Archive for 'Reimbursement'

SNF Denials Rise As Hospitals Provide More Observation Stays

Posted on 07. Dec, 2009 by .


Don’t let this rising trend cause technical denials for your SNF claims.

Your SNF admits a Part A-eligible resident requiring daily skilled rehab after a hospitalization spanning several days. The person has days left in his benefit period, so everything’s good to go — right?

Not so fast: Providers report seeing patients with long hospital observation stays that don’t count as a three-day qualifying hospital inpatient stay. Thus, your Medicare team should be on the lookout for this phenomenon — and know what to do if an observation stay results in a technical denial.

Anecdotally, “we know the trend is national,” says Doug Beardsley, VP of member services for Care Providers of Minnesota. He’s aware of one SNF that recently admitted a resident who’d been in the hospital for six days for a total shoulder replacement.

“And all six of those days were for observation.”

Next: Field-tested ways to protect your SNF’s reimbursement …


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IRF Reimbursement: Buckle Down for a Whirlwind of Admission Changes

Posted on 07. Dec, 2009 by .


You have your work cut out for you, but the door is open for more business.

You saw the big changes in the IRF PPS rule last summer. Now that the details are out, it’s time to evaluate one of the biggest impacts on your inpatient rehab facility — admissions.

Change Your Admission Priority

The days of massive denials targeting medical necessity will start to diminish come January 2010. “The number one criteria for admission to rehab is now functional need, and that’s a tremendous change from 2004, when the number one priority was medical necessity,” says Fran Fowler, FAAHC, managing director of Health Dimensions Group in Atlanta.

So if you’re used to empty beds because you’ve been turning away patients who are “too well” — and sending patients back to the hospital who are “too sick” — expect that to change. “Under the old rule, you might have had a post-stroke patient without active comorbidities who needed rehab, and he would not have been admitted, but that person would be admitted now,” Fowler explains.

Coming up. The new documentation requirements for screenings. (more…)

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Long-Term Care News Op Ed Feature: Reta Underwood

Posted on 23. Nov, 2009 by .


Do you ever wish someone at CMS would look at the big picture? 

The way I see it no-one at the agency is making sure the MDS and RAI manual, survey requirements and payment systems correspond to one another. I can cite numerous examples where these areas don’t match. For one, there’s no place to capture preventive care on the MDS 2.0 or 3.0. The whole concept of preventive and curative care is missing from the assessment form.

For example, there’s no way on the MDS to capture diagnostics related to bladder and bowel problems,, such as looking at the causes of incontinence or bowel problems.

Other examples include:

Urinary tract infection: The current MDS 2.0 RAI manual says code UTI with a physician diagnosis of UTI, symptoms and significant lab findings as determined by the physician. The F315 guidance talks about the resident having three or more symptoms of UTI (in order to diagnose UTI) based on McGreer criteria. There’s no Medicare reimbursement at all for UTI, yet it is costly from various avenues. (more…)

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MDS Tip: Make ADL Training Real With These Hands-On Teaching Techniques

Posted on 01. Nov, 2009 by .


Photo: Rinina25 & Twice25

Having trouble getting CNAs or nurses to nail down the differences between different levels of self-performance for coding activities of daily living (ADLs)?

Consider hosting an “‘ADL focus of the week,’ where you spend the whole week on one ADL, such as eating or transfers,” suggests Marty Pachciarz, RN, RACCT, a consultant with the Polaris Group in. Tampa, Fla. Have the administrator pretend to be a resident whom the staff moves as part of bed mobility or transfers. Then discuss whether the staff provided limited or extensive assistance — “in other words, have some fun with it,” advises Pachciarz.

Also conduct 10-minute ADL coding inservices on the unit, she suggests. These can work well when you focus on how to code one resident’s ADLs, Pachciarz notes.

Tip: Let the residents know you’re doing training and get them involved, suggests Sheryl Rosenfield, RN, BC, a consultant with Zimmet Healthcare Services Group in Morganville, N.J.

© Long-Term Care Survey Alert.


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Should You Use Rehab As Your SNF Patient’s Principal Diagnosis?

Posted on 19. Oct, 2009 by .


Find out the secret to navigating the murkier scenarios in your long-term care facility.

Your SNF has admitted a Medicare Part A skilled patient with an active medical condition who is receiving rehab therapy. Should you use rehab as the principal diagnosis?

Short answer: “In my mind,” says Ellen Strunk, PT, MS, GCS, a consultant with Rehab Resources & Consulting Inc., “it all boils down towhat is the reason for the admission to the SNF?”

Key point: “The coding guidelines are very clear that if the reason for admission is rehab, then you put rehab as the principal diagnosis (V57) on the health record and the UB-04 claim form,” emphasizes Charlotte Lefert, RHIA, coding strategy facilitator for the LTC Community of Practice for the American Health Information Management Association. “The next code(s) would be the diagnosis that is the reason for the rehab.” (more…)

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2 Red Flags Spell Payer Scrutiny at Your IRF

Posted on 03. Sep, 2009 by .


Plus, things you may not know you can do with physician orders.

You know how easy it is to get denials in your inpatient rehab facility — but paring them down can be just as easy. Check to see if your IRF is showing patterns of these four items, and nip them in the bud. Better reimbursement is likely to follow.

1. Weekend and Monday Discharges. Your fiscal intermediary or Medicare Administrative Contractor may be suspicious if you’ve met the three-hour rule requirement for five days right before the weekend begins, but you keep the patient through the weekend and discharge on Sunday or Monday, says Denese Estep, OTR, senior consultant for DE Consulting LLC in Sherwood, Ark.

And this can look especially suspicious if you don’t offer therapy on the weekends. “The rules state that you have to justify admission during the entire stay,” Estep continues. “So what exactly did you treat functionally or medically over the weekend that required the patient to be there? Why could you not have discharged on Friday?” If there’s a good reason, your answers should be spelled out clearly in your documentation. (more…)

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Revenue-Boosting ICD-9 Tips for SNF Coders

Posted on 19. Aug, 2009 by .


Experts reveal fifth-digit moves than can support medical necessity for hospital admission.

Ready to stop denials? Master these diagnosis coding strategies.

1. Use the most specific codes possible to communicate the resident’s condition. You may have to get more information and documentation from the physician to use the most specific code possible, says Shelley Safian, MAOM/HSM, CCS-P, CPC-H, CPC-I, CHA, associate professor at Herzing University in Winter Park, Fla. But doing so pays off.

For instance, using a more specific code can convey a much more serious situation that justifies a level of care or services provided, says Safian.

Asthma is one example. A fifth digit for that diagnosis conveys whether the person has status asthmaticus, a life-threatening condition. “A code for an asthma attack would not support medical necessity for admission into the hospital, whereas that fifth digit reporting the status asthmaticus certainly would,” Safian points out. (more…)

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