Consolidated Billing in a SNF

Transcription

1 Consolidated Billing in a SNF Kris Mastrangelo, OTR/L, LNHA, MBA President & CEO Harmony Healthcare International (HHI) We C.A.R.E. About Care Version

2 About Kris Kris Mastrangelo, OTR/L, LNHA, MBA President and CEO Owns and operates Harmony Healthcare International (HHI) Nationally recognized, premier Healthcare Consulting firm specializing in C.A.R.E. Compliance, Audit and Analysis, Reimbursement, Regulatory, Rehabilitation Education and Efficiency Follow v Copyright 2017, All Rights Reserved 2

3 Objectives Identify the basic concepts of Consolidated Billing Identify excluded services (i.e. bundled vs. unbundled) Identify parameters of ambulance services from a reimbursement perspective v Copyright 2017, All Rights Reserved 3

4 Consolidated Billing History

5 Consolidated Billing History Former process fostered billing and liability concerns SNFs chose to furnish services either: Directly, using its own resources; Through the SNF s transfer agreement hospital; or Under arrangement with an independent therapist Unbundling services were allowed v Copyright 2017, All Rights Reserved 5

6 SNF Consolidated Billing Section 4432(b) of the Balanced Budget Act Prospective Payment System (PPS) SNF must submit all Medicare claims for services that its residents receive Excluded services are not subject to Consolidated Billing v Copyright 2017, All Rights Reserved 6

7 Providers Impacted Physicians Hospital Swing Beds Imaging Centers Ambulance Suppliers Hospitals and Critical Access Hospitals Radiology Centers v Copyright 2017, All Rights Reserved 7

8 Under Arrangement SNF furnish services directly or under arrangement Outside supplier receives payment from the SNF The entities reach a mutual understanding on terms of payment How to submit an invoice How payment rates will be determined Turn-around time between billing and payment v Copyright 2017, All Rights Reserved 8

9 Circumstances for Exclusion Admitted as an inpatient to a hospital, Critical Access Hospital (CAH) or to another SNF Receives services from a home health agency under a plan of care Receives outpatient services from a hospital or Critical Access Hospital (CAH) Discharged from the SNF unless readmitted by midnight of the same day v Copyright 2017, All Rights Reserved 9

10 Inclusions All services furnished to a SNF resident in a covered Part A stay Psychological services furnished by a clinical social worker Services incident to the professional services of a physician or other health care professional v Copyright 2017, All Rights Reserved 10

11 5 Major Categories

12 5 Major Categories The SNF annual update file contains a comprehensive list of HCPCS codes involved in editing claims submitted to FIs for services subject to SNF consolidated billing) The CMS has divided these codes into 5 Major Categories v Copyright 2017, All Rights Reserved 12

13 5 Major Categories Major Category I Exclusion of Services Beyond the Scope of a SNF Major Category II Additional Services Excluded when Rendered to Specific Beneficiaries Major Category III Additional Excluded Services Rendered by Certified Providers Major Category IV Additional Excluded Preventive and Screening Services Major Category V Part B Services Included in SNF Consolidated Billing v Copyright 2017, All Rights Reserved 13

14 Major Category I: Exclusion of Services Beyond the Scope of a SNF These services must be provided on an outpatient basis at a hospital, including a critical access hospital (CAH) only, not by a SNF, and are excluded from SNF PPS and Consolidated Billing for beneficiaries in a Part A stay. v Copyright 2017, All Rights Reserved 14

15 Major Category I: Exclusion of Services Beyond the Scope of a SNF Services directly related to these services, defined as services billed for the same place of service and with the same line item date of service as the services listed below, are also excluded from SNF Consolidated Billing, with exceptions as listed on next slide v Copyright 2017, All Rights Reserved 15

16 Major Category I: Exclusion of Services Beyond the Scope of a SNF Note that anesthesia, drugs incident to radiology and supplies (revenue codes 037x, 025x, 027x and 062x) will be bypassed by enforcement edits when billed with CT Scans, Cardiac Catheterizations, MRIs, Radiation Therapies, or Angiographies or surgeries. In general, bypasses also allow CT Scans, Cardiac Catheterization, MRI, Radiation Therapy, Angiography, and Outpatient Surgery HCPCS codes 0001T 0021T, 0024T 0026T, or (except HCPCS codes listed as inclusions under Major Category I.F) to process and pay. This includes all other revenue code lines on the incoming claim that have the same line item date of service (LIDOS). v Copyright 2017, All Rights Reserved 16

17 Major Category I Major Category I is further broken down into subcategories: A. Computerized Axial Tomography (CT) Scans B. Cardiac Catheterization C. Magnetic Resonance Imaging (MRIs) D. Radiation Therapy E. Angiography, Lymphatic, Venous and Related Procedures F. Outpatient Surgery and Related Procedures (Inclusions)* G. Emergency Services* H. Ambulance Trips-With Application to Major Category II* v Copyright 2017, All Rights Reserved 17

18 Major Category I F. Outpatient Surgery and Related Procedures (Inclusions) Inclusions, rather than exclusions, are given in this one case, because of the great number of surgery procedures that are excluded and can only be safely performed in a hospital operating room setting. It is easier to automate edits around the much shorter list of inclusions under this category, representing minor procedures that can be performed in the SNF itself. The physician s service itself may be excluded for the codes listed (identified in the Carrier A/B MAC files) in this section, however, when these codes are billed by the hospital they are for the technical/facility charge and are not excluded. v Copyright 2017, All Rights Reserved 18

19 Major Category I G. Emergency Services These services are identified on claims submitted to Fiscal Intermediary/Medicare Administrative Contractor by a hospital or Critical Access Hospital (CAH) using revenue code 045x (Emergency Room x represents a varying third digit). Related services with the same line item date of service (LIDOS) are also excluded. Note that to get a match on the LIDOS there must be a LIDOS and HCPCS in revenue code 045x. To bypass services related to the ER encounter which are performed on subsequent service dates, hospitals must identify those services by appending a modifier ET (Emergency Services) to those line items. v Copyright 2017, All Rights Reserved 19

20 Major Category I H. Ambulance Trips With Application to Major Category II Ambulance trips associated with Major Category I (A-E and G services) are excluded from SNF Consolidated Billing. In addition, ambulance trips associated with Major Category II (A. services provided in renal dialysis facilities (RDFs)) are also excluded from SNF Consolidated Billing. v Copyright 2017, All Rights Reserved 20

21 Ambulance Criterion A. An ambulance trip that transports a beneficiary to the SNF for the: initial admission, or from the SNF following a final discharge v Copyright 2017, All Rights Reserved 21

22 Ambulance Criterion B. Medically necessary ambulance services that are furnished in conjunction the following excluded service categories: Cardiac Catheterization Computerized Axial Tomography (CT) Scans Magnetic Resonance Imaging (MRIs) Ambulatory Surgery that involves the use of an Operating Room Emergency Services Radiation Therapy Services Angiography Certain Lymphatic and Venous Procedures Part B Dialysis Services Effective April 1, 2000, BBRA unbundled ambulance services that are necessary to transport an SNF resident offsite to receive Part B Dialysis Services v Copyright 2017, All Rights Reserved 22

23 Ambulance Criterion Transportation for the Medicare Part A Beneficiary was discussed, specifically, transportation via chair car. Medicare does not cover non-ambulance transport. The SNF is therefore not financially responsible for non-ambulance transport. Ambulance transport is a Medicare covered service and depending on the service and location of the service, the SNF may or may not be fiscally responsible. It is important to document that the beneficiary is informed of a non-covered service. The Notice of Exclusions from Medicare Benefits Skilled Nursing Facility (NEMB-SNF) form is recommended as a formal means of communicating financial responsibility with the beneficiary. v Copyright 2017, All Rights Reserved 23

24 Major Category II Major Category II: Additional Services Excluded when Rendered to Specific Beneficiaries These services must be provided to specific beneficiaries, either: (A) End Stage Renal Disease (ESRD) beneficiaries, or (B) beneficiaries who have elected Hospice, by specific licensed Medicare providers, and are excluded from SNF PPS and consolidated billing. SNFs will not be paid for Category II.A. services (dialysis, etc.) when the SNF is the place of service, as to receive Medicare payment, these services must be provided in a renal dialysis facility. Hospices must also be the only type of provider billing Hospice services. v Copyright 2017, All Rights Reserved 24

25 Major Category II A. Dialysis, EPO, Aranesp, and Other Dialysis Related Services for ESRD Beneficiaries Specific coding is used to differentiate dialysis and related services that are excluded from SNF consolidated billing for ESRD beneficiaries in three cases: 1. When the services are provided in a RDF (including ambulance services listed under Major Category I. above), 2. Home dialysis when the SNF constitutes the home of the beneficiary, and 3. When the drugs EPO or Aranesp are used for ESRD beneficiaries. SNFs may not be paid for home dialysis supplies. v Copyright 2017, All Rights Reserved 25

26 Major Category II Providers/Suppliers may bill their intermediary or carrier for an ESRD-related diagnostic test, provided the test is outside of the ESRD-facility composite rate. The use of the Consolidated Billing modifier would allow these services to be bypassed from the SNF Consolidated Billing edits. Please refer to Change Request 2475 for greater detail. v Copyright 2017, All Rights Reserved 26

27 Major Category II 1. Coding Applicable to Services Provided in a RDF or SNF as Home Institutional dialysis services billed only by a RDF are identified by type of bill 72X. Services for Method 1 and 2 ESRD beneficiaries billed by a RDF must be accompanied by the dialysis related diagnosis code The applicable HCPCS codes are identified in the excel file as Dialysis Supplies and Dialysis Equipment. v Copyright 2017, All Rights Reserved 27

28 Major Category II 3. Coding Applicable to EPO and Aranesp Services Epoetin alfa (trade name EPO) is a drug Medicare approved for use by ESRD beneficiaries. Darbepoetin alfa (trade name Aranesp) is a drug Medicare approved for use by ESRD beneficiaries. When epoetin alfa or darbepoetin alfa are given by the dialysis facility in conjunction with dialysis, these drugs are excluded and must be billed by the RDF. Instructions for billing RDF services are in publication 100-4, chapter 8. v Copyright 2017, All Rights Reserved 28

29 Major Category II 3. Coding Applicable to EPO and Aranesp Services (cont.) To distinguish epoetin alfa or darbepoetin alfa given to ESRD beneficiaries from the same drugs given to non-esrd beneficiaries CMS has developed separate codes. The instructions for billing for non- ESRD epoetin alfa or darbepoetin alfa are located in publication 100-4, chapter 17, section These drugs for non-esrd use are always bundled to the SNF for beneficiaries in a covered Part A stay. v Copyright 2017, All Rights Reserved 29

30 Major Category II B. Hospice Care for a Beneficiary s Terminal Illness Hospice services for terminal conditions are identified with the following bill types: 81X or 82X. Services provided to ESRD beneficiaries, or to beneficiaries who have elected Hospice provided by licensed Medicare Hospice providers are excluded from SNF PPS and consolidated billing. ESRD services provided within the SNF are included in the SNF payment. ESRD services (category IIA) are separately reimbursable only when provided in a renal dialysis facility (TOB 072X) or as home dialysis to patients whose home is the SNF. SNFs may not be paid directly for home dialysis supplies. Hospice services are reimbursable only when billed by a Hospice provider (TOB 081X or 082X). v Copyright 2017, All Rights Reserved 30

31 Major Category III Major Category III: Additional Excluded Services Rendered by Certified Providers These services may be provided by any Medicare provider licensed to provide them, except a SNF, and are excluded from SNF PPS and consolidated billing. HCPCS Code ranges for chemotherapy, chemotherapy administration, radioisotopes and customized prosthetic devices are set in statute. This statute also gives the Secretary authority to make modifications in the codes that are designated for exclusion within each of these service categories; accordingly, the minor and conforming changes in coding that appear in the instruction are made under that authority. v Copyright 2017, All Rights Reserved 31

32 Major Category III A. Chemotherapy B. Chemotherapy Administration Chemotherapy Administration codes listed with an asterisk (*) in the file are included in SNF PPS payment for beneficiaries in a Part A stay when performed alone or with other surgery, but are excluded if they occur with the same line item date of service as an excluded chemotherapy agent. A chemotherapy agent must also be billed when billing these services and physician orders must exist to support the provision of chemotherapy. Codes listed w/o an asterisk (*) are treated the same as those with an (*) for all providers except hospitals, including CAHs. Codes w/o an (*) are excluded surgery codes and may be billed w/o a chemotherapy agent in hospital settings only. v Copyright 2017, All Rights Reserved 32

33 Chemotherapy All chemotherapeutic medications administered in the SNF are the fiscal responsibility of the SNF. The chemotherapy drug administered at the cancer center or other venue is only excluded if it is specifically identified as exclude on the SNF Exclusion List. It is important to search the list using both the generic and brand name. v Copyright 2017, All Rights Reserved 33

34 Major Category III C. Radioisotopes and their Administration D. Customized Prosthetic Devices v Copyright 2017, All Rights Reserved 34

35 Major Category IV Major Category IV: Additional Excluded Preventative and Screening Services These services are covered as Part B Benefits and are not included in SNF PPS. Such services must be billed by the SNF for beneficiaries in a Part A stay with Part B eligibility on type of bill (TOB) 22x. Swing Bed providers must use TOB 12x for eligible beneficiaries in a Part A SNF level. Chapter 18 Preventive and Screening Services of the Claims Processing Manual provides further coverage and billing guidance. v Copyright 2017, All Rights Reserved 35

36 Major Category IV A. Mammography B. Vaccines (Pneumococcal, Flu or Hepatitis B) C. Vaccine Administration D. Screening Pap Smear and Pelvic Exams E. Colorectal Screening Services F. Prostate Cancer Screening G. Glaucoma Screening H. Diabetic Screening I. Cardiovascular Screening J. Initial Preventative Physical Exam K. Abdominal Aortic Aneurysms (AAA) Screening v Copyright 2017, All Rights Reserved 36

37 Major Category V Major Category V: Part B Services Included in the SNF Consolidated Billing Therapy services are included in SNF PPS and consolidated billing for residents in a Part A stay, and must be billed by the SNF alone for its Part B residents. This category applies to therapies billed with revenues codes 42X (physical therapy) 43X (occupational therapy) 44X (speech-language pathology) Must be billed by the SNF for Part B residents and nonresidents v Copyright 2017, All Rights Reserved 37

38 Frequency of Billing SNF claims are billed to Medicare: Upon discharge of the resident Benefits exhausted Resident denied skilled care Billed on a monthly basis v Copyright 2017, All Rights Reserved 38

39 Demand Bills Reminder Demand bills are submitted by the provider as requested by the beneficiary Condition Code 20 should be included on the claim for demand bills All charges associated with Condition Code 20 must be submitted as non-covered v Copyright 2017, All Rights Reserved 39

40 Areas of Opportunity SNF fails to inform the supplier resident is in a covered Part A stay Valid payment contract was not arranged Resident temporarily leaves SNF and obtain services subject to Consolidated Billing from another provider v Copyright 2017, All Rights Reserved 40

41 Communication and Relationships Notify outside providers and suppliers Inform beneficiary Establish payment arrangements with outside provider v Copyright 2017, All Rights Reserved 41

42 Part A SNF Claim Submission Errors

43 Part A SNF Claim Submission Errors Reason Code EA031- claim processing system shows patient has an HMO Add Condition Code 04 to the claim if patient has an HMO Reason Code C7010- claim overlaps a hospice election period If services are unrelated to the terminal illness, include Condition Code 07 on the claim v Copyright 2017, All Rights Reserved 43

44 Common Part A SNF Claim Submission Errors Reason Code SNF claims should be billed in sequence Submit the prior bill Reason Code Sum of covered days and noncovered days must equal the statement covers period Verify the following: Covered and non-covered days Statement from and through dates Patient status v Copyright 2017, All Rights Reserved 44

45 CMS Manual References Medicare Claims Processing Manual Publication , Chapter 6-SNF Inpatient Part A Billing and SNF Consolidated Billing Guidance/Guidance/Manuals/Downloads/clm104c06.pdf Medicare Claims Processing Manual Publication , Chapter 7-SNF Part B Billing (Including Inpatient Part B and Outpatient Fee Schedule) Guidance/Guidance/Manuals/Downloads/clm104c07.pdf v Copyright 2017, All Rights Reserved 45

46 Excluded Services There are a number of services that are excluded from SNF consolidated billing These services are outside the PPS bundle, and they remain separately billable to Part B when furnished to a SNF resident by an outside supplier v Copyright 2017, All Rights Reserved 46

47 Excluded Services Physicians services, PA s, NP s, CNS, Certified Midwives, Psychologist, CRNA s Dialysis Related Services EPO (Epogen) for certain dialysis residents Hospice Care Ambulance Services Ambulatory Surgery involving use of an operating room v Copyright 2017, All Rights Reserved 47

48 Excluded Services Physicians Services- Furnished to SNF residents are not subject to consolidated billing Many physician services include both a professional and technical component The technical component is subject to consolidate billing v Copyright 2017, All Rights Reserved 48

49 Excluded Services Physician s PA s working under a physicians supervision NP s and CNS working in collaboration with a physician Certified Midwife Qualified Psychologist Certified Registered Nurse Anesthetists v Copyright 2017, All Rights Reserved 49

50 Excluded Services Dialysis Services described in section 1861(s)(2)(F) of the Social Service Act (i.e., Part B coverage of home dialysis supplies and equipment, self-care home dialysis support services, and institutional dialysis services and supplies) v Copyright 2017, All Rights Reserved 50

51 Excluded Services Epogen Services described in section 1861(s)(2)(0) of the social Security Act, i.e., Part B coverage of Epoetin Alfa ( EPO, trade name Epogen) for certain dialysis patients. Note: Darbepoetin Alfa ( DPA, trade name Aranesp) is now excluded on the same basis as EPO Must be given at dialysis center v Copyright 2017, All Rights Reserved 51

52 Excluded Services Hospice Care Hospice care related to a resident s terminal condition Hospice services for terminal conditions are identified with the following bill types: 81X or 82X v Copyright 2017, All Rights Reserved 52

53 Excluded Services Ambulance Services for residents in a Part A stay are excluded under the following: The ambulance trip to the SNF for admission The ambulance trip from the SNF to home, unless readmitted prior to midnight The ambulance trip to a hospital based or nonhospital based dialysis facility To hospital or CAH for inpatient admission Round trip to hospital for emergency services v Copyright 2017, All Rights Reserved 53

54 Excluded Services Ambulance charges associated with the following services that are not the responsibility of the SNF: Cardiac Catheterization CT Scan MRI s Ambulatory Surgery involving the use of an operating room Angiography Lymphatic and venous procedures Radiology Therapy v Copyright 2017, All Rights Reserved 54

55 Excluded Services Ambulance charges associated with the following excluded services are the responsibility of the SNF: To MD office Chemotherapy Services Radioisotope services For customized prosthetic devices v Copyright 2017, All Rights Reserved 55

56 Excluded Services Ambulance charges between SNF s is the responsibility of the transferring SNF v Copyright 2017, All Rights Reserved 56

57 Excluded Services CT Scans and MRI s must be performed in a hospital setting v Copyright 2017, All Rights Reserved 57

58 Excluded Services Outpatient Surgery and Related Procedures Inclusion rather than exclusions, are given in this one case, because of the great number of surgery procedures that are excluded and can only be safely performed in a hospital operating room setting v Copyright 2017, All Rights Reserved 58

59 Excluded Services Emergency Services- Claims submitted by Hospital Revenue Code 045x v Copyright 2017, All Rights Reserved 59

60 Excluded Services Additional excluded services rendered by certified providers Chemotherapy Chemotherapy Administration Radioisotopes and their Administration Customized Prosthetic Devices ( L Codes) v Copyright 2017, All Rights Reserved 60

61 Excluded Services Additional excluded preventive and screening services: Mammography Vaccines (pneumococcal, Flu or Hepatitis) Vaccine Administration Screening Pap Smear and Pelvic Exams Colorectal Screening Services v Copyright 2017, All Rights Reserved 61

62 Excluded Services Additional excluded preventive and screening services: Prostate Cancer Screening Glaucoma Screening Diabetic Screening Cardiovascular Screening Initial Preventative Physical Exam v Copyright 2017, All Rights Reserved 62

63 Excluded Services Preventive and Screening- These services are covered as Part B benefits and are not included in SNF PPS payment for beneficiaries in a Part A stat with Part B eligibility on type of bill 22x v Copyright 2017, All Rights Reserved 63

64 Minimizing Financial Responsibility Ensure resident s are receiving services at appropriate designated Medicare providers Review labs, diagnostics for medical necessity and frequency If possible, schedule services at the same time as other residents to minimize service Fees Use preferred providers for non-excluded services v Copyright 2017, All Rights Reserved 64

65 Minimizing Financial Responsibility Verify services provided are not excluded from consolidated billing Review invoices for accuracy of charges and dates of service Ensure SNF is responsible for payment Attempt best pricing of services prior to payment v Copyright 2017, All Rights Reserved 65

66 Minimizing Financial Responsibility Emergency Room Services Emergency Room Services that span midnight may be returned to the hospital unpaid stating SNF responsible for payment. Hospital ER s are to add modifier ET to the HCPCS codes v Copyright 2017, All Rights Reserved 66

67 Best Practices Educate Staff Negotiate rates Involve key players in the admission process, identify potential bills Check SNF Help file- it is actually the facilities bill Ensure the patient is on Part A benefits SNF needs to function as a HMO v Copyright 2017, All Rights Reserved 67

68 TIPS Question if services could be done post discharge Build working relationship with orthopedist, specialists (follow-up, see how necessary blood, x-ray, do in SNF) Lab and X=Ray PPD v Copyright 2017, All Rights Reserved 68

69 Benefit Period Skilled 60 days in non-certified bed does not end benefit period if resident remains at skilled level of care Part B therapy services 5x/wk is a skilled level of care and impacts benefit period v Copyright 2017, All Rights Reserved 69

70 Billing Type of Bills (TOB) Admit through Discharge Claim Interim First Claim Interim Continuing Claim Interim Last Claim ( Discharge) Replacement of Last Claim No Pay Claim v Copyright 2017, All Rights Reserved 70

71 Billing SNF No Pay Claims (210) Non Covered days and charges beginning day after active care ended Bill type 210 Need not be submitted monthly Appropriate Status Code Occurrence Span Code 74 Condition code 21 HIPPS Code=AAAOO R&B changes only Need not be submitted prior to Part B claims v Copyright 2017, All Rights Reserved 71

72 No Pay Claims Providers must submit a no-payment claim for residents that have previously received Medicare covered care and subsequently dropped to a noncovered level of care but continued to reside in a Medicare Certified area of the facility v Copyright 2017, All Rights Reserved 72

73 No Pay Claims CMS only requires one final no payment claim upon final discharge Covered period from day after date of active care ended (Occurrence Code 22) to date of discharge. Discharge would include movement of a resident from a Distinct Part (Medicare Certified) to a non-certified Medicare bed. * Should submit on an annual basis at a minimum. Monthly is allowable. v Copyright 2017, All Rights Reserved 73

74 Billing SNF Benefits Exhaust Claims Covered days and charges Bill Type 211, 212, 213, or 214 Submit monthly Appropriate Status Code Occurrence Span Code 70 HIPPS Code= AAAOO Room and Board charges only need be included Submit prior to submitting Part B claims v Copyright 2017, All Rights Reserved 74

75 Benefit Exhaust Claim Partial or Full Benefits Exhaust Claim Partial- portion of the claim contains one or more benefit days available Full- no benefit days are available on the submitted claim v Copyright 2017, All Rights Reserved 75

76 Benefit Exhaust Claim Use appropriate Bill Type (211, 212, 213, or 214) Submit all covered days and charges as if beneficiary had available days Use appropriate patient status code v Copyright 2017, All Rights Reserved 76

77 Billing SNF FYI (04) claim for Medicare Beneficiaries Submit as covered Set up claim as if Medicare Primary Add condition code (04) HIPPS Code = AAAOO Room and Board charges only v Copyright 2017, All Rights Reserved 77

78 Billing Resident Status indicate the patient s status as of the through date of the billing period. Discharge to home Discharge to hospital Discharge to other SNF Discharge home with HH Left AMA or discontinued care Expired Still inpatient Discharged to a nursing facility certified under Medicaid not Medicare v Copyright 2017, All Rights Reserved 78

79 Adjusting Claims Adjustment bills based on corrected MDS assessments must be submitted within 120 days of the through date on the bill. An edit is in place to limit the time for submitting this type of adjustment request to 120 days from the service through date. Beginning 1/1/09, claims submitted for all adjustments will need to include condition code D2 v Copyright 2017, All Rights Reserved 79

80 Leave of Absence A leave of absence is a situation where the patient is absent, but not discharged, for reasons other than admission to a hospital, other SNF, or distinct part of the same SNF v Copyright 2017, All Rights Reserved 80

81 Leave of Absence Billing Occurrence Span Code 74- for dates the patient is absent at midnight Value Code 81-non covered days Revenue code 180 Units # of days resident was out of the building at midnight Total charges for Rev Code 180=$0 v Copyright 2017, All Rights Reserved 81

82 Bed Holds Facilities may charge a bed hold fee under Part A stay if: Resident is informed in advance of their option to hold a bed and associated costs Resident must affirmatively elect to make them prior to billing v Copyright 2017, All Rights Reserved 82

83 Default Billing CMS Default Billing Rule Demand Bill situations MSP Situations Denial of Payment Situations First 8 days of a benefit period, following a 3 day qualifying stay Disenrollment from Medicare Advantage Plan v Copyright 2017, All Rights Reserved 83

84 Default Billing An MDS assessment is always required for Medicare payment except in one of the following situations: Demand Bill MSP Situations Denial of Payment 1 st 8 days of a benefit period Disenrollment from Medicare Advantage Plan v Copyright 2017, All Rights Reserved 84

85 Default Billing Facilities may not bill default when an MDS assessment is not completed v Copyright 2017, All Rights Reserved 85

86 Late Assessment Situation where PPS Assessment is completed with an ARD outside the allowable time period for the specific PPS assessment. Resident stays in facility under Part A stay. Facility will bill default from the beginning the payment period up to ARD of late assessment v Copyright 2017, All Rights Reserved 86

87 Late Assessment Situation where PPS Assessment is completed with an ARD outside the allowable time period for the specific PPS assessment. Resident stays in facility under Part A stay. Facility will bill default from the beginning the payment period up to ARD of late assessment v Copyright 2017, All Rights Reserved 87

88 Late Assessment Situation where PPS Assessment is completed with an ARD outside the allowable time period for the specific PPS assessment. Resident stays in facility under Part A stay. Facility will bill default from the beginning the payment period up to ARD of late assessment v Copyright 2017, All Rights Reserved 88

89 Missed Assessment This occurs when a PPS assessment was not completed and the patient is now off Medicare Part A Facility is not able to collect reimbursement from Medicare program Facility must submit days associated with missed assessment as provider liability v Copyright 2017, All Rights Reserved 89

90 Tips for Submitting Claims Ensure MDS s are submitted and accepted prior to billing Verify Leave of Absence Days Monitor that ancillary charges are supported by medical record Verify and update ICD-10 Codes with each claim Communicate skilled and non-skilled levels of care v Copyright 2017, All Rights Reserved 90

91 Resources CMS, Medicare Claims Processing Manual: Guidance/Guidance/Manuals/Internet-Only-Manuals- IOMs-Items/CMS html CMS, Medicare Claims Processing Manual, Chapter 6 SNF Inpatient Part A Billing and SNF Consolidated Billing Guidance/Guidance/Manuals/Downloads/clm104c06.pdf CMS, Medicare Claims Processing Manual, Chapter 7 - SNF Part B Billing (Including Inpatient Part B and Outpatient Fee Schedule) v Copyright 2017, All Rights Reserved 91

92 Connect with Kris Harmony Healthcare International (HHI) facebook.com/harmonyhealthcareinternational linkedin.com/company/harmony-healthcare harmonyhealthcareinternational 92

93 Thank You

94 HarmonyHelp Harmony Healthcare International (HHI) provides an invaluable resource for the entire interdisciplinary team. The HarmonyHelp site provides a Knowledge Center and Live Support. Knowledge Center 24-Hour Access Manuals Tools CARE Community Hot Topics Frequently Asked Questions (FAQs) Live Support Ask A Specialist via Call via phone Live Chat via messaging Imagine having questions answered by a Harmony HealthCARE Specialist within minutes of the inquiry. For more information about HarmonyHelp: or 94

95 harmony18 7 th Annual LTPAC harmony16 Knowledge / Network / Entertainment Interdisciplinary Symposium November 1 ST & 2 ND 2018 Register today to lock in the lowest rate! Click Here to Register! Uncasville, CT v Copyright 2017, All Rights Reserved 95

96 Percent Harmony Healthcare International (HHI) FREE PEPPER Analysis 100% 80% 60% 40% 20% 0% Therapy RUG Days National Comparative Data (Actual Percentages) Therapy High ADL Days 90+ Day Episode of Care 80th Percentile Actual SNF 20th Percentile Target Areas Contact: v Copyright 2017, All Rights Reserved 96

97 Points Assigned Harmony Healthcare International (HHI) FREE Five-Star Analysis Mobility Decline (L) NEW Five-Star Quality Measure Points Analysis 50 Rehospitalization Above=2% Improvements in Function (S) VBP 30 Re-hospitalization (S) Emergency Discharged to the Department Visit Community (S) (S) Contact: info@harmony-healthcare.com Quality Measure v Copyright 2017, All Rights Reserved 97

98 Harmony Healthcare International (HHI) FREE Medicare Part A Revenue and Risk Analysis Contact: info@harmony-healthcare.com v Copyright 2017, All Rights Reserved 98