By RETA UNDERWOOD, ADC
Basic knowledge of Medicare's skilled care criteria has been historically considered a “must-know” for skilled nursing facility (SNF) admission coordinators. Now it's become a New Age “must-know” for nursing home survival involving all departments and all staff. Nurses, social workers, physicians, and even activity directors and nursing assistants must be Medicare-savvy in order to reap the benefits of the Medicare programs’ Prospective Payment System (PPS). Failure to follow Medicare eligibility guidelines and fulfill documentation needs can result in denials of payment, regulatory sanctions within the survey process, and worse. Even if you’re confident of your performance in this area, a little review can’t hurt.
Who Signs Certification
Certification Time Frame
Recertification Time Frame
Attending physician or another physician with knowledge of the case with authorization from attending physician, or a member of hospital's medical staff with knowledge of the case
No later than the 12th day of hospitalization
Interval between recertification is not to exceed 30 days
Attending physician or physician on staff at SNF with knowledge of case
Obtain at time of admission or shortly thereafter
First recertification no later than the 14th day of inpatient extended care services. Sub-sequent at intervals not exceeding 30 days
Obtain at time POC is established or shortly thereafter
Physician must certify at least once every 60 days
For initial 90-day period, must obtain written certification statements from medical director of hospice or physician member of the hospice interdisciplinary group and the attending physician
If written certification is not obtained within 2 calendar days of the initiation of hospice care, a verbal certification must be obtained
Must be obtained for each period of hospice care; written certification by hospice medical director or physician member of interdisciplinary group
Who is responsible?Like all certified Medicare providers, the SNF is responsible for obtaining the required physician certification and recertification statements and for retaining them on file for verification by the intermediary, if needed.
Who can sign?A certification or recertification statement must be signed by the attending physician or a physician on the SNF's staff who has knowledge of the case, or by a nurse practitioner or clinical nurse specialist who does not have a direct or indirect employment relationship with the facility but is working in collaboration with the physician.
What is required and when for recertification?The recertification statement must be completed no later than the 14th day of a stay and at each subsequent 30-day interval. This statement must contain an adequate written record of the reason(s) for the continued need for extended care services, the estimated period of time required for the patient to remain in the facility, and any plans, when appropriate, for home care. The recertification statement made by the physician does not have to include this entire statement if, for example, all of the required information is in fact included in progress notes. In such a case, the physician's statement could indicate that the individual's medical record contains the required information and that continued posthospital extended care services are medically necessary. A statement reporting only that continued extended care services are medically necessary is not, in and of itself, sufficient. See the table for allotment of responsibility on this. For more information on physician certification, please refer to Publication 100-01, Medicare General Information, Eligibility and Entitlement Manual, available at http://www.cms.hhs.gov/Manuals/IOM/list.asp.
It is important to recognize that eligibility requirements did not change upon implementation of the Medicare PPS. Qualifying stay criteria still consist of four focus points, each of which should be reviewed and addressed before accepting a patient for admission:
A medically necessary three-day hospital stay must have occurred. This does not include emergency room hours; rather, the clock starts ticking at the time the patient is admitted to an acute care bed. The hospital discharge must have occurred on or after the first day of the month in which the individual attains age 65 or becomes entitled to health insurance benefits under the disability or chronic renal disease provisions of the Medicare law. The three consecutive calendar days’ requirement can be met by stays totaling three consecutive days in one or more hospitals. In determining whether the requirement has been met, the day of admission, but not the day of discharge, is counted as a hospital inpatient day.
The patient must receive Part A care within 30 days of the qualifying hospital stay. Customarily, this is not a problem unless the patient is returning after being discharged home or is being readmitted from another setting. In such cases, it is very important to determine the reason for the return service, how it relates to the original qualifying stay, and whether a Medical Predictability Order was written.
Part A care is needed for a condition that was treated during the qualifying hospital stay.
The patient receives a skilled level of care in either skilled nursing or rehabilitation.
Case example.A patient is admitted from home to an acute care hospital in which he stays four days for treatment of pneumonia and congestive heart failure. The patient receives intravenous Lasix and a three-day course of antibiotics and is placed on warfarin therapy. The patient presented with weakness and, without extensive assist from staff, is nonambulatory during the four-day stay. Before admission the patient routinely drove a car and was independent in instrumental activities of daily living (IADLs). The physician discharges the patient to a skilled setting for nursing services, during which the patient is to be monitored for therapeutic labs, lung sounds, vitals, and edema. In addition, the patient is to receive a therapy evaluation and rehabilitation treatment as indicated in hopes of returning to the home setting.
If the patient requires nursing and/or rehabilitation therapy, the patient may receive needed services for up to 100 days using the Medicare Part A benefit. Of the 100 days, the first 20 days are paid at 100% and the remaining 80 days at 80%.
As important as it is to qualify the stay, qualifying the patient can prove to be just as critical. Before one can use Medicare Part A benefits, one must be eligible to participate in the Medicare program. A person over 65 years of age, a person who has received Social Security Disability (SSD) for 24 months, or a person with End-Stage Renal Disease (ESRD) is an example of someone eligible for Medicare Part A benefits.
Generally, the only foolproof way to qualify a patient is to have the patient present his/her Medicare card for verification. If the patient has been approved but has yet to receive a card, he/she should be able to produce a Certificate of Social Insurance Award, SSA-30. This shows the health insurance coverage notice (HICN), dates of entitlement to Part A and/or Part B benefits, and the following statement: “This notice may be used if Medicare services are needed before you receive your health insurance card.”
If the patient is unable to present a Medicare card or the SSA-30, a phone call to the facility's Medicare intermediary is advisable.
Nursing services and the conditions being treated in a SNF that originated during the qualifying hospital stay and for which the patient's Medicare Part A benefits are used should be documented when they are provided and received, not at some later date. Service documentation can occur as seldom as once per day but usually it occurs more often. The same documentation scenario goes for rehab therapy, adding the duration of time, in minutes, that the therapy service was provided to meet physician orders.
What documentation format is needed?With the exception of the Minimum Data Set (MDS), Medicare does not dictate documentation formats and the variations are many. In the past, this was a problem for the industry as a whole. Frontline staff were often ill-prepared to document qualifying services, let alone know the ramifications and the importance of what they wrote. Not anymore! Many nursing professionals have taken performance of this task to great heights, benefiting the facility and its staff. These nurses occupy the RAI/MDS Assessment Coordinator's role. A good RAI/MDS Coordinator not only coordinates the assessment schedule, but is also involved in the patient's admission, treatment, and discharge. “The Medicare requirements are always at the front of my mind,” says Angela Beatty, a seasoned nursing veteran and RAI Coordinator of Wesley Manor Retirement Community in Louisville, Kentucky. “Nursing staff is made aware of the specific service and assessment format they are to use,” she explains.
The use of flow sheets is a popular alternative to narrative charting, and many computer programs are available to assist the care professional in documentation. But neither takes the place of a responsible person who oversees the utilization and documentation of Medicare benefits in one's facility. “The MDS is the start and end point when documenting,” says Beatty.
The most important item on the MDS when Medicare is involved is the assessment reference date (ARD), which sets the observation time frame for staff assessment. PPS MDS assessments, when processed independently, are “for payment only” assessments. It is important to keep in mind three important variables for recordkeeping: Medicare for skilled status, PPS for reimbursement, and the MDS for services provided when setting the ARD.
A small oversight can make a big difference!The RUG-53 PPS category for Rehabilitation Plus Extensive Services and that for Rehabilitation are separated by only one difference, which is the nursing services that a patient is receiving/has received during the ARD period for IV feeding or medication, suctioning, tracheostomy care, or ventilator/respirator care. The payment difference of these two categories is significant.
Something to think about regarding ADL scores.Patients who are receiving rehab services need to have ADLs documented during rehab services as well as during routine bedside care. For example, if a bath occurs during occupational therapy (OT) but is documented as an 8 on the MDS, that is an inaccurate assessment. The same goes for recording other ADL-related activities. It is not that they did not occur; it's that they occurred during a treatment service with staff that most often is not expected to document this service in MDS terminology. This is an opportunity to educate professional service providers to improve assessment accuracy and RUG-53 calculation.
Why the MDS connection?CMS considers the resident's MDS the primary document. The MDS is the foundation of regulatory compliance, clinical assessment, recording of services provided, and payment for these services. Medicare audits and survey reviews both tie into and involve the MDS assessment in various ways.
What's the worst that can happen?The improper utilization of a patient's Medicare coverage can result in fraud accusations, denial of a claim or, when survey and enforcement review is tied to it, a loss of provider certification and even licensure, resulting in facility closure.
What does my signature represent?The attestation statement on the signature section of the MDS assessment (Section AA Item 9) holds assessors responsible and accountable. F-tag 278 (483.20[j]) Penalty for Falsification can result in fines up to $5,000 per assessment.
In conclusion, and in short, please brush up on your Medicare documentation. It might mean not just your survey survival, but your facility's survival, for you to get it right.Reta Underwood, ADC, is President of Consultants for Long Term Care, Inc., Louisville, Kentucky.
This Web site provides a host of valuable information and resource tools.
The Hospital and Skilled Nursing Facility Manuals (Publications #10 and #12) provide excellent information about the Medicare programs’ coverage, payment, admission, and billing procedures.
Consultants for Long Term Care, Inc.'s Medicare Documentation Outline will be posted free of charge to readers.