Providers have begun receiving non-medical additional document requests for claims utilizing the benefit period waiver in response to the COVID-19 public health emergency. These reviewers are being flagged with a “7COVD” code and have primarily been reported under Wisconsin Physician Services (WPS).
These suspended claims may be the result of a billing issue. As such, review the proper guidelines below for how claims involving the waiver for the 60-day wellness period should be billed.
Despite the many adaptations and additional considerations that have been adopted in the battle against COVID-19, healthcare providers in skilled nursing facilities (SNFs) maintain their primary focus of quality patient rehabilitation and care. In the midst of planning and delivering care in a pandemic, some may ask, Does data collection really matter right now? What’s GG got to do with it? The answers are Yes and everything!
CMS has indicated the value of data collection of our patient’s functional abilities (i.e. Section GG) by signaling it as a key comparison of quality across post-acute settings, an indicator of resource use impacting reimbursement, and critical to guiding patient-centered care planning. Although CMS stated exceptions and extensions were granted because data collection may be greatly impacted by the response to COVID-19, beginning July 1, SNFs are expected to report their quality data to meet the SNF QRP requirements for the third quarter of 2020. (Download CMS’ SNF QRP Tip Sheet)
Knowing this data eventually will be publicly posted, the question now becomes Does it reflect our exhausting efforts to deliver care during this public health emergency? That answer is yet to be determined, but it is never too late for a review and refresh of Section GG content as well as considerations for coding and patient identification in the current environment.
Accuracy of Section GG coding depends not only upon the healthcare professional’s familiarity with the objective scales, but also with each item’s definition, intent and parameters for coding. For example, walking items may be completed within separate sessions. A single walking item may include a brief rest, as long as the resident does not sit down. These considerations may assist in completing a thorough assessment in isolation. CMS provides training videos on the SNF QRP Training webpage for instructional purposes.
Facilities can use Section GG data to capture potential changes in function that may require skilled intervention by completing interim assessments. It is the role of the interdisciplinary team to identify potential impacts of isolation on a patient’s biopsychosocial wellbeing and intervene as appropriate.
Finally, review the submission requirements for the SNF-QRP, so a technicality does not overshadow the successful outcomes your teams are creating. Avoid dashes, utilize the activity not attempted codes as necessary, incorporate at least one goal into the patient’s care plan and submit the completed data for at least 80% of your Medicare A claims.
The interdisciplinary team should champion the role of data collection, even in a pandemic, to ensure that we are facilitating the appropriate plan of care, capturing the true picture of the resident’s needs and maintaining the highest quality of rehabilitation and care. Our patients are counting on us!
CMS reports a new issue is affecting some inpatient hospital and skilled nursing facility (SNF) claims when an interrupted stay is billed at the end of the month. The system incorrectly assigns edits U5601-U5608 (overlapping a hospital claim).
If you billed the interrupted stay correctly, and your claim is rejected, modify your billing so the claim spans past the last day of the interrupted stay:
Bill two months at a time, or
Bill a month plus the days in the following month that span the interrupted stay plus 1 day
According to CMS, adjusting the statement covered from and through dates to encompass the entire interrupted stay will allow your claim to process and pay correctly. Medicare Administrative Contractors will finalize any suspended claims that meet the criteria, so you can make corrections and resubmit your claim.
If CMS rejected an inpatient hospital claim, the hospital should ask the SNF to modify their claim. Until October 5, a SNF cannot submit an adjustment to a paid claim; they must cancel the paid claim and all subsequent claims in the same stay and resubmit them in sequential order.
External reviewers have begun targeting Section GG as a focal point of pre/post-pay medical review audits. Because the PDPM function score is derived from Section GG data, and that score correlates to a case mix group for payment, reviewers will seek supportive documentation for decision making related to coding on the MDS.
Therapy evaluations, recertifications, and discharge documents serve as clinical support of that decision making.
Section GG coding should be reflective of the patient’s clinical characteristics.
Objective data within the therapy evaluation/discharge should correlate to the section GG scores.
Example: Bathing noted as Min assist by OT would be scored as 3 – Partial/Moderate Assistance.
Ensuring accurate data information at the beginning of the stay is the first key to successful outcomes. Accurate coding on sections I, C, and K of the MDS are critical. This clinical classification serves as a predictor of resource needs (therapy needs) from CMS and establishes an admission (baseline) for the patient that may be used as parameters in the future for patient progression.
Consider implementing proactive internal audits that review supportive documentation for MDS coding and continue to educate staff on proper coding to strengthen medical review success.
To access our tools for success, please CLICK HERE.
The U.S. Department of Health and Human Services (HHS) has provided more detailed Provider Relief Fund (PRF) reporting guidance. HHS reports they will be releasing more detailed reporting instructions by August 17, 2020.
These reporting instructions will provide directions on reporting obligations applicable to any provider that received a payment from the following CARES Act/PRF distributions:
General Distributions:
Initial Medicare Distribution
Additional Medicare Distribution
Medicaid, Dental & CHIP Distribution
Targeted Distributions:
High Impact Area Distribution
Rural Distribution
Skilled Nursing Facilities Distribution
Indian Health Service Distribution
Safety Net Hospital Distribution
According to HHS, the reporting system will become available to recipients for reporting on October 1, 2020.
All recipients must report within 45 days of the end of CY 2020 on their expenditures through the period ending December 31, 2020.
Recipients who have expended funds in full prior to December 31, 2020 may submit a single final report at any time during the window that begins October 1, 2020, but no later than February 15, 2021.
Recipients with funds unexpended after December 31, 2020, must submit a second and final report no later than July 31, 2021.
Detailed PRF reporting instructions and a data collection template with the necessary data elements will be available through the HRSA website by August 17, 2020.
Several new Centers for Medicare & Medicaid Services (CMS) initiatives designed to protect nursing home residents from COVID-19 have been announced. Read Reliant’s Real Time Memo covering the new funding, enhanced testing, and additional technical assistance and support from CMS.
The Centers for Medicare & Medicaid Services (CMS) announced they will provide a targeted approach for additional resources to nursing homes in COVID-19 hotspot areas.
CMS reports that plans include the following:
Deployment of Quality Improvement Organizations (QIOs) to nursing homes in the hotspot areas.
Implementation of an enhanced survey process tailored to meet the specific concerns of hotspot areas.
Coordination of federal, state and local efforts to leverage all available resources to these facilities.
CMS reports the purpose of these efforts is to target facilities with known infection control issues by providing resources and support that will help them improve quality and safety and protect vulnerable Americans.
In the July 17th MLN Matters Special Edition Article, Medicare Fee-for Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19), CMS provided updates on both diagnostic testing and SNF benefit period waiver.
Medicare Coverage of COVID-19 Testing for Nursing Home Residents and Patients
CMS instructed Medicare Administrative Contractors and notified Medicare Advantage plans to cover coronavirus disease 2019 (COVID-19) laboratory tests for nursing home residents and patients.
Starting on July 6, 2020, and for the duration of the public health emergency, consistent with sections listed in the CDC guidelines titled, “Interim SARS-CoV-2 Testing Guidelines for Nursing Home Residents and Healthcare Personnel,” original Medicare and Medicare Advantage plans cover diagnostic COVID-19 lab tests.
Diagnostic Testing
Testing residents with signs or symptoms of COVID-19
Testing asymptomatic residents with known or suspected exposure to an individual infected with SARS-CoV-2, including close and expanded contacts (e.g., there is an outbreak in the facility)
Initial (baseline) testing of asymptomatic residents without known or suspected exposure to an individual infected with SARS-CoV-2 as part of the recommended reopening process
Testing to determine resolution of infection
Original Medicare and Medicare Advantage Plans don’t cover non-diagnostic tests.
Skilled Nursing Facility (SNF) Benefit Period Waiver – Provider Information
In the MLN Medicare Fee-For-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19) article, CMS provided clarification in three areas on the SNF Benefit period waiver:
The waiver authorizes a one-time renewal of benefits for an additional 100 days of Part A SNF coverage without first having to start a new benefit period (this waiver will apply only for those beneficiaries who have been delayed or prevented by the emergency itself from commencing or completing the process of ending their current benefit period and renewing their SNF benefits that would have occurred under normal circumstances).
Beneficiaries who exhaust their SNF benefits can receive a renewal of SNF benefits under the waiver except in one particular scenario: that is, those beneficiaries who are receiving ongoing skilled care in a SNF that is unrelated to the emergency, as discussed in the article.
To bill for the benefit period waiver: submit a final discharge claim on day 101 with patient status 01, discharge to home and readmit the beneficiary to start the benefit period waiver.
Shipping of testing supplies was initiated the week of July 20th and will continue over the following 14 weeks.
Testing distribution is being prioritized based on epidemiological hotspot data.
Facilities must have a Clinical Laboratory Improvement Amendments (CLIA) Certificate of Waiver in order to receive the testing equipment.
CMS reports they will expedite review of CLIA waivers for COVID-19 testing.
For more information on how to obtain a CLIA waiver, CLICK HERE.
To be eligible, in addition to having a current CLIA Certificate of Waiver, the nursing home must meet certain epidemiological criteria.
For the list of nursing homes receiving instruments and tests in the first wave, CLICK HERE.
Testing Information
Each facility will receive at least one diagnostic test instrument (from manufacturers QUIDEL or BD) and approximately 400 tests to get started (these numbers will be adjusted for the size of the facility).
Additional antigen tests can be ordered at $25/test through a concierge service from the respective manufacturer.
The test instruments have the capacity to perform 15-20 antigen tests within an hour with near immediate results.
CMS indicated the Medicare program does not reimburse for surveillance testing, but if a patient tests positive, the test may be billed as diagnostic.
Facilities were encouraged to work with other facilities or to potentially share equipment until supply needs for each facility can be met.
CMS reported that they are aware of the likelihood of false negatives with rapid testing; however, the quick result can prove beneficial to the facility for infection control compared to the current lag time of results from the lab.
Additionally, on-site rapid testing may prove beneficial not only due to results obtained more quickly, but it is also more cost effective (the cost of on-site tests is $25 as opposed to the $100-$150 per test cost for current laboratory tests).
For CMS’ FAQ document regarding COVID-19 testing platforms and tests, CLICK HERE.
To access the press release from HHS regarding testing, CLICK HERE.
Alexander Bain invented the “Electric Printing Telegraph” in 1843 which became the world’s first faxing device. One hundred seventy-seven years later, we still use fax, and so do hackers. Faxing is so commonly used in our industry that we sometimes forget to be cautious. Hackers use it to send phishing emails which entice users to click on links that download malicious codes. In some instances, you are required to enter your credentials, giving the hacker the opportunity to steal them.
To avoid becoming a victim of fax phishing, see the example email below with tips to stay safe.
During times of pandemic and national emergency, when flexibilities or waivers are allowed by CMS, supportive documentation is crucial to justify the need for our skilled care. Throughout the public health emergency, many providers have utilized the available waivers for SNFs, including “skilling in place.” With use of these waivers the following should be considered:
Physician involvement, skilled nursing notes, and therapy evaluations and treatments should demonstrate medical necessity and skilled interventions relative to specific patient care needs.
A signed physician certification will not suffice; the documentation needs to clearly support the order.
The patient assessment, physician documentation, justification for the reason why the patient should be skilled in place versus discharged to the hospital, and hospital notes that document rationale for not admitting a patient or discharging early should all be obtained and recorded.
Consistent and thorough documentation related to the care being delivered and why the particular care being provided is appropriate to the patient’s diagnosis, illness, or condition should be included.
Strong facility processes, ongoing communication, and frequent medical record spot checks are the most effective ways to ensure that your records can best support the patient-centered care that is provided through the health care emergency and beyond.
After the emergency declaration is rescinded, it is very likely that CMS, either through the Office of the Inspector General (OIG) or contractors, will look to ensure that Medicare dollars were spent appropriately without fraud, waste or abuse. When evaluating the use of the waivers, it is important to focus on CMS’ goal to take “aggressive actions and exercise regulatory flexibilities to help healthcare providers contain the spread of 2019 Novel Coronavirus Disease (COVID-19).” Documentation will be critical to explain the rationale for the use of the waivers as well as clinical decision making for application.
In conclusion, a thorough interdisciplinary treatment record is crucial to support the specialized services provided during this health care emergency. As we continue to provide excellent resident-centered care, we should ensure that we demonstrate the complexity, sophistication, and medical necessity of the services that we provide in our documentation. Documentation is paramount to fortify defensibility following this pandemic and to ensure our residents continue to have access to quality care.
CMS released a memorandum addressing COVID-19 survey activities, enhanced enforcement, and engagement of Quality Improvement Organizations (QIOs). CMS also released a state-by-state report on COVID-19 cases for residents and staff along with numbers of infection control focused surveys completed. The memorandum includes guidance related to
Focused Infection Control Nursing Home Surveys and CARES Act Supplemental Funding
States that have not completed focused infection control surveys in 100% of their state’s nursing homes by July 31, 2020 will be required to submit a corrective action plan outlining the strategy for completion of these surveys within 30 days.
Access to CARES Act allocations will be impacted by state performance on completing the nursing home infection control focused surveys.
COVID-19 Survey Activities
Requiring states to implement the following COVID-19 survey activities. States that fail to perform these survey activities timely and completely could forfeit up to 5% of their CARES Act allocation, annually.
Expanded Survey Activities
Emphasizes Nursing Homes Re-opening Recommendations, which indicates that once a state has entered Phase 3 of the reopening process, states may use their discretion as to whether and how they decide to expand survey activity beyond the current survey prioritization.
Enhanced Enforcement for Infection Control Deficiencies
For all infection control deficiencies at a scope and severity of D or above, CMS will impose a directed plan of correction that will include the use of root cause analysis.
Support From Quality Improvement Organizations (QIOs)
Nursing homes can take advantage of weekly National Nursing Home Training that focuses on infection control, prevention and management to help prevent the transmission of COVID-19.Nursing homes can locate the QIO responsible for their state here.
The Centers for Medicare and Medicaid Services (CMS) initiated posts of COVID-19 nursing home data which will be updated weekly.
In addition, results of targeted inspection surveys and reports are available on Nursing Home Compare. CMS plans to post the results of the inspections monthly as they are completed.
The Centers for Medicare & Medicaid Services (CMS) instructed Medicare Administrative Contactors and notified Medicare Advantage plans to cover coronavirus disease 2019 (COVID-19) laboratory tests for nursing home residents and patients. This instruction follows the Centers for Disease Control and Prevention’s (CDC) recent update of COVID-19 testing guidelines for nursing homes that provides recommendations for testing of nursing home residents and patients with symptoms consistent with COVID-19 as well as for asymptomatic residents and patients who have been exposed to COVID-like symptoms in an outbreak.
Medicare Advantage plans must continue not to charge cost sharing (including deductibles, copayments, and coinsurance) or apply prior authorization or other utilization management requirements for COVID-19 tests and testing-related services.
For the full Medicare Learning Network article, CLICK HERE.
The Centers for Medicare and Medicaid Services (CMS) issued a Frequently Asked Questions document on visitation for nursing home residents that provides clarifications and considerations including:
Visitation for compassionate care situations
CMS clarifies compassionate care situations are not exclusive to end-of-life situations. An example is provided explaining a resident who was living with their family prior to being admitted to the nursing home may experience trauma due to the change in their environment and sudden lack of family. Therefore, this may qualify as a compassionate care situation.
Outside visits
CMS encourages creative means of connecting residents and families including visitation outside of the facility while ensuring all actions for preventing COVID-19 transmission are followed.
Communal activities
Residents (without COVID-19 symptoms) may eat in the same room with social distancing.
Group activities may be facilitated (for residents who have fully recovered from COVID-19, and for those not in isolation for observation, suspected or confirmed COVID-19 status) with social distancing among residents, appropriate hand hygiene, and use of a cloth face covering or facemask.
Steps for reopening to visitors
Nursing homes should continue to follow CMS and CDC guidance for preventing the transmission of COVID-19 and follow state and local direction.
CMS does not recommend reopening facilities to visitors (except for compassionate care situations) until phase three when the following criteria are met:
No new onset of COVID-19 in the nursing home for 38 days
No staff shortages
Adequate supplies of PPE and essential cleaning and disinfection supplies
Adequate access to testing for COVID-19
Referral hospitals have bed capacity on wards and ICUs
Factors to consider regarding visitation
CMS encourages that any decisions to relax requirements or conduct creative alternatives within nursing homes be made in coordination with state and local officials after a careful review of facility-level, community, and state factors/orders.
To access the complete FAQs document from CMS’ Current Emergencies webpage, CLICK HERE.
It has been said “a picture is worth a thousand words.” That quote is so true in this COVID-19 era where friends and family must keep their distance from loved ones in nursing homes. The compassion and care that nursing home staff provide includes, now more than ever, the social wellbeing of residents and patients. Sharing photographs and videos is a wonderful way to keep connected. However, don’t forget Health Insurance Portability and Accountability Act (HIPAA) compliance still is required.
Photos or videos containing any portion of a resident’s or patient’s face are considered Protected Health Information (PHI). That doesn’t mean you cannot take and share photos or videos. HIPAA allows use and disclosure of photos or videos when proper authorization is provided by the resident, patient, or responsible party.
To be HIPAA compliant, authorization documentation must include the following:
The purpose for using and disclosing photos or videos; for example, “to share with her daughter/son”
The timeframe the authorization applies; for example, “to send to daughter/son while the facility is on lockdown”
Explanation that the resident, patient, or responsible party have the right to revoke the authorization at any time
Explanation that the health care provider will not condition treatment, payment, or enrollment or eligibility for benefits on the resident, patient, or responsible party signing the authorization
Signature of the resident, patient or responsible party
Thanks to all for keeping residents and patients safe and connected while remaining HIPAA compliant.
While it is still unclear at this time when we will begin to see normal audit activity resume from traditional Medicare entities, some Managed Care companies have lifted their suspensions and may have resumed normal auditing practices as early as May 15, 2020. Humana released a memo on May 14, 2020 stating the following
“Given that health system capacity is opening up and procedures are increasing steadily, we will begin to resume some of the regular processes that we suspended on April 1, 2020, to support providers with the strain on the healthcare system posed by COVID-19 at the heart of the crisis…The first of these is for medical record requests for claim reviews, which we will resume effective May 15, 2020.
Resuming pre-payment medical record claims review. As of May 15, Humana may begin to request medical records from your organization prior to issuing payment, consistent with our policy in place prior to the April 1 suspension.
Resuming post-payment medical record claims review. Since April 1, Humana has not requested medical records in connection with our post-payment review process. Our post payment claims review team will now resume making requests for medical records as required, consistent with our policy in place prior to April 1.
Humana leaders will continue to monitor service volumes as well as the progression of the COVID-19 curve and recovery and will review our policies and procedures as necessary as this crisis evolves.”
Please be prepared to start seeing these requests again in the coming days and weeks and notify your Medical Review/Appeals department as soon as possible. It is highly possible that there will still be barriers to obtaining medical records timely and extensions may need to be requested. We are all in this together and are happy to assist in any way possible.
In response to State Medicaid Agency and stakeholder requests, CMS has updated the MDS 3.0 item sets (version 1.17.2) and related technical data specifications. These changes will support the calculation of PDPM payment codes on OBRA assessments when not combined with the 5-day SNF PPS assessment, specifically the OBRA comprehensive (NC) and OBRA quarterly (NQ) assessment item sets, which was not possible with item set version 1.17.1. This will allow State Medicaid Agencies to collect and compare RUG-III/IV payment codes to PDPM codes and thereby inform their future payment models.
For more information, visit MDS 3.0 Technical Information page. Supporting materials including the 1.17.2 Item Change History report and the revised 1.17.2 Item Sets can be accessed in the file: MDS 3.0 Final Item Sets v1.17.2 for October 1 2020 zip, also posted in the Downloads section of the MDS 3.0 Technical Information page.
CMS has delayed the release of the updated versions of the Minimum Data Set (MDS) needed to support the Transfer of Health (TOH) Information Quality Measures and new or revised Standardized Patient Assessment Data Elements (SPADEs) in order to provide maximum flexibilities for providers of Skilled Nursing Facilities (SNFs) to respond to the COVID-19 Pubic Health Emergency (PHE).
The release of updated versions of the MDS will be delayed until October 1st of the year that is at least 2 full fiscal years after the end of the COVID-19 PHE. For example, if the COVID-19 PHE ends on September 20, 2020, SNFs will be required to begin collecting data using the updated versions of the item sets beginning with patients discharged on October 1, 2022.
