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Medicare
News and Rules for
Therapists |
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Encompass Consulting &
Education, LLC
E-Newsletter
May/June 2010 Vol
5, Issue
4 | |
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Dear Pauline, |
This has been a very busy
month for Encompass, so unfortunately, I missed getting
the April/May edition out.
A big thank you to those of
you who responded to our Planning for
Cruzin' CEUs Survey.
We are already working on a 6 day cruise with 2
days at sea so we can provide at least 2 presentations,
or even more with alternative programs for both Part A
and B. We will have final plans by the end of this
month.
News you can use is about
the wait and see game that CMS is having to play while
waiting for Congress to take action.
No real changes in the Medical Review
activities but CMS issed a transmittal that defines
Clinical Judgment's role in
the MR process. See "Update
on Medical Review Activities".
"Tip of the
Month" is information on the "legible
signature issue. CMS has issued a transmittal addressing
that topic.
Encompass
Seminars: We
launched our RUG$
to Riche$
workshop in Florida last month with those attending
giving it a big thumbs up. We have done some
modifications based on their feedback, and, for those of
you who attended the program, we will be sending you
that info by e-mail.
In
June,
the program will be presented in St
Louis, MO, Evanston, IL and Springfield
IL
In
July
it will be presented in White
Plains, NY
with us moving onto Ohio
with
presentations in Cleveland,
Columbus and Cincinnati.
We
haven't forgotten Part B practitioners, the our Medicare
Part B Made Easy being presented
in Columbia,
MO
on June 24th, followed by White
Plains,
Cincinnati and
Denver,
CO
in July. This program focuses on the documentation
aspect of Medicare compliance.
We
will be updating our Medicare
Made Easy for SNF
to include all of the new guidelines for MDS 3.0 and
RUGs IV. That program will re-commence in
Denver
in July.
Visit our website for other dates and locations
and, as always, we are looking for host sites or even
other locations to sponsor the programs if we're not in
your area.
In our
Q&A section we address
areas of interest to both SNF and Outpatient providers.
Please feel free to forward this
Newsletter to anyone you believe would be interested in
its content. Please use the
link at the end of the newsletter to forward to a
friend. This way we can keep track of forwards and
improve our
content. | | |
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| News You
Can Use |
Not
too much news at the moment, everyone is waiting on Congress
for yet other changes in flawed policy.
CMS
issued a notice to its contractors to withhold payment on Part
B claims from June 1st for 15 working days. This is because
the 21+% reduction in payment became effective as of June 1st
as Congress was in recess for Memorial Day without addressing
the decrease. There is a bill that would postpone the
scheduled reductions for 3 plus years while the flawed
calculation in SGR is re-calculated.
CMS
also announced that it will comply with the legislation that
put a hold on the implementation of RUGs IV till October 2011,
as well as including the instructions for concurrent therapy
and the look back period. (PPACA - Healthcare Reform).
However, the ability to use the MDS 3.0 to create RUG III
payments is not available, therefore they will make payments
based on RUG IV groupers and then, when the technical ability
to create RUG III payments, they will recalculate payments and
adjust accordingly. This hybrid software, HR3, would take at
least 6 months to develop.
In
the meantime, there is a bill before Congress that will
rescind this delay and RUG IV will go into effect as
previously scheduled on October 1st. I guess that
just another indication of what happens when Congress passes a
bill without reading it
first! |
| Update on
Medical Review Activities |
In May, CMS issue CR 6954,
updating the Medicare Program Integrity Manual by
adding a new Section 3.14 on Clinical Review
Judgment.
This update clarifies
existing language regarding clinical review judgments. It also
requires that Medicare claim review contractors (MACs, CERT,
RACs, ZPICs and PSC) instruct their clinical review staffs to
use the clinical review judgment process when making complex
review determinations about a claim.
This clinical review
judgment involves two steps:
1. The synthesis of all
submitted medical record information (e.g. progress notes,
diagnostic findings, medications, nursing notes, etc.) to
create a longitudinal clinical picture of the patient; and
2. The application of this
clinical picture to the review criteria to determine whether
the clinical requirements in the relevant policy have been
met.
"NOTE:
Clinical review judgment does not replace poor
or inadequate medical record documentation, nor is it a
process that review contractors can use to override, supersede
or disregard a policy requirement (policies include laws,
regulations, Centers for Medicare & Medicaid (CMS)
rulings, manual instructions, policy articles, national
coverage decisions, and local coverage
determinations)."
So what does this mean? The
reviewer takes into consideration, all of the presented
documentation to "see the picture of the patient and their
medical needs".
Does the patient meet the
medical necessity requirements for their site of service? This
is a technical requirement for all Part A providers such as
hospital, IRF, SNF and HHA. Although the patient may need the
services of the therapist or nursing, do they need the
intensity of services (daily for IRF and SNF) or is the
patient homebound (for HHA).
If the technical component
is not met, then the claim is denied and is not
appealable.
As we always say in our seminars "Paint the
picture" of what the patient needs and "connect the
dots" so the reviewer understands why they need you
and why they qualify for treatment in that
location. |
| Tip of the
Month |
| Respond to any ADR request
promptly; other than patient care, it's your top priority. The
time frame for response is on the notification along with a
list of all requested documentation. Designate someone to
"coordinate" the collection of the required documentation, the
distribution of that documentation to the appropriate
professional for audit and review, and final collection of the
MR information.
The
CERT contractor still has insufficient documentation as one of
the top denial reasons |
| Q&A
for SNF |
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Question:
In
the SNF setting, how often is it required to screen long term
residents for ROM or is this the responsibility of
nursing/MDS?
Answer:
Absolutely
it is the responsibility of NURSING. Therapy got into the
habit of doing that in the '90s because
contract companies got paid by the time therapists spent in a
facility (and the facility got to recoup all of that money).
The quarterly screening is of no use as it
should be just a review of the chart to see if there is
anything that would warrant an evaluation!
Referrals for therapy should start from nursing,
either during the residents stay or through the care planning
when the results of the MDS should be reviewed.
The new MDS 3.0 has made it an extremely easy
process and asks the question does the patient have a
functional limitation in ROM that either interferes with daily
functioning, particularly activities of daily living, or
places the patient at risk for injury.
If answered in the positive, then it would be
addressed either through a therapy evaluation if appropriate,
or through restorative nursing
programs. |
| Q&A
for Outpatient Part B |
Question:
I
have been on your website and reading your advice on the
Advance for PT website and have found it very helpful, however
I have a question in regards to a Medicare eval for
outpatient private practice clinic in Ohio that I
could not find an answer to.
Do I need to have actual certification dates on
my eval sent to the referring Dr. like the old 700 forms or
just go by the 90 day certification? For example, if I eval a
patient on 2/1/10 and want have a plan of care for 3x/week x 6
weeks, do I need certification dates on the eval designated as
plan of care certification 2/1/10 to 3/15/10, or is my
frequency and duration along with eval date considered enough
for certification? Also, if I have a plan of
care for 6 weeks designated on my eval, do I need to do a
re-certification at the end of 6 weeks or wait until the 90
days as long as I am sending a progress note every 10 visits
or 30 days?
Answer: I'm glad you read our column. The answers to
your questions are
a) There is no such thing
now as a certification period. Medicare has changed it to a
certification interval and has defined that as the longest
time on the POT. Therefore, in your example you have either 18
treatments or six weeks to achieve your goals, which ever
takes the longest. So if your patient missed two visits in the
6 weeks then the longest time would be to reach the 18
treatment. At this time you would re-cert the patient by
developing a new POT to send to the physician for review and
approval.
b) You do not have to send
the progress note to the physician unless they want to see it.
The 10 visit/30 day note is to relate all of the progress made
by the patient, why you are still continuing with care and
what you are planning to achieve during the next progress
report period.
As with all Medicare regulations, they are for
payment purposes only. IF your State Practice Act indicated
something different than Medicare, go with the
strictest requirement.
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Medicare News and Rules for therapists is brought to you
by Encompass Consulting & Education, LLC. A therapist
owned company specializing in Consulting & Educational
services for therapists and other professionals providing
Medicare services in SNF, Rehab Agencies, Private Practice and
Hospital Outpatient clinics.
Pauline M. Franko, PT, MCSP is owner and CEO of the
company and is also known as the "Medicare Advisor" columnist
for the "Advance for" family of News Magazine providing
answers to Medicare questions for over 10 years. She also acts
a resource for the respected Eli Reports and matters
concerning rehab services and
Medicare. |
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Thank you so much for subscribing to our
Newsletter. Please feel free to forward this to anyone
you believe would be interested in receiving news about
Medicare. Please use the link below, as this way we are able
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Sincerely
Pauline
Pauline Franko
Encompass Consulting & Education,
LLC
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