On March 10, the Centers for Medicare & Medicaid Services (CMS) took further action to ensure patients have access to the critical healthcare services they need in the wake of the 2019 Novel Coronavirus (COVID-19) outbreak. Following a meeting with President Trump and Vice President Pence, many leading insurance companies and their industry associations announced they will be treating COVID-19 diagnostic tests as covered benefits and will be waiving cost sharing that would otherwise apply to the test. The President also directed CMS to provide more flexibility to Medicare Advantage and Part D plans to ensure they have the tools they need to provide seniors with the best coverage. As a result, CMS published a memorandum to Medicare Advantage (MA) and Part D health and prescription drug plans informing them of the flexibilities they have to provide healthcare coverage to Medicare beneficiaries for COVID-19 testing, treatments, and prevention.
There is no requirement that a coder in SNFs be certified. It would be ideal to have certified coders in the SNF, but this is not a realistic expectation. Those responsible for coding need medical terminology, anatomy, and pathophysiology knowledge. This can be a medical records professional (associate degree), bachelor’s degree, or master’s degree educational preparation. A degree does not ensure that the person has a coding certification. Many health unit coordinator programs include diagnosis in the course curriculum. Frequently, nurses have chosen to work in the health information management field. Nurses make good coders due to their educational background but need to be careful not to read into a provider’s documentation or assume relationships between documentation entries.
One quarter down, and PDPM appears to be mostly positive for SNFs. CMS is reporting a higher average per diem payment level than under RUGs. Despite some added coding complexity, paperwork burdens are down for providers (for example, we have two MDSs during most stays now vs. many more under RUGs).
If every “i” is not dotted and every “t” not crossed when submitting a claim, an overpayment may result, even if services rendered to the patient were medically necessary. The appeals process is designed to give providers a chance to explain their case. It’s also a mechanism to make sure the audit was conducted properly. The following tips may not help you win every appeal, but they certainly won’t hurt your case.
A truly successful SNF optimizes quality outcomes and reimbursement for their Medicare Part A patients. The Patient-Driven Payment Model (PDPM) supports this concept by shifting the focus from quantity of services to drive payments to basing payments on resident characteristics and quality outcomes. Outcomes are person centered, and SNFs can utilize several programs to provide that person-centered care.
Ambulance transfers are extremely expensive for SNFs and their Medicare Part A–covered patients. “The high costs associated with transfers create a significant financial risk for SNFs,” says Barbara Reimer, consultant with the Fox Group.