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.
- A New Method for Auditing PDPMIn this podcast, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, chief nursing officer for AAPACN, and Jessie McGill, RN, BSN, RAC-MT, RAC-MTA, senior curriculum development specialist with AAPACN, discuss a new method for auditing the …
- PDPM Audit by MDS SectionMost methods for auditing Patient-Driven Payment Model (PDPM) reimbursement focus on impacts to the HIPPS code. However, AAPACN’s PDPM Audit by MDS Section tool uses an approach that can result in identifying missed opportunities for …
- Southern California Wildfires – California (2025) Current emergencies Southern California Wildfires – California (2025) Secretary Becerra used his authority in the Public Health Service Act to declare a public health emergency (PHE) on January 10, 2025, giving us the flexibility to support our …
- PDPM Overview for Supporting SNF StaffThe Centers for Medicare & Medicaid Services (CMS) implemented the Patient-Driven Payment Model (PDPM) in October 2019 for residents receiving Medicare Part A coverage in the skilled nursing facility (SNF). PDPM replaced the previous legacy …
- Q&A: Our facility recently had a bill rejected because the ICD-10 code of M62.81, Muscle weakness (generalized), and R53.1, Weakness, were both coded on the bill. Does anyone know the reason why they both cannot be on the same bill since they do seem to mean two different things?Question: Our facility recently had a bill rejected because the ICD-10 code of M62.81, Muscle weakness (generalized), and R53.1, Weakness, were both coded on the bill. Does anyone know the reason why they both cannot …
- FY 2025 ICD-10-CM Codes and Coding Guidelines: April UpdateCDC announces no new ICD-10-CM codes effective April 1, 2025. The April 1, 2025 diagnosis code update files now available address revisions and typographical errors. Use these files for discharges occurring from April 1, 2025 …
- CMS Seeks TEP Nominations: Development of PAC QRP Interoperability MeasureProject Title: Standing Technical Expert Panel (TEP) for the Development of Post-Acute Care (PAC) Quality Reporting Program (QRP) Interoperability Measure Dates: The Technical Expert Panel (TEP) nomination period opens on January 20, 2025, and closes on February …
- SNF Provider Preview ReportsThe SNF Provider Preview Reports have been updated and are now available. These reports contain provider performance scores for quality measures, which will be published on the compare tool on Medicare.gov and the Provider Data Catalog (PDC) during the April 2025 …
- Q&A: If the Notice of Medicare Non-Coverage (NOMNC) was not provided timely, is the facility liable for the days daily skilled services were no longer being provided until the last covered day (LCD) issued on the NOMNC?Question: If the Notice of Medicare Non-Coverage (NOMNC) was not provided timely, is the facility liable for the days daily skilled services were no longer being provided until the last covered day (LCD) issued on …
- Q&A: A resident was previously skilled for 100 days under Medicare Part A for a peg tube and subsequently discharged home with no home health services. If this resident remains at home for 60 days or longer, will he earn a new 100-day Medicare benefit period?Question: A resident was previously skilled for 100 days under Medicare Part A for a peg tube and subsequently discharged home with no home health services. If this resident remains at home for 60 days or longer, …
- 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 …
- NOMNC and DENC: New Forms Must Be Used Starting Jan. 1, 2025; Different Start Date for DENC Only for Medicare AdvantageFFS & MA NOMNC/DENC What’s New 11/18/2024: New NOMNC and DENC for Original Medicare and Medicare Advantage The Office of Management and Budget (OMB) has approved a revised Notice of Medicare Non-Coverage (NOMNC / CMS-10123) …
- FYI for Your Billers: Billing Instructions Related to Expedited Determinations Based on Medicare Change of Status NotificationsIssue Date 2024-12-27 Implementation Date 2025-02-15 CR # 13918 Publication # 100-04 Transmittal Year 2024 SUBJECT: Billing Instructions Related to Expedited Determinations Based on Medicare Change of Status Notifications (MCSNs) I. SUMMARY OF CHANGES: The purpose of this Change Request …
- NHSN December NewsVaccination Updates for the Respiratory Virus Season Reporting Annual Healthcare Personnel Influenza Vaccination Data This is a friendly reminder that reporting annual influenza vaccination data among healthcare personnel (HCP) is required for CMS-certified free-standing acute …
- Residents on Part B Therapy? Provide Beneficiary Notices to Avoid a Financial HitNurse assessment coordinators (NACs) who manage Medicare services typically are at least familiar enough with the beneficiary notice requirements that skilled nursing facilities (SNFs) must meet under fee-for-service (FFS) Medicare Part A to monitor those …
- FY 2026 SNF VBP Program December 2024 Quarterly Reports AvailableThe December 2024 Quarterly Confidential Feedback Reports for the fiscal year (FY) 2026 Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program are now available to download via the Internet Quality Improvement and Evaluation System (iQIES). These …
- TIP: Updated NOMNC and DENC Must Be Used Starting Jan. 1, 2025 The Office of Management and Budget (OMB) has updated the Notice of Medicare Non-Coverage (NOMNC), (Form CMS-10123), and the Detailed Explanation of Non-Coverage (DENC), (Form CMS-10124). Providers must use the current notices until Dec. 31, …
- OIG: Nursing Facility Industry Segment-Specific Compliance Program GuidanceFrom https://oig.hhs.gov/compliance/nursing-facility-icpg/ The Nursing Facility ICPG—together with OIG’s General Compliance Program Guidance (GCPG) that applies to all individuals and entities involved in the health care industry—serves as OIG’s updated and centralized source of voluntary compliance program guidance for …
- SNF ABN Update: What Changed and How to Keep the Process Running SmoothlyEffective Oct. 31, 2024, skilled nursing facilities (SNFs) now are required to use an updated Skilled Nursing Facility Advance Beneficiary Notice of Noncoverage (SNF ABN), also known as form CMS-10055, and the corresponding revised instructions …
- NHSN Respiratory Pathogens and Vaccination Module Webinars in December and JanuaryUpcoming Webinars Topic: NHSN LTCF Component: Respiratory Pathogens and Vaccination Updates Initial Webinar: Wednesday, December 11, 2024, at 1:00 PM Eastern Time (US and Canada) Register in advance for this webinar on December 11: https://cdc.zoomgov.com/webinar/register/WN_XUstZ8zQTRG5WqqygPwShA …
- 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 …
- 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 …
- 2025 Medicare Parts A & B Premiums and DeductiblesOn November 8, 2024, the Centers for Medicare & Medicaid Services (CMS) released the 2025 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs, and the 2025 Medicare Part D …
- Q&A: When is the new Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) (2024) required to be used? Question: When is the new Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) (2024) required to be used? Answer from Jessie McGill, RN, BSN, RAC-MT, RAC-MTA: The updated SNF ABN (2024), CMS form 10055, must …
- Hurricane Francine NewsFinal FEMA Exception Memo for Francine: https://www.cms.gov/medicare/quality/snf-quality-reporting-program/reconsideration-and-exception-extension
- Florida Hurricane Milton CMS/HHS NewsFinal FEMA Exception Memo for Milton: https://www.cms.gov/medicare/quality/snf-quality-reporting-program/reconsideration-and-exception-extension Limited Waiver of HIPAA Sanctions & Penalties During a Declared Emergency: 2024 Public Health Emergency for State of Florida in Response to Hurricane Milton October 8, 2024 What: President Joseph R. …
- 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/
- Hurricane Helene Resources: SC, TN, NC, GA, and FLFinal FEMA Exception Memo for Helene: https://www.cms.gov/medicare/quality/snf-quality-reporting-program/reconsideration-and-exception-extension Hurricane Helene – South Carolina and Tennessee (2024) Secretary Becerra used his authority in the Public Health Service Act to declare a public health emergency (PHE) on September 30, 2024, …
- SNF QRP Quick Facts ToolsThe Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) has developed a variety of measures that use data from the MDS 3.0, Medicare Fee-for-Service Claims, and Centers for Disease Control and Prevention (CDC) National Healthcare …
- Updated Fiscal Years 2026 and 2027 SNF VBP Performance StandardsThis communication pertains to the Fiscal Year (FY) 2026 and FY 2027 Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program performance standards for the Total Nursing Staff Turnover (Nursing Staff Turnover) measure which the Centers …
- Livanta Medicare BFCC-QIO NewsProvider Bulletin #22a October 1, 2024 Dear Colleague, We are pleased to announce several important updates for the provider community and others who rely on Livanta’s services as a Medicare Beneficiary and Family Centered Care …
- CDC ICD-10 Browser Tool Updated for FY 2025Search ICD-10-CM Codes ICD-10-CM Browser Tool is available at https://icd10cmtool.cdc.gov/ From https://www.cdc.gov/nchs/icd/icd-10-cm/index.html
- Updates to ICD-10-CM Coding Guidelines: Key Revisions and Their ImplicationsThe International Classification of Diseases, Clinical Modification, 10th revision (ICD-10-CM), coding system is an essential tool needed to document and bill accurately for healthcare services in the long-term care (LTC) setting. Annual updates to both …
- Q&A: A resident was transferred to the hospital and admitted twice during the 60-day wellness period. Will the hospital admissions prevent him from achieving a 60-day wellness period?Question: A resident was transferred to the hospital and admitted twice during the 60-day wellness period. Will the hospital admissions prevent him from achieving a 60-day wellness period? Answer from Jeff Taylor: The resident will …
- Q&A: Can a resident be skilled for Medicare Part A for wound vac services and, on few occasions, daily dressing changes? The resident is in a skilled-level environment with 24-hour nursing services.Question: Can a resident be skilled for Medicare Part A for wound vac services and, on few occasions, daily dressing changes? The resident is in a skilled-level environment with 24-hour nursing services. Answer from Scott …
- TIP: CMS Revised the SNF ABN Form and InstructionsThe Centers for Medicare & Medicaid Services (CMS) recently released a revised Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN), form CMS-10055, and the form instructions. The revised form is mandatory for use beginning Oct. …
- Skilled Teaching and Training: Benefit From the Care Team’s ExpertiseLike care plan management and evaluation and observation and assessment of a resident’s condition, teaching and training activities are a core nonskilled component of resident care that can rise to the level of a skilled …
- Revised SNF ABN (Form CMS-10055) Mandatory Oct. 31, 2024With the help of contractors, CMS revised the SNF ABN, Form CMS-10055, and the form instructions. The SNF ABN form and instructions are located in the download section and are available for immediate use, but …
- SNF QRP QM Calculations and Reporting User’s Manual V6.0, Change Table, Risk Adjustment and Imputation Appendix Files, and HCC ICD-10 CrosswalksThe Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Quality Measure Calculations and Reporting User’s Manual Version 6.0 and accompanying documents are now available. The SNF QRP Measure Calculations and Reporting User’s Manual Version 6.0 …
- SNF QRP FAQs for FY 2025An update to the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) FreAn update to the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Frequently Asked Questions (FAQs) document is now available. This document has …
- FY 2027 (CY 2025 Data) SNF QRP MDS Reporting Requirements and Data Submission DeadlinesSNF QRP Data Elements Used for Reporting Assessment-Based QMs and Standardized Patient Assessment Data Elements Affecting FY 2027 APU Determination and Data Collection and Final Submission Deadlines for FY 2027 posted The Skilled Nursing Facility …
- Documentation and Monitoring for a Skilled StayIn this podcast, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, chief nursing officer for AAPACN, and Jennifer LaBay, RN, RAC-MT, RAC-MTA, QCP, CRC, curriculum development specialist with AAPACN, discuss documentation and monitoring for a …
- Q&A: Does an Interim Payment Assessment (IPA) take the place of a Significant Change in Status Assessment (SCSA) for a Medicare Part A resident or should both be completed?Question: Does an Interim Payment Assessment (IPA) take the place of a Significant Change in Status Assessment (SCSA) for a Medicare Part A resident or should both be completed? Answer from Carol Maher, RN-BC, RAC-MTA, …
- Q&A: A resident will continue skilled coverage for direct nursing care for an unstageable wound. What documentation is needed to support coverage for the wound?Question: We have a resident who is on Medicare Part A and therapy is being discontinued. She will continue skilled coverage for direct nursing care for an unstageable wound. There is a daily treatment including dressing change, …
- FY 2025 SNF PPS Final Rule: SNF QRP Adds Third Way to Trigger 2% APU CutThe Fiscal Year (FY) 2025 Skilled Nursing Facility Prospective Payment System (SNF PPS) Final Rule, released on July 31, 2024, and scheduled for publication on Aug. 6, 2024, largely finalized “as-is” the FY 2025 SNF …
- FY 2025 SNF VBP ResourcesFrom https://www.cms.gov/medicare/quality/nursing-home-improvement/value-based-purchasing From https://www.cms.gov/medicare/quality/nursing-home-improvement/value-based-purchasing/confidential-feedback-reporting-review-and-corrections From https://www.cms.gov/medicare/quality/nursing-home-improvement/value-based-purchasing/scoring-methodology-payment-adjustment
- FY 2025 I0020B Lookup File of ICD-10 CodesThe Microsoft Access database containing the International Classification of Diseases (ICD)-10 codes allowed for item I0020B has been updated to reflect the codes that will be active as of October 1, 2024 (FY2025). The ZIP …
- Hurricane Debby – Georgia, South Carolina, and FloridaHurricane Debby – Georgia and South Carolina (2024) Secretary Becerra used his authority in the Public Health Service Act to declare a public health emergency (PHE) on August 07, 2024, giving us the flexibility to support our …
- Hurricane Beryl – Texas (2024) Emergency InformationSecretary Becerra used his authority in the Public Health Service Act to declare a public health emergency (PHE) on July 12, 2024, giving us the flexibility to support our beneficiaries in Texas, effective retrospectively since July 05, 2024. …
- FY 2025 SNF PPS Final Rule (CMS 1802-F) and Fact SheetLink to rule: https://www.federalregister.gov/public-inspection/2024-16907/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities Wage index files: CMS-1802-F Wage Index Tables for FY 2025 – Final (ZIP) Fact Sheet: On July 31, 2024, the Centers for Medicare & Medicaid Services (CMS) issued a final rule updating Medicare …
- FY 2025 PDPM ICD-10 Mappings FileFrom https://www.cms.gov/medicare/payment/prospective-payment-systems/skilled-nursing-facility-snf/patient-driven-model
- FY 2025 Final Wage Index Files
- Skilled Observation and Assessment Hinges on a Reasonable Probability of ComplicationDirect skilled services under Medicare Part A often are easy to identify because these services involve specific, complex caregiver-to-resident actions. Their “inherent complexity” means that they can “be performed safely and/or effectively only by or …
- Care Plan Management and Evaluation Can Be a Skilled Service for At-Risk ResidentsThe development, management, and evaluation of the resident care plan is the OBRA backbone of the Resident Assessment Instrument (RAI) process for all residents regardless of payer source, so it may surprise some nurse assessment …
- How to Use the ICD-10-CM Coding ManualSince the start of the Patient-Driven Payment Model (PDPM) in October 2019, the International Classifications of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) has been thrust into the forefront of daily tasks for the nurse assessment …
- Q&A: Can we skill a resident for uncomplicated tube-feedings if he is no longer receiving skilled care related to the primary reason for the Medicare stay?Question: Can we skill a resident for uncomplicated tube-feedings if he is no longer receiving skilled care related to the primary reason for the Medicare stay? Answer from Carol Maher, RN-BC, RAC-MTA, RAC-MT, RAC-CTA, RAC-CT, …
- SNF VBP Early Look Performance Score Report Webinar and MaterialsOverview of the Early Look Performance Score Report for the SNF VBP Program The Centers for Medicare & Medicaid Services (CMS) developed and published the Overview of the Early Look Performance Score Report for the Skilled …
- Q&A: Can we use administrative presumptive of coverage even though direct skilled care will only be provided on the first three days of the stay?Question: We are admitting a resident today after a qualifying hospital stay who will only have a skilled service of IV antibiotics for the first three days of their stay. Could we use administrative presumptive …
- Q&A: For blood transfusions and other services that are not excluded in consolidated billing, is our billing office supposed to submit a bill directly to Medicare for this service? Question: For blood transfusions and other services that are not excluded in consolidated billing, is our billing office supposed to submit a bill directly to Medicare for this service? Answer from Carol Maher, RN-BC, RAC-MTA, …
- Common Myths about SNF Medicare Advantage Plan ManagementIn this podcast, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, chief nursing officer for AAPACN, and Maureen McCarthy, RN, BS, RAC-MT, QCP-MT, DNS-MT, RAC-MTA, president and CEO of Celtic Consulting, and AAPACN board member, …
- NAC Preparation Guide for the Triple Check Meeting ToolGathering all of the necessary reports for the triple check meeting is a lot for nurse assessment coordinators (NACs) to keep track of. AAPACN’s NAC Preparation Guide for the Triple Check Meeting tool can help …
- OIG Work Plan Updates Target Special Focus Facilities and Medicare Advantage PreauthorizationsRecently Added Items Announced Agency Title Component Report Number(s) June 2024 Centers for Medicare and Medicaid Services Assessment of the Special Focus Facility Program for Nursing Homes Office of Evaluation and Inspections OEI-01-23-00050;OEI-01-23-00052 June 2024 …
- SNF QRP: Achieving a Full APU Webinar Slides, Recording, and Updated Q&A DocumentThe Centers for Medicare & Medicaid Services (CMS) hosted a webinar on March 26, 2024, to educate providers of current changes and to help them achieve a full Annual Payment Update (APU) in the Skilled Nursing Facility …
- A Closer Look at the Medicare Part A Presumption of CoverageSkilled nursing facility (SNF) staff must understand the intricate guidelines that regulate Medicare Part A coverage for SNF stays. Several technical requirements must be met before a resident qualifies for a Medicare Part A SNF …
- Part A Basics: 30-Day Transfers and the Medical Appropriateness ExceptionThe 30-day transfer rule and its medical appropriateness exception typically don’t come up on a daily basis in skilled nursing facilities (SNFs), yet these requirements—and flexibilities—are a key component of the fee-for-service Medicare Part A …
- Q&A: Is the Part A PPS Discharge (End of PPS) Assessment required for Medicare Advantage or Managed Care residents?Question: Is the Part A PPS Discharge (End of PPS) Assessment required for Medicare Advantage or Managed Care residents? Answer from Carol Maher, RN-BC, RAC-MTA, RAC-MT, RAC-CTA, RAC-CT, CPC It is up to the Managed …
- Q&A: Is a Notice of Medicare Noncoverage (NOMNC) beneficiary notice required when the resident and family request services be ended?Question: A resident is receiving speech-language pathology services under Medicare Part B. The resident and family decided they no longer want to pay the copays and requested services be ended. Is a Notice of Medicare …
- Overview of the FY 2025 SNF PPS Proposed RuleIn this podcast, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, chief nursing officer for AAPACN, and Jessie McGill, RN, BSN, RAC-MT, RAC-MTA, curriculum development specialist for AAPACN, discuss the fiscal year 2025 Skilled Nursing …
- TIP: NOW AVAILABLE: Draft MDS 3.0 RAI User’s Manual version 1.19.1The draft Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) User’s Manual version (v)1.19.1 is now available in the Downloads section on the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual page. The MDS …
- Updated Medicare Enrollment Guide for Institutional Providers, Including SNFsThis site includes access to a provider enrollment and certification roadmap: https://www.cms.gov/medicare/provider-enrollment-and-certification/enroll-as-an-institutional-provider
- CMS Updates Medical Review Policies for Signature Requirements (Again)Transmittal #R12663PI Issue Date 2024-05-30 Subject Medical Review Policies for Signature Requirements Implementation Date 2024-06-10 CR #13556 Publication #100-08 Transmittal Year 2024 Downloads
- FY 2025 Final MDS 3.0 Item Sets version 1.19.1 Effective Oct. 1, 2024The final Minimum Data Set (MDS) 3.0 Item Sets version (v)1.19.1 are now available. The MDS Item Sets v1.19.1 will be effective beginning October 01, 2024. Items in sections A, B, D, GG, I, J, …
- SNF QRP Quick Reference GuideAn updated Quick Reference Guide is now available. The Quick Reference Guide provides high-level information on the SNF Quality Reporting Program, including frequently asked questions and helpful links. PAC-SNF-QuickReferenceGuide-20240425 (PDF) From https://www.cms.gov/medicare/quality/snf-quality-reporting-program/submission-deadlines
- PDPM Clinically Complex Nursing Qualifiers: Coding and Documentation RefresherThe Patient-Driven Payment Model (PDPM) includes four ways for a resident to classify into the Clinically Complex category of the Nursing payment component. If a resident has conditions or is receiving services that qualify for …
- Tricky NAC Issues Even Some Experts MissNurse 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 …
- Seven Ways NACs Can Be Proactive With New Medicare Advantage Plan RulesA skilled nursing facility (SNF) accepts a resident in a Medicare Advantage plan for admission after the plan provides a prior authorization. The resident receives skilled services for the allotted amount of time, and the …
- Q&A: Can a long-term care resident who exhausted his Medicare benefits three months ago, but continued to receive dialysis three times per week earn a new 100-day benefit period?Question: A long-term care resident who is on dialysis three times per week exhausted his Medicare benefits and has been in the facility with Medicaid as the primary payer for the last three months. He …
- Q&A: Is the facility responsible for the expense of a family requested specialty enteral tube feeding formula for a resident on a Medicare Part A stay?Question: Is the facility responsible for the expense of a family requested specialty enteral tube feeding formula for a resident on a Medicare Part A stay? Answer from Carol Maher, RN-BC, RAC-MTA, RAC-MT, RAC-CTA, RAC-CT, …
- MDS Tools to Make the NAC’s Job EasierIn this podcast, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, chief nursing officer for AAPACN, and Jessie McGill, RN, BSN, RAC-MT, RAC-MTA, and Jennifer LaBay, RN, RAC-MT, RAC-MTA, QCP, CRC, curriculum development specialists for …
- Q&A: I found two assessments with outdated dementia ICD-10 codes that do not map to PDPM. How do I update these codes?Question: Recently, I found two assessments that had a dementia diagnosis that does not map to a PDPM category, including F01.C2 for vascular dementia. How do I update these codes? Answer from Jeff Taylor:There are …
- TIP: CMS Released a Correction to the PDPM Files for Oct. 1, 2024The Centers for Medicare & Medicaid Services (CMS) announced corrections to the Patient-Driven Payment Model (PDPM) mapping files for I0020B, the primary diagnosis representing the reason for the skilled nursing home stay, which is also …
- Medicare Advantage Final Rule Includes Expedited Determination Process Changes for SNFsSee the section “Enhance Enrollees’ Rights to Appeal a Medicare Advantage Plan’s Decision to Terminate Coverage for Non-Hospital Provider Services” for details on expedited determination changes for Medicare Advantage residents. Contract Year 2025 Medicare Advantage …
- FY 2025 SNF PPS Proposed Rule: Four Key Proposals for NACs to Keep an Eye onIn the March 28, 2024 Fiscal Year (FY) 2025 Skilled Nursing Facility Prospective Payment System (SNF PPS) proposed rule, the Centers for Medicare & Medicaid Services (CMS) doesn’t propose the dizzying number of changes that …
- TIP: CMS Released FAQs for MA Plan 2024 Final Rule The Centers for Medicare & Medicaid Services (CMS) issued a final rule that clarified Medicare Advantage (MA) coverage criteria for basic benefits, use of prior authorization, and the annual review of utilization management tools. While …
- Why NACs Need to Actively Manage Physician Certs/Recerts—and What to Look forThe nurse assessment coordinator (NAC) who also serves as the primary Medicare nurse doesn’t always complete either the physician certification/recertification process or the beneficiary notification process for Medicare residents, says Scott Heichel, RN, RAC-MT, RAC-CTA, …
- Q&A: We have a resident on a traditional Medicare Part A stay who was discharged back to the hospital on day three. How should I schedule the 5-Day PPS assessment and the Admission assessment, and would this change if he returns within the 3-day interruption window?Question: We have a resident on a traditional Medicare Part A stay who was discharged back to the hospital on day three. How should I schedule the 5-Day PPS assessment and the Admission assessment, and …
- 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 …
- 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, …
- 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 …
- 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 …
- 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 …
- 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 …
- 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 …
- 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 …
- 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 …
- 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 …
- 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 …
- 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 …
- 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 …