SNF Rehab and MDS Experts answer your questions.
Most popular questions each month posted below.
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**We are leaving the Q&A for MAY, JUNE & JULY open to all non-members since there have been so many rule changes related to the National Emergency. We feel it is imperative that everyone have the correct information. Please visit our COVID-19 Resource Page for regularly updated information HERE
(August 2020 – PT DOR, TX)
Q: Are there specific billing codes to be used while billing telehealth for therapy services for SNF residents?
Answer:
(August 2020 – PT DOR, TX)
Q: What are the platforms acceptable to use for telehealth?
Answer:
(August 2020 – Billing Supervisor, CA)
Q: Our claims for the past few months have rejected when we have used the “waiver” for Medicare Part A. How can we fix this? Can we?
Answer:
(August 2020 – PT Director of Rehab, PA)
Q: Is documentation required to use the 1135 Waiver for the 3 midnight stay or the 60 day spell of wellness for Part A?
Answer:
(July 2020 – PTA Director of Rehab, Alabama)
Q: What waivers are still in effect for the Public Health Emergency and for how long?
Answer:
A: On July 25, 2020, the Department of Health and Human Services released a declaration of renewal of the National Public Health Emergency which will be in effect for the next 60 days. This declaration renews those changes that have been made as a result of the initial declaration in January 2020.
Some of the rule changes that skilled nursing facilities have been utilizing for the past few months include those created by the 1135 Waiver and other rule making, such as:
- Medicare Part A 3 Night Inpatient Stay Waiver
- Medicare Part A 60 Day Benefit Period Waiver
- MDS Submission Deadline Relaxation
- Telehealth for Medicare Part A (though not billed as true telehealth)
- Telehealth for Medicare Part B
- Skilled Maintenance Therapy Provided by PTA’s and C/OTA’s for Part B
You can catch up on all the details of the above changes with these articles:
- 3 Day Stay and 60 Day Benefit Period
- Assistants Providing Part B Skilled Maintenance Therapy
- Telehealth for SNF Part B
For continued updates on COVID-19 changes impacting SNF therapy, visit our COVID-19 SNF Resource Page.
(July 2020 – SLP Rehab Director, NJ)
Q: Where can I find the new SNF ABN form (for Medicare Part B) that we are supposed to start using?
Answer:
A: The Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, expired in March 2020. CMS has just issued a new form to take it’s place, effective on 8/31/2020. On August 4th, CMS issued a statement saying the implementation date for the new ABN would be pushed to 1/1/2021 due to the PHE. SNFs are encouraged to start using it now, with the official deadline of 1/1/2021.
The CMS-R-131 is issued by providers to Medicare Part B beneficiaries in situations where Medicare payment is expected to be denied. The ABN is issued in order to transfer potential financial liability to the Medicare beneficiary in certain instances. Though there are no changes in content with the new form, SNF’s are required to provide the most updated form or financial penalty may result.
What do SNF’s need to do?
Print and/or Download the new CMS-R-131 form and begin using it now. Replace the form with a 3/2020 expiration date in the lower left corner. The new form has an expiration date of 6/30/2023.
Deadline for implementing the new CMS-R-131?
August 31st, 2020 On 8/4/20, CMS moved the due date to 1/1/2021
Where can SNF’s print the new form?
Where can SNF’s print the form instructions?
Why would a SNF issue this form?
The CMS-R-131 is issued in order to transfer financial liability to beneficiaries to convey that Medicare is not likely to provide coverage in a specific case. An example in the SNF would be if therapy deemed services no longer medically necessary, and the resident insisted on continuing services. The form would be issued only if therapy were to continue providing the services. The form outlines that Medicare will likely NOT pay for the service, and provides a cost estimate to the resident that he/she will be responsible for paying.
(June 2020 – Administrator, NY)
Q: Is teletherapy allowed for SNF Part A residents?
Answer:
A: As you know, CMS has made many incremental changes to the telehealth regulations since the start of the pandemic.
On 5/27, CMS allowed SNF Part B therapy services. This can be found on page 120 of the link below in Section LL entitled “Outpatient Therapy.” See question #1.
On 6/19, CMS referenced SNF Part A therapy for the first time as an allowable service. CMS continues to update the same document with the changes so it can be a bit confusing. This can be found on page 99 in the SNF Section. See question #5.
Here is the document COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing.” https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf
Here is a snapshot from the document for the Part A approval:
So basically the SNF therapy services are billed using the same Part A rules for minutes. Evaluation minutes are not included on the MDS, treatment minutes are. Again, this is subject to your State Practice Act rulings on provision of telehealth for your specific discipline.
(June 2020 – SLP DOR, TN)
Q: Please provide the latest information on SNF Part B TeleHealth. We are being told this is now allowed. Is it? And WHY would we do it???
Answer:
A: CMS approved TeleHealth for Part B institutional providers, including the SNF, on 5/27/20. We have an article that sums up the findings and will answer your questions HERE.
Basically, CMS released an updated version of the Medicare Fee-for-Service Billing FAQ Document {AKA Medicare Part B}. This Document replaced the FAQ Document released March 15th, and contained the information SNF therapy professionals have been waiting for. On the last 2 pages of this 71 page document, CMS included a new section “FF: Outpatient Therapy Services,” which contains 3 questions, 2 of which pertained to the SNF:
- Can outpatient therapy services that are furnished via telehealth and separately paid under Part B, be reported on an institutional claim (e.g., UB-04) during the COVID-19 PHE?
- Can therapy services furnished using telecommunications technology be paid separately in a Medicare Part A skilled nursing facility (SNF) stay?
- Can outpatient therapy services be furnished and paid separately for patients receiving Medicare home health services?
CMS answered “Yes” to question 1, and “No” to #2 and #3. Specifically, CMS’s answer for #1 above was as follows:
Outpatient therapy services that are furnished via telehealth, and are separately paid and not included as part of a bundled institutional payment, can be reported on institutional claims with the “-95” modifier applied to the service line. This includes:
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Hospital – 12X or 13X (for hospital outpatient therapy services);
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Skilled Nursing Facility (SNF) – 22X or 23X (SNFs may, in some circumstances, furnish Part B physical therapy (PT)/occupational therapy (OT)/speech-language pathology (SLP) services to their own long-term residents;
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Critical Access Hospital (CAH) – 85X (CAHs may separately provide and bill for PT, OT, and SLP services on 85X bill type);
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Comprehensive Outpatient Rehabilitation Facility (CORF) – 75X (CORFs provide ambulatory outpatient PT, OT, SLP services);
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Outpatient Rehabilitation Facility (ORF) – 74X (ORFs, also known as rehabilitation agencies, provide ambulatory outpatient PT & SLP as well as OT services)
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Home Health Agency (HHA) – 34X (agencies may separately provide and bill for outpatient PT/OT/SLP services to persons in their homes only if such patients are not under a home health plan of care)
When and why would a SNF therapist utilize TeleHealth?
First, remember that the definition of Telehealth is the evaluation and treatment of a patient when the provider is off-site, or NOT at the location of patient. Second, there are very specific rules for the provision of these services, including the need for audio AND video communications, among many other requirements. Finally, CMS is TEMPORARILY approving this for SNF Part B because of the National Emergency. The need to provide services in this manner should be related to the situation your SNF is in due to the pandemic, whether it be restrictions on therapists entering the facility, the residents inability to have therapists in their room, staffing issues related to the emergency, etc. The need for Telehealth in the SNF from a therapy perspective, should be a rare occurrence. Physicians and other providers may be more likely to provide these services to the SNF resident because physicians are typically not on site at the SNF all day. Therapy staff, however, are on site, which is part of the reason why Telehealth services were not a need prior to the pandemic.
All Telehealth services provided during the National Emergency have to be billed to Medicare using a special modifier. This alerts CMS to the use of these services. If your therapy department opts to provide services in this manner, it would be wise to document the rationale, as the requirements for medical necessity and skilled care still stand. Your chart may be subject to audit, particularly if your MAC receives the claim and detects that you are an outlier in your region.
**We are leaving the Q&A for May open to all non-members since there have been so many rule changes related to the National Emergency. We feel it is imperative that everyone have the correct information. Please visit our COVID-19 Resource Page for regularly updated information HERE
(May 2020 – OT DOR, ME)
Q: Please explain what CMS meant in a recent update when they said PTA’s and OTA’s could provide Maintenance Therapy under Part B? Wasn’t this always allowed?
Answer:
Prior to the 4/30/20 rule update, skilled maintenance therapy services billed using the Physician Fee Schedule (Part B) in all settings (SNF, Outpatient, etc) were required to be provided by a physical or occupational therapist. Assistants were not allowed to furnish these programs under Part B, even though they are able for Part A.
On 4/30/20, CMS made the change under the heading “Healthcare Workforce Augmentation” and states the following:
“To bolster the U.S. healthcare workforce amid the pandemic, CMS continues to remove barriers for hiring and retaining physicians, nurses, and other healthcare professionals to keep staffing levels high at hospitals, health clinics, and other facilities. CMS also is cutting red tape so that health professionals can concentrate on the highest-level work they’re licensed for.”
CMS is allowing physical and occupational therapists to delegate maintenance therapy services to physical and occupational therapy assistants in outpatient settings. This frees up physical and occupational therapists to perform other important services and improve beneficiary access.
Please note that this rule change is TEMPORARY and will expire when the National Emergency is over.
(May 2020 – PT Regional Manager, East Coast)
Q: Can you explain the most recent changes in TeleHealth? Are SNF therapists allowed to provide this service?
Answer:
There have been multiple incremental changes in TeleHealth during March and April. The most recent change on 4/30/20 is as follows:
- Therapists in the Private Practice setting that bill on Professional Claim Forms (not a UB-04 Institutional claim form) are able to provide TeleHealth services using the existing CPT codes
- PTA’s and OTA’s in the Private Practice setting that are supervised by the therapist are also able to provide Telehealth services
- Supervision requirements for assistants providing TeleHealth to Medicare B beneficiaries in Private Practice can be met through the use of A/V technology if needed as a result of the pandemic
Regarding the SNF Setting:
- Therapy services provided in the SNF SETTING do not include Telehealth, e-visits or any of the Medicare Part B virtual services. This is because SNF’s are institutional providers.
- If a SNF setting needs to use technology to facilitate an evaluation or treatment WITH THE THERAPIST ON SITE, then this is not considered Telehealth. Again, SNF therapists are not approved for telehealth. Using technology to augment a situation would be allowed as a result of the National Emergency. An example of this may include a facility that has set up therapy teams for COVID + and – residents, and a therapist that is not permitted to access a set of residents needs to assess a transfer status of that resident. The therapist, while in the building but not directly with the resident, uses A/V technology to observe the CNA’s working with a resident and/or an assistant working with a resident, in order to make a decision about changing a transfer status. This is allowed and billed as if the therapist were directly with the resident. This situation is not allowed if the therapist is OFF SITE.
- SNF therapists are not eligible to evaluate and/or treat from OFF SITE. This is TeleHealth, and TeleHealth is not approved for the SNF setting.
- CMS has not made any statements approving SNF therapists to supervise assistants from OFFSITE
STATE PRACTICE ACTS still prevail in these situations. If your state does not allow telehealth or non-direct supervision of an assistant, then it cannot be provided, even if Medicare allows it
CMS has provided clarification to the rule changes on multiple phone calls. Here is a link to the 5/5/20 call where CMS provided confirmation AUDIO FILE
On 5/6/20, APTA also confirmed this information HERE
Please note that this rule change is TEMPORARY and will expire when the National Emergency is over.
(April 2020 – SLP DOR, FL)
Q: Where can I find the CMS information on Telehealth and new changes due to COVID-19?
Answer:
A: CMS released the Interim Final Rule on March 30th, 2020. This interim final rule with comment period (IFC) gives individuals and entities that provide services to Medicare beneficiaries needed flexibilities to respond effectively to the serious public health threats posed by the spread of the 2019 Novel Coronavirus (COVID-19).
CLICK HERE for the Interim Final Rule
Here is the link to our article that summarizes the changes due to COVID-19:
Keeping Up With COVID-19: Waiver Impact on SNF Medicare Part A & B, Telehealth and E-Visits
(March 2020 – PTA DOR, MI)
Q: Can you provide information about LCD’s (Local Coverage Determinations)?
Answer:
(February 2020 – PM – OT Director of Rehab, Ohio)
Q: Do you have any information on Humana’s requirement for using the new PTA/OTA modifiers? We have been told Humana is now requiring the CO and CQ modifiers for SNF Part B.
Answer:
(January 2020 – JD- Rehab Manager, NY)
Q: As of 1/1/20, our Rehab EMR is not allowing us to bill a PT or OT Evaluation with the codes 97150 (Group) or 97530 (Therapeutic Activity). What happened?
Answer:
*Answer updated 2/1/20 with new CMS information
(December 2019 – VP Op, National)
Q: Who can complete the BIMS (Brief Interview of Mental Status) for a Part A resident? Can a PTA or COTA?
Answer:
(November 2019 – Multiple requests on this topic)
Q: Can you provide information on the regulations for Restorative Nursing? I am specifically looking for information that approves Restorative Nursing and Therapy to occur simultaneously. We have always waited to refer to Restorative until after skilled therapy was complete. Our company is now requiring Restorative Nursing to begin on day 1 or 2 for our Part A admissions.
Answer: {We are posting the answer here for Members and Non-Members, as this question has been asked several times this month and the source document with the regulation is important for all SNF therapy professionals to read.}
The official reference to Restorative Nursing from CMS is in the RAI Manual.
The information is on page 531-533 and the primary information is in the excerpt below:
https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_october_2019.pdf
- Restorative nursing program refers to nursing interventions that promote the resident’s ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psycho-social functioning.
- A resident may be started on a restorative nursing program when he or she is admitted to the facility with restorative needs, but is not a candidate for formalized rehabilitation therapy, or when restorative needs arise during the course of a longer-term stay, OR in conjunction with formalized rehabilitation therapy. Generally, restorative nursing programs are initiated when a resident is discharged from formalized physical, occupational, or speech rehabilitation therapy.
“The following criteria for restorative nursing programs must be met in order to code O0500 on the MDS:
• Measurable objective and interventions must be documented in the care plan and in the medical record. If a restorative nursing program is in place when a care plan is being revised, it is appropriate to reassess progress, goals, and duration/frequency as part of the care planning process. Good clinical practice would indicate that the results of this reassessment should be documented in the resident’s medical record.
• Evidence of periodic evaluation by the licensed nurse must be present in the resident’s medical record. When not contraindicated by state practice act provisions, a progress note written by the restorative aide and countersigned by a licensed nurse is sufficient to document the restorative nursing program once the purpose and objectives of treatment have been established.
• Nursing assistants/aides must be trained in the techniques that promote resident involvement in the activity.
• A registered nurse or a licensed practical (vocational) nurse must supervise the activities in a restorative nursing program. Sometimes, under licensed nurse supervision, other staff and volunteers will be assigned to work with specific residents. Restorative nursing does not require a physician’s order. Nursing homes may elect to have licensed rehabilitation professionals perform repetitive exercises and other maintenance treatments or to supervise aides performing these maintenance services. In situations where such services do not actually require the involvement of a qualified therapist, the services may not be coded as therapy in item O0400, Therapies or O0425, Part A Therapies, because the specific interventions are considered restorative nursing services (see item O0400, Therapies and O0425, Part A Therapies). The therapist’s time actually providing the maintenance service can be included when counting restorative nursing minutes. Although therapists may participate, members of the nursing staff are still responsible for overall coordination and supervision of restorative nursing programs.
- This category does not include groups with more than four residents per supervising helper or caregiver.”
- This item does not include procedures or techniques carried out by or under the direction of qualified therapists, as identified in Speech-Language Pathology and Audiology Services item O0400A or O0425A, Occupational Therapy item O0400B or O0425B, and Physical Therapy item O0400C or O0425C.”
(October 2019- OT DOR)
Q: If a resident dis-enrolls from a Managed Medicare plan to straight Medicare A, do we complete a 5 day assessment? In addition, would NTA (Non Therapy Ancillary) component triple for that period?
Answer:
(October 2019-PT DOR)
Q: We are being told by our medical coder and billing department that we cannot use R26.2 and M62.81 as treatment diagnosis because they cannot put these codes on the bill as they are “return to provider” codes and the bill will not be paid if there are ANY return to provider codes. Is this true? In light of all the changes is there a difference between medical and treatment codes now? Also, is there a difference in what codes we use for Med A versus Med B?
Answer:
(October 2019- Regional Rehab Director)
Q: When completing the Part A PPS Discharge MDS for a resident that crossed over from RUG-IV to PDPM – do we count the total minutes of therapy for the whole stay or just since October 1st under PDPM? Also, does the 25% limit on Group and Concurrent Therapy start October 1st or does is it retro to the start of therapy if prior to October?
Answer:
(September 2019 – PT/DOR)
Q: If we do not complete the BIMS or the Staff Assessment, how will we get a score? How will the cognitive level be determined?
Answer:
(September 2019 – MDS Coord/RN)
Q: Do we need to complete IPA’s for our non-Medicare Part A skilled residents for October 1st?
Answer:
(September 2019 – DOR, PTA)
Q: Does the ICD-10 Code we pick for Section I0020B on the MDS need to match the code we put on the billing claim? We review these at Triple Check?
Answer:
(August 2019 – DOR, PT)
Q: Please clarify when the SNF needs to issue a NOMNC (Notice of Medicare Non-Coverage) form for Medicare Part B residents.
Answer: Below you will find 3 references that support the answer.
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