Keane Care

RAI Manual Changes - April 2012
CMS has released the revised RAI Manual to accompany the MDS 3.0 changes that go into effect April 1, 2012. Many small changes were made to the form, with significant changes made to resident interviews for unplanned discharges and asking residents about returning to the community.

Use the link below to open the zip file containing revised manual pages.

Note to Keane clients: our update for these changes is in beta release with general release scheduled for the first week in March.

MDS 3.0 Training Materials Website

New Quality Measures Scheduled for Release
CMS staff reported on the new Quality Measures based on MDS 3.0 at the SNF Open Door Forum call on January 19. The MDS 3.0 Quality Measures are on schedule to be released April 19, 2012 on Nursing Home Compare. SNFs scores will be posted as a private preview on the CASPER system by the end of January 2012. The final QMs will be posted in February and a decision about which will be used for 5 Star Ratings will be made by April 2012.

The draft list follows and is made up of 11 Short-Stay QMs and 18 Long-Stay QMs. Briefly, a Short Stay is 100 or fewer cumulative days in facility. A Long Stay is 101 days or more.

Short Stay Quality Measures
Percent of residents:
- on a Scheduled Pain Medication Regimen on Admission who self-report a decrease in pain intensity or frequency
- who self-report moderate to severe pain
- with pressure ulcers that are new or worsened
- were assessed and appropriate given seasonal flu vaccine
- received the seasonal flu vaccine
- were offered and declined seasonal flu vaccine
- did not receive seasonal flu vaccine, due to medical contraindication
- were assessed and appropriately given Pneumococcal vaccine
- received Pneumococcal vaccine
- were offered and declined Pneumococcal vaccine
- did not receive Pneumococcal vaccine due to medical contraindication

Long Stay Quality Measures
Percent of residents:
- experiencing one or more falls with major injury
- who self report moderate to severe pain
- high-risk residents with pressure ulcers
- with a urinary tract infection
- low-risk residents who lose control of their bowel or bladder
- who have/had a catheter inserted and left in their bladder
- who were physically restrained
- whose need for help with activities of daily living has increased
- who lose too much weight
- who have depressive symptoms
- were assessed and appropriately given the seasonal flu vaccine
- received the seasonal flu vaccine
- were offered and declined seasonal flu vaccine
- did not receive seasonal flu vaccine, due to medical contraindication
- were assessed and appropriately given the Pneumococcal vaccine
- received the Pneumococcal vaccine
- were offered and declined Pneumococcal vaccine
- did not receive Pneumococcal vaccine, due to medical contraindication

MDS 3.0 Technical Information

FAQ re: Non-compliance with 5010 Claims
CMS has published six Questions and Answers regarding its plan for a 90-Day Discretionary Enforcement Period for non-compliance with the 5010 standard for electronic claims. Click the link below to view the Q&A.

Note to Keane Clients: Version 5010 bill specifications have been created and released for all Medicare Administrative Contractors, Fiscal Intermediaries and states that were in use in 2011 (this does not include custom specs that you created). You should be in production mode or be in the testing process for the payors you bill electronically unless the payor has instructed you otherwise.

FAQs

2012 Medicare Deductibles, Coinsurance, and Therapy Caps - Updated
CMS has released the updates for these 2012 rates:

- Inpatient deductible is $1,156.00
- SNF Coinsurance is $144.50 for days 21-100
- Part B Deductible is $140.00

Use the link below to download the CMS MLN Matters article.

Therapy caps for calendar year 2012 will be $1880 ($1880 for PT and Speech therapy combined, and a separate $1880 for Occupational Therapy). The caps are for outpatient therapy under Part B.

In 2005 exceptions to the therapy caps were initiated for medically necessary services. These exceptions apply to much of the therapy provided to SNF patients. The exceptions were extended through CY 2011, and are scheduled to expire on December 31, 2011. The update added December 7 says that if the exceptions are extended, CMS will provide more information.

Activities are underway to encourage legislative action to extend the exceptions.

MedLearn Matters MM7567 Updated 12

MMLN on Therapy Cap Values for CY 2012

ICD-10 Diagnosis Code Updates Released
CMS has posted the 2012 ICD-10 CM code updates, including the 2012 ICD-10 index, General Equivalence Mappings (GEMs), and information on preparing to implement the revised set of codes for diagnoses. Implementation of ICD-10 codes is less than 2 years away --October 1, 2013.

The link below takes you to CMS' Overview page with links to many resources on ICD-10.

Note to Keane Care clients: We are scheduling release of ICD-10 for first quarter 2013 to provide ample time for our clients to become familiar with working with the codes. in your system.

CMS' ICD-10 Overview page

5010 Delay in Enforcement
On November 17, 2011, the CMS Office of E-Health Standards and Services (OESS) announced that it would not initiate enforcement action until March 31, 2012, with respect to any HIPAA-covered provider that is not in compliance with the ASC X12 Version 5010 (Version 5010) standards for electronic claims.

The compliance date for use of these new standards remains the same, January 1, 2012 for providers even though enforcement action will not be applied until March 31, 2012. See CMS' statement for more information (link below).

Note to Keane Care Clients: Keane intends to carry out our original schedule, but please check our 5010 Update Report for the release date for your state. Our Update Report is posted on the clients-only section of our Website and is updated regularly. Use link below.

Keane 5010 Progress Report

CMS statement on Enforcement Delay

H@ MDS Login Procedure Changing
CMS is changing how LTC facilities connect to CMSNet to transmit MDS files -- from AT&T to Verizon. It will affect your h@ login ID and will make it easier to connect. This will not affect your login ID for all other accounts (CASPER Login ID and State Login ID).

The CMSNet migration is tentatively scheduled to begin November 15, 2011 and will be completed by the end of the first quarter of 2012. It is being phased in by state. For your start date, see the Migration Schedule that you can download from the QTSO Website along with an Installation Guide, and Frequently Asked Questions. Use the link below.

QTSO Website

MDS 3.0 & RUG-IV Clarifications
At CMS's SNF National Provider call of November 3, 2011, officials reviewed issues related to the FY2012 MDS 3.0 and RUG-IV changes and clarified points that have been questioned.

Included in the slides from the call is the new assessment schedule, Q&A on combining scheduled and unscheduled PPS assessments (Start of Therapy, EOT/EOT-R, and COT), and exactly what a facility must consider for a COT (Change-of-Therapy) OMRA (slides 13-24).

Other clarifications were about timing of COT OMRAs when they coincide with day of discharge and with scheduled PPS assessments: for example, if the ARD of a scheduled PPS assessment is set for Day 7 or prior of the COT observation period, then no COT is required.

Please note that you don't have to combine a scheduled assessment, such as a 14-day, with a COT when the 7th day of the COT observation period is day 14 and you planned to do the 14-day assessment on day 14. This means that if a Rehab RUG is lower during this COT observation period then it doesn't go back to day 8--the new RUG can start on day 15.

Leave of Absence policies were also clarified in the presentation. Open the slides from the link below (scroll down to the Downloads section).

Slides from SNF National Provider Call

RAI Manual Chapter 6 update posted
The rules for carrying out Change of Therapy and EOT-R OMRAs are now in Chapter 6 of the RAI manual (V1.07) dated October 2011. The chapter includes

Characteristics of the RUG-IV classifications

Explanations of the AI Code (last 2 positions of the HIPPS code used for billing)

Rules on combining assessments when there are more than one assessment within one PPS scheduled assessment window (pages 6-8 thru 17).

Walk-thru that puts into words the software calculations that determine a RUG-IV score.

To download updated Chapter 6, use the link below (scroll to Downloads/MDS 3.0 RAI manual (V1.07) zip file.

MDS 3.0 Training Materials Website

Leave of Absence & COT Clarification
The revised guidance document (see the October 6 entry) has generated additional questions about the Leave of Absence policy and NASL has submitted them to CMS. An example:

Question: Wednesday is Day 2 of the COT observation window, and the patient receives 100 minutes of PT and OT therapy services during the day. However, that night the patient is taken to the emergency room at 9:00 PM and returns to the SNF on Thursday morning at 10:00 AM and resumed therapy treatments later that day. The overnight LOA makes Wednesday a non-billable day, but in considering whether a COT OMRA is necessary, would the 100 minutes provided on the LOA day count toward the 7-day COT window?

CMS Response: The 100 minutes would count for the COT observation period. I would note, just to be clear, that if a COT OMRA is deemed necessary, even after including those 100 minutes, the LOA day would still not be billable to Medicare.

Errors in recent RAI manual
CMS has posted an document listing errors in the most recent RAI Manual. The most substantive error is to Page 2-56 Section 2.11 Combining Medicare Assessments and OBRA Assessments: the text does not reflect the new PPS assessment schedule and will be corrected to read:

"For Medicare, the ARD must be set for days 13 or 14, but the regulation allows grace days up to day 18. However, when combining a 14-day Medicare assessment with the Admission assessment, the use of grace days for the PPS assessment would result in a late OBRA Admission assessment. To assure the assessment meets both standards, an ARD of day 13 or 14 would have to be chosen in this situation."

For the full list of errors, use the following link.

RAI Errata document

Updated! Q&A from Aug 23 and Sept 1 Open Door Forums
CMS has updated the pdf that was posted on September 29 to include more information on Leave of Absence on page 2. It was also reported that they've answered the question at Section VI, #8 regarding dashed responses.

Topics include setting ARDs, COT clarification, group therapy, revised MDS schedule, revised EOT rules, and new EOT-R policy. The following are examples. Use the link below to download the 12-page document.

Question II-16. COT rules when a patient's therapy category changes, but the patient index maximizes into the same non-therapy RUG: A COT OMRA is only necessary in cases when the patient's RUG used for billing would change as a result of changes in therapy.

Question II-22, regarding completion of interview questions for a COT OMRA: facilities may complete the resident interviews within a day or two of the ARD of the COT OMRA. If the interviews are not completed by this time, then facilities should use the staff assessment to complete that portion of the COT OMRA.

We would note, however, that... facilities are expected to continually evaluate the therapy intensity for a given SNF resident and anticipate the possibility that a COM OMRA may be necessary.

Question II-23, regarding COT OMRAs with a non-compliant ARD: COT OMRAs with the ARD set for something other than Day 7 of the COT observation period will be treated as if the ARD has been set late. As such... facilities should bill the default rate for all days that are not in compliance with the ARD requirement.

III-1, Group therapy definition: a single therapist or therapy assistant providing therapy to four residents doing the same or similar activities at the same time. III-2, Unplanned patient absence: as long as the therapy session was planned for four residents, then the group session may continue. Group therapy minutes reported on the MDS will still be divided by four.

IV-1, Effective date of assessment schedule: Any ARDs set after October 1, 2011 must be in line with the updated assessment schedule. When October 1, 2011 is Day 19, 34, 64, or 94 of the stay, assessments should be completed by September 30 or the assessments will be considered late and payment penalties will apply.

IV-3, Grace days still exist under the revised assessment schedule. There is no penalty for using grace days.

V-4, Minimum number of therapy minutes for a therapy day. Answer: If a patient receives 15 or more codable minutes of therapy in one discipline in a given day, including a therapy evaluation, then this would count as a therapy day.

V-5, EOT needed when one disciple is discontinued? Answer: An EOT OMRA is necessary only when all therapies have been discontinued.

CMS' followup Q&A document

Billers need Validation reports
Similar to this time last year, it will be very important that clinicians share with Medicare billers the MDS 3.0 CMS Validation reports. They are the reports clinicians receive after submitting PPS assessments and it lists the appropriate RUG to bill based on whether an assessment is for FY2011 or FY2012.

If the billing period is split between fiscal years, FY11 RUG-IV and FY12 RUG-IV groups will both be needed to establish payment for the entire period. As of 9/18/11, the validation reports now reflect both RUG groups.

- CMS' submission system now calculates both the FY11 RUG-IV and FY12 RUG-IV groups for ARDs from 8/22 through 10/31
- For FY11, the FY12 RUG group will be shown in Error Message #1059
- For FY12, the FY11 RUG group will be shown in Error Message #1060

New Change of Therapy (COT) OMRA
This new assessment type is required for patients classified into a therapy RUG-IV group, whenever the therapy minutes change so much that the resident classifies to a different RUG. The Assessment Reference Date (ARD) of the Change-of-Therapy (COT) OMRA would be set for Day 7 of a COT observation period. Described as a rolling 7-day observation period, facility staff must review the status of residents in therapy RUGs every 7 days to see if a COT OMRA is needed. The ARD (assessment reference date) would go back to the first day of the 7-day look-back period.

End of Therapy with Resumption (EOT-R)
An End-of-Therapy OMRA must be completed when a resident in a therapy RUG receives no therapy services for three consecutive days, regardless of the reason. Beginning October 1, SNFs may choose to complete an EOT-R assessment, using the EOT OMRA form and completing the new items, O0450A and O0450B. To use an EOT-R rather than a Start-of-Therapy, the RUG must be the same as before EOT and therapy must have restarted no more than 5 days after the last day of therapy.

Use the link below for a revised MDS 3.0 schedule and more information on the transition.

Cheat sheet for FY2012 MDS Transition

RAI Manual Changes - September 20, 2011
CMS has posted two sets of changes to the RAI Manual effective October 1, 2011.

The changes posted September 20 are in Chapter 2, 6, and Chapter 3, Section O.

A larger set of changes were posted August 31, 2011. Tables showing the changes are included with the new manual pages. Sections that have been updated include: Title Page, Table of Contents, Chapter 1, Chapter 2, Chapter 3 (Introduction, Sections: C, H, I, K, M, N, and O), Chapter 4, Chapter 6 and Appendices (A, B, C, and E).

Use the link below to download.

MDS 3.0 Training Materials Website

FY 2012 Final Rule: References and Training
Use the links below training materails and a summary of the main changes for MDS 3.0 and RUG-IV per the FY 2012 Final Rule, effective October 1, 2011.

One link is to the slides used in the August 23 (and September 1) CMS training sessions.

The other is to a summary prepared by Keane that includes the new MDS schedule and the criteria for therapy intensity by RUG category: minutes, days, disciplines.

The changes are

- New Change-of-Therapy (COT) OMRA

- How Group Therapy is allocated

- Revised MDS 3.0 schedule

- Revised End-of-Therapy OMRA policy and End-of-Therapy with Resumption

- Revised Therapy Student Supervision Requirements

Keane Summary of Changes

CMS Training Slides

RAI Manual change and new YouTube videos
CMS has clarified the definition of worsening regarding coding pressure ulcers in the MDS 3.0 RAI Manual (Chapter 3) V1.06 July 2011, Appendix A and Section M.

The clarification: "worsening" is when a pressure ulcer has progressed to a deeper level of tissue damage compared to the previous assessment. The ulcer is staged at a higher number on a scale of 1-4 (using the staging assessment determinations assigned to each stage; starting at stage 1). For the purposes of identifying the absence of a pressure ulcer, zero pressure ulcers is used when there is no skin breakdown or evidence of damage.

New videos are posted on YouTube regarding MDS 3.0: Facility Leadership Video and Interdisciplinary Team Video, use the link below to download.

CMS MDS 3.0 Training Materials Website

Therapy Claims Reprocessing
Since February 2011 CMS has been reprocessing millions of claims that were affected by passage of the Affordable Care Act that led to changes in the Medicare Physician Fee Schedule for services provided January 1 to May 31, 2010. The affected claims were reprocessed automatically.

CMS sent a notice yesterday that contractors have encountered situations where claims were not reprocessed correctly. These claims involved therapy services when the KX modifier was not used because the patient had not reached the therapy cap, but where the patient subsequently received therapy services beyond the cap.

In an announcement, CMS advises providers that its contractors will no longer automatically reprocess claims involving services subject to the therapy cap. Providers now must request the contractors reprocess therapy claims that would have been subject to the cap. Studies have shown that approximately 14 percent of therapy claims exceed the cap each year.

NASL reports that it has heard that the fee schedule adjustments may amount to only a few cents and suggest that if you have a large number of claims affected, it might be worth your effort to request the contractor to reprocess your therapy cap claims.

Medicare Claims Processing Manual rev. 2/18/11

Clarification of Billing occurrence code 16
Medlearn Matters MM7339 article clarifies how to use occurrence code 16: "In all cases where an End of Therapy (EOT) - Other Medicare Required Assessment (OMRA) is completed, SNFs must submit occurrence code 16, date of last therapy, to indicate the last day of therapy services for the beneficiary."

CMS further clarified on June 24th: "Please note that only one occurrence code may be billed on a single claim, therefore, you would use the final date therapy was provided in relation to the latest EOT OMRA applicable for the claim being billed."

Note to Keane clients: the code can be added now via UB Data Entry and will be automated in an upcoming release.

Medlearn Matters MM7339 Revised

Complaint and Enforcement Info on Nursing Home Compare
CMS will begin posting information about complaints and enforcement actions on its Nursing Home Compare Website beginning July 21, 2011. Providers can preview the information to be posted at the CASPER site at the top of your MDS State Welcome page beginning June 15. Questions may be emailed to bettercare@cms.hhs.gov.

The Nursing Home Compare site already includes survey results (requirements that the nursing home failed to meet). Use the link below for the Website.

CMS' Nursing Home Compare Website

Overuse of Dashes in MDS 3.0
CMS has added a memo to the MDS 3.0 Training Materials Website to advise providers that they have found an inappropriately large percentage of dashes (up to 40%) in the first five months, especially for quality measure items such as pain and pressure ulcers.

The memo points out that excessive use of dashes affects the accuracy of the quality measures reported on Nursing Home Compare and the 5-Star Nursing Home Quality Rating System. The memo includes this instruction for coding resident interviews on unplanned discharge:

For the BIMS, PHQ-9 and Pain interviews, if the resident is discharged unexpectedly and the resident interview has not yet been completed the staff assessment should be completed if appropriate clinical record information is available. In this case the gateway questions, C0100, D0100 and/or J0200 should be coded No (0) and the staff assessment should be completed.

Download the complete memo using the link below.

CMS memo

Bundling Errors for CT Scans and Dacogen
CMS has learned that some new HCPCS billing codes created for January 2011 should have been excluded from SNF consolidated billing bundled payment and allowed to be paid separately:

CT Scans (HCPCS 74176, 74177, and 74178). Effective July 5, 2011, for dates of service on or after January 1, 2011, claims processing edits will be revised.

Dacogen (HCPCS code J0894), a high-intensity chemotherapy drug. Effective October 3, 2011, for claims with dates of service on or after January 1, 2011 claims processing edits will be revised.

SNFs that submitted claims with dates of service on or after January 1, 2011 for these services would have had claims denied. If this happened to you contact your Medicare Carrier, Fiscal Intermediary, or Medicare Administrative Contractor to have the claims reopened and reprocessed.

CMS Proposals for 2012 Payment
CMS is considering several options before setting the 2012 Medicare payment rates for SNFs. One calls for an increase in payment, one calls for a decrease.

One option is the standard rate update that would provide an increase of $530 million, or 1.5 percentage points. The increase is derived from applying the 2012 market basket index of 2.7 percent reduced by 1.2 percentage points to account for greater efficiencies in the operation of nursing homes. This provision was called for in the Affordable Care Act.

The other option CMS is considering adjusts for an unexpected spike in nursing home payments during FY 2011, beginning October 1, 2010. Under this option, CMS would restore overall payments to their intended levels which would require reducing FY 2012 payments to Medicare SNFs by $3.94 billion, or 11.3 percent lower than payments for FY 2011.

In implementing RUG-IV, CMS adjusted payment to ensure that the new system did not trigger a change in overall payment levels. Instead, the new system appears to have resulted in a significant increase in Medicare expenditures. CMS has come to this conclusion because actual utilization under RUG-IV has differed significantly from the original projections.

For example, CMS has found that patients are being classified into one of the highest paying RUG-IV therapy groups more than 40 percent of the time (as compared to less than 10 percent as originally projected by CMS), thus triggering Medicare payments far in excess of the original projections.

CMS will be reviewing RUG-IV claims data as it becomes available and will evaluate recalibrating the payment system for the FY 2012 final rule.

In addition to discussing the SNF PPS payment rate update for FY 2012, this proposed rule proposes to:

Implement section 6101 of the Affordable Care Act that requires Medicare SNFs and Medicaid nursing facilities to disclose certain information to HHS and other entities regarding the ownership and organizational structure of their facilities; and

Revise the definition of group therapy and to require allocation of group therapy minutes in assigning RUG-IV payment groups; and

Add a new Medicare-required assessment to be completed when changes occur in the intensity of therapy.

Modify the required schedule for completing the MDS 3.0; and

Revise the policy regarding line-of-sight; supervision of therapy students.

The proposed rule went on display on April 28, 2011 and public comments will be accepted until June 27. Use the link below to download the rule.

Proposed Rule published May 6, 2011

Accountable Care Organizations (ACO) Proposed
CMS has proposed a new program, ACO (Accountable Care Organizations) to encourage improved quality and reduce Medicare expenditures in return for payment incentives.

Post-Acute Care providers will be able to participate in ACOs, but only physicians and hospitals can form an ACO. To receive incentive payments, ACOs must first meet quality measures in the areas of patient/caregiver experience, care coordination, patient safety, preventive health, at-risk population/frail elderly health.

To qualify for a shared savings payment, an ACO must achieve minimum savings. That minimum savings amount will be based on the previous per capita Medicare Parts A and B expenditures for beneficiaries in each of three previous years. CMS will estimate a benchmark that will be adjusted annually.

The ACO proposal is part of the Affordable Care Act; comments will be accepted until June 6, 2011.

For full information visit CMS' Shared Savings Program Website, link below.

CMS' Shared Savings Program Website

Intermediary Errors in Applying MPPR
CMS has learned that the Fiscal Intermediary Shared System (FISS) is taking the Multiple Procedure Payment Reduction (MPPR) on claims regardless of whether services were provided on the same day. As a result of this coding error, therapy claims with dates of service on or after January 1, 2011, processed between January 3 and February 6, 2011, with one of the specified therapy codes in Change Request (CR) 7050, were processed incorrectly.

System changes were successfully implemented on February 7, 2011, and CMS has instructed Medicare contractors to adjust claims that processed incorrectly.

CMS has also learned that FISS was using a 20% reduction rather than the 25% reduction for institutional claims. As a result, all therapy services subject to the MPPR with dates of service on or after January 1, 2011, have been paid incorrect amounts.

Medicare contractors will install a corrected rate file in early May, and CMS has instructed Medicare contractors to adjust claims no later than June 30, 2011.

Nursing Home Compare Changes
Changes are coming to CMS Nursing Home Compare Website per the Affordable Care Act and MDS 3.0. Effective April 23, the Website will clearly spell out resident and consumer rights and the courses of action they can take if they feel their rights are being violated.

In July 2011, Nursing Home Compare will include information about the number of substantiated complaints received and number of enforcement actions. The Survey and Certification letter of March 18, 2011, outlines these changes. Use the link below to read it.

The Quality Measures and Five Star ratings currently on the Nursing Home Compare Website will be "frozen" until October 2011. Those measures were calculated using MDS 2.0 data submitted during quarters one thru three of 2010. Quality Measures based on MDS 3.0 data is expected to be available in early 2012.

Survey & Certification letter of March 18, 2011

CMS' Nursing Home Compare Website

Error in logic for -3810 (Submitted Late)
CMS has identified an error in the logic for -3810 (Record Submitted Late).

The -3810d message is being issued in error for any new (X0100 = 1) comprehensive assessment (A0310A = 01, 03, 04, 05) where the Z0500B is more that 14 days prior to submission.

CMS will enhance the system to only apply edit -3810c for new (X0100 = 1) comprehensive assessments. In the meantime, please disregard that message, but do not disregard error -3810c for comprehensive assessments, or -3810d for non-comprehensive assessments.

MDS 3.0 Changes take effect April 1, 2011
Two significant changes for MDS 3.0 will take effect on April 1 this year:

1. Section S edits, additions and deletions for these states: AK, AR, CA, CT, FL, MA, MD, ME, MS, NE, NY, OH, PA, SD, VT, and WV.

2. Modification assessments will be rejected if the modification is a change to the reason(s) for assessment, or a change to the ARD. Note: CMS recommends that providers stop using the Modification assessment to change these values NOW. After 4/1/2011 assessments that do not comply will be rejected.

Note to Keane Care clients: an update to your MDS 3.0 software to handle these changes was released the week of March 7.

List of changes to MDS 3.0 Section S items

MPPR - Multiple Procedure Payment Reduction for Selected Therapy Services
A change is being made for some therapy services paid under the Medicare Physician Fee Schedule (Part B, Outpatient). This Multiple Procedure Payment Reduction (MPPR) is 25 percent, applied only to the Practice Expense (PE) part of payment.

Payment for this therapy is broken into three parts: Work, Practice Expense, and Malpractice. The PE part will be reduced 25 percent after the first unit when more than one unit or procedure is provided to the same patient on the same day.

Full payment is made for the unit or procedure with the highest PE payment. The MPPR applies to all services furnished to a patient on the same day, regardless of whether one or multiple therapy disciplines are provided such as PT, OT, or Speech-Language Pathology.

Note to Keane clients: updates for Keane AR-Billing software are now available to accommodate this change.

Medlearn Matters

Medicare Claims: submit within 12 months, new Website
CMS reminds LTC providers that the Affordable Care Act of March 23, 2010, reduces the maximum period for submission of Medicare claims to no more than 12 months. Previously providers had from 15 to 27 months.

This policy became effective for services furnished on or after January 1, 2010. Claims for services furnished prior to January 1, 2010, had to be submitted no later than December 31, 2010. Medlearn Matters 7270 addresses this further including exceptions, link below.

CMS has added a Web page with information and Medlearn Matters articles written for Medicare Fee-for-Service (not Medicare Advantage plans) about common billing errors and improper activities identified through the CMS claim review programs. Use the link below.

Medlearn Matters 7270

MLN Provider Compliance web page

Transition to the Version 5010, the new version of X12 standards for HIPAA transactions including claims
The standard format for electronic Medicare claims is changing and the mandatory compliance date is January 1, 2012. The regulation applies to all Medicare fee-for-service trading partners (not Medicare Advantage plans) who are HIPAA-covered healthcare providers.

Medicare Administrative Contractors and Fiscal Intermediaries will be ready to begin testing the base versions of all transactions in January 2011, and the 5010 Errata version in April 2011. Both versions should be tested, however, production claims cannot be submitted until the successful completion of testing the Errata version.

Note to Keane clients: We plan to provide our clients with the base version of the ANSI 837 Institutional Claim Transaction for testing in January 2010. The ANSI 837 Professional Claims Transaction will be available in a later release. That release also will include the ability to import the 5010 version of the 835 Health Care Claim Payment/Advice and the ability to read the 277CA Claims Acknowledgement.

Keane will begin developing and testing for Medicaid as the individual states companion guides become available, following the states testing schedules.

If you submit claims directly to your Medicare MAC/FI or Medicaid EDI, you should be contacting them now to get their specific testing instructions and implementation schedules.

Timeline and resources for 5010 implementation

CMS' 5010 Timeline Flyer

Surveyors' guidance for MDS 3.0 is revised in Appendix PP, State Operations Manual (SOM)
Transmittal 70, dated January 7, 2011 corrects errors in Transmittal 66 that included Appendix PP of the State Operating Manual. The revised pages are dated 1-07-11. The changes released with Transmittal 66 in October 2010 include changing "MDS 2.0" to "MDS 3.0" and "RAP" to "CAA." The CMS-672/802 forms revised for MDS 3.0 were issued with Transmittal 66 and continue to be dated 10/10.

Use the link above to download Transmittal 70 and the SOM.

Transmittal 70

New MDS 3.0 Educational Materials
Additions to the MDS 3.0 Training Materials Website as of December 20, 2010:

- RAI Manual Appendix F - MDS 3.0 Item Matrix is in the download section. It shows the MDS 3.0 items required for each assessment type as well as how the items are used, such as RUG, Survey and Certification, Quality Indicators, and Quality Measures.

- More slide presentations from the August 2010 MDS 3.0 National Train-the-Trainer Conference are in the zip file labeled "MDS 3.0 Training Slides December 2010.zip"

These videos were posted to YouTube:

- Section O Special Treatments, Procedures, and Programs

- Clips of interviews from the Video on Interviewing Vulnerable Elders (VIVE): Interview Techniques, Preferences, Cognition, Mood, Self Harm 1, Self Harm 2, and Pain

MDS 3.0 Training Materials Website

Therapy Caps Exclusions and RUG-IV Implementation
The President signed into law the Medicare Extenders Act that extends the Part B therapy cap exceptions process that excludes most SNF residents from the caps through December 31, 2010.

The bill also repeals the requirement for CMS to create a hybrid software system that would apply RUG-III to MDS 3.0. With this bill, RUGs will continue to be calculated using RUG-IV with MDS 3.0 as they have been doing since October 1, 2010.

The proposed cut in Medicare payment to physicians will not be implemented due to the Act.

Short-Stay Assessments: the criteria
The criteria for triggering a Medicare Short-Stay Assessment is complex. To use the special RUG-IV short stay rehabilitation therapy classification, all eight of the following conditions must be met, as specified in the RAI Manual.

The good news is that your Keane Care MDS 3.0 software will compare the assessment with the criteria and if it qualifies, automatically check Z0100C (Is this a Medicare Short Stay assessment?) for you.

1. The assessment must be a Start of Therapy OMRA (A0310C = 1 or 3). This assessment may be completed alone or combined with any OBRA assessment or combined with a PPS 5-day or readmission/return assessment. A Start of Therapy OMRA should be combined with a discharge assessment when the end of Part A stay is the result of discharge from the facility, but not combined with a discharge if the resident dies in the facility or is transferred to another payer source in the facility.

2. A PPS 5-day (A0310B = 01) or readmission/return assessment (A0310B = 06) has been completed. The PPS 5-day or readmission/return assessment may be completed alone or combined with the Start of Therapy OMRA.

3. The ARD (A2300) of the Start of Therapy OMRA must be on or before the 8th day of the Part A Medicare stay. The ARD minus the start of Medicare stay date (A2400B) must be 7 days or less.

4. The ARD (A2300) of the Start of Therapy OMRA must be the last day of the Medicare Part A stay. The Start of Therapy OMRA ARD must equal the end of Medicare Part A stay date (A2400C). See instructions for Item A2400C in Chapter 3 of the RAI Manual.

5. The ARD of the Start of Therapy OMRA may not be more than 3 days after the start of therapy date (Item O0400A5, O0400B5, or O0400C5, whichever is earliest). It is not possible to have the ARD for the Short stay Assessment to be 5-7 days after the start of therapy since therapy must have been able to be provided only 1-4 days.

6. Rehabilitation therapy started during the last 4 days of the Medicare Part A covered stay (including weekends). The end of Medicare stay date (A2400C) minus the earliest start date for the three therapy disciplines (O0400A5, O0400B5, or O0400C5) must be 3 days or less.

7. At least one therapy discipline continued through the last day of the Medicare Part A stay. At least one of the therapy disciplines must have a dash-filled end of therapy date (O0400A6, O0400B6, or O0400C6) indicating ongoing therapy or an end of therapy date equal to the end of covered Medicare stay date (A2400C).

8. The RUG group assigned to the Start of Therapy OMRA must be Rehabilitation Plus Extensive Services or a Rehabilitation group (Z0100A). If the RUG group assigned is not a Rehabilitation Plus Extensive Services or a Rehabilitation group, the assessment will be rejected.

When "return anticipated" does not happen
Sometimes a resident is discharged return anticipated and the facility learns later that the resident will not be returning to the facility. Another Discharge assessment is not necessary although the state may require a modification assessment to change "return anticipated" to "return not anticipated". Please contact your State RAI Coordinator for clarification.

If your state requires a modification, then you can certainly do one. It would not be rejected by the ASAP system. The ARD needs to be the same on both assessments.

CMS-672/802 forms for Surveyors updated
CMS has posted an Advance Copy of the Revisions to Appendix PP of the State Operations Manual (Guidance to Surveyors for LTC Facilities) that includes the revised CMS-672 and 802 forms requested by surveyors when they arrive for a survey.

In this version, references to MDS 2.0 and RAPs have changed and Interpretive Guidelines regarding infection control and nurse aids and nurse aide training were clarified.

See the blog entry of August 4, 2010 (below) for information and links to the Advance Copy of Temporary Changes to Appendix P, State Operations Manual (SOM). That revision outlines how surveys will be conducted without QI reports.

Note to Keane Care clients: adding automatic completion of the 672/802 forms to our MDS 3.0 software is a top priority and we will keep you informed.

CMS Survey & Certification Website

Therapy Coding Changes in RAI Manual Update
The RAI manual changes released for September 2010 include some specific changes to Chapter 3 - Section O that address coding of therapy minutes on MDS 3.0. CMS has included a list of changes in the September 2010 RAI manual file (link below). A summary:

Section O0100 - Special Treatments and Programs: a September RAI Manual change (page O-1) adds these instructions: "Do not code services that were provided solely in conjunction with a surgical procedure or diagnostic procedure, such as IV medications or ventilators. Surgical procedures include routine pre-and post-operative procedures."

Other changes affect how therapy minutes and days are counted in MDS 3.0 Section O0400. Page numbers refer to RAI manual, Chapter 3.

Family education can be counted when the resident is present - page O-16

Therapist time cannot be counted while resident is taking a break - page O-16

Set-up time has to be coded under the mode (individual, concurrent, group - or for initial mode if more than one - O-17

Therapy Aides' set-up time is also counted under the mode. Therapy Aides must be under direct supervision, defined as therapist/assistant must be in the facility and immediately available. O-19

If therapy does not meet the criteria for individual, concurrent or group, it cannot be coded on the MDS. O-20

Students: must be supervised by therapist/assistant who shall not be treating or supervising other individuals, is able to immediately intervene/assist, and both student and resident are under line-of-sight supervision. O-20

Definition of ongoing therapy was further defined. O-22

Examples were added for counting and coding therapy minutes - O-22 to O-25

MDS MDS 3.0 Training Materials

CMS Call on SNF PPS Assessments & Policies
CMS' September 1 National Provider Call, "SNF PPS Assessments and Policies", addressed the rules for the different types of PPS assessments including two new assessments: Start of Therapy and Short-Stay, both designed to help providers receive appropriate payment for residents receiving therapy.

The Start-of-Therapy (SOT) assessment is optional. It's used to obtain a therapy RUG any time during a stay. The ARD for an SOT is 5-7 days after start of first therapy and payment starts first day of therapy. If the final RUG, after index maximizing, is not a therapy RUG the assessment will be rejected.

For example, if the resident qualifies for a RLB (Rehab Low Intensity) RUG and an HE2 (Special Care High) RUG, the final RUG would be HE2 since its CMI is 47 (urban) vs. 44 (urban) for RLB. In other words, HE2 pays more.

The Short-Stay Assessment is used for therapy delivered to residents who are discharged on or before day 8. It is submitted as a Start of Therapy OMRA (completed alone or combined with any OBRA assessment or combined with a PPS 5-day). The eight conditions it must meet are detailed in Chapter 6 of the RAI Manual (pages 6-12 thru 6-14 and 6-22 to 6-23).

When you complete the assessment, the software determines if it meets the criteria and if it does, answers Yes in Z0100C. The RUG is calculated using average daily minutes actually provided as shown in Chapter 6 of the RAI Manual and in the PowerPoint from the September 1 National Provider Call.

Materials from the call include a PowerPoint and a chart showing the RUG-IV RUGs with ADLs and their Case Mix Index. Link below.

CMS' SNF Spotlight Website

Transition from RUG-III to RUG-IV
CMS addressed how to handle assessments for residents whose Part A stay spans September and October 2010 during its phone call with LTC providers on August 24th. The materials posted at the below Website include the PowerPoint from the presentation and spreadsheets to help you calculate exact assessment dates.

Reminders from the presentation:

Transition applies only to SNF PPS

Transition options only apply to residents who have covered Part A days in September and October 2010 (when RUG assignment from one SNF PPS assessment covers days in September and October

Substituting an assessment with an MDS 3.0 PPS assessment is OPTIONAL.

SNF PPS Spotlight Website

Survey Changes Announced
Temporary changes to the SNF survey process are a step back to 1995, before Quality Indicator/Quality Measures reports helped surveyors choose residents and topics to review when they arrived onsite. It may also be a trip back in time to manual completion of the CMS-672/802 forms, at least for a short time.

The Advance Copy of the Description of Temporary Changes to Appendix P, State Operations Manual (SOM) that was released July 30, 2010 outlines how surveys will be conducted without QI reports (link below).

Residents will be selected for the sample using the original process that was based on off-site information such as complaints, if any, results of the initial tour, and information from the facility's CMS-802 form, the Resident Roster.

CMS-672/802 forms used by surveyors onsite are being revised. They are currently completed using MDS 2.0 data. CMS is revising the forms to work with MDS 3.0 and will release a draft mid-August 2010, followed by a crosswalk that shows which MDS 3.0 items trigger 672/802 items. Keane Care will use the crosswalk to program the MDS 3.0 672/802 reports and release them as an update.

Changes reported in the July 30, 2010 document to the 672/802 include dividing the 802 item, Falls/Fractures/Abrasions/Bruises into two fields. Also separated will be Behavioral Symptoms/Depression. As with the current forms, some fields, such as Fecal Impaction for MDS 3.0, are not in the MDS and must be completed manually.

Advance Copy of Temporary Changes to SOM Appendix P

FY 2011 Medicare Part A SNF Payment
CMS has published a notice of SNF Medicare Part A Prospective Payment rates for FY 2011 that includes a market basket increase of 1.7 percent.

The daily payment amounts for each RUG group are also included. Two sets of rates are given--one calculated with the RUG-IV grouper and one with the Hybrid RUG-III grouper.

RUG-IV rates will be paid beginning October 1, 2010 and continue until the Hybrid grouper software is available. At that time CMS will begin using the Hybrid software and re-process claims submitted since October 1, 2010. The hybrid grouper software will be used until October 1, 2011 when RUG-IV is officially implemented.

SNF Medicare PPS Notice

MDS 3.0 RAI Manual Revisions and Training Materials
CMS' MDS 3.0 Training Materials Website now includes:

MDS 3.0 RAI Manual including instructions for completing all the MDS 3.0 sections (Chapter 3).

MDS 3.0 Training Slides V1.00 July 12, 2010 - The slides were used at CMS' in-person training sessions and are available in PowerPoint or PDF for each MDS 3.0 section.

MDS 3.0 Instructor Guides V1.00 July 12, 2010 - Use these guides if you are conducting training using CMS' training slides. .

Video on Interviewing Vulnerable Elders June 14, 2010 (temporarily pulled from Website

MDS 3.0 ADL Flowchart V1.02 June 14, 2010 - An updated version of the ADL Decision Flowchart

Download all at CMS' new MDS 3.0 Training Materials Webiste (link below).

MDS 3.0 Training Materials Website

ICD-10 Facts
The next big date to add to your regulatory to-do list: October 1, 2013 and the change from ICD-9-CM to ICD-10 for diagnosis coding. ICD-10 facts are outlined in MedLearn Matters SE1019 (link below) and summarized here:

The first ICD-10-related milestone is less than two years away. It's the change to the Version 5010 electronic standard for claims. This version supports ICD-10 code structure.

October 1, 2013 is the deadline for Medicare and Medicaid claims. "If you are not ready, your claims will not be paid." "There will be no delays. There will be no grace period for implementation."

ICD-10-CM diagnoses codes will be used by all providers in every healthcare setting.

ICD-10-PCS procedure codes will be used only for hospital claims for inpatient hospital procedures.

There will be no impact on Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes.

The number of ICD-10-CM codes is approximately 70,000, compared to 14,000 ICD-9-CM codes

ICD-10 codes are longer and use more alpha characters to support greater detail.

General Equivalence Mappings (GEMs) dictionaries will be available to convert data from ICD-9-CM to ICD-10-CM/PCS and vice versa.

The MedLearn Matters article includes examples of how ICD codes are changing. More information about ICD-10 is posted on CMS' Website (link below).

MLN Matters Special Edition Article #SE1019

CMS' ICD-10 Website

RUG-IV System Summarized
RUG-IV is scheduled to arrive with MDS 3.0 in October 2010. Based on the STRIVE time study, CMS has changed the RUG system for Medicare Part A payment to SNFs to adjust for changes in incentives, patient population, and industry practices since RUG-III was implemented.

CMS states in the Final Rule of July 31, 2009 that it will continue to pay the same total amount, but the amount paid per RUG will shift.

Under RUG-IV many fewer patients will qualify for Rehab Plus Extensive Services RUGs, the highest-paid category. To compensate for fewer dollars paid through those RUGs, the Final Rule states that CMS will pay significantly more for the complex medical groups, including Extensive Care, Special Care, and Clinically Complex.

For a summary of the changes to the RUG categories and how patients qualify for them, see the Keane Care White Paper (link below).

White Paper on RUG-IV

Update on MDS 3.0 and RUG-IV
CMS has reached a decision about how to implement the one-year delay for RUG-IV. MDS 3.0 will be implemented October 1, 2010 as scheduled. The Healthcare Reform Act (Patient Protection and Affordable Care Act - PPAC) delayed the implementation of RUG-IV for one year, except for the MDS 3.0 items on concurrent therapy and look-backs for special treatments in MDS 3.0 Section O.

CMS officials at the May 3-4 AANAC conference said they have decided to pay claims using the RUG-IV Grouper after October 1, 2010 until they have created the new hybrid RUG-III Grouper. Once this new grouper is available the MACs and FIs will automatically reprocess the claims using the new RUG III hybrid Grouper.

In response to a question, CMS officials said the delay of RUG-IV should not affect state Medicaid payment.

CMS MDS 3.0 Website

Five Star Rating System -- Update re MDS 3.0
CMS' Five Star Rating system awards all SNFs with an overall rating of 1 thru 5 stars on its Nursing Home Compare Website (link below).

The ratings were calculated using survey data, staffing information, and Quality Measures.

In response to a question at the March 11, 2010 SNF Open Door Forum, CMS officials announced that the Quality Measures system will "close" in September due to MDS 3.0 implementation. A year of data will be collected before the Quality Measures are recalculated and released. The officials didn't have an answer for a question about the impact of that on the Five Star system.

Nursing Home Compare is generally updated on the 3rd Thursday of the month. CMS will post preview reports for providers that they can access from their MDS State Welcome pages.

To access the previews, select the CASPER Reporting link located at the bottom of the login page. Then click on the Folders button and access the report in your "st LTC facid" folder. A help desk will be available for that week at 1-800-839-9290; open from 9 to 5 EST. The help desk will close for the quarter on July 30, 2009.

Nursing Home Compare Website

CMS Five-Star Quality Rating Website

Good News re Therapy Caps
The Therapy Cap Exclusions were extended to March 31, 2010, retroactive to January 1, 2010 as part of the healthcare legislation signed today. The exceptions process exempts most beneficiaries in LTC settings from the caps.

A message from CMS on March 4, states that "some therapy providers have been holding claims for services furnished on or after January 1, 2010, for patients who exceeded the cap but qualified for an exception under previous law. These providers may submit those claims to Medicare effective immediately.

"Therapy providers, who submitted claims which were denied, for services furnished on or after January 1, 2010, for patients who exceeded the cap but whose services now qualify for an exception, should contact their Medicare contractor to request that their claim be adjusted to add the KX modifier and ensure the appropriate exception applies."

The amount of the caps for outpatient therapy under Medicare Part B for calendar year 2010 is $1860. The caps are $1860 per year for physical therapy and speech language pathology combined and $1860 for occupational therapy services.

MIP Joins RAC -- Medicaid and Medicare Audits
The Medicare Recovery Audit Contractor program is charged to look for Medicare over and under-payment to providers. It is a permanent program that went into effect March 1, 2009 following a demonstration in CA, FL, NY, MA, SC, and AZ that resulted in over $900 million in overpayments being returned to the Medicare Trust Fund and nearly $38 million in underpayments returned to healthcare providers.

For full information visit CMS' RAC Website (link below).

The Medicaid Integrity Group at CMS has launched a preliminary Program, MIP, using the Medicaid claims data it receives for research. The program is conducting audits in 17 states now and will be operational nationwide by December 31, 2009.

MIP issues final audit reports to states and it is the states' responsibility to initiate action as necessary. Use the link below to CMS' Website.

CMS' Medicaid Integrity Program Website

Medicare Recovery Audit Contractor: CMS Website

Final Rules: ICD-10 and Version 5010
The Final Rule on the adoption of the ICD-10 code set for diagnoses was released January 16, 2009. It sets a compliance date of October 1, 2013 for adoption of ICD-10, replacing the ICD-9 code set. Also published was the Final Rule for Version 5010 of the standard for electronic health care transactions, including claims and remittance, that will replace the 4010 standard on January 1, 2012. The 5010 standard will support ICD-10 codes.

The HHS press release of January 15, 2009 (use link above) states that ICD-10 and 5010 will facilitate the United States' ongoing transition to an electronic health care environment. It gives an overview of the reasons for moving to the ICD-10 code set, including greater specificity, better support for quality data, more accurate payment, and comparison of US data to international data since most countries use ICD-10. The release also gives details of the benefits of ICD-10.

CMS' ICD-10 Fact Sheet is available at http://www.cms.hhs.gov/MLNProducts/downloads/ICD-10factsheet2008.pdf

Final Rule on ICD-10 Adoption

Press Release on Final Rules