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Tricky NAC Issues Even Some Experts Miss

Article / Billing and Reimbursement / NAC

Nurse assessment coordinators (NACs) definitely experience variety in their jobs, to state the obvious. Management and completion of the Minimum Data Set/Resident Assessment Instrument (MDS/RAI) process, Medicare management, and ICD-10-CM coding are just a few of the areas they are expected to master in their role. With these responsibilities alone, the NAC must follow the regulations and instructions in the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual (RAI User’s Manual), the State Operations Manual (SOM), the Medicare General Information, Eligibility and Entitlement Manual, the Medicare Benefit Policy Manual (MBPM), the Medicare Claims Processing Manual (MCPM), the ICD-10-CM Official Guidelines for Coding and Reporting, and even the Social Security Act (SSA).

In addition, NACs must familiarize themselves with the various instructions, question-and-answer documents, guides, errata documents, and training materials on the Center for Medicare & Medicaid Services (CMS) website. It is nearly impossible to know it all specifically because the regulatory language is complicated. NACs may ask themselves, “How didn’t I know that?” when an MDS tag is received during a survey or a Medicare Part A claim is denied. But rest assured, they are not alone. Even experts can miss things. This article highlights some of the trickier NAC issues that have stumped many who work diligently in the field.

MDS Coding

The most recent update to the RAI User’s Manual, effective Oct. 1, 2023, changed many of the instructions on how to complete the MDS. CMS provided training and a follow-up question-and-answer document to offer further clarification.

Resident Interview Timing

Some of these changes were expected, but others were surprising, namely the look-back period for completing some of the resident interviews. CMS provided additional clarification regarding the timing of resident interviews (CMS, 2023a). But participants still questioned when resident interviews should be completed, stemming from confusion between when to complete the interview versus the resident’s response look-back period.

CMS referred back to the coding conventions in chapter 3, section 3.3 of the RAI User’s Manual (CMS, 2023b).The standard look-back period is 7 days unless otherwise stated. Specifically, CMS explained in the response to question 32 in the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Participant Questions document that the Patient Health Questionnaire (PHQ)-2 to 9 should be completed during the standard 7-day look-back period (CMS, 2023a).

Although the interview asks about the resident’s mood over the last 14 days, only the resident’s response uses the 14-day time period. In addition, the pain interview look-back period was clarified in response to questions 83 and 91 on the SNF QRP Participant Questions document. Although the resident response to the pain interview is based on the 5-day look-back period, the interview itself should be conducted within the 7-day look-back period (CMS, 2023a). These clarifications may depart from previous practice.

Look-back periods Section O0110

The removal of the “while not a resident” column and the addition of the “admission” and “discharge” columns on MDS version 1.18.11 has puzzled some NACs about how to define the look-back period for section O0110. All three columns in O0110 consider what special treatment, procedure, or program was provided while in the facility, but it can only go back to the date of entry at A1600. No longer is there any look-back into the preadmission period for O0110.

The “admission” column is only present on a 5-Day PPS assessment, and the look-back period is the first three days of the Medicare stay beginning with the Medicare start date at A2400B. The “discharge” column is only present on a PPS End of Stay assessment and has a look-back of the last three days of the Medicare stay, ending with A2400C. The “while a resident” column has a look-back period of 14 days, but it only looks back as far as the date of entry at A1600. These distinctions may lead to uncertainty about where to code the information from the hospital. With the removal of the “while not a resident” column, there is no longer a place to code O0110 items from the hospital stay. To help navigate how to identify the look-back period correctly, the AAPACN tool Section K and O Assessment Periods can help.

Medicare Coverage

Medicare Payment for Day of Discharge

Thought the day of discharge was never reimbursable under Medicare Part A? Not true. In three situations, the day of discharge is a paid Medicare day. Chapter 6, section 40.3.5 of the MCPM explains that if a resident newly admitted to a SNF, with the expectation of an overnight stay, is discharged, dies, or transfers to a non-Medicare participating provider (such as an assisted living or private dwelling), that day is a paid Medicare day (CMS, 2023c).

In any of these situations, the facility may either bill the day at the default rate (ZZZZZ) or complete a 5-Day PPS assessment to obtain a Health Insurance Prospective Payment System (HIPPS) code. This allowance of billing the default codes is outlined in the exceptions to provider liability in the RAI User’s Manual (CMS, 2023b), indicating if the stay is less than 8 days within a spell of illness, the default code may be billed when there is no assessment in the Internet Quality Improvement Evaluation System (iQIES). In many cases, it may be financially beneficial to complete a 5-Day PPS assessment with the information available, a decision made at the discretion of the facility.

Post-Hospital Stay

The term post-hospital stay is used in many manuals referencing Medicare Part A coverage in a SNF, also known as an extended care stay. The 3-day qualifying hospital stay (QHS) is required to initiate a post-hospital stay. Chapter 8, section 20.2.1 of the MBPM indicates post-hospital requirements are met if the resident is admitted to a SNF within 30 days of the discharge from the QHS (CMS, 2023d).

But how does this rule apply to the disaster waiver used with nationally declared disasters (e.g., floods, hurricanes, or wildfires)? The COVID-19 Public Health Emergency (PHE) made everyone aware of the QHS waiver because it was applied to a SNF stay and waived the QHS for residents impacted by COVID. When the PHE ended a year ago, many people believed the waiver applied to all post-hospital stay requirements. They mistakenly thought that those residents who didn’t have a QHS would be eligible to use the 30-day transfer rule after the PHE ended, if applicable. Not so. Although post-hospital care in chapter 8 of the MBPM is not specifically defined, the SSA makes it explicit. Section 1861(i) of the SSA states, “The term ‘post-hospital extended care services’ means extended care services furnished an individual after transfer from a hospital in which he was an inpatient for not less than 3 consecutive days before his discharge from the hospital in connection with such transfer” (SSA, 2024). Thus any residents who use the disaster waiver of the QHS are not eligible to take advantage of the 30-day transfer rule once the disaster waiver expires. These residents must have a QHS to access their benefit period if they end Medicare coverage related to a disaster-related stay and become eligible for continued skilled coverage.

References

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