Billing and Reimbursement
AAPACN’s billing and reimbursement resources include articles, tips, and tools to keep post-acute care leaders informed of changes and to ensure facility success under various payment models.
- NHSN Healthcare Personnel (HCP) Flu Vaccination Module for SNF QRP ReportingThe HCP Flu Vaccination Module, which is part of the HCP component in NHSN, is used to input required NHSN data for the SNF QRP. This site provides access to the HCP Vaccination Module: Influenza …
- FY 2025 SNF VBP Program March 2024 Quarterly Reports AvailableThe March 2024 Quarterly Confidential Feedback Reports for the fiscal year (FY) 2025 Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program are now available to download via the Internet Quality Improvement and Evaluation System (iQIES). …
- Q&A: A resident enrolled in hospice revoked services for a skilled Medicare Part A stay during the month. What is required for beneficiary notices and assessments if the resident transitions to a Medicare Advantage plan at the beginning of the next month?Question: A resident was on Hospice in community. He revoked hospice and had a qualifying hospital stay. He opted to receive rehab in the skilled nursing facility and then return to home. Medicare guidelines state …
- CMS Transmittal: PDPM Corrections to Interrupted Stay EditsTransmittal # R12525OTN Issue Date 2024-03-01 Subject Patient Driven Payment Model (PDPM) Corrections to Interrupted Stay Edits Implementation Date 2024-04-01 CR #13360 Publication #100-20 Transmittal Year 2024
- Q&A: When a resident is admitted to the nursing facility for hospice services, do we have to use the admitting hospice diagnosis as the primary diagnosis?Question: When a resident is admitted to the nursing facility for hospice services, do we have to use the admitting hospice diagnosis as the primary diagnosis? Answer from Carol Maher, RN-BC, RAC-MTA, RAC-MT, RAC-CTA, RAC-CT, …
- REGISTRATION OPEN for March 26 SNF QRP Webinar: Achieving a Full APU – UpdateThe Centers for Medicare & Medicaid Services (CMS) is hosting a webinar to educate providers of current changes and to help providers to achieve a full Annual Payment Update (APU) in the Skilled Nursing Facility …
- FY 2026 (Calendar Year 2024) SNF QRP Program Data Collection & Final Submission Deadlines REVISEDUpdated February 2024 The FY 2024 Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Final Rule (88 FR 53200) revised data collection and submission requirements for the SNF Quality Reporting Program (QRP) affecting the Fiscal …
- NHSN HCP Flu Vaccination Module Announcement and Feb – April WebinarsAnnouncements This is a friendly reminder to log into NHSN and make sure your facility has an active Facility Administrator. Please note that only the Facility Administrator can enroll a facility in a one or …
- April 1 – Sept. 30, 2024, Release of ICD-10-CMThe FY2024 ICD-10-CM codes are to be used from April 1, 2024 through September 30, 2024. Note: This replaces the FY 2024 – October 1, 2023 release. These files listed below represent the ICD-10-CM FY2024 April …
- SNF QRP Listening Session Summary ReportSUMMARY REPORT PUBLISHED: SNF QRP Listening Session: Possible Expansion of MDS Data Submission to All SNF Patients Regardless of Payer CMS has published a summary report on the virtual SNF QRP Listening Session that was …
- Skilled Nursing Care & Skilled Therapy Services to Maintain Function or Prevent or Slow Decline: CMS ReminderMedicare covers skilled nursing care and skilled therapy services under skilled nursing facility, home health, and outpatient therapy benefits when a beneficiary needs skilled care to maintain function or to prevent or slow decline, as …
- Q&A: If a resident on a Medicare Part A stay leaves the facility on a leave of absence (LOA) with the family and is back in the facility after two midnights, are any assessments required?Question: If a resident on a Medicare Part A stay leaves the facility on a leave of absence (LOA) with the family and is back in the facility after two midnights, are any assessments required? …
- Q&A: Are we required to complete physician certifications and recertifications for Medicare Advantage or just for Original Medicare? Where is the source guidance?Question: Are we required to complete physician certifications and recertifications for Medicare Advantage or just for Original Medicare? Where is the source guidance? Answer from Scott Heichel RN, RAC-MT, RAC-CTA, DNS-CT, QCP, ICC, IPCO: It is …
- Navigating the 2024 Landscape: Updates and Changes in Medicare Impacting Skilled Nursing FacilitiesThe year 2024 brings a plethora of updates to the Medicare program, several significantly impacting skilled nursing facilities (SNFs). SNF staff must stay well informed about these updates to ensure proper billing and adequate coverage …
- Q&A: Is there a standard letter or beneficiary notice that we have to use when a resident exhausts Medicare benefits?Question: Is there a standard letter or beneficiary notice that we have to use when a resident exhausts Medicare benefits? Answer from Carol Maher, RN-BC, RAC-MTA, RAC-MT, RAC-CTA, RAC-CT, CPC: No, there isn’t a required …
- Expedited Determination Notices: Keys to Avoiding Financial Liability, Survey IssuesThe expedited determination beneficiary notification process covers a lot of ground in skilled nursing facilities (SNFs), affecting residents in the fee-for-service (FFS) Medicare Part A program and Medicare Advantage plans, as well as residents who …
- 2023 Medicare Fee-for-Service Supplemental Improper Payment Data for SNFs: Root CausesSkilled Nursing Facility CERT reports Skilled nursing facilities (SNF) is defined as all services with a provider type of SNF, including SNF inpatient, SNF outpatient, and SNF inpatient Part B. The projected improper payment amount …
- SNF Cost Report Data Set for 2021The Skilled Nursing Facility (SNF) Cost Report dataset is a public use file that provides select measures from the skilled nursing facility annual cost report. This data includes provider information such as facility characteristics, utilization data, …
- FY 2025 Draft MDS 3.0 Item Sets version 1.19.1 Effective Oct. 1, 2024The draft Minimum Data Set (MDS) 3.0 Item Sets version (v)1.19.1 and Item Matrix are now available. The MDS Item Sets v1.19.1 will be effective beginning October 01, 2024. From https://www.cms.gov/medicare/quality/nursing-home-improvement/resident-assessment-instrument-manual
- Part B Therapy: 2024 Threshold Amounts and Updated Code ListTherapy Services: Per-Beneficiary CY 2024 Threshold Amounts The CY 2024 KX modifier threshold amounts are: More Information: Therapy Code List: 2024 Annual Update CMS updated the list of codes (ZIP) that sometimes or always describe therapy services and …
- Q&A: A resident was admitted skilled, under managed Medicare, on 11/28. He transferred from managed care to traditional Medicare Part A on 12/29. Are we required to complete another 5-Day for the Medicare stay starting 12/29?Question: A resident was admitted skilled, under managed Medicare, on 11/28. He transferred from managed care to traditional Medicare Part A, on 12/29. Are we required to complete another 5-Day for the Medicare stay starting …
- Q&A: Can staff interviews for the PPS discharge assessment be performed after the ARD date or do all the interviews need to be “dashed” since they were not performed?Question: We have a resident on traditional Medicare Part A who was issued a NOMNC on 12/22, with a last covered day of 12/24. Can staff interviews for the PPS discharge assessment be performed after …
- PDPM At-a-Glance ToolThe PDPM At-a-Glance tool breaks down the complex methodology of each component used in the Patient-Driven Payment Model—physical therapy (PT), occupational therapy (OT), speech-language pathology (SLP), non-therapy ancillaries (NTA), and nursing. This tool provides key …
- 2024 Part A MAC Update: HCPCPS Consolidated Billing Code FileADD Effective 10/1/2023 Major Category I. C. – Magnetic Resonance Imaging (MRI) Major Category II. A. – Dialysis, EPO, Aranesp, Other Related Services for ESRD Major Category III. A. -Chemotherapy Major Category III.D.-Customized Prosthetic Devices …
- TIP: CMS Addressed Dashes on Unplanned Discharges During Open Door ForumDuring the Dec. 7, 2023, Skilled Nursing Facility/Long-Term Care Open Door Forum, Centers for Medicare & Medicaid Services (CMS) officials clarified that column 3, Discharge Performance, is required on all OBRA discharge assessments, regardless of …
- SNF QRP and SNF VBP Claims-Based Measure Manual and Accompanying Files – AvailableThis document presents technical specifications for the production of Medicare fee-for-service (FFS) claims-based measures (CBMs) for the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) and Value-Based Purchasing (VBP) program maintained by the Centers for …
- CMS Health Equity Confidential Feedback Report Live Q&AVideo and transcript available This live Q&A session allowed participants to ask CMS subject matter experts about the methodologies and interpretations of the CMS Health Equity Confidential Feedback Reports for post-acute care (PAC) providers in …
- Medicare Expedited Determination vs. Financial Liability Notices: What’s the Difference?Beneficiary notification requirements under the Medicare program can be confusing for nurse assessment coordinators (NACs) who serve as the lead Medicare nurse and other interdisciplinary team members in skilled nursing facilities (SNFs), says Carol Maher, …
- MDS Items Impacting Reimbursement for PDPM and SNF QRP – Updated ToolDo you know what MDS items impact reimbursement under the Patient-Driven Payment Model (PDPM) or the Skilled Nursing Facility Quality Reporting Program (SNF QRP)? Use this quick guide, MDS Items Impacting Reimbursement for PDPM and …
- MLN Network Provider Minute Video: The Importance of Proper DocumentationThis video will help providers and physicians understand the need and importance of medical record documentation to support the services billed. Watch this video to learn more about what the CERT program has identified as …
- At-a-Glance QM, QRP, and VBP ToolWith so many Quality Measures originating from three different payment initiative programs, it’s a lot to keep track of. AAPACN’s At-a-Glance QM, QRP, and VBP tool organizes all of the measures for you. This tool has been …
- PDPM Grouper UpdateThe “PDPM Grouper JAR Package V2.2001.zip” is now available. This V2.2001 release is an update to adjust the OBRA logic for target dates on or after October 1, 2023. The logic for standalone OBRA assessments will …
- 2025 Medicare Advantage Proposed Rule Includes Some SNF-Related ProposalsBiden-Harris Administration Proposes to Protect People with Medicare Advantage and Prescription Drug Coverage from Predatory Marketing, Promote Healthy Competition, and Increase Access to Behavioral Health Care in the Medicare Advantage Program Fact sheet Contract Year …
- FY 2024 SNF PPS Web PricerThe application has been updated to include Fiscal Years (FYs) 2020 through 2024 updates for the Hospice, Inpatient, Inpatient Psychiatric Facility, Inpatient Rehabilitation Facility, Long Term Care Hospital and Skilled Nursing Facility Prospective Payment System …
- CY 2024 Final Physician Fee Schedule and Other Part B ProposalsNov 02, 2023 https://www.cms.gov/newsroom/press-releases/cms-finalizes-physician-payment-rule-advances-health-equity Final policies will expand behavioral health services, advance the President’s Cancer Moonshot, support family caregivers, and accelerate value-based care The Centers for Medicare & Medicaid Services (CMS) announced it is finalizing policies …
- Stop and Read: Skilled Documentation Audit and Education Lessons for the NACSkilled nursing facilities (SNFs) are increasingly subject to skilled medical review audits from both fee-for-service Medicare (e.g., the SNF Five-Claim Probe and Educate initiative) and individual Medicare Advantage plans. Audit success ultimately hinges on documentation …
- SNF PPS MedPAC Payment Basics Fact Sheet / Educational ToolPAYMENT BASICS: SNF PPS Skilled nursing facility services payment system Additional payment basics tools: https://www.medpac.gov/document-type/payment-basic/
- Lessons From TPE Audits: How the DNS Can Lead Toward Better Skilled DocumentationIn May 2023—after the Comprehensive Error Rate Testing (CERT) program determined that skilled nursing facility (SNF) Medicare Part A services have been “a top driver” of the overall Medicare fee-for-service improper payment rate since the …
- CMS Post-Acute Care Health Equity Confidential Feedback Reports, Online Webinar, and Fact SheetAs part of our commitment to advance health equity and strengthen the Medicare Program, the Centers for Medicare & Medicaid Services (CMS) has released two Health Equity Confidential Feedback Reports to post-acute care (PAC) providers: the …
- Q&A: A Medicare Part A resident expired three days after admission. He received skilled nursing services only and did not complete any MDS interviews. Is a 5-Day PPS assessment needed?Question: A Medicare Part A resident expired three days after admission. He received skilled nursing services only and did not complete any MDS interviews. Is a 5-Day PPS assessment needed? Answer from Carol Maher, RN-BC, …
- Q&A: Does the physician or physician extender have to acknowledge at risk for malnutrition prior to the assessment reference date (ARD) to code it in section I?Question: Does the physician or physician extender have to acknowledge at risk for malnutrition prior to the assessment reference date (ARD) to code it in section I? Answer from Jeff Taylor: Risk for malnutrition is …
- 2024 Medicare Parts A & B Premiums and DeductiblesFrom https://www.cms.gov/newsroom/fact-sheets/2024-medicare-parts-b-premiums-and-deductibles On October 12, 2023, the Centers for Medicare & Medicaid Services (CMS) released the 2024 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs, and the 2024 Medicare …
- CMS Transmittals Update Manuals to Exclude Marriage and Family Therapist and Mental Health Counselor Services From Consolidated BillingTransmittal #R12283CP Issue Date 2023-10-05 Subject Internet Only Manual Updates to Pub. 100-02 and 100-04 to Implement Consolidated Appropriations Act 2023 Changes for Skilled Nursing Facility (SNF) Policy: The Consolidated Appropriations Act, 2023 (Pub. L. …
- Q&A: Is there a requirement that we complete a 5-Day assessment for HMOs or Medicare Advantage plans?Question: Is there a requirement that we complete a 5-Day assessment for HMOs or Medicare Advantage plans? Answer from Jeff Taylor: Each payer makes its own rules regarding what’s required for reimbursement. This is essentially …
- Q&A: We identified that we could have completed an Interim Payment Assessment (IPA) on a resident back in July. Is there a timeframe that allows you to go back and open that IPA and complete it? Question: We identified that we could have completed an Interim Payment Assessment (IPA) on a resident back in July. Is there a timeframe that allows you to go back and open that IPA and complete it? …
- Q&A: We completed a combined 5-Day/Admission assessment on day 15 of the stay. After submission, our system shows we are out of compliance for CAAs/MDS based on the signature/completion date. Do we need to bill default for the one day we were out of compliance?Question: We completed a combined 5-Day/Admission assessment on day 15 of the stay. After submission, our system shows we are out of compliance for CAAs/MDS based on the signature/completion date. Do we need to bill …
- 2024 SNF Consolidated Billing HCPCS Code Annual Update TransmittalTransmittal #R12266CP Issue Date 2023-09-28 Implementation Date 2024-01-02 CR #13394 Publication #100-04 Transmittal Year 2023 R12266CP
- Preparing for Success with ICD-10-CM Changes Oct. 1: How the Facility Coder and Provider Can Ensure Accurate Diagnosis CodesEffective International Classification of Diseases, Tenth Edition, Clinical Modification (ICD-10-CM) coding relies on meticulous clinical documentation. It’s not just about assigning codes; it’s about ensuring consistent and comprehensive documentation that substantiates every facet and the …
- TIP: CMS Updates SLP-Related Comorbidities, Removing All Parkinson’s Disease CodesOn Sept. 18, 2023, the Centers for Medicare & Medicaid Services (CMS) added a note within the Fiscal Year (FY) 2024 PDPM ICD-10 Mapping file that effectively removed several diagnosis codes from impacting the Speech-Language …
- Provider ICD-10-CM Documentation Tip Sheet for Long-Term CareICD-10-CM coding requires consistent and complete documentation from the provider (physician/nonphysician practitioner) to support all aspects and specific details of the diagnosis. This AAPACN Provider ICD-10-CM Documentation Tip Sheet for Long-Term Care tool serves as …
- FY 2024 ICD-10-CM Codes and Coding Guidelines Effective Oct. 1, 2023: Errata and Updated Files2024 release of ICD-10-CM October 1, 2023 release of ICD-10-CM The FY2024 ICD-10-CM codes are to be used from October 1, 2023 through September 30, 2024. Note: This replaces the FY 2023 – April 1, …
- FY 2024 PDPM ICD-10-CM Mappings File UpdatedFrom https://www.cms.gov/medicare/payment/prospective-payment-systems/skilled-nursing-facility-snf/patient-driven-model
- Oct. 1, 2023 Will See Performance Period Data Collection for Five SNF VBP QMsThe key takeaway of the Fiscal Year (FY 2024) Skilled Nursing Facility Prospective Payment System (SNF PPS) final rule, published on Aug. 7, 2023, is that the director of nursing services (DNS) will need to …
- SNFRM: Technical Specifications for This SNF VBP Measure2023 Measure Updates and Specifications Report Skilled Nursing Facility Value-Based Purchasing Program Skilled Nursing Facility 30-Day All-Cause Readmission Measure –Version 2.0 This report describes updates that have been made to the Skilled Nursing Facility 30-Day …
- SNF QRP FAQs for FY 2024An update to the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Frequently Asked Questions (FAQs) document is now available. This document has been updated to reflect the finalized policies for the SNF QRP in …
- FY 2024 SNF PPS Final Rule Initial Timeline for NACs: How/When the MDS Takes Center-StageBreathing room will be in short supply for nurse assessment coordinators (NACs) and other interdisciplinary team members who need to implement and monitor the multitude of changes to the Skilled Nursing Facility Quality Reporting Program …
- Q&A: A resident exhausted benefits in March 2023 with a new G-tube and 100% tube feeding. She was recently admitted to the hospital for three days and had the G-tube removed and was eating by mouth. Can this resident be skilled for Medicare Part A? Question: A resident exhausted benefits in March 2023 with a new G-tube and 100% tube feeding. She was recently admitted to the hospital for three days and had the G-tube removed and was eating by …
- FY 2024 SNF VBP Program Fact Sheet, Timeline, and FAQsFY 2024 SNF VBP Resources
- FY 2025 (Calendar Year 2023) SNF QRP APU Table for the MDS Data Submission Threshold–RevisedThe FY 2024 Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Final Rule (88 FR 53200) revised data collection and submission requirements for the SNF Quality Reporting Program (QRP) affecting the Fiscal Year (FY) 2025 …
- FY 2026 (Calendar 2024) SNF QRP Data Collection and Final Submission Deadlineshe FY 2024 Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Final Rule (88 FR 53200) revised data collection and submission requirements for the SNF Quality Reporting Program (QRP) affecting the Fiscal Year (FY) 2026 …
- FY 2025 (Calendar 2023) SNF QRP Data Collection and Final Submission Deadlines — RevisedThe FY 2024 Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Final Rule (88 FR 53200) revised data collection and submission requirements for the SNF Quality Reporting Program (QRP) affecting the Fiscal Year (FY) 2025 …
- SNF QRP QM Calculations and Reporting User’s Manual V5.0, Change Table, Risk Adjustment and Imputation Appendix Files, and HCC ICD-10 CrosswalksThe Skilled Nursing Facility Quality Reporting Program (SNF QRP) Quality Measure Calculations and Reporting User’s Manual Version 5.0 serves as an update to the specifications used to calculate quality measures that are included in the SNF …
- Beneficiary Notice Guidelines ToolAre you confused about which beneficiary notices are needed and when? The Beneficiary Notice Guidelines tool lists scenarios that you might run into, clarifying exactly what notices are needed to reduce the risk of claim denials and …
- Optional State Assessment (OSA) Item Set and OSA Manual for Oct. 1, 2023 Implementation–UpdatedThe Optional State Assessment (OSA) Item Set and OSA Manual have been updated, and the updated versions are now available in the Downloads section on the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual page. …
- Business Case TemplateThere are times when the nursing department needs new solutions or process changes to enhance resident care or improve staff workload. Often, these are high-cost solutions that require approval from the governing body, executive staff, …
- Effective Business Case Development for Budget Wins and Better Care OutcomesThe phrase “budget development time” often elicits moans and groans from facility leadership. During this process, leadership usually asks the director of nursing services (DNS) if he or she has any requests of items to …
- The DNS’s Role in the Annual BudgetIn this podcast, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, chief nursing officer for AAPACN, and Denise Winzeler, BSN, RN, LNHA, DNS-MT, QCP-MT, curriculum development specialist for AAPACN, discuss the director of nursing services’ …
- TIP: CMS Updated the Five-Star Administrator Turnover Exclusion CriteriaEffective with the July 2023 Five-Star refresh, the Centers for Medicare & Medicaid Services (CMS) revised the nursing-home level exclusion criteria on an erroneously high number of administrators applied to the administrator turnover measure. Previously, …
- FY 2024 SNF PPS Final Rule and Correction NoticeThe final rule and key files: Final Rule Permalink Correction Notice: https://www.federalregister.gov/documents/2023/10/04/2023-22050/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities FY 2024 PDPM ICD-1- Mapping (ZIP) (effective 10-01-2023) CMS-1779-F Wage Index Tables for FY 2024 – Final (ZIP) PDPM Case-Mix – Tables 5 and 6 …
- Q&A: How do I determine if a resident needs a new qualifying hospital stay to use remaining Medicare benefits?Question: A resident was in our skilled nursing facility (SNF) stay with a qualifying hospital stay over a month ago. She was skilled in our facility until a week ago when she discharged home. She …
- Q&A: I submitted an Admission/5-Day assessment and recently learned that the 5-Day is not needed because Managed Care is the payer, not Medicare. How do I correct this?Question: I have a resident who we thought was Medicare Part A and completed and submitted an Admission/5-Day assessment. I am now being told that the resident was Managed Care and I need to inactivate …
- TIP: Facilities Must Update ICD-10-CM Diagnosis Codes by Oct. 1, 2023The Centers for Medicare & Medicaid Services (CMS) released the revised ICD-10-CM diagnosis codes for fiscal year 2024, which will become effective Oct. 1, 2023. Facility staff will need to review diagnosis codes for residents …
- CMS Transmittal: SNF PDPM Claims Processing Edits UpdateR12146OTN Issue Date 2023-07-21 Subject The purpose of this Change Request (CR) is to update current Skilled Nursing Facility (SNF) PDPM claims processing edits in order to process and pay claims correctly. A. Background: This …
- BIMS MDS Coding Video Tutorial UpdatedThe Centers for Medicare & Medicaid Services (CMS) is offering an updated video tutorial to assist providers with guidance application and interview strategies for the cognitive assessment known as the Brief Interview for Mental Status …
- Q&A: We have a resident who was admitted with a Peg tube about a year ago. He was hospitalized and had it replaced. The resident returned to us under Medicare. Does anyone know if you would consider this a new Peg tube and would the resident qualify to utilize the 100 days?Question: We have a resident who was admitted with a Peg tube about a year ago. He was hospitalized and had it replaced. The resident returned to us under Medicare. Does anyone know if you …
- TIP: Medicare Advantage PPS Assessments Are Not Submitted to iQIESThe RAI User’s Manual clarifies that PPS assessments that are completed for the purpose of insurance payment, such as with a Medicare Advantage (MA) plan, are not CMS required assessments and are not to be …
- OSA Crash Course: Keys to Navigating this Medicaid-Only Payment AssessmentIn a number of Medicaid case-mix states, the MDS v1.18.11 item sets won’t be the only MDS item sets that are implemented on Oct. 1, 2023—a fact that should temper some excitement about certain MDS …
- How Will October 2023 MDS Changes Impact PDPM and Medicare Payment?Many changes are coming to the Minimum Data Set (MDS) effective Oct. 1, 2023. The Centers for Medicare & Medicaid Services (CMS) released the draft of the Long-Term Care Resident Assessment Instrument (RAI) User’s Manual …
- Review of ICD-10-CM Changes Effective Oct. 1, 2023In this podcast, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, vice president of education and certification strategy for AAPACN, and Jennifer LaBay, RN, RAC-MT, RAC-MTA, QCP, CRC, curriculum development specialist with AAPACN, discuss some …
- Medicare Managed Care Basics: Critical Intel for the DNSData from the Centers for Medicare & Medicaid Services (CMS) shows that, as of January 2023, half of all Medicare beneficiaries are now enrolled in a Medicare Advantage plan, according to a recent Kaiser Family …
- CMS Releases Medicare Advantage Skilled Nursing Facility Utilization DataThe Centers for Medicare & Medicaid Services (CMS) updated two data products with skilled nursing facility utilization data for beneficiaries enrolled in Medicare Advantage (MA). The Medicare Advantage Geographic Variation PUF (MA GV PUF) now …
- Q&A: If a resident on a Medicare Part A stay expires the same day as admission, is it a billable day?Question: If a resident on a Medicare Part A stay expires the same day as admission, is it a billable day? Answer from Carol Maher, RN-BC, RAC-MTA, RAC-MT, RAC-CTA, RAC-CT, CPC:Yes, if a Medicare A …
- Q&A: A long-term resident has had a feeding tube for more than 10 years. He exhausted Medicare Part A benefits years ago. Can he be skilled with the new G-tube placement?Question: A long-term resident has had a feeding tube for more than 10 years. He exhausted his Medicare Part A benefits years ago. He recently experienced recurrent aspiration and had an extended hospitalization with a …
- TIP: The COVID-19 PHE Ended – Tools and ResourcesThe end of the COVID-19 public health emergency (PHE) on May 11, 2023, has marked the end of many waivers, including the 3-day qualifying hospital stay and benefit period waivers. For many new nurse assessment …
- Restorative Nursing Payment and Documentation Issues: Keys to SuccessRestorative nursing can impact fee-for-service Medicare Part A payment in the Behavioral Symptoms and Cognitive Performance category and the Reduced Physical Function category of the nursing component in the Patient-Driven Payment Model (PDPM), says Carol …
- AAPACN Advocates for Skilled Nursing Facilities: Response to Comment Request for FY 2024 SNF PPS Proposed RuleThe American Association of Post-Acute Care Nursing (AAPACN) team collaborated with its members and post-acute care experts to advocate for skilled nursing facility (SNF) professionals by making comments on the fiscal year (FY) 2024 SNF …
- TIP: New ABN Form Must Be Used by June 30, 2023In April 2023, the Centers for Medicare & Medicaid Services (CMS) released an updated Advanced Beneficiary Notice (ABN) form, CMS-R-131. This ABN form is used when Medicare Part B services end and a beneficiary notice …
- MLN Publication: SNF Three-Day Qualifying Hospital Stay and Medicare Billing RulesSkilled Nursing Facility 3-Day Rule Billing Format Fact Sheet ICN: MLN9730256 Publication Description: Learn communication of coverage, claims processing edits, and financial responsibility. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/snf3dayrule-mln9730256.pdf
- SNF QRP: 2023 Impact of Mississippi Stormshttps://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-QR-Reconsideration-and-Exception-and-Extension
- Best Practices to Dispute Takebacks for Medicare/Insurance Begin With PreventionIn the 1730s, Benjamin Franklin wrote “An ounce of prevention is worth a pound of cure” to inspire the city of Philadelphia to adopt better fire prevention techniques. What he delivered to history was a …
- Q&A: Would therapy 5 times a week prevent a 60-day wellness period?Question: I have a resident who had a recent 3-day qualifying stay for Medicare Part A. He had exhausted all benefits in January but continued to have Medicare Part B therapy 5 days a week for …
- Q&A: For the Nursing component of PDPM, a resident with a diagnosis of Parkinson’s disease with a function score of 15 was calculated into the Physical Function Reduced PA1 case-mix group and not into Clinically Complex. Is this a software error?Question: For the Nursing component of PDPM, a resident with a diagnosis of Parkinson’s disease with a function score of 15 was calculated into the Physical Function Reduced PA1 case-mix group and not into Clinically …
- TIP: SNFs Still Must Use Condition Code DR After the COVID-19 PHE EndsThe Centers for Medicare & Medicaid Services (CMS) clarified on a recent MLN Connects newsletter that skilled nursing facilities (SNFs) must continue to use the condition code DR (disaster related) on Medicare Part A claims …
- SNF QRP: Discharge Function Score for SNFs Draft Technical Report: Imputation Appendix FileCMS has posted the Discharge Function Score for Skilled Nursing Facilities (SNFs) Draft Technical Report: Imputation Appendix File, which accompanies the Discharge Function Score for Skilled Nursing Facilities (SNFs) Draft Technical Report. The Imputation Appendix …
- TIP: CMS Released Updated FAQ on the End of the COVID-19 PHEIn late April, CMS updated the resource “Frequently Asked Questions: CMS Waivers, Flexibilities, and the End of the COVID-19 Public Health Emergency.” This document addresses key questions regarding billing for vaccines, Medicare coverage, the 3-day …
- Q&A: A resident had a fall at home that resulted in a fracture but did not receive surgery. The provider’s progress notes indicated, “Unspecified fall, initial encounter” (W19.XXXA), as the primary medical diagnosis. Should I use this diagnosis?Question: A resident had a fall at home that resulted in an acetabular fracture but did not receive surgery. The provider’s progress notes indicated, “Unspecified fall, initial encounter” (W19.XXXA), as the primary medical diagnosis. Should …
- Q&A: A resident on Medicare Part A went out on a leave of absence (LOA) for a temporary home visit on Saturday and returned on Monday. How do we bill this?Question: A resident on Medicare Part A went out on a leave of absence (LOA) for a temporary home visit on Saturday and returned on Monday. How do we bill this? Answer from Carol Maher, …
- TIP: CMS Releases Optional State Assessment (OSA) Item Set and ManualOn April 24, the Centers for Medicare & Medicaid Services (CMS) posted the Optional State Assessment (OSA) Item Set, OSA Manual, and OSA Change History table in the Downloads section on the Minimum Data Set …
- TIP: CMS Clarified End of COVID-19 Waivers Impact on 30-Day Transfer RuleAAPACN received clarifying information from the Centers for Medicare & Medicaid Services (CMS) related to the end of the COVID-19 public health emergency (PHE) and how residents covered under Medicare Part A using the 3-day …
- White Paper: FY 2024 SNF PPS Proposed Rule: SNF QRP and SNF VBP Changes GaloreThe Centers for Medicare & Medicaid Services (CMS) recently posted the Fiscal Year (FY) 2024 Skilled Nursing Facility Prospective Payment System (SNF PPS) proposed rule for public inspection. The payment news is good—a 3.7 percent …