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NACs Need to Know: 5 Key Medicare Part A Requirements That Haven’t Changed Under PDPM

The nurse assessment coordinator (NAC) often handles the entire Medicare program in the facility, from managing the PPS schedule to leading the skilled coverage decision. With PDPM in full swing, a lot seems to have changed, but some things have not.


“The implementation of the Patient-Driven Payment Model (PDPM) changed the payment system used for traditional Part A residents,” says Suzy Harvey, RN-BC, RAC-CT, managing consultant at BKD in Springfield, MO. “It did not change the coverage policies for skilled services.”

Key requirements that remain in place—and that NACs need to know about—include the following:


Prerequisites for Part A coverage and billing

The requirements that must be in place to qualify and bill for Part A skilled coverage are the same under PDPM as they were under the RUG-IV case-mix classification system, says Harvey. “These policies are primarily laid out in chapter 8, ‘Coverage of Extended Care (SNF) Services Under Hospital Insurance,’ of the Medicare Benefit Policy Manual.” Note: A recent CMS transmittal updated chapter 8 for PDPM, effective November 5.


Prerequisites that haven’t changed include the following, according to Harvey:

The resident must have a three-day qualifying hospital stay.

  • Section 20.1, Three-Day Prior Hospitalization, in chapter 8 of the Benefit Policy Manual.

Part A skilled services must be initiated within 30 days of discharge from the qualifying hospital stay unless the resident qualifies for a medical appropriateness exception.

  • Section 20.2, Thirty-Day Transfer, in chapter 8 of the Benefit Policy Manual.

The resident must have benefit days available—either via a new 100-day benefit period or the continuation of an open 100-day benefit period.

  • Section 10.4, Benefit Period (Spell of Illness), in chapter 3, “Deductibles, Coinsurance Amounts, and Payment Limitations,” of the Medicare General Information, Eligibility, and Entitlement Manual.

In order to bill Part A, providers must obtain the appropriate, timely physician certification or recertification that either indicates that the resident requires posthospital daily SNF inpatient services for an ongoing condition related to the qualifying hospital stay or that the resident has been correctly assigned into a case-mix classifier that meets administrative presumption requirements.

  • Section 40, Certification and Recertification by Physicians for Extended-Care Services, in chapter 4, “Physician Certification and Recertification of Services,” of the General Information, Eligibility, and Entitlement Manual.
  • Section 40, Physician Certification and Recertification of Extended-Care Services, in chapter 8 of the Benefit Policy Manual, which includes information about the difference between a direct and indirect employment relationship and how that impacts who can sign certs/recerts.


Daily skilled services

“The four factors that historically must be met for SNF care to be covered under Medicare Part A—and that are spelled out in section 30, Skilled Nursing Facility Level of Care – General, of chapter 8 in the Benefit Policy Manual—still define what is a skilled level of care,” says Melanie Tribe-Scott, BSN, RN, RAC-MT, RAC-MTA, QCP, president of Sunlight Consulting in Warwick, RI.


“For example, the resident must need daily skilled services. If therapy is the only skilled service, it must be needed and provided at least five days a week. The fact that therapy minutes no longer impact payment under PDPM hasn’t changed the requirement that therapy must be provided a minimum of five days a week to meet a skilled level of care,” she explains. “And with the exception of restorative nursing services that must be provided a minimum of six days a week to be considered daily, nursing services that are the only skilled service must be provided at least seven days a week to meet the daily requirement.”


An occasional missed day here and there may be inconsequential, adds Harvey. “However, providers that consistently fail to provide daily skilled services may face scrutiny from CMS contractors.” For details, see section 30.6, Daily Skilled Services Defined, in chapter 8 of the Benefit Policy Manual.


The therapy and nursing services that count as skilled remain the same as well, says Tribe-Scott. “For example, the treatment of a decubitus ulcer that is Stage 3 or worse is still a direct skilled nursing service, and observation and assessment of a resident’s condition, such as an unstable cardiac condition, is one of the nursing management services that continues to be skilled as well.” For details, see section 30.2, Skilled Nursing and Skilled Rehabilitation Services, in chapter 8 of the Benefit Policy Manual.


Reasonable and necessary care

“SNFs are still charged with delivering the care that is clinically indicated. Any skilled services you provide must be reasonable and necessary,” says Tribe-Scott. “What you deemed clinically necessary on September 30 [prior to the transition to PDPM] should still be clinically necessary now. This is especially important with skilled therapy. CMS has indicated that it will monitor inconsistencies in therapy intensity, duration, and manner of delivery between RUG-IV and PDPM. You have to provide care that is clinically appropriate for an appropriate length of stay.”


The following excerpts from section 30 in the Benefit Policy Manual clearly define what is reasonable and necessary:

The services delivered are reasonable and necessary for the treatment of a patient’s illness or injury, i.e., are consistent with the nature and severity of the individual’s illness or injury, the individual’s particular medical needs, and accepted standards of medical practice. The services must also be reasonable in terms of duration and quantity. …

EXAMPLE: Even though the irrigation of a suprapubic catheter may be a skilled nursing service, daily irrigation may not be “reasonable and necessary” for the treatment of a patient’s illness or injury.


Therapy evaluations

The implementation of an interrupted stay policy under PDPM has caused some confusion about when therapy evaluations are required for a resident receiving Part A skilled therapy services, says Harvey. “However, this therapy policy hasn’t changed either. Therapists still have to do an evaluation when a resident is admitted to the SNF for therapy services. If that resident subsequently discharges and is readmitted after the three-day interruption window, it is a new admission that requires a new therapy evaluation. But if that resident discharges and comes back within the three-day interruption window, the original stay didn’t officially end, so the therapy plan of care, updated as needed, continues at that point.”


In addition, completing an Interim Payment Assessment (IPA) doesn’t indicate the need for a new therapy evaluation, says Harvey. “When you do an IPA, you are identifying a change in the resident’s condition that would impact at least one of the five case-mix-adjusted PDPM payment components. You’re not ending therapy and beginning it again. Therapy should review the therapy plan of care to determine if it needs to be updated, but there’s no requirement for a new therapy evaluation just because the facility chooses to complete an IPA.”


Beneficiary notices

Although the interrupted stay policy confused some providers, beneficiary notice requirements haven’t changed, says Tribe-Scott. “For example, if a facility determines that a Part A resident no longer meets skilled criteria and downgrades the resident to a custodial level (i.e. the resident remains in the building receiving unskilled services), that resident may still require both a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to protect them against financial liability and a Notice of Medicare Non-Coverage (NOMNC) to allow them to contest their discharge from skilled care under the expedited-determination process. This is true even if that resident becomes skilled again within the three-day interruption window and therefore has an interrupted stay.”


The key is not to overthink the requirements, says Tribe-Scott. “Some providers are questioning, for example, ‘What if this resident gets picked up again and is skilled in two days?’ However, your team needs to provide the required beneficiary notices in real time. What may or may not happen within the interruption window doesn’t matter when it comes to the beneficiary notices. You have to provide them to the resident when they are required.”

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