MDS 3.0 and 2014 Final Rule Updates

FY 2014 Final Rule and
MDS 3.0 Updates
HARMONY UNIVERSITY
The Provider Unit of
Harmony Healthcare International, Inc. (HHI)
Presented by:

Christine Twombly, RN, RAC-MT, LHRM
Regional Consultant / Trainer

Speaker Bio
Clinical Consultant and Trainer with Harmony Healthcare
International (HHI)
Over 26 years of experience in Long-Term Care
Certified Gerontological Nurse
Certified AANAC Master Teacher and Certified Resident
Assessment Coordinator (RAC-CT)
Licensed Health Care Risk Manager (LHRM)
Hands-on experience with MDS assessments and related care
planning
Extensive experience with SNFs to conduct Medicare
documentation and billing compliance assessments and
providing assistance with third-party medical review and the
appeals process
Copyright © 2013 All Rights Reserved

Harmony Healthcare International, Inc.

2

FY 2014 Final Rule and
MDS 3.0 Updates
Disclosure: The planners and presenters of this education
activity have no relationship with commercial entities or
conflicts of interest to disclose
Planners:
Elisa Bovee, MS, OTR/L
Diane Buckley, BSN, RN, RAC-CT
Beckie Dow, RN, RAC-MT
Keri Hart, MS CCC, SLP, RAC-CT
Kristen Mastrangelo, OTR/L, MBA, NHA
Christine Twombly, RNC, RAC-MT, LHRM
Presenter: Christine Twombly, RNC, RAC-MT, LHRM



3

FY 2014 Final Rule and MDS 3.0 Updates
Disclosure
Speaker:
Christine Twombly, RNC, RAC-MT, LHRM

The speaker has no relevant financial
relationships to disclose
The speaker has no relevant nonfinancial
relationships to disclose



4

Criteria for Successful Completion
Complete Sign-in and Sign-Out on
Attendance Form
Attendance for entire session
Completion and submission of speaker
Evaluation Form



5

Today’s Objectives
The learner will be able to summarize the
changes to the MDS 3.0 item set, effective
October 1, 2013
The learner will be able to identify significant
changes in the MDS process that impact the
delivery and recording of therapy services on
the MDS 3.0 assessment
The learner will be able to summarize the
reimbursement impact of MDS 3.0 and the
2014 PPS SNF Final Rule


6

Changes to MDS and PPS Effective 10/1/13

“It is not the strongest of the species that
survives, nor the most intelligent that
survives. It is the one that is the most
adaptable to change.”

Charles Darwin


7

MDS 3.0 (V1.11.2):
New Items



8

MDS 3.0 User Manual Updates
CMS had anticipated issuing the MDS
Manual update on September 5, 2013
Actual release date of September 24,
2013 left providers and software
vendors with limited time prior to
10/01/13 effective date to learn and
implement changes



9

Changes to the MDS form impacts every
MDS with an ARD on or after 10/1/13
New items have been added to Section K and
Section O
Existing items have been added to additional
assessment item sets
Section H0200A, M0210, and N0300 now included on
more item sets

Changes to wording of existing items for
clarification



10

Section K: Swallowing/Nutritional Status
K0700 has been replaced by K0710
Instructions have been added to the form to
complete this item only if K510A and/or
K510B are checked
Three columns for coding
While NOT a Resident
While a Resident
During Entire 7 Days



11

Section K710



12

Section O:
Addition of item to separately code cotreatment minutes for each discipline
Co-treatment minutes are included in
individual minutes count, and also coded
separately under co-treatment (O-29)
Addition of O0420: Distinct Calendar Days of
Therapy



13

Section O0400A: Speech therapy



14

Section O0400B: Occupational therapy



15

Section O0400C: Physical therapy



16

Section O0420: Distinct Calendar Days of
therapy :



17

RAI User’s Manual
Effective October, 2013:
Item Set Changes



18

Items added to additional item sets:
The following items previously coded only on
the comprehensive item set have been added
to the quarterly and additional item sets
Section H0200 Urinary Toileting Program
Section M 210: Unhealed Pressure Ulcers
Section N 300: Injections



19

RAI User’s Manual
Effective October, 2013:
Item Coding Clarifications



20

Chapter 2
Clarification of assessment scheduling for
discharge assessments, EOT OMRA and COT
OMRAs

Chapter 3
Clarification of The “Rule of 3” applied to self
performance coding in Section G
Coding instructions of new items in Sections K
and O
Clarification of signing Section Z0400



21

Chapter 2: Discharge Assessments
Discharge assessment ARD is not set
prospectively as with other types of
assessments
The ARD for a discharge assessment is
always equal the discharge date and
may be coded on the assessment any
time during the discharge assessment
completion period (discharge date + 14
days)


22

Chapter 2: Discharge Assessments:
For a stand-alone discharge assessment the
facility does not have to open the assessment
on day of discharge when the resident leaves
unexpectedly
This does not alleviate the requirements of
other assessments that may be combined with
the discharge assessment (For example: 14
day/discharge assessment combination)



23

Chapter 2: Discharge Assessments
Discharge Assessments and EOT OMRA :
CMS has clarified the requirement for an EOT
OMRA when the resident is discharged from
Medicare by linking the EOT OMRA
completion requirement to the End of
Medicare date coded in A2400C
When the date coded at A2400C is prior to the
third consecutive day of missed therapy
services, then no EOT OMRA is required



24

Chapter 2: EOT OMRAs
Discharge Assessments and EOT OMRA
If the date coded at A2400C is on or after the third
consecutive day of missed therapy services, then an
EOT OMRA would be required
In cases where the date coded at A2400C is the same
as the date discharge coded at A2000, that is cases
where the discharge from and this date is on or prior
to the third consecutive day of missed therapy



25

Chapter 2: EOT OMRAs
Discharge Assessments and EOT OMRA:
CMS has clarified the requirement for an EOT
OMRA when the resident is discharged from
Medicare by linking the EOT OMRA
completion requirement to the End of
Medicare date coded in A2400C
When the date coded at A2400C is prior to the
third consecutive day of missed therapy



26

Chapter 2: COT OMRAs
A COT OMRA is required when a resident
was receiving a sufficient level of therapy to
qualify for a Rehabilitation category and
when the intensity of therapy (as indicated by
the total RTM delivered, and other therapy
qualifiers) changes to such a degree that it
would no longer reflect the RUG-IV
classification and payment assigned on the
most recent assessment used for Medicare
payment


27

Chapter 2: COT OMRAs
When the most recent assessment used for
PPS, excluding an End of Therapy OMRA,
has a sufficient level of therapy to qualify for
a Rehabilitation category (even if the final
classification index maximizes to a group
below Rehabilitation), then a change in the
provision of therapy services is evaluated in
successive 7-day Change of Therapy
observation periods until a new assessment
used for PPS occurs


28

Chapter 2: LOA days Impact on
Assessment Scheduling
Medicare days are calculated by the Midnight
census. Any days the resident is not in the
facility at midnight due to a LOA not
Medicare utilized days
When a Medicare resident is on an LOA that
includes a hospital observation stay of less
than 24 hours the impact of this absence on
the assessment schedule depends of the type
of assessment being completed



29

Assessment scheduling
LOA days impact on MDS schedule
OBRA assessment is not affected by the LOA
From a PPS scheduled assessment stand point any
LOAs are “skipped” when setting ARD
For unscheduled assessments such as EOT and
COT OMRA the LOA are including when
determining the due date of the next scheduled
assessments



30

CMS has clarified that the ARD of a
scheduled Medicare Assessment can
not be set outside the Medicare benefit
covered days
Since the day in which the beneficiary is
out of the facility at midnight is not a
covered day, the scheduled ARD can
not be set on this date


31

2-72: Indicates there may be cases in
which a SNF plans to combine a
scheduled and unscheduled assessment
on a given day, but then that day
becomes an LOA day for the resident.
In such cases, while that day may still
be used as the ARD of the unscheduled
assessment, this day cannot be used as
the ARD of the scheduled assessment.


32

Chapter 2—Setting the ARD
Outside the Benefit Period
For example:
Admission May 3nd
5-day MDS was completed with an ARD of
May 10
The resident was in ER from 8 pm on May 17 until
May 18 at 2 am
May 17 is the COT date; and if the COT is
required, it would need to have an ARD of May 17
The scheduled 14-day MDS must have an ARD
that falls on a Medicare A benefit day; therefore,
the two assessment cannot be combined


33

Chapter 3: Section G ADLs
Accurate ADL coding is essential to
quality care planning and appropriate
reimbursement under PPS
Section G has been identified as being
at high risk for errors
Significant effort has been made to
clarify the code of self performance of
the ADLs


34

Self-Performance coding:
Independent: Resident completed activity
with no help or oversight every time during
the 7-day look-back period and the activity
occurred at least three times
Supervision: Oversight, encouragement, or
cueing was provided three or more times
during the last 7 days



35

Limited assistance: Resident was
highly involved in activity and received
physical help in guided maneuvering of
limb(s) or other non-weight-bearing
assistance on 3 or more times during
the last 7 days



36

Extensive assistance: Resident performed
part of the activity over the last 7 days, and
help of the following type(s) was provided
three or more times:
Weight-bearing support provided three or more
times, OR
Full staff performance of activity provided three
or more times during part (three or more times
but not all of the last 7 days)


37

Total dependence: Full staff performance of
an activity with no participation by resident
for any aspect of the ADL activity and the
activity occurred three or more times. The
resident must be unwilling or unable to
perform any part of the activity over the
entire 7-day look-back period



38

Activity occurred only once or twice: The
activity occurred but fewer than three times
or more
Activity did not occur: The activity did not
occur or family and/or non-facility staff
provided care 100% of the time for that
activity over the entire 7-day look-back



39

Chapter 3: Section G “Rule of 3”
Developed to help determine the
appropriate code to document ADL
Self-Performance on the MDS
All staff who complete this section must
fully understand the components of
each ADL, the ADL Self-Performance
coding level definitions, and the
“Rule of 3”


40

The following ADL Self-Performance coding
levels are exceptions to the Rule of 3:
Independent – Code only if resident completed
the ADL activity with no help or oversight every
time and activity occurred at least three times
Total dependence – Code only if resident
required full staff performance of the ADL
activity every time and the activity occurred three
or more times



41

Instructions for the Rule of 3:
When an ADL activity has occurred three or more
times, apply the Rule of 3 below (keeping the ADL
coding level definitions and the above exceptions
in mind) to determine ADL Self-Performance code
These steps must be used in sequence
Use the first instruction encountered that meets the
coding scenario (e.g., if #1 applies, stop and code that
level)



42

Step 1: When an activity occurs three or
more times at any one level, code that
level
Step 2: When an activity occurs three or
more times at multiple levels, code the
most dependent level that occurred
three or more times



43

Step 3: When an activity occurs three or more
times and at multiple levels, but not three
times at any one level, apply the following:
a. Convert episodes of full staff
performance to weight-bearing
assistance
b. When there is a combination of full staff
performance and weight-bearing assistance
that total three or more times, code
extensive assistance (3)


44

Step 3 (Cont.)
c. When there is a combination of full staff
performance/weight-bearing assistance
and/or non-weight-bearing assistance that
total three or more times, code limited
assistance (2)
If none of the above are met, code supervision



45

ADL Algorithm has been updated to
include the following at the top of the
page:
START HERE: Remember to review the
instructions for the Rule of 3 and the ADL
Self-Performance Coding Level definitions
before using the algorithm. STOP at the
first code that applies when moving down
the algorithm.


46

Chapter 3: Section K: Percent of
Intake by Artificial Means
Steps for Assessment:
1. Review intake records from the last 7 days
2. Add up the total amount of fluid received
each day by IV and/or tube feedings only
3. Divide the week’s total fluid intake by 7 to
calculate the average of fluid intake per day
4. Divide by 7 even if the resident did not
receive IV fluids and/or tube feeding on each
of the 7 days


47

1. While NOT a resident
Performed while not a resident and in the last 7
days
If resident has entered more than 7 days ago leave
this item blank

2. While a resident
Performed while a resident and during the last 7 days

3. During the entire 7 days
Performed during the ENTIRE 7 days



48




49

Example 1:
A long-term care resident with swallowing
difficulties is able to take oral fluids by mouth
with supervision, but not enough to maintain
hydration. She received the following daily
fluid totals by supplemental tube feedings
(including water, prepared nutritional
supplements, juices) during the last 7 days.
How should 710b be coded?


50

Example 1 (Cont.)
Sun.
Mon.
Tues.
Wed.
Thurs.
Fri.
Sat.

1250 cc
775 cc
925 cc
1200 cc
1200 cc
500 cc
450 cc

Total

6,300 cc



51

Example 1 (Cont.)
Coding: K0710B columns 2 and 3 would be
coded 2, 501cc/day or more
Rationale: The total fluid intake by
supplemental tube feedings = 6,300 cc 6,300 cc
divided by 7 days = 900 cc/day 900 cc is
greater than 500 cc, therefore code 2, 501
cc/day or more is correct



52

Example 2:
A long-term care resident with the flu was
experiencing ongoing nausea, vomiting and
diarrhea and due to concern related to
dehydration received 1 liter of IV fluids over
24 on day during the 7 day period.
How should 710 b be coded?



53

Example 2 (Cont.)
Coding: K0710B columns 2 would be coded
1, 500cc/day or less
Rationale: The total fluid intake by IV= 1000
cc. 1000 cc divided by 7 days = 142.8 cc/day,
which is 500 cc.
Column 3, should be blank
Rationale: IV fluids were not provided the
entire 7 days


54

Chapter 3: Section O: Therapy
Addition of co-treatment minutes PT, OT, ST
Co-treatment minutes are included in
individual minutes count, and also coded
separately under co-treatment (O-29)
Addition of language supporting Jimmo
Settlement !
Addition of O0420: Distinct Calendar Days of
Therapy



55

Therapy: Co-treatment Part A
Two clinicians each from a different
disciplines treat one resident at the same time
with different treatments
Both disciplines may code the treatment
session in full
All policies regarding mode, modalities and
student supervision must be followed as well
as all other federal, state, practice and facility
policies



56

The decision to co-treat should be made on a
case by case basis and the need for
co-treatment should be well documented for
each patient
Because co-treatment is appropriate for
specific clinical circumstances and would not
be suitable for all residents, its use should be
limited



57

When coding therapy minutes co-treatment
minutes are also coded as individual
minutes for both disciplines involved in the
co-treatment session
Co-treatment Minutes are also separately
coded in 3A as co-treatment minutes for both
disciplines
Any treatment minutes co-treatment in 3A as
co-treatments do not impact the RUG



58

Therapy: Co-treatment Part B
Therapists, or therapy assistants, working
together as a "team" to treat one or more
patients under Medicare Part B cannot each
bill separately for the same or different
service provided at the same time to the same
patient
Where a physical and occupational therapist
both provide services to one patient at the
same time, only one therapist can bill for the
entire service or the PT and OT can divide the
service units


59

Therapy: Distinct Calendar Days
Enter the number of calendar days that the
resident received Speech-Language Pathology
and Audiology Services, Occupational
Therapy, or Physical Therapy for at least 15
minutes in the past 7 days. If a resident
receives more than one therapy discipline on
a given calendar day, this may only count for
one calendar day for purposes of coding Item
O0420.



60

Therapy: Distinct Calendar Days
Day

1

2

3

4

5

6

7

8ARD

Date

2/1

2/2

2/3

2/4

2/5

2/6

2/7

2/8

30

0

15

30

0

15

30

0

15

PT

15

OT

15

ST

15

Total

0

0

15

15

15

90

0

45

Running

0

0

15

30

45

135

135

180

How many Distinct Calendar Days?
5 Distinct Days



61

FY 2014 Final Rule



62

Final Rule
On August 1, 2013, the Centers for
Medicare & Medicaid Services (CMS)
published the Final Rule for the
Prospective Payment System and
Consolidated Billing for Skilled
Nursing Facilities (SNF) for FY 2014
Effective October 1, 2013 for FY 2014



63

New SNF Rates
The Final Rule provides for a net market
basket increase for SNFs of 1.3% beginning
October 1, 2013
Full market basket increase of 2.3 percentage
points
Less a 0.5 percentage point multifactor
productivity adjustment required by Section
3401(b) of the Affordable Care Act (ACA)
Less 0.5 percentage point reduction to correct for
an error in forecasting the market basket in FY
2012


64

Impact on Reimbursement
CMS estimates that the net market
basket update would increase Medicare
SNF payments by approximately $500
million in FY 2014
Nationally projected $7 per Medicare
patient day



65

Therapy Co-treatment
RAI User's Manual reporting
requirement for coding co-treatment
minutes on the MDS
Will not impact RUG calculation at this
time



66

Therapy Co-treatment
Indicator that CMS is concerned about
over utilization
Applies to Medicare Part A only
When two clinicians (therapists or
therapy assistants), each from a
different discipline, treat one resident at
the same time with different treatments,
both disciplines may code the treatment
session in full


67

Distinct Days of Therapy
Clarify that classification criteria for the
Rehabilitation Medium RUG categories require
that the resident receive 5 distinct calendar
days of therapy
If not achieved, the RUG would reduce to a
Nursing RUG
Applies to COT review and Management



68

Current RUG classification allows
classification criteria for the Medium
Rehab category without 5 distinct days
of therapy
Impact of missed therapy days
Potential Nursing RUG despite significant
therapy involvement



69

Day

1

2

3

4

5

6

7

8ARD

Date

2/1

2/2

2/3

2/4

2/5

2/6

2/7

2/8

PT

0

0

60

60

60

0

0

60

OT

0

0

60

60

60

0

0

60

ST

0

60

60

60

0

0

60

Total

0

0

180

180

180

0

0

180

Running

0

0

180

360

540

540

540

720

How many Distinct Calendar Days of
Therapy?
Less Than 5 Distinct Days does not =RM
Nursing RUG applies


70

Distinct Days of Therapy-Daily Basis
The daily basis requirement can be met by
furnishing multiple therapy types on different days
of the week that collectively add up to "daily" skilled
services
CMS clarified that to meet this requirement, the
patient must actually need skilled rehabilitation
services to be furnished on different days
"It is not sufficient for the scheduling of therapy
sessions to be arranged so that some therapy is
furnished each day, unless the patient's medical
needs indicate that daily therapy is required.”


71

Impact on Provider
Another factor in ARD Management
Increase in Change of Therapy (COTs)
Rate reduction retroactive 7 days
Increase Lower 14 Nursing RUGs
Increase audits and denials
Increase in use of Short Stay Policy
Providers still struggle with this
Potential for Rehabilitation Medium patients to not
meet Rehab skilled criteria



72

SNF Therapy Research Project
“Currently, the therapy payment rate
component of the SNF PPS is based
solely on the amount of therapy
provided to a patient during the 7-day
look-back period, regardless of the
specific patient characteristics”



73

“As an initial step, the project will review past
research studies and policy issues related to SNF PPS
therapy payment and options for improving or
replacing the current system of paying for SNF
therapy services received”
CMS has contracted with Acumen, LLC, and the
Brookings Institution to identify alternatives to the
existing methodology used to pay for therapy
services received under the SNF PPS
CMS invites comments and ideas on the existing
methodology


74

CMS will “regularly” update the public on
the progress of this project on the project Web
site:
http://www.cms.gov/Medicare/Medicare-FeeforServicePayment/SNFPPS/therapyresearch.
html



75

Impact on Providers
SNF Therapy Research Project could
significantly change the reimbursement
model for therapy services provided
under Medicare Part A
Diagnosis may factor in



76

Presumption of Coverage
“The establishment of the SNF PPS did not
change Medicare’s fundamental
requirements for SNF coverage”
CMS proposes to continue presumption of
coverage for beneficiaries correctly assigned
to one of the upper 52 groups
Automatically classified as meeting the
SNF level of care definition up to and
including the Assessment Reference Date
on the 5-day assessment


77

Presumption of Coverage
“We note that this administrative
presumption policy does not supersede the
SNF’s responsibility to ensure that its
decisions relating to level of care are
appropriate and timely, including a review to
confirm that the services prompting the
beneficiary’s assignment to one of the upper
52 RUG–IV groups (which, in turn, serves to
trigger the administrative presumption) are
themselves medically necessary”


78

Impact on Providers
Warning by CMS to ensure
documentation of skilled coverage
criteria in the first days of a patient’s
stay
Potential increase in audits



79

Consolidated Billing
Consolidated billing requirements are
unchanged
Acknowledged certain chemotherapy
items, chemotherapy administration
services, radioisotope services and
customized prosthetic representing recent
advances that might meet its criteria for
exclusion from SNF



80

Consolidated Billing
Corrections of error to the annual priced exclusion
files will show that HCPCS Codes 11042, 11043, and
11044 (surgical debridement codes) will be corrected
to ensure that they are excluded from consolidated
billing
“Flexibility to revise the list of excluded codes in
response to changes of major significance that may
occur over time (for example, the development of
new medical technologies or other advances in the
state of medical practice)’’ (65 FR 46791)



81

Consolidated Billing-Reminder
April 2013
The annual update file contains the
complete list of HCPCS Codes that are
excluded from SNF CB for claims
submitted to Fiscal Intermediaries/A/B
MACS for payment
Effective for claims with dates of service
on or after 1/01/2013 unless otherwise
noted below


82

Swing Beds FYI
CMS notes that critical access hospitals
(CAHs) will continue to be paid on a
reasonable cost basis for SNF level
services furnished under a swing bed
agreement and that all non-CAH swing
bed rural hospitals continue to be paid
under the SNF PPS



83

AIDS Add On
128 percent for SNF residents with Acquired Immune
Deficiency Syndrome (AIDS) remains
Transition from ICD-9-CM coding system to the ICD10-CM coding system, starting October 1, 2014.
ICD-10-CM diagnosis code of B20 for purposes of
defining AIDS Add-On. Includes AIDS, AIDS
related complex (ARC) and HIV infection,
symptomatic.
Current code 042 also includes AIDS like
syndrome and new Final code B20 does not
Impact On Providers
May exclude some patients from meeting criteria


84

Physician Assistants-Certification
CMS finalized revisions to the regulation
related to the SNF level of care certification
and re-certifications by including Physician
Assistants in the provision authorizing Nurse
Practitioners and Clinical Nurse Specialists to
sign SNF level of care certifications and recertifications
Impact On Providers
Allows additional Physician Extenders to sign
Physician Certification


85

CMS Review Impact FY2012 Changes
CMS concludes that it has found no evidence of
possible negative impacts that had been anticipated
by SNF providers in comments on the FY 2012 Final
Rule, particularly the potential for a “double hit” from
the combined impact of the recalibration of the FY 2011
SNF parity adjustment and the FY 2012 policy change
Recalibration of the FY 2011 SNF parity adjustment
to align with RUG-III
Allocation of group therapy
Implementation of changes to the MDS 3.0 patient
assessment instrument, most notably adding the
COT OMRA requirements


86

Distribution of MDS Assessments
MDS

FY2011 %

FY2012 %

Scheduled PPS
SOT
EOT
EOT/SOT Combined
EOT-R
Combined SOT and
EOT-R
COT

95
2
3
0
N/A
N/A

84
2
3
0
0
0

N/A

11



87

FY2014
Transition Memo released September 20
Prior to RAI Manual Release
Impacts Days billed in September
Review for accuracy



89

FY 2014 Transition
An MDS may generate a RUG that bills for
days in September 2013 (FY2013) and October
2013 (FY2014)
The CMS transition policy dictates payment
for these scenarios
In short, MDSs with an ARD from October 1
through October 13 will generate a “FY2013
RUG” that will be communicated to billers
through the MDS validation report process



90

FY 2014 Transition
Facilities must ensure MDS/PPS
Coordinators communicate with the
Business Office to provide the MDS
transmission validation reports to
accurately bill
The FY2013 transition RUG will be
based on FY2013 RUG qualifications
and the FY2014 will require the new
requirements


91

Distinct Calendar Days of Therapy
MDS Change: For all assessments with
an ARD on or after 10/1/2013, must
include Item O0420 (Distinct Calendar
days) must be coded with the number
of distinct calendar days that the
resident received therapy services



92

RUG-IV: Extensive Rehabilitation and
Rehabilitation Medium and Low Categories
Extensive Rehabilitation and Rehabilitation
Medium and Low Categories Criteria
Change: Rehabilitation Medium must have
greater than 5 Distinct Calendar Days and 150
Minutes of Therapy; Rehabilitation Low must
have 3 distinct calendar days and 45 minutes
of therapy with 2 rehabilitation/restorative
nursing for 6 days


93

COT reviews completed on or after
October 1, follow FY2014 requirements
of Distinct Calendar Days to meet
Rehab Medium and Low Criteria



94

Swallowing and Nutritional Status
Items
MDS Change: For all assessments with an
ARD on or after 10/1/2013, must include
K0710A and item K0710B with the proportion
of total calories the resident received through
parental or tube feeding and the average fluid
intake per day by IV or tube feeding,
respectively
RUG IV: Special Care High (fever) / Low
and Clinically Complex (ADL=0-1) K0710A
and item K0710B3 must be coded


95

FY2013 Transition RUG
September Days Billed

ARD on
or before
9/30/13

October Days Billed

Bill actual RUG for all days of
service associated with that
assessment even if some of those
days of service are on or after
10/1/2013

Bill actual RUG for all days of
service associated with that
assessment even if some of those
days of service are on or after
10/1/2013

ARD
FY2013 transition RUG should be
10/1/2013 used to bill any days of service
through
before 10/1/2013 which are
10/13/2013

Bill actual RUG for FY2014 for
days on or after October 1, 2013

ARD date Not Applicable
after
10/13/2013

Bill actual RUG for FY2014 for
days on or after October 1, 2013

associated with that assessment



96

FY2013 RUG
An MDS with an ARD after 10/13/13
will not report a transitional RUG as
there is not a scenario when a MDS
with an ARD on or after 10/14/13 will
pay for days both in September and
October 2013



97

Audit Environment:
More Changes

Increase in Medicare Documentation
Reviews
Significant increase in the number of medical review
requests from Medicare Administrative Contractors
(MACs)
Medicare Part A and B
Billing inconsistencies
ICD-9 Coding triggers

Similar pattern to Medical Record Reviews within
the nursing facility setting in the early 90's
Number of "Help Letters“ was astoundingly high
Investigations into potential fraudulent billing
practices increased


99

Zone Program Integrity Contractor
(ZPIC)
Goal is to identify Fraud
CMS launched another major initiative
to target providers other than the
hospital setting as the RAC auditors
have been focusing on hospital audits
Southeast, South Central, Midwest,
Northeast and West Coast regions of
the U.S. are seeing the most ZPIC audits
at this time
2012


100

Unified Program Integrity Contractor (UPIC)
CMS is developing a new integrity contractor
called a Unified Program Integrity Contractor
(UPIC). The previous Medicare
Administrative Contractors (MACs) and
Zone Program Integrity Contractors (ZPICs)
will comprise the new contractor, though
MACs will not disappear entirely, they will
simply be absorbed by the UPIC. This
contractor will focus on both Medicare and
Medicaid integrity issues.


101

Medicare Recovery Auditors (RAs)
Recovery Audit Contractors (RACs) are
now known as The Medicare Recovery
Auditors (RAs)
The RAs post what area they are
targeting on the web. Providers are
able to review their jurisdiction’s
website for an update on what the RAs
are finding in their data collection.


102

Medicare Recovery Auditors (RAs)
RAs review claims on a post-payment basis
There are three types of review:
Automated (no medical record needed)
Semi-Automated (claims review using data and
potential human review of a medical record or
other documentation)
Complex (medical record required)
Look-back up to three years from the date the claim
was paid
Required to employ nurses, therapists, certified
coders and a physician CMD


103

Be Prepared
Give Clinically Appropriate Care
Understand Medicare Coverage requirements
Technical
Clinical

Accurately document care provided
Bill accurately
Respond to documentation requests timely and
completely
Communicate trends and audit outcomes to staff

Get back to Basics !!


104

Questions/Answers

Harmony Healthcare International
1 (800) 530 – 4413
www.Harmony-Healthcare.com
CTwombly@harmony-healthcare.com



105
105

Harmony Healthcare International
Have you Considered a Customized Complimentary
HARMONY(HHI) MEDICARE PROGRAM
EVALUATION
or
CASE MIX ANALYSIS
for your Facility?

Perhaps your facility has potential for additional revenue
Assess your facility against key indicators and national norms

Email us at for more information
RUGS@harmony-healthcare.com
Analysis is cost & obligation free


106

MDS 3.0 and 2014 Final Rule Updates

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