Kerry Dunning, MHA, MSH, CPAR, RAC-CT

Kerry Dunning LLC

May 2017

Kerry Dunning has no proprietary interest in any product,

instrument, device, service, or material discussed during this

learning event.

This presentation was current at the time it was presented.

Medicare regulations and state policies change frequently so

this information is intended to be a general summary. It does

not take place of written law and regulations as the final source of information.

Do you believe your swing bed program is

in compliance with Medicare compliance?

YES

NO

NOT SURE

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After attending this presentation, attendee will be able to:

1. Recognize the need for improved focus on Swing Bed

Programs in CAH hospitals -- AUDITS

2. Demonstrate an understanding of the factors that impact

Medicare rate and revenue -- MEDICAL NECESSITY

3. Identify methods to improve swing bed related outcomes --

TEAMWORK

Comply with CoPs

Conform to Federal/State laws and regulations

Complete Medicare required paperwork

Admit patients appropriate to a post-acute, skilled level

of care

Use RAI and MDS

Meet medical necessity documentation requirements

Be compliant with billing and coding regulations

specific to skilled services

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Medicare requirements include:

Verification of days available for skilled nursing care

3 night qualifying stay

MSP

Physician Certification

Practical Matter

Physician Orders/H&P

Physician sign/date Therapy POC

Medical Necessity Documentation and Daily Documentation

ADLs

Beneficiary Notices

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1. How are your coders aware of primary services used

in skilled nursing?

2. When is the 3-midnight rule still in play?

3. Do you allow LOAs?

4. What services should not occur in a swing bed?

5. When are swing bed claims submitted?

6. How are you tracking outcomes? Trends? Cost?

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CERT-- Comprehensive Error Rate Testing

ZPICs-- Zone Program Integrity Contractor

MAC-- Medicare Administrative Contractor (FI)

GAO-- Government Accountability Office

RA – RAC Auditors

OIG – Office of Inspector General

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• One MAC recently reported that out of 508 errors identified in a CERT audit of certain Medicare claims, the contractor found that:

– 311 errors were due to “insufficient documentation.”

• Notably, a majority of the errors in this category were because the medical record “did not contain a valid physician’s signature” or because a diagnostic test performed “did not contain a valid physician’s order” or an identification of the provider who rendered the service

– 132 errors were due to “lack of medical necessity” based on the medical documentation submitted

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Findings of the 100 claims reviewed through February 2016 are as follows:◦ 54 claims were accepted◦ 35 claims received correction for the following reasons:

RUG level adjusted due to incorrect therapy minutes

No therapy orders

Occurrence code 50 (ARD)

Occurrence span code 70 (3 day stay)

6 claims were partially denied for the following reasons:◦ Incorrect therapy minutes/use of E-stim minutes toward total therapy minutes◦ Late certification/recertification

5 claims were denied in full for the following reasons: ◦ Untimely certification/recertification◦ No qualifying hospital stay◦ No skilled care◦ Incorrect billing

CAH Swing beds are exempt from SNF consolidated billing, however they do need to follow the direction in the CMS Internet Only Manual (IOM), Publication 100-4, Chapter 3, Section 10.4 on bundling hospital charges. These charges should be included on the 18X type of bill

Services provided by the CAH, while the beneficiary is inpatient in the CAH Swing bed that are considered exclusions from SNF Consolidated Billing, shall be billed on an 85X type of bill. All related outpatient charges shall be included on the 85X type of bill that would typically be billed for outpatient services.

As stated in the IOM, Publication 100-4, Chapter 3, Section 60, swing bed services must be billed separately from inpatient hospital services. Therefore, any swing bed patient who requires inpatient hospital services must be discharged from the swing bed and admitted as a hospital inpatient.

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Scenario: George, a Medicare patient, was in a covered swing bed stay receiving skilled nursing for complications related to a heart attack. During the stay, George began to complain of severe headaches, so the physician ordered a CT of the brain with and without contrast. After reviewing the exam, the physician determined the findings were normal and no additional treatment or skilled services were required, so the physician discharged George and he was free to go home. The CAH will bill the charges for the CT scan on an outpatient claim because the procedure is listed as one of the major categories for skilled nursing facility (SNF) consolidating billing.

TRUE OR FALSE?

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False. Although the CT scan is considered a major

category and is an “excluded” service under the SNF

PPS consolidated billing requirements, CAHs are

exempt from using the list and services provided while

the patient is in a CAH’s swing bed should be included

on the swing bed claim, regardless of the reason for the

service, the findings, or whether additional services

were required. <Social Security Act §§ 1888(e)(7),

1883(b)(3), 42 CFR 413.114, MLN Matters SE0606>

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What is skilled care?

◦ It is not ACUTE

Determination for skilled services:

◦ If the inherent complexity of the service is such that it can only

be performed safely and/or effectively under the general

supervision of skilled nursing or skilled rehabilitation

personnel

◦ A non-skilled service could be considered skilled when,

because of special medical complications, skilled personnel are

required to perform or supervise the service, or to observe the

patient

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Skilled Therapy

◦ Be directly and specifically related to an active treatment plan,

designed by the physician after consultation with a qualified

therapist

◦ Be of a level of complexity, or the patient’s condition such that the

judgment, knowledge and skills of a qualified therapist are required

◦ Be provided with an expectation that the condition of the patient

will improve in a reasonable and predictable period of time, or the

services must be required to establish a safe and effective

maintenance program

◦ Be reasonable and necessary under accepted standards of clinical

practice, in terms of the amount, frequency and duration of the

services

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Who –Performing, supervising and referring practitioners

What (and how many) –Services and quantities of services performed

Where –Place of service

When –Date of service

Why –Medical necessity and diagnosis

How –Interdisciplinary Team approach

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• Daily Documentation is required to reflect the skilled services being provided.

– Objective measures of the current level of assistance required for functional tasks

– A description of the skilled services provided

– Assessment of the patient's response to the services.

– Progress towards the treatment goals

– Documentation of any treatment variations with the associated rationale

– Accurate documentation of treatment time in minutes, to be recorded on the MDS

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The facility must conduct initially and periodically a

comprehensive, accurate, standardized, reproducible

assessment of each resident’s functional capacity

The assessment process must include direct observation and

communication with the resident, as well as communication

with licensed and non-licensed direct care staff members on

all shifts

State Operations Manual Appendix W -Survey Protocol, Regulations

and Interpretive Guidelines for Critical Access Hospitals

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The RAI helps Swing Bed staff look at patients holistically—as individuals for whom quality of life and quality of care are mutually significant and necessary. Interdisciplinary use of the RAI promotes this emphasis on quality of care and quality of life.

Importance? OIG Report: SNFs often fail to meet Care Planning and Discharge Planning Requirements (2013)

An interdisciplinary team that includes at least the attending physician and a registered nurse with responsibility for the beneficiary must prepare the care plan. SSA, § 1819(b)(2)(B), 42 U.S.C. 1395i–3(b)(2)(B).

OIG says discharge planning be conducted by an IDT including a physician

IDT can include SWB Coordinator, Therapy, Social Services, Dietary, Medicare Nurse/DON, etc.

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Do you meet every morning (or morning huddle with

nursing and therapy)? Once a week? Only at

Discharge?

Do you document discussions? Do you document on

individual charts?

How is the physician involved?

Medicare requires double checks –

what is yours?

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Who gets MSP and what is the double check?

If patients are coming from another hospital what is the

verification of the 3 midnight stay?

Who makes sure all the signatures are on patient rights?

What is the process for the patient’s care plan and

discharge planning?

Is the nursing admission assessment completed within

24 hours of admission and what is the swing bed policy

on completion?

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ADLs require review for accuracy of documentation

All documentation of functional level and assist should

be reviewed including ADL records, nursing progress

notes, and therapy evals and progress notes

ADL inservices for both the nursing assistants and

professional nurses should be routine

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Do you believe your swing bed program is in compliance with Medicare compliance?

YES

NO

NOT SURE

25

1.

2.

3.

4.

5.

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After attending this presentation, attendee will be able to:

1. Recognize the need for improved focus on Swing Bed

Programs in CAH hospitals -- AUDITS

2. Demonstrate an understanding of the factors that impact

Medicare rate and revenue -- MEDICAL NECESSITY

3. Identify methods to improve swing bed related outcomes --

TEAMWORK

Kerry Dunning LLC

• Ms. Dunning has 20 years in health care consulting and over 30 years in the industry.

• She specializes in the post-acute market working with hospital based skilled nursing

and swing bed programs, critical access hospitals, freestanding skilled facilities,

inpatient/outpatient rehab programs, inner city teaching hospitals and rural health care

systems.

• Ms. Dunning worked for HCA and HealthTrust hospitals in administrative roles;

Horizon Rehabilitation and ServiceMaster Rehabilitation as a Sr. Vice President and

Chief Operating Officer; with GPS Healthcare as the Chief Senior Services Officer;

and has spent more than 20 years as an independent consultant.

• In addition to serving as an Adjunct Instructor in the College of Health at the

University of North Florida, Ms. Dunning regularly leads workshops and webinars

regarding Medicare, skilled nursing (including MDS), swing bed programming, and

reimbursement cycle improvement. She also works on international health care

projects and research.

• Her favorite job is on-site helping facilities take better care of patients.

904-923-7229

Kerry.dunning@kerrydunningllc.com