Reimbursement Archives - Montero Therapy Services

Medicare Part B Rules for 2019 – Short and Sweet Version

January 2, 2019 By Montero Therapy Services Leave a Comment

Therapists in the SNF (Skilled Nursing Facility) setting are starting out 2019 with a few less documentation requirements to worry about. Less? Now that’s a first! So what’s up for 2019?

The Final Rule {you’re starting to see the pattern that these Final Rules are never final, right?} released November 1st, 2018 by CMS included updates to payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS). What services are furnished under the Medicare Physician Fee Schedule? You guessed it…. Medicare Part B.

What Do SNF Therapists Need to Know?

1- Discontinuation of Functional Status Reporting Requirements for Outpatient Therapy

Functional Limitation Reporting (FLR), a.k.a. G-Codes, will not be required for therapy Part B visits provided on or after 1/1/19
If your therapy software is still requiring these codes, it may be because software updates that trigger these codes have not been updated yet, or possibly your therapy software uses the G-Codes as a basis for outcome measure tracking
Medicare will allow these codes to continue to be reported on claims for now until software providers can update their systems
Chapter 15 of the Medicare Benefit Policy Manual {where Part B rules live} has not yet been updated with the Final Rule changes

2- Therapy Cap

The cap has been gone for 1 year and is not coming back! But…..
The Final Rule requires the use of the KX modifier to all therapy services that “would have exceeded the previous therapy cap amounts”
The Therapy Cap has now become the KX Modifier Threshold
KX modifier is needed on Part B claims for services over the “threshold” in order for the services to be paid by Medicare
New “threshold” for 2019 is $2040 for OT, $2040 for PT and Speech combined (up 1.5% from last years amount)
Payment will be denied of no KX once threshold is hit
**Important reminder and repeated for therapists again in the Final Rule**

By applying the KX modifier to the claim, the therapist or therapy provider is confirming that the services are medically necessary as justified by appropriate documentation in the medical record.

3- Manual Medical Review

Threshold continues at the same amount of $3000 until 2028 {Wow, Medicare is really thinking ahead!}
Review is not automatic. CMS is limiting reviews to “outliers” and those with questionable practice patterns

4- PT and OT Evaluation CPT Codes

Nothing new here…
After a long enough data collection period with the new PT and OT evaluation complexity codes, it was anticipated that a change in payment structure may be released. However, no changes were proposed in the recent Rule.

5- Reduction of Payment for Part B Services Provided by Assistants (PTA, COTA, OTA)

All therapy services on or after 1/1/20 provided in whole or in part by an Assistant will need to be billed using the new payment modifiers
- New PTA Payment Modifier: CQ
- New OTA Payment Modifier: CO

All therapy services on or after 1/1/2022 provided in whole or in part by an Assistant will have a payment reduction of 15% applied

What does provided in whole or in part mean?

CMS is defining in whole or in part as provision of more than 10% of a therapy service by an assistant. The Final Rule states that specifics to this point will be addressed in the 2020 Proposed and Final Rules. {This is an improvement from the Proposed Rule which defined in whole or in part as “any minute!”} By using the payment modifiers in 2020, CMS will have 2 years of data collection to assess potential revisions to the requirements.

What else did CMS add in this Section of the Rule?

In the discussion of Assistants, the Final Rule reiterates that Assistants “may not provide evaluative or assessment services, make clinical judgments or decisions; develop, manage or furnish maintenance program services.” This is important to point out because as of next year at this time, we will be identifying all assistant treatments on the billing claims (if >10% of the service).

Change…

Remember, these changes are for Part B therapy only, regardless of the setting. We are still waiting on the official updates to Chapter 15 of the Medicare Benefit Policy Manual, but the above changes are official from the Final Rule. So what will we see in the SNF setting with the changes above, in particular the changes related to assistants? We may see a shift in who assistants provide therapy to in the SNF; possibly a shift away from Part B and toward Part A and Managed Care to avoid the payment reduction. One would hate to think that some providers will take the time to figure out how to have assistants provide 9% of the therapy service to avoid the payment reduction……let’s hope not!

For now, we will go with the flow and see what change brings. Heaven knows we are used to it!

Any questions on the information, please submit them to our Just Ask Q&A Forum!

In Your Corner,

Dolores and the Montero Therapy Team

www.RehabManagerTraining.com

Links if you want to further explore this area

Article explaining Part B changes

Final Rule 11/1/18 – PDF Version (852 pages)

Chapter 15 – Medicare Benefit Policy Manual Rules for Part B

Chapter 15 – Section 220.4 – Functional Limitation Reporting – Info has not been updated to remove G Code requirement as of 1/1/19

Medicare Claims Processing Manual – Info for G Codes has not been updated as of 1/1/19

SNF Therapy and MDS Changes for October 1st 2018 – Part A & Part B

September 4, 2018 By Montero Therapy Services Leave a Comment

If you are a therapy or MDS professional in the SNF setting, you know that change comes at least twice a year – January 1st and October 1st.

Why? January 1st is the start of the calendar year and brings with it the changes from the Physician Fee Schedule for Medicare Part B. October 1st is the start of the SNF fiscal year and brings with it the changes for PPS Medicare Part A, which may also include changes to the MDS and reimbursement.

So…. change is nothing new for us! SNF professionals get suspicious when things are quiet for too long anyway!

Let’s take a look at what is coming….

Medicare Part A Changes

The changes impacting Medicare Part A reimbursement that will take effect 10/1/18 fall under a few different umbrellas. Up to this point, therapy managers, therapists and MDS Coordinators may not have focused on all aspects of Part A reimbursement since the primary “umbrella”, the RUG-IV Prospective Payment System (PPS) has been the hogging the spotlight for years. However, since it will be lights out for RUG-IV next October when PDPM (Patient Driven Payment Model) kicks in, it is time to start focusing on the other umbrellas. PDPM will only be a small piece of the puzzle moving forward and it is critical that professionals understand the bigger picture.

1- SNF Value-Based Purchasing Program (SNF VBP)

We have known about the SNF VBP program for a while, but SNFs will only begin to feel the effects starting 10/1/18, when the VBP payment impact kicks in for all SNFs that participate with Medicare Part A.

So what is SNF VBP?

The SNF VBP Program is the shift CMS is taking toward paying based on quality rather than quantity – or “value over volume.” The program rewards SNFs with incentive payments for the quality of care they give to people with Medicare – based on scoring of different Measures. For now, there is only 1 measure.

The Measure that kicks in for payment 10/1/18 is called: SNF 30-Day Readmission Measure (SNFRM – NQF #2510)

This measure looks at all Medicare Part A residents who were discharged from the hospital to a SNF, and then ended up back in the hospital for an unplanned readmission within 30 days of the original hospital discharge. This includes residents that are in your SNF and go back to the hospital AND residents that you have discharged home or to a lesser level of care who then go back to the hospital {Yes, somewhat out of your control!} Facilities are scored and ranked to determine what their incentive payment will be, if any, based on a particular data collection period.

How is this program paid for?

EVERY SNF loses 2% off the top of their PPS reimbursement for the year in order to fund this program! But don’t worry…the SNF VBP program allows a chance to earn some or all {or none} of it back. Your Achievement and Incentive Scores will determine your points, score and ranking, which in turn, determines if you receive any of the 2% back. Most won’t.

Why is SNF VBP important to therapy and MDS professionals?

First and foremost, you are losing 2% off the top and have a chance to get it back by demonstrating the quality care you provide. Staying on top of this measure is somewhat in your control, even after the residents leave your facility. For example, residents admitted to your SNF from the hospital require adequate monitoring of medical stability. It goes without saying that staying on top of each resident’s medical condition is a must. The newer admissions may not be 100% stable – as we know by the revolving door we sometimes see when residents leave the hospital too soon. Therapy may not be the priority when residents arrive – yes, they may not be able to tolerate Ultra minutes – and therapy sure as heck should not be pushing someone lacking stability into distress. Treat wisely. Also, your SNF should have internal measures as to how to handle an acute crisis where sending the resident out to the hospital can be avoided. Availability of qualified PA’s, NP’s, and MD’s on a 24/7/365 basis is a must. The last thing you want if for a doc to say “send them out” when you know the issue is minor enough to be successfully handled internally. Also important to note here is “readiness for discharge.” With the push for decreased length of stay, this measure may give you leverage when fighting for more days of coverage to ensure medical stability before a resident is sent home.

Important resource links

This is only the tip of the iceberg so if you are interested in more on this topic, check out these links:

2- SNF Quality Reporting Program (SNF QRP)

The SNF QRP program has been around for a few years and has lots of moving pieces, some new each year and some old. Remember MDS Section GG?

So what is SNF QRP?

SNF QRP came to us by way of the IMPACT Act of 2014 which, in part, required a movement toward standardizing data between post acute care settings {SNFs, HHAs, IRFs and LTCHs} with a goal of improving quality of care, communication and coordination of care between settings. [See this article] A shift toward standardizing data elements in each of the assessment tools used in the different settings began. If you work in multiple setting, you will recognize some of the same questions of the MDS, IRF-PAI, etc. The data collected can be used to “Measure” quality and outcomes.

What are the Measures? {There are quite a few to keep track of!}

The 3 old measures that kick in for payment 10/1/18 are in the areas of Skin, Falls and Function. These are the Measures we were collecting data for over a year ago which will impact payment in October. Keep in mind that we are still in a collection period now which will determine future payment in 2019 and beyond.

SNF QRP Assessment-Based Measures (From MDS Questions)

NQF Measure ID	Measure Title
NQF #0674	Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay)
NQF #0678	Percent of Patients or Residents with Pressure Ulcers that are New or Worsened
NQF #2631	Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function

The 3 new claims based measures will also impact payment 10/1/18, though these are not derived from MDS questions.

SNF QRP claims-based measures (From Billing Claims)

Measure	Data Source
Discharge to Community- Post Acute Care (PAC) Skilled Nursing Facility (SNF) Quality Reporting Program (QRP)	Medicare FFS claims
Potentially Preventable 30-Days Post-Discharge Readmission Measure for Skilled Nursing Facility (SNF) Quality Reporting Program (QRP)	Medicare FFS claims
Medicare Spending Per Beneficiary – Post-Acute Care (PAC) Skilled Nursing Facility Measure	Medicare FFS claims

The following new Measures start data collection 10/1/18 to 12/31/18 (no dashes!) and will impact payment 10/1/19:

Measure	MDS Section
Drug Regimen Review	Section N
Change in Skin / Pressure Ulcer / Injury	Section M
Change in Self Care	Section GG
Change in Mobility	Section GG
Discharge Self Care Score	Section GG
Discharge Mobility Score	Section GG

How are the Measures used for payment or penalty?

Remember the push for “no dashes” in Section GG??? This was the reason. Any “incomplete” MDS Section GG section for Skin, Falls and Function during the collection period will now come back to haunt you. You will receive a 2% PPS payment reduction if less than 80% of your submitted PPS 5 day and DC MDS’s were not 100% complete – no missing info or dashes. Collection periods in the past will impact payment now. Remember – once a collection period is over, you will be in a new collection period….so it’s never really “over.”

Why is SNF QRP important to therapy and MDS professionals?

SNF QRP is HUGE for therapy professionals! These are the outcomes for our Medicare Part A residents…..self care, mobility, successful discharge to the community. All therapy professionals should be keenly aware of the MDS items that contribute to these outcomes. Some therapy software programs incorporate the MDS questions into the therapy initial evaluations and discharge summaries…..but that DOES NOT cut it! Therapists need to look at an MDS directly to get the full scope of the SNF QRP. Therapists need to understand the connection between what they are filling out in therapy software and what may actually populate the MDS. Since MDS Coordinators have the “big picture” in mind, they should be the gate-keepers of what populates to Section GG from therapy software, in addition to being on “dash-patrol.”

Important resource links

3- MDS 3.0

Every year we see MDS item question additions and/or changes. This October is no exception. There are multiple changes this year to support the SNF QRP Measures described above, as well as to support next years PDPM. MDS changes can also impact State Case Mix.

What is changing?
- Section A: New Medicare numbers
- Section I: Primary Medical Dx for SNF Stay – added in preparation for PDPM
- Section J: Prior Surgery – added in preparation for PDPM
- Section M: Skin – added term “injury”
- Section N: Medications – Added items for Drug Regimen Review
- Section O: Special Treatments, Procedures – clarified invasive vs non-invasive ventilator
- **Section GG: Functional Abilities and Goals – Major Changes!
  - Added “Prior Level of Function”
  - Added to Self Care: Shower/Bathe Self; Upper and Lower Body Dressing; Don/Doff Footwear
  - Added to Mobility: Roll; Car Transfer; Walk 10′; Walk 10′ Uneven Surfaces; Step/Curb; 4 & 12 Steps; Pick item from floor
Why is this important to therapy and MDS professionals?

These new or modified questions will impact the SNF QRP, measured outcomes and reimbursement for years to come. They are also set up to determine PDPM payment. Section GG is growing in leaps and bounds and therapy professionals have the ability to make a direct impact in this area.

4- Medicare Part B

The Proposed Rule out this July was only 665 pages… We will need to wait for the Final Rule which is not typically out until November. However, we can project that the following changes will take place January 1st:

Value-Based Programs….Yes, Part B has Quality Measures to report on as well! What used to be PQRS transitioned into MIPS, or Merit Based Incentive Payment and is going strong. The good news is….therapists in the SNF setting do not need to worry about these changes as they pertain to therapists in private practice at this time. If you are a therapist that is also a Medicare Provider of Part B in any setting, most of those 665 pages are for you!
Functional Limitation Reporting: FLR or G-Code Reporting came to us in 2013 and according to the Proposed Rule, will be history 1/1/19. The FLR requirements for Part B therapy will be removed from Chapter 15 of the Medicare Benefit Policy Manual.
Therapy Cap: Since the Cap has been repealed, there should not be much discussion on this in the Final Rule with the exception of a possible update to the $ threshold that marks use of the KX Modifier and the potential manual medical review
PT and OT Evaluation CPT Codes: After a long enough data collection period with the new PT and OT evaluation complexity codes, it was anticipated that a change in payment structure may be released. However, no changes were proposed in the recent Rule.
New Modifiers for PT and OT Assistants: In preparation for changes to come 1/1/22 with reimbursement reductions in all Part B settings to 85% of the Fee Schedule for services provided by PT and OT Assistants, 2 new modifiers will be mandated starting 1/1/20 to indicate on the billing claim which services were provided “in whole or in part” by an assistant. There will likely be further {intense} discussion on this topic as the Proposed Rule indicates that “any minute” of billable services provided by an assistant must be coded as provided by an assistant.
- What does this mean? Well, if a resident received 30 minutes of therapy for 1 unit of therapeutic exercise and 1 unit of gait training, if an assistant provided ANY services contributing to either of those units, the unit would be subject to reduced reimbursement. An exception would be if the assistant was helping a therapist…as in this case the therapist would be billing the full time.
- Remember, this is for Part B only. What we may see is a shift of Assistants providing the Part A and Managed Care treatment and Therapists providing the Part B services. We will have to wait on this for now.

Summary – and a Word About PDPM

Yes, 10/1/19 will be here before we know it and PDPM will bring about major changes for the SNF setting, therapists and MDS Coordinators.

But… let’s slow down for a minute and focus on 10/1/18.

If you truly read the above information on VBP and QRP, you will see that the Shift toward “value” and the Measures that require reporting rely on the input from therapy professionals.

THIS is the information that you need to master if you plan to stick around the SNF setting after 10/1/19, be successful and really show your worth! The shift to value is NOT going anywhere, unlike PPS.

Therapy in the SNF setting always was…and always will be…about SERVICE to the resident.

Learn everything you can about the “big picture.” Your service will make all the difference…in quality….and in outcomes.

Any questions, please submit them to our Just Ask Q&A Forum.

In Your Corner,

Dolores and the Montero Therapy Team

Rehab and MDS Compliance Experts – www.RehabManagerTraining.com

Want more details on the changes to come? Join Us for our Upcoming Course – We have designed this course with the busy professional in mind. The course will be released to you on September 19th. You will have 2 full weeks to listen to webinar as many times as needed – and you will then have access to a 1 hour live Q&A Session on 10/3/18 from 2-3 pm EST where we will provide a quick review of the material highlights and then open up the webinar for your questions. Don’t miss out!

Webinar: SNF Therapy & MDS Changes for October 1st 2018 and Beyond – Registration

Coming Soon To A SNF Near You – A New Medicare Part A Payment Model

April 29, 2018 By Montero Therapy Services Leave a Comment

Since the release of the Advanced Notice of Proposed Rulemaking (ANPRM) approximately 1 year ago, the talk in SNF Rehab Departments has been about RCS-1 and the looming potential changes coming down the road that would not only change reimbursement for Medicare Part A , but impact the way therapy is currently provided. Along with the facts about RCS-1, there were many many myths and rumors as to how therapy life in the SNF would forever change. See our last article “RCS-1: To be or not to be.

Therapists nationwide were awaiting the SNF PPS Proposed Rule due to be released this spring, in hopes of getting clarification on the changes to come. {For those new to the process, the Proposed Rule released each year outlines changes for the start of the next FY (Fiscal Year) which starts on October 1st. It is released to allow time for comments from providers before releasing the Final Rule prior to October 1st.}

We knew changes were coming, however, as of last month in an ODF (Open Door Forum), CMS stated they were still analyzing comments and feedback related to the proposed changes…and official policies and a start date had not yet been set.

…and then yesterday, April 27th, CMS released the anticipated 266 page Proposed Rule. Yes, change is coming…but not until October 1, 2019….and it was NOT RCS-1!

This new rule proposes the replacement of the existing case-mix classification methodology, the Resource Utilization Groups, Version IV (RUG-IV) model, with a revised case-mix methodology called the Patient-Driven Payment Model (PDPM) effective October 1, 2019. RCS-1 was essentially revamped in response to comments and additional data analysis….and then renamed.

So What Happened?

Well, CMS has commented in the Final Rule for at least the last 5 years that there was significant concern regarding the therapy trends in the SNF . CMS has cited 2 concerns in particular:

The percentage of residents classifying into the Ultra-High therapy category has increased steadily (reaching >60% of total scores in 2017)
The percentage of residents receiving just enough therapy to surpass the Ultra-High and Very-High therapy thresholds has also increased (some SNF’s achieved 100% of RU and RV RUGS with exact minutes of 720 and 500 respectively…like magic)

In the 2015 SNF PPS Final Rule, CMS stated: “We believe the increase in “thresholding” is a strong indication of service provision predicated on financial considerations rather than resident need.” “….Therefore, services which are not specifically tailored to meet the individualized needs and goals of the resident, based on the resident’s condition and the evaluation and judgment of the resident’s clinicians, may not meet [the] definition for covered SNF care, and we believe that internal provider rules should not seek to circumvent the Medicare statute, regulations and policies, or the professional judgment of clinicians.”

{Did you know CMS said this? Looks like they may have been on “your side” all along….though not all were listening….}

So, after years of recommendations and clear data from the OIG and MedPAC to make a change, CMS took a stand last May, gave fair warning of a new payment system (RCS-1) and allowed comments for an extended period of time. CMS really did listen to all the comments and concerns about RCS-1, took them into account and created a payment model with a new name – PDPM.

For those not paying attention to the multitude of CMS statements over the years reiterating that therapy service provision should be based on the resident’s individual needs, this Proposed Rule would rename the payment model so no one could forget… The Rule states:

To make clear the purpose and intent of replacing the existing RUG-IV system, the model we are proposing in this rule is called the Patient-Driven Payment Model (PDPM).

Ok, got it! Patient-Driven…..not therapy-driven, not minute-driven!

Nuts and Bolts of the new PDPM?

PDPM is a new payment model, very similar to the previously proposed RCS-1, that sets daily Medicare Part A payment rates on factors other than therapy days and minutes. Data from the MDS, starting with the ICD-10 code and category that supports the SNF Part A stay, are used to classify a resident. Additional MDS data including function, cognition, swallowing disorders and other clinical diagnoses also contribute to classifications. Unlike the RUG-IV classification where each resident is only classified into 1 RUG group based on the MDS, PDPM breaks apart therapy and nursing to allow for a separate classification for each.

Here is a breakdown of the contributing components:

Nursing is finally “free” from therapy’s grip. With RUG-IV, Rehab RUG’s often trumped Nursing RUG’s. PDPM will use a similar set up as RUG-IV for nursing, minus the Rehab RUG’s. RCS-1 had the total # of RUGS down from 66 to 43, and now PDPM takes it down even further to a total of 25 by combining existing groups. The method for calculating the ADL score will also change and Section GG items will be added to the mix.

PT case mix and payment will be determined by the ICD-10 code category for SNF admission and the functional score based on MDS questions. There are a total of 16 potential PT case mix groups as show here,

OT case mix and payment are determined exactly like PT, however, case mix scores and payment will differ for each category.

Of note, the daily payment amount for PT and OT will pay the full rate for the first 20 days and then decrease by 2% every 7 days thereafter for the remaining 80 days.

Speech case mix and payment is determined by the ICD-10 code category for SNF admission, as well as factors including swallowing disorders, mechanically altered diets, speech co-morbidities and cognition (all from MDS answers). The daily speech rate does not decrease over time like the PT and OT rates.

Now remember….minutes don’t matter. In fact, these PT, OT and Speech categories/case-mix are not even impacted by the presence or absence of an active therapy program. Each resident will fall into a PT, OT and SLP case mix group regardless of therapy services. Yes….facilities are paid a daily rate for therapy services even if therapy is not active. If therapy is active, the payment rate does not change with the amount of time spent with the resident. Why? CMS expects the SNF to save payment for when therapy services are necessary.

There is also a case mix category called “Non-Therapy Ancillary” that will use MDS questions from Section I, K, M and O to determine a case mix score. This payment is tripled for the first 3 days of the stay to cover any costs upfront.

In addition to the 5 case mix based categories above, there is also a non-case mix payment (flat rate) for “overhead costs” such as room and board, laundry, capital expenses, dietary, etc.

The payment rate for the above 6 categories will be added up to make the total daily per diem payment rate. So with RUG-IV we had 1 category determining daily payment and now with PDPM, the eggs are spread into 6 baskets.

What Can Therapists Do To Prepare?

Read the Proposed Rule! It is only 266 pages. You may not need all the info in there, but it will give you greater perspective on why changes were made and the data that drove the changes. It also gives you insight into Medicare’s thought process for Part A payment.

Education is always the best bet. If you are not familiar with the MDS, now is the time to get your feet wet. The MDS tool is and will continue to be the central point for outcomes, Part A reimbursement, Quality Measures, Star Ratings, State case mix and more.

Oh, and there is so much more info out there if you are interested. Here are a few links to get you started.

SNF PPS Proposed Rule for Oct 1st 2018

Acumen Technical Report – SNF PPS Data for PDPM – April 2018

SNF PPS Payment Driven Payment Model CMS Webpage

*Keep in mind that this is a Proposed Rule…and things may change as the date approaches.

Will SNF Therapy Change When “Minutes Won’t Matter?”

Technically it shouldn’t. But will they? Possibly initially…until the dust settles.

If your facility was providing therapy services based on resident’s need and not financial targets, nothing should change, right? CMS used existing provider data to revamp the payment system, and says that if your facility was not one that provided an “excess” of Rehab Ultra, you may be looking at a significant increase in reimbursement under the new model. However, if your facility was one of those with a super high percentage of Ultra High RUG’s, your facility may see a dip in reimbursement with PDPM.

CMS put out a comparison tool so facilities could look themselves up to see how reimbursement would change under PDPM assuming all other variables stayed the same. Find your facility (you will need to know your CCN number) and see what the difference (+ or -) would be if PDPM was in effect in 2017. You can also see your facility revenue which may be eye opening for you!

PDPM Comparison Tool (It is an excel file that you can download and search for your facility. Compare revenue under RUG-IV with PDPM.)

So….

Don’t fall into the doomsday mode out there! There is plenty of Medicare Part A dollars that will continue to be available in the system. You just need to find a facility or company that is willing to “share” with you! Now is the time to find a facility or company that sees you for your value BEYOND your ability to provide minutes!

A new payment model may be a blessing in disguise for therapists in the SNF setting. Therapists who have been around since pre-PPS {cough} remember what autonomy felt like and remember not only being able to make a difference in each residents life, but the life of the SNF as a whole. Back then, therapists were team players that knew the rules…knew what the DOH was looking for…knew what the big picture looked like . Therapists have always been team players, but let’s be honest here…therapist autonomy was somewhat hijacked when PPS and managed Rehab departments came into play.

If you have questions about PDPM or anything else SNF related, send them to our Just Ask Q&A Forum and our team will help you out.

In Your Corner,

Dolores and the Montero Therapy Team

www.MonteroTherapyServices.com

RCS-1 – To Be Or Not To Be ?

April 1, 2018 By Montero Therapy Services Leave a Comment

Chances are that NO ONE has ever read Hamlet’s famous soliloquy by Shakespeare, “To be or not to be…” and thought…hmmm… this reminds me of Medicare, CMS and the potential new SNF reimbursement system RCS-1. {Right?}

In all honesty, I have not thought about Hamlet since 9th grade English. But what I remember {from the Cliff Notes} was that Hamlet was contemplating whether it was more noble to suffer life’s troubles or escape by ending his life. Heavy stuff!! This made me wonder….is CMS thinking the same thing about PPS these days? Are they thinking they can end the troubles that RUG-IV brought with it by killing it off? Maybe.

Rehab companies and those SNF’s that have reaped the benefits of the PPS and Ultra RUG may be hoping “not to be.” However, even though most therapists don’t yet know the ins and outs of what RCS-1 will be, they are ready to take a chance on “to be.”

Therapists in the SNF setting report their clinical judgement is steamrolled over by aggressive reimbursement targets for extending length of stay, questioning therapist recommended discharge dates and having someone other than the primary therapist determine daily treatment minutes to meet financial targets and not clinical needs. Therapists in some settings feel they have become minute robots, providing the # of minutes assigned to them for each resident on their daily schedule, minutes that allow for the achievements of RUG targets that are either exact or pretty close to the RUG minimum {because we wouldn’t want to waste minutes…uggg}. See our article on why “exact RUG minutes are a no-no.”

What is RCS-1?

RCS-1 is a new payment model that sets daily Medicare Part A payment rates on factors other than therapy days and minutes. RCS stands for Resident Classification System, and as the name implies, uses resident data to classify a resident into a category for payment. Data from the MDS, starting with the ICD-10 code and category that supports the SNF Part A stay, are used to classify a resident. Additional MDS data including cognition, function, swallowing disorders and other clinical diagnoses also contribute to classifications. Unlike the RUG-IV classification where each resident is only classified into 1 RUG group based on the MDS, RCS-1 breaks apart therapy and nursing to allow for a separate classification for each.

Nursing is finally “free” from therapy’s grip. With RUG-IV, Rehab RUG’s often trumped Nursing RUG’s. RCS-1 will use the same RUG-IV set up for nursing, minus the Rehab RUG’s. The 66 total RUGs will dwindle to 43.

PT and OT share a category and both function and cognition (from the MDS answers) determine the category, case mix and payment rate. After 14 days, the daily rate for the PT/OT category decreases by 1% every 3 days for the remainder of the 100 days.

Speech is in a category by itself and factors including swallowing disorders, mechanically altered diets, speech co-morbidities and cognition (all from MDS answers) determine the category, case mix and payment rate.

Now remember….minutes don’t matter. In fact, these PT/OT and Speech categories/case-mix is not even impacted by the presence or absence of an active therapy program. Each resident will fall into a PT/OT and SLP case mix group regardless of therapy services. Yes….facilities are paid a daily rate for therapy services even if therapy is not active. If therapy is active, the payment rate does not change with the amount of time spent with the resident. Why? CMS expects the SNF to save payment for when therapy services are necessary.

In addition to the 4 case mix based categories above, there is also a non-case mix payment (flat rate) for “overhead costs” such as room and board, laundry, capital expenses, dietary, etc.

The payment rate for the above 5 categories will be added up to make the total daily per diem payment rate. So with RUG-IV we had 1 category determining daily payment and now with RCS-1, the eggs are spread into 5 baskets.

What Can Therapists Do To Prepare?

Will SNF Therapy change when “minutes won’t matter?” Technically it shouldn’t. If your facility was providing therapy services based on resident’s need and not financial targets, nothing should change, right? If your facility was not one that provided an excess of Rehab Ultra, you may be looking at a significant increase in reimbursement. However, if your facility was one of those with a super high percentage of Ultra High RUG’s, your facility may see a dip in reimbursement with RCS-1.

CMS put out a comparison tool so facilities could look themselves up to see how reimbursement would change under RCS-1 assuming all other variable stayed the same. Find your facility and see what the difference (+ or -) would be if in FY2014 we used RCS-1 vs RUG-IV. You can also see your facility revenue which may be eye opening for you!

RCS-1 Comparison Tool (It is an excel file that you can download and search for your facility.)

So….

Now is the time to find a facility or company that sees you for your value BEYOND your ability to provide minutes! Robot days are over.

So RCS-1 may be a blessing in disguise for therapists in the SNF setting. Therapists who have been around since pre-PPS {cough} remember what autonomy felt like and remember not only being able to make a difference in each residents life, but the life of the SNF as a whole. Back then, therapists were team players that knew the rules…knew what the DOH was looking for…knew what the big picture looked like . PPS and “managed Rehab departments” took therapists autonomy away to some degree and also did not leave time for anything other than minutes and productivity.

RCS-1 – or ANYTHING but the RUG-IV system we have now that incentivizes all the wrong things – may just the “blessing in disguise” that many therapists were hoping for.

On 3/8/18, CMS held an Open Door Forum call that included a brief discussion on RCS-1. On that call, John Kane from CMS cautiously stated that CMS “has not proposed or finalized any policies.” Kane added that “analysis based on comments received was still in progress” and that CMS did not have a timeline.

RCS-1 is not about IF… but rather, WHEN. That…. is the question.

If you have questions about RCS-1 or anything else SNF related, send them to our Just Ask Q&A Forum and our team will help you out.

In Your Corner,

Dolores

www.MonteroTherapyServices.com

Is a Range in Therapy Frequency Acceptable for Part A or B?

March 11, 2018 By Montero Therapy Services Leave a Comment

A common question from Rehab Departments in skilled nursing facilities:

Can our treatment orders have a range in frequency?

What is acceptable?

Part A: 5-6x per week vs 6x per week
Part B: 2-3x per week vs 3x per week

We can all have our opinion on this topic…but let’s look at Medicare’s opinion…since they are paying {or not paying} the bill!

The answer is split into 2 parts, 1 for Medicare A and 1 for Medicare B.

Let’s start with Medicare Part B since the answer is pretty clear-cut.

1- Medicare Part B: The Medicare Benefit Policy Manual, Chapter 15, the Chapter that contains all the rules for Medicare Part B (in all settings including SNF) clearly states that the frequency should be set to strive for the most efficient and effective treatment. This phrase is repeated at least 3 times in the excerpt below. The Manual goes a step further to acknowledge that a patient’s frequency may change during the course of care, and that these changes should be based on the therapist’s assessment of daily progress. The Manual outlines the practice of “tapering” a frequency as an acceptable practice, and provides specific examples on how/why to do this.

Based on this information, establishing a therapy order as a range could lead to a denial. CMS is acknowledging that a patient’s frequency could change, and the Part B Manual presents a method to accommodate this by using “# of visits over a period of weeks” via tapering. Medicare’s focus is covering “reasonable and necessary” services based on the patient’s need – not staffing or convenience of scheduling. In our auditing services, we have come upon denials for services where a range was used. Medicare Part B would only cover {pay for} the lower end of the range. (ie: Therapy order was for 2-3x/week. Medicare only covered 2 visits per week citing unclear medical necessity for the 3rd visit).

Here is the link to the Part B Manual with the key phrases listed. Ultimately your facility/company will have to set a policy for this and be able to back up their decision on audit.

This excerpt from the Manual will help clarify:

Section 220.1.2 – Plans of Care for Outpatient Physical Therapy, Occupational (Includes SNF Part B)

Therapy, or Speech-Language Pathology Services

Contents of Plan

The plan of care shall contain, at minimum, the following information as required by regulation (42CFR424.24, 410.61, and 410.105(c) (for CORFs)). (See §220.3 for further documentation requirements):

Diagnoses;

Long term treatment goals; and

Type, amount, duration and frequency of therapy services.

The plan of care shall be consistent with the related evaluation, which may be attached and is considered incorporated into the plan. The plan should strive to provide treatment in the most efficient and effective manner, balancing the best achievable outcome with the appropriate resources. The frequency refers to the number of times in a week the type of treatment is provided. Where frequency is not specified, one treatment is assumed. If a scheduled holiday occurs on a treatment day that is part of the plan, it is appropriate to omit that treatment day unless the clinician who is responsible for writing progress reports determines that a brief, temporary pause in the delivery of therapy services would adversely affect the patient’s condition. The frequency or duration of the treatment may not be used alone to determine medical necessity, but they should be considered with other factors such as condition, progress, and treatment type to provide the most effective and efficient means to achieve the patients’ goals. For example, it may be clinically appropriate, medically necessary, most efficient and effective to provide short term intensive treatment or longer term and less frequent treatment depending on the individuals’ needs. It may be appropriate for therapists to taper the frequency of visits as the patient progresses toward an independent or caregiver assisted self-management program with the intent of improving outcomes and limiting treatment time. For example, treatment may be provided 3 times a week for 2 weeks, then 2 times a week for the next 2 weeks, then once a week for the last 2 weeks. Depending on the individual’s condition, such treatment may result in better outcomes, or may result in earlier discharge than routine treatment 3 times a week for 4 weeks. When tapered frequency is planned, the exact number of treatments per frequency level is not required to be projected in the plan, because the changes should be made based on assessment of daily progress. Instead, the beginning and end frequencies shall be planned. For example, amount, frequency and duration may be documented as “once daily, 3 times a week tapered to once a week over 6 weeks”. Changes to the frequency may be made based on the clinicians clinical judgment and do not require re-certification of the plan unless requested by the physician/NPP.

Medicare Part B would accept a fluctuation in frequency, whether the visits are front-loaded and then tapered, or would accept a frequency of 3x per week for a set number of weeks with a reduction in frequency to 2x per week when the therapist deems this appropriate. Setting your frequency on the initial evaluation and the plan of care with a range sends the message that you are not sure what’s best for your patient as you are stating that an “either / or” scenario will work. Make a solid frequency plan and if it needs to be changed, change it! Don’t write a frequency to cover all the “what ifs.”

Let’s take a look at Medicare Part A:

2- Medicare Part A: For Medicare Part A, you may have to read between the lines in the Manual for therapy specifics about frequency. However, the basic principles of medical necessity and “reasonable and necessary” are clearly stated and have to be proven by the therapist in order to justify coverage.

Here is a link to Chapter 8 of the Medicare Benefit Policy Manual where all the SNF Part A rules are located. Keep in mind that Chapter 8 speaks to “Skilled Part A Coverage,” which can be accomplished via therapy services and/or nursing services, so Chapter 8 does not have a “therapy section” like Chapter 15 does for Part B.

In order to qualify for skilled Part A coverage for therapy in a SNF, the frequency has to be at least 5 calendar days per week. This is a fact spelled out in the Manual. When you add a range to this frequency, similar to the info in Part 1 above, you raise the question of why? Why 5 vs 6 vs 7 days per week and why might the frequency fluctuate? Why would you need a range? Would it be based on the patient’s needs, or staffing needs, or RUG needs?

You have to be very careful with Part A due to the calculation of RUG scores based on total minutes. If you had a frequency range of 5-6 days per week and were able to achieve your RUG in 5 days so you did not use the 6^th day that week (ie: RU) but the following week you needed the 6^thday to achieve the RUG RU, this would pose a problem of potential “unreasonable and unnecessary” therapy. In the multiple lawsuits that have come to light in the last 2 years, this type of practice of misusing the therapy frequency was cited.

Part A audits have resulted in paying for only the lower end of a set frequency. This may not seem like a big deal…but if you understand the payment structure for Part A, you can only begin to imagine the nightmare of a denial for this reason and the snowball effect if may have.

Consider this scenario:

Your therapy frequency is written 5-6x per week for 4 weeks. Upon audit, CMS deems the 6th visit per week unreasonable and unnecessary and therefore eliminates the minutes for each 6th visit per week. This would then recalculate every RUG score for the period. No big deal? What if the recalculation now indicates that COT’s should have been completed? You can not go back and add missed MDS assessments, so now, not only would you be faced with a RUG score reduction for payment of days, you may also have days represented by a missing assessment, which then become “provider liable” days, meaning, payment for those days = 0. The potential 30 days of Part A coverage at RU can result in 14 days at RV and 16 days at a non-RUG/non-billable score.

Setting your Part A therapy evaluation treatment plan with a solid frequency, and then adjusting that frequency based on clinical need, is the way to go.

Summary:

So, does either the Part A or Part B Manual state specifically that a range CAN’T be used? No. Does the language used and examples given in BOTH Manuals lean heavily toward a solid plan provided in the most efficient manner? Yes. Has Medicare actually denied Part A and Part B claims when a range was used? Yes!

If you are “on the fence” with establishing a frequency and are thinking about a range, consider using the higher of the range only. Then once the therapy plan is in progress, the clinician will have a better idea if the frequency needs to be changed after a week or so. Frequencies can be changed as often as needed with documentation to support the change. This change is part of providing reasonable and necessary therapy in the most efficient manner, and something that can only be determined by the therapist directly involved in the care for that resident.

Make a solid plan. Stick to it. If it needs to be modified, modify it. Then stick to the new plan until modification is needed again. Believe it or not, needing to modify the plan requires assessment and shows your skill as a clinician.

Any questions, submit them to our Just Ask Q&A Forum and one of our experts will help you out!

In Your Corner,

Dolores and the Montero Therapy Team

Medicare Part B Rules for 2019 – Short and Sweet Version

What Do SNF Therapists Need to Know?

Change…

SNF Therapy and MDS Changes for October 1st 2018 – Part A & Part B

Medicare Part A Changes

1- SNF Value-Based Purchasing Program (SNF VBP)

2- SNF Quality Reporting Program (SNF QRP)

3- MDS 3.0

4- Medicare Part B

Summary – and a Word About PDPM

Coming Soon To A SNF Near You – A New Medicare Part A Payment Model

So What Happened?

Nuts and Bolts of the new PDPM?

What Can Therapists Do To Prepare?

Will SNF Therapy Change When “Minutes Won’t Matter?”

So….

RCS-1 – To Be Or Not To Be ?

What is RCS-1?

What Can Therapists Do To Prepare?

So….

Is a Range in Therapy Frequency Acceptable for Part A or B?

Let’s start with Medicare Part B since the answer is pretty clear-cut.

Let’s take a look at Medicare Part A:

About Us

The Long-Term Care Team

Connect with Montero