HCPro.com: Billing Alert for Long-Term Care

It's essential to know how to correctly submit your Medicare claims in order to get the reimbursement your facility deserves. Billing Alert for Long-Term Care provides the crucial tips and strategies that billers need for success.

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October 2008 (Volume 10, Issue 10)	view entire issue

New rules on default billing end CMS flip-flops
With the August publication of the skilled nursing facility (SNF) PPS and consolidated billing final rule for fiscal year 2009, CMS finally put to rest more than a year of confusion regarding exactly when SNFs can bill the Medicare Part A default rate if a PPS MDS assessment hasn’t been completed and accepted into the state database, says Rena R. Shephard, MHA, RN, RAC-MT, C-NE, founding chair and executive editor of the American Association of Nurse Assessment Coordinators and president of RRS Healthcare Consulting Services in San Diego. In March 2007, CMS published Transmittal 196 to update SNF PPS medical review policies. The transmittal’s stringent limitations on billing the default rate when an MDS wasn’t completed set off an uproar in the nur-sing home industry and created conflicting opinions among CMS officials. At SNF/Long-Term Care Open Door Forums throughout 2007 and early this year, agency officials made several reversals in their thinking about default billing.

Late vs. missed assessments: The difference is money
The skilled nursing facility (SNF) PPS and consolidated billing final rule for fiscal year 2009 clarifies the difference between a late assessment and a missed assessment—a key concept when it comes to default billing, says Ronald A. Orth, RN, NHA, RAC-CT, CPC, owner and president of Milwaukee-based Clinical Reimbursement Solutions, LLC.

CMS affirms that SNFs can charge Medicare bed holds
Since CMS transitioned to an online manual system, the ability to bill Medicare beneficiaries when a skilled nursing facility (SNF) holds a bed during a leave of absence (LOA) basically has been an unwritten rule, says Elizabeth Malzahn, manager at FR&R Healthcare Consulting, Inc., in Deerfield, IL. “The instructions didn’t make it into the Internet-only manual, so the only ref-erence available was in the defunct paper manual,” she says. However, SNFs now have some up-to-date directions. Transmittal 1522 clarifies the rules for charging Medicare bed holds “in language people can actually understand,” Malzahn says.

BALTC Q&A
Editor’s note: “Q&A” was written by Lee A. Heinbaugh, president of The Heinbaugh Group, a long-term care consulting company in Lakewood, OH.

How FIs view changes in therapy services during a payment period
Effective April 30, 2007, fiscal intermediaries and Part A/B Medicare administrative contractors conduct medical reviews of Medicare Part A skilled nursing facility PPS claims using automated MDS quality control (QC) system software. Medical review staff members obtain electronic copies of MDS assessments from the state databases, enter data from those MDSs in the MDS QC system software, and evaluate the associated medical record to calculate their resource utilization group (RUG) scores. The following excerpt from Section 6.1.3D, Bill Review Process: Outcome of Medical Record Review, in Chapter 6, “Intermediary Medical Review Guidelines for Specific Services,” of the Medicare Program Integrity Manual explains how Medicare contractors will approach claims in which the level of therapy services changed during the payment period:

Other recently-published articles from Billing Alert for Long-Term Care:

Hospice services: Know when and how your facility should bill

Benefits exhaust and no-pay bills

BALTC Q&A

Medicare Part D: SNFs, LTCPs, and dual-eligible residents

Recovery audit contractors: Ready or not, here they come

Take the pain out of immunizations with roster billing

Billing for ambulance services: Combat common problems and reduce costs for your facility

BALTC Q&A

Rein in the facility census

Coding patient status on the UB-04

BALTC Q&A

Don’t overlook condition codes

Don’t let your billing office bypass resident resource payments

How FIs view changes in therapy services during a payment period

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