RUG IV Update Faculty: Diane Atchinson, RN-BC, MSN, ANP, RAC-CT President, DPA Associates, Inc Kansas City, MO 64113 E Mail: diane@dpaassociates.com Topics to be discussed Medicare RUG groups CMS Open Forums-updates Unscheduled Assessments Weekly therapy RUG management 5 areas that can not be changed without it affecting your Medicare payments RUG usage and MDS type of assessments Triple check program 1
Medicare RUG s 66 groups Top 53=skilled services if all Medicare criteria is met Reasonable and necessary Practical matter Days to use 3 hospital overnights Skilled need daily Certifications Letters-denial and expedited review Crosswalk in back of MDS manual CMS Updates CMS focus on both Medicare and MDS manual changes including QM s, QAPI etc Google CMS Open Forum to register or to get call in info www.cms.gov/outreach-andeducation/outreach/opendoorforums/odf_snfltc This is the only way you will know about updates Your responsibility as a provider to know these updates 2
Unscheduled assessments Start of therapy (SOT)=Optional (2-41) Review the nursing CMI versus therapy and decide if you want to do. Always focus on the higher CMI ARD will be 7 days after you started therapy includes evaluation date End of therapy (EOT-R) (2-47) 2 scenario's All therapy ends (planned) and will switch to a nursing RUG ARD is day 1-3 after all therapy ended No therapy provided for 3 consecutive days (includes weekends) for any reason ARD is day 1-3 after all therapy ended Will bill the nursing RUG for these days If therapy is restarted within 5 days of stopping, and at the same RUG level, note the day of resumption in section O Therapy RUG payment starts on the day therapy was resumed Change of therapy (COT) (2-49) Medicare ARD sets weekly review of RUG maintenance Includes: # of days of therapy Therapy minutes # of disciplines to get the RUG Medicare reimbursement policies If with your weekly review the RUG criteria is met, continue with routine weekly reviews If with your weekly review the RUG criteria is not met as noted above, need to do a change of therapy assessment ARD would be day 7 of your review Payment changes on the first day of the decline or increase in therapy services, ie back 7 days ARD of this assessment resets your weekly review dates 3
Combining scheduled and unscheduled assessments (2-51) If your weekly review date is within a window to complete a scheduled assessment you have the following options If the RUG will increase, combine the assessments The payment will start 7 days back If the RUG will decrease, do not combine the assessments Use the scheduled assessment Payment will begin the day after the ARD date Weekly therapy reviews Review of RUG maintenance Days of therapy for the RUG are met Minutes of therapy for the RUG are met Number of disciplines for the RUG are met Availability of therapy provision at least 6 days/week to make up for lost days instead of doing a COT Review the % of COT s being done-are you over the national average of 11% Short stays now looking at providing 7 days of therapy 4
SNF policy about Medicare participation Upon admission are you ensuring the Medicare criteria is center stage Residents need to be made aware in writing why they are being skilled If they choose not to participate daily for any reason, they could lose their Medicare stay Manage-beauty shop appointments that conflict with therapy, outings, activities, MD appointments, family visits Medicare future payments How much longer do you think CMS and managed care organizations are going to want to pay for therapy 7 days a week when it is only being provided 5 days??? 5
5 areas that can not be changed for Medicare Assessments Type of provider (A0200) Type of assessment (A0310) Entry date (A1600) on an entry tracking record Discharge date (A2000) on a discharge record ARD (A2300) CMS Discussion on this issue Providers have 14 days from the ARD date to complete a Medicare assessment and then an additional 14 days to transmit it Once it is transmitted and accepted, your options to make these changes are: Complete a new MDS (Medicare) and set the ARD for the date you found the error All data collected reflects this ARD lookback Would be coded for the type of assessment it should be Affect on payment If still on Medicare, you bill the default rate for the time up the ARD date of the new assessment or for the full payment period if past that date If not on Medicare, you can not bill for the time this MDS would have paid for Take away message Use those 28 days to ensure that the 5 areas are correct for Medicare residents prior to transmission or Review these 5 areas for accuracy prior to transmission. Document is review. 6
CMS 2012 update 1.2 % increase in RUG payments Begins 10/1/12 CMS 2012 Updates-RUG Usage RUG Category FY 2011 Q1, 2 FY 2012 Rehab+SE 2.5 1.8 Rehab 87.9 88.5 SE 0.6 0.7 Special Care 4.6 5.0 Clinically 2.5 2.3 Complex Behaviors 0.4 0.3 Physical fun 1.5 1.5 7
Therapy RUG Usage Therapy FY 2011 Q1, Q2 FY 2012 Ultra high 44.9 46.2 Very high 26.9 26.7 High 10.8 10.7 Medium 7.6 6.6 Low 0.1 0.1 Mode of therapy Type STRIVE FY 2011 Q1,Q2 FY 2012 Individual 74 91.8 99.5 Concurrent 25 0.8 0.4 Group <1 7.4 0.1 8
Distribution of MDS Assessment Types Assessment FY 2011 Q1, Q2 FY 2012 Scheduled 95 84 SOT 2 2 EOT 3 3 SOT/EOT 0 0 EOT-R n/a 0 SOT/EOT-R n/a 0 COT n/a 11 How to use this data Compare your facility data regarding RUG usage and MDS types to national averages If you are way under, why If you are over, be able to justify this Audit focus when you are over national averages 9
Are you Tripling checking??? Triple check program Part of corporate compliance Compare MDS and therapy data prior to billing including ancillary charges Easier to make changes/corrections prior to billing 10
Resident Assessment Policy and Procedure and Checklist for the Triple Check Program Employees Responsible: MDS Medicare Coordinator, Business office manager, Medical Records, and Central Supply Policy: The objective is to ensure that Medicare is billed accurately and in a timely manner for all allowable incurred costs the facility has acquired under the Medicare program. Procedure: The MDS Medicare Coordinator will be responsible for implementing monthly the Medicare Triple Check process to verify that claims are accurate prior to submission to the Fiscal Intermediary. Each month the interdisciplinary team will verify all Medicare claims prior to submission. The Medicare Triple Check process will be completed by the following individuals: a) MDS Medicare Coordinator b) Therapy Director or designee c) Business office Manager or designee d) Medical Records e) Central Supply as requested The Medicare Triple Check process will ascertain and document key items for each Medicare claim using the Medicare Triple Check Audit Tool in order to ensure that the Medicare Triple Check meeting is completed in a timely manner, each of the facility participants will complete each of their respective key items (# coincide with the Medicare Triple Check Audit Tool) in advance. The Medicare Triple Check meeting is for verification and crosscheck review of the Medicare claim by the interdisciplinary team. Verification and crosscheck means that the key items should be verified by a member of the team other than those responsible for completing the information. The Medicare Triple Check Audit Tool will be completed by the Business Office Manager during the Triple Check Meeting and filed within the month-end closing reports. Items that have been verified as correct will be noted with an x. Items that have been identified as incorrect shall be noted with an o and necessary steps to obtain the correct information should be noted in the remarks section. Incorrect items that are corrected immediately during the meeting should be marked with an o in order to accurately reflect the communication and processes within the facility and assist in identifying additional training needs. Any item marked with an O will be brought to the attention of the DON and CFO at the end of the meeting.
Resident Assessment Policy and Procedure and Checklist for the Triple Check Program Medicare Claims identified with errors during the Triple Check will be put on hold and will not be transmitted to Fiscal Intermediary until the claim is corrected. Any Medicare Claim that is unable to be submitted will be brought to the CFO attention immediately. Once the incorrect item has been corrected, the Business Office Designee will indicate the correction and date in the remarks section of the Medicare Triple Check Audit Tool that contained the error. Business Office Manager or Designee 1. Verify qualifying stay on UB-04 FL#35-36 to medical records face sheet. 2. Verify that resident has benefit days available per the Common Working File (CWF). 3. Verify admit date on UB-04 FL#12 agrees to manual census log. 4. Verify covered service dates on UB-04 FL#6 agree to Medicare log and manual census log. 5. Verify that there is a signed and completed MSP form in patient s financial file. 6. Verify daily room rate charges are documented in FL# 42,43 and 47 Business Office Designee and MDS Medicare Coordinator 1. Verify that each of the MDS used in following checks agrees to validation report received from the state repository. 2. Verify that assessment reference dates per each MDS agrees to UB-04 FL#45 3. Verify that RUG level per each MDS agrees to UB-04 FL#44 4. Verify that assessment type for each MDS agrees to modifier on UB-04 FL#44 5. Verify that number of accommodation units on UB-04 FL#46 agree to assessment type for each MDS. Verify that total number of accommodation units agrees to covered service dates FL#6. 6. Verify that all ancillary services and charges for the billing period are line itemed FL # 42,43, and 47 Facility Rehab Director or Designee 1. Verify that Physical Therapy minutes per the daily treatment grid agree to service log. Agree days and minutes per the MDS to the treatment grid. Agree number of units billed on the UB- 04 FL# 42,43,44,46 and 47 to the service log. 2. Verify that Occupational Therapy minutes per the daily treatment grid agree to service log. Agree days and minutes per the MDS to the treatment grid. Agree number of units billed on the UB-04 FL# 42,43,44,46 and 47 to the service log 3. Verify that Speech Therapy minutes per the daily treatment grid agree to service log. Agree days and minutes per the MDS to the treatment grid. Agree number of units billed on the UB- 04 FL # 42,43,44,46 and 47 to the service log. MDS Medicare Coordinator and/or Medical Records 1. Verify that the physician SNF orders have been obtained and implemented 2. Verify that the medication record are complete
Resident Assessment Policy and Procedure and Checklist for the Triple Check Program 3. Verify that UB-04 FL diagnosis codes in FL # 67 corresponds to the physician diagnosis on either of the following: hospital discharge summary, transfer order form or via a telephone order obtained timely after admission. Medical Records 1. Verify that rehabilitation services are stated on physican orders 2. Verify that physician certification/recertification form has been completed and signed by physician. 3. Verify that denial letter and expedited review letters have been sent as appropriate.
Resident Assessment Policy and Procedure and Checklist for the Triple Check Program Resident Name MR # Physician Admit Date to Medicare A stay Discipline Business office manager Business Office and MDS Medicare Coordinator UB 04 item FL Description Y/N Comments/follow up 35-36 Hospital acute stay that lead to the skilled service (3 overnights) Observation does not count CWF Common working file 12 Admit date to SNF 6 Statement cover period MSP Medicare as secondary payor form completed #42,43,46,47 Room and board: revenue code, description, # of days MDS validation report and total charges Sent and accepted prior to biling 45 ARD date on MDS to be billed 44 RUG and HIPPS code 46 # of days to bill 7 Type of bill 42,43,44,46,47 Line item of all ancillary services provided during the billing period Pharmacy Lab-date and type X rays-date and type Medical Supplies Medical equipment MDS Medicare Coordinator and Rehab Director 42 PT Revenue code 43 Description 46 # of units 47 Total charges
Discipline MDS Medicare Coordinator and HIM Resident Assessment Policy and Procedure and Checklist for the Triple Check Program UB 04 item FL 42 OT Revenue code 43 Description 46 # of units 47 Total charges 42 Speech Revenue code 43 Description 46 # of units 47 Total charges SNF orders Description Y/N Comments/follow up Upon admission on transfer sheet or via a timely telephone order 67----- ICD 9 codes for skilled services HIM Rehab orders Upon admission or with physician order Certs/recerts Denial letter and expedited review letter Completed and signed timely Completed and sent timely (2 days notice) as appropriate
1 2 3a PAT. 4 TYPE CNTL # OF BILL b.med. REC. # 5 FED.TAX NO. 6 STATEMENT COVERS PERIOD 7 FROM THROUGH 8 PATIENT NAME a 9 PATIENT ADDRESS a b b c d 10 BIRTHDATE 11 SEX ADMISSION CONDITION CODES 12 DATE 13 HR 14 TYPE 15 SRC 16 DHR 29 ACDT 30 17 STAT 18 19 20 21 22 23 24 25 26 27 28 STATE e 31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37 CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH CODE FROM THROUGH a b 38 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES CODE AMOUNT CODE AMOUNT CODE AMOUNT a b c d a b 42 REV.CD. 43 DESCRIPTION 44 HCPCS / RATE / HIPPS CODE 45 SERV.DATE 46 SERV.UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 10 11 11 12 12 13 13 14 14 15 15 16 16 17 17 18 18 19 19 20 20 21 21 22 22 23 PAGE OF CREATION DATE TOTALS 23 50 PAYER NAME 51 HEALTH PLAN ID 52 REL. INFO 53 ASG. 54 PRIOR PAYMENTS 55 EST.AMOUNT DUE 56 NPI BEN. A 57 A B OTHER B C PRV ID C 58 INSURED S NAME 59 P.REL 60 INSURED S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO. A B C A B C 63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME A B C 66 DX 67 A B C D E F G H I J K L M N O P Q 69 ADMIT 70 PATIENT 71 PPS 72 73 DX REASON DX a b c CODE ECI a b c 74 PRINCIPAL PROCEDURE a. OTHER PROCEDURE b. OTHER PROCEDURE 75 CODE DATE CODE DATE CODE DATE 76 ATTENDING NPI QUAL LAST FIRST c. OTHER PROCEDURE d. OTHER PROCEDURE e. OTHER PROCEDURE CODE DATE CODE DATE CODE DATE 77 OPERATING NPI QUAL LAST FIRST 80 REMARKS 81CC a 78 OTHER NPI QUAL b LAST FIRST 68 A B C c 79 OTHER NPI QUAL UB-04 CMS-1450 APPROVED OMB NO. 0938-0997 d LAST FIRST National Uniform NUBC Billing Committee THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.
UB-04 NOTICE: THE SUBMITTER OF THIS FORM UNDERSTANDS THAT MISREPRESENTATION OR FALSIFICATION OF ESSENTIAL INFORMATION AS REQUESTED BY THIS FORM, MAY SERVE AS THE BASIS FOR CIVIL MONETARTY PENALTIES AND ASSESSMENTS AND MAY UPON CONVICTION INCLUDE FINES AND/OR IMPRISONMENT UNDER FEDERAL AND/OR STATE LAW(S). Submission of this claim constitutes certification that the billing information as shown on the face hereof is true, accurate and complete. That the submitter did not knowingly or recklessly disregard or misrepresent or conceal material facts. The following certifications or verifications apply where pertinent to this Bill: 1. If third party benefits are indicated, the appropriate assignments by the insured /beneficiary and signature of the patient or parent or a legal guardian covering authorization to release information are on file. Determinations as to the release of medical and financial information should be guided by the patient or the patient s legal representative. 2. If patient occupied a private room or required private nursing for medical necessity, any required certifications are on file. 3. Physician s certifications and re-certifications, if required by contract or Federal regulations, are on file. 4. For Religious Non-Medical facilities, verifications and if necessary recertifications of the patient s need for services are on file. 5. Signature of patient or his representative on certifications, authorization to release information, and payment request, as required by Federal Law and Regulations (42 USC 1935f, 42 CFR 424.36, 10 USC 1071 through 1086, 32 CFR 199) and any other applicable contract regulations, is on file. 6. The provider of care submitter acknowledges that the bill is in conformance with the Civil Rights Act of 1964 as amended. Records adequately describing services will be maintained and necessary information will be furnished to such governmental agencies as required by applicable law. 7. For Medicare Purposes: If the patient has indicated that other health insurance or a state medical assistance agency will pay part of his/her medical expenses and he/she wants information about his/her claim released to them upon request, necessary authorization is on file. The patient s signature on the provider s request to bill Medicare medical and non-medical information, including employment status, and whether the person has employer group health insurance which is responsible to pay for the services for which this Medicare claim is made. 8. For Medicaid purposes: The submitter understands that because payment and satisfaction of this claim will be from Federal and State funds, any false statements, documents, or concealment of a material fact are subject to prosecution under applicable Federal or State Laws. 9. For TRICARE Purposes: (a) The information on the face of this claim is true, accurate and complete to the best of the submitter s knowledge and belief, and services were medically necessary and appropriate for the health of the patient; (b) The patient has represented that by a reported residential address outside a military medical treatment facility catchment area he or she does not live within the catchment area of a U.S. military medical treatment facility, or if the patient resides within a catchment area of such a facility, a copy of Non-Availability Statement (DD Form 1251) is on file, or the physician has certified to a medical emergency in any instance where a copy of a Non- Availability Statement is not on file; (c) The patient or the patient s parent or guardian has responded directly to the provider s request to identify all health insurance coverage, and that all such coverage is identified on the face of the claim except that coverage which is exclusively supplemental payments to TRICARE-determined benefits; (d) The amount billed to TRICARE has been billed after all such coverage have been billed and paid excluding Medicaid, and the amount billed to TRICARE is that remaining claimed against TRICARE benefits; (e) The beneficiary s cost share has not been waived by consent or failure to exercise generally accepted billing and collection efforts; and, (f) Any hospital-based physician under contract, the cost of whose services are allocated in the charges included in this bill, is not an employee or member of the Uniformed Services. For purposes of this certification, an employee of the Uniformed Services is an employee, appointed in civil service (refer to 5 USC 2105), including part-time or intermittent employees, but excluding contract surgeons or other personal service contracts. Similarly, member of the Uniformed Services does not apply to reserve members of the Uniformed Services not on active duty. (g) Based on 42 United States Code 1395cc(a)(1)(j) all providers participating in Medicare must also participate in TRICARE for inpatient hospital services provided pursuant to admissions to hospitals occurring on or after January 1, 1987; and (h) If TRICARE benefits are to be paid in a participating status, the submitter of this claim agrees to submit this claim to the appropriate TRICARE claims processor. The provider of care submitter also agrees to accept the TRICARE determined reasonable charge as the total charge for the medical services or supplies listed on the claim form. The provider of care will accept the TRICARE-determined reasonable charge even if it is less than the billed amount, and also agrees to accept the amount paid by TRICARE combined with the cost-share amount and deductible amount, if any, paid by or on behalf of the patient as full payment for the listed medical services or supplies. The provider of care submitter will not attempt to collect from the patient (or his or her parent or guardian) amounts over the TRICARE determined reasonable charge. TRICARE will make any benefits payable directly to the provider of care, if the provider of care is a participating provider. SEE http://www.nubc.org/ FOR MORE INFORMATION ON UB-04 DATA ELEMENT AND PRINTING SPECIFICATIONS