CMS recognizes the massive number of ultra-high therapy claims submitted by SNFs over the years and the staggering amount of Medicare dollars paid to facilities as a result, and the agency’s awareness is dramatically changing the reimbursement game. Warning of CMS’ awakening happened with the release of the Skilled Nursing Facility Utilization and Payment Public Use File data this past March. Now, recovery audits have increased, settlements paid by SNFs are hitting record highs, and there is greater scrutiny of therapy billing—along with talk of Medicare payment model restructuring.
Q: What is therapy’s role in Section GG—the new section of the MDS?
A: CMS is expecting us to collaborate on Section GG, so there is no expectation of a flow sheet. There’s no expectation at all by CMS on what the backup documentation needs to be, but they did say that they’re expecting our clinicians to collaborate on that. So we’re looking at day one, two, and three of the patient’s usual performance, which is really what we should be looking at before we apply any rehab strategies, although rehab is generally coming in either the day of admission (for some really good facilities) or the day after admission. But you’re really trying to get at where that patient is on their own, where they usually function. Then you’re looking at setting discharge goals, which we’re absolutely going to have to have therapists involved in, because function is their main area. And although nurses are performing care plan goals all the time, to address and to have a really good, accurate goal as to where we think we can get this patient to at the end of their stay, we have to involve the therapists in that care planning. We need to be able to collaborate and assess: “If the patient started off at X level, what level do you think we can get them to by the time of discharge? Is that a realistic goal?” And then collecting the documentation to make sure that we’re gaining to that goal towards the end of the resident’s stay. There is an expectation from CMS that we have to have some documentation in the medical record.
They will accept an interdisciplinary note that the team gathered. For instance, PT, OT, and nursing and the nursing assistant have met regarding Mr. Jones. He’s been observed, and it’s been reported that he requires X amount of assistance with Y ADL. That component would be sufficient enough to meet the supportive documentation in the medical record.
Each year, Medicare’s open enrollment period begins October 15 and ends December 7. The open enrollment period allows Medicare plan beneficiaries to review their current plan coverage and make changes to their plan selections. During the course of a year, details within the plans can change, such as provider and pharmacy network status, cost sharing requirements, and prescription drug coverage. In addition, as beneficiaries experience changes in their health, they may find that the benefits offered by their current plan no longer meet their needs. For this reason, CMS encourages beneficiaries to review their selections annually, including reviewing the documents that are sent during open enrollment, such as Evidence of Coverage and Annual Notice of Change. Changes made during open enrollment will take effect January 1 of the following year.
Below is a comprehensive list of changes CMS made tot he Conditions of Participation directly from the final rule. We’ve included a note to indicate when an entire change or a portion of the change is not required in Phase 1.
Experts say it’s the most comprehensive revision to the SNF Conditions of Participation (CoPs) since 1991 and changes will do everything from requiring SNFs to provide additional staff training and hiring scrutiny in an effort to protect against abuse and exploitation, to bolstering minimum health and safety standards in an effort to head off preventable re-hospitalizations.