documentation system review to ensure adequate support, including identification of unnecessary or excess charting
- RN training in MDS, assessments, documentation
- Development, implementation, and support in achieving effective Medicare and triple-check meetings
Stay up-to-date with important news by accessing this newsletter and more in the
on our ACT website!