Q&A from our June 14th Medicare Workshop

Questions for Maureen McCarthy, RN, BS.
Q: Do weekly rehab notes satisfy requirements for Med A?
A:Yes, the expectation is that therapy will be treating 5x/week to be considered a 'daily skilled service'; additional treatment is therapeutic for the resident but is not required. They must keep daily records to support the therapy modality used during treatment, the number of minutes treated, and at least the initials of the therapy staff treating the resident. Progress notes are required to document the resident's significant progress in a reasonable period of time and weekly notes are sufficient. Some facilities or therapy vendors prefer to show the progress of a resident daily and require their staff to document accordingly.

Q: If a patient is receiving rehab at an RU (Rehab Ultra) level for the 60-day assessment and was dropped down to a RL (Rehab Low) level 2 weeks later, will they still receive reimbursement at the RU level through the end of the billing cycle?
A: Yes, the facility will receive payment at the same level until the next assessment is due.

Q: When a resident reaches their $1780 therapy cap but have a diagnosis that will allow an exception to the cap allowing therapy to continue, is an ABN needed to notify the responsible party of reaching their cap?
A: No, an ABN is not required if therapy services will not be discontinued. Advanced Beneficiary Notice is designed to allow the resident the opportunity to appeal the decision to discontinue therapy services. In this case, the ABN will be issued prior to therapy services ending, not with the cap exception.

Q: Does a diagnosis of Hemiplegia, oxygen therapy or daily insulin coverage with stable blood sugars keep a resident skilled?
A: No, daily skilled nursing services require the skilled observation or assessment of a nurse 7 days per week. Medicare coverage is not diagnosis driven, and does not cover residents at their baseline condition. It depends on the documentation of the daily skilled services received by the resident in the medical record. If your documentation supports that the resident is experiencing complications due to one, or all of the conditions above, or if patient teaching is being performed for a resident that would be covered. Just the fact that someone is receiving oxygen would not alone warrant Medicare coverage.

Q: Which notice of non-coverage should we give for a resident who is electing hospice coverage?
A: Most residents are fully aware of their conversion to Hospice, but some do not understand that this benefit replaces Medicare Part coverage. If a resident elects outpatient Hospice coverage, they may be responsible for room & board payments. Therefore, it is safe to initiate an expedited review notice 48 hours prior to ending Medicare coverage. The Hospice nurse sometimes does this but the facility is ultimately responsible for notifying the resident that they will no longer be providing Medicare covered services.

Q: What is the process if the resident does not understand the notice because his decision-making abilities per the MDS show moderately impaired decision making and the resident has no responsible party?
A: If the decision-making is moderately impaired, then the resident would need reminders or cues to help him understand. It is CMS's expectation that the resident sign if they are able to and can understand the intent of the letter. Therefore, unless a conservator is assigned the resident should be the one to sign the notice and I would recommend a note in the record to describe the teaching provided in order to ensure the resident's understanding of the notice.

Q: Should an expedited review notice be given to a resident when skilled services are ending following the exhaustion of benefits?
A: No, the resident was notified that Medicare benefits have been exhausted before their 100th day of coverage. Only the staff member responsible for submitting GAP or no-pay bills would be required to be aware of that 'skilled services ending' date in order to bill accordingly. This begins the 60-day count to determine if another 100-day Medicare benefit period is available to the resident should they qualify at a future date.

Q: Do you need to do both an expedited review notice and a SNF denial when benefits exhaust and skilled care ends?
A: Yes, if the resident is benefit exhausting (using all 100 Medicare Part A days in a benefit period), and nursing or therapy skilled care is ending on the same day, you would notify the resident with both letters. If the resident was benefit exhausting and remained at a skilled level of care (even though the facility will not be paid by Medicare) they will only need the SNF denial letter. In this case the care will not change, the resident will continue to receive skilled services.

Q: What happens if we don't give benefits exhaust denial on admission because we were not notified of a prior SNF stay and the CWF was not updated timely? Is the SNF provider liable?
A: No, if you think the resident has days left then you are billing Medicare. You would have a remittance advice denying payment due to no Part A days available. You would use this R/A to bill the state. A benefits exhaust denial is given when you are initiating Medicare coverage and run out of days. Usually on admission you are giving a 'no 3-day stay' a Œno 60-day break in skilled services' or a 'no skilled need' denial.

Q: Can we still bill Medicare for flu shots when we do not charge the staff for them?
A: Yes, the uniform billing system applies only to the resident's you are billing for. It is to make sure all payers are billed the same amount for the services provided.

Q: If a resident becomes skilled between day 30 and 60 after being skilled off Medicare with a level of care drop. How do I bill my 210 Medicare bill?
A: There is currently no way to notify Medicare that the resident is now at a skilled level of care without a discharge. I would suggest holding back the monthly GAP bill until you are sure the resident has had a 60-day break.

Q: Which bill gets the 74 span code and what dates go on the bill for resident's with GAP bills and Part B bills?
A: The 74 span code goes on the 210 bill so that Medicare will know that a bill is coming for Part B services for this resident. The dates are indicated in the span fields for the dates therapy services were provided during that month. It is usually a 'from and through' dating sequence not each specific date treated. The 74 Code will be in effect on August 27th. Until that date all 210 bills should be submitted before submitting Part B Claims. For more information see CR5583.