Update on CMS & MAC Claims Processing

Below is an update from AHCA on processing of Medicare claims under the Patient-Driven Payment Model. Please note particularly the part that suggests holding claims until Thursday, October 24.

On October 17th, CMS transmitted is quarterly update to all Medicare Administrative Contractors (MACs) as scheduled. CMS also indicated the MACs would need until October 24th to load, test, and launch the update.

Today, we have heard from several members about problems with claims submitted last Friday and yesterday. This likely is because the MACs require more time (e.g., until the targeted October 24th) to finish installation and testing.

Last evening, we informed CMS (both payment policy staff as well as MAC officers about the responses from MACs to-date (e.g., lower likely payments than billed). We will remain in contact with CMS in the coming days.

For now, we recommend holding submission of claims until October 24th – the date CMS indicated the MACs should be ready. On October 25th, COB, we will be in contact with membership about the result of claims submission. If problems persist, AHCA will escalate the issue quickly.

The final submission deadline for this quarter is November 14th, 2019. Only data successfully submitted by this time is used on the Nursing Home Compare website and in the five star rating calculations.

Tips:

  • Once information is uploaded, check your Final Validations Report which is accessed in the Certification and Survey Provider Enhanced Reporting (CASPER folder) to verify data was submitted successfully.
  • It may take up to 24 hours to receive the validation report.
  • QIES helpdesk is available for assistance help@qtso.com
  • Do not wait until just a few days before the deadline to submit PBJ data for the reasons above.

Click here to learn more.

CMS announced the MDS 3.0 RAI Manual v1.17.1 which will take effect on October 1, 2019 is now available. 
This version of the RAI manual provides clarification to existing coding and transmission policy.

Click here to download the manual.

Article by Cassie Murray, OTR, QCP, IASSC CYB, Chief Operating & Clinical Officer, Healthcare Therapy Services, Inc.

On Friday 4/19, CMS released the pre-publication of the FY 2020 Skilled Nursing Facility Prospective Payment System Proposed Rule. As expected, the Patient-Driven Payment Model is confirmed to go into effect October 1, 2019.
SNF Proposed Payment Updates for FY 2020:

  • Proposed SNF payment update is 2.5% (increase of $887 million from FY2019)
  • The proposed updated Base Rates for the PDPM Components (unadjusted federal per diem rates for urban and rural):

TABLE 3: FY 2020 Unadjusted Federal Rate Per Diem–URBAN

TABLE 4: FY 2020 Unadjusted Federal Rate Per Diem-RURAL

SNF Quality Reporting Program:

  • For FY 2022, CMS proposes the adoption of two process measures:
    • Transfer of Health Information to the Provider-Post-Acute Care.
    • Transfer of Health Information to the Patient-Post-Acute Care.
  • CMS proposes to update specifications for Discharge to the Community SNF QRP Measure to exclude baseline nursing facility residents from the measure.
  • CMS proposes to collect standardized patient assessment data using MDS for all patients regardless of payer source.

PDPM Changes:

  • CMS proposes to change the SNF group therapy definition to match the IRF group therapy definition. This would allow for qualified therapists or assistants to treat two to six patients in a group performing the same or similar activities.
  • CMS proposes that non-substantive updates to ICD-10 codes used in PDPM be made through the PDPM website. Substantive changes would continue to be made through traditional notice and rulemaking processes. Non-substantive updates are to maintain consistency with the most recent ICD-10 code set.
  • CMS proposes updates to the regulation text to coincide with the assessment changes under PDPM:
    • Initial patient assessment regulation would state: “assessment schedule must include performance of an initial patient assessment no later than the 8th day of post-hospital SNF care”.
  • The Optional Interim Payment Assessment would be included in the regulation.

Stakeholder comments will be accepted until June 18, 2019.

Click here to view the CMS Fact Sheet.

Click here to view the FY 2020 Proposed Rule Pre-publication.