CMS is empowered to take proactive steps through 1135 waivers as well as, where applicable, authority grantedunder section 1812(f) of the Social Security Act (the Act) and rapidly expand the Administration’s aggressive efforts against COVID-19.
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The federal government on Thursday acknowledged some errors in processing Medicare claims under the new payment system for nursing homes, promising to make a full correction by the start of its next fiscal year.
The main issue has to do with the sequence of initial claim filings for Patient-Driven Payment Model (PDPM) reimbursements, the Centers for Medicare & Medicaid Services (CMS) announced in a release from the Medicare Learning Network.
SNF PDPM Claims Issue
Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) initial claims that are processed out of sequence are not paying the correct Variable Per Diem (VPD)-adjusted rate. Also, all adjustment claims are not processing correctly. Claims need to process in date of service order for each stay for the VPD to calculate correctly. We will correct this issue in October. In the interim:
ADL is enhancing its software in preparation for the Patient Driven Payment Module (PDPM). Our goal is to assist facility staff in classifying patients into the appropriate payment groups based on data driven clinical characteristics. PDPM is value based and rewards patient outcomes.
Effective October 01, 2019, each patient will be assigned a case mix classification that drives reimbursement. The primary diagnosis (Section I10020B on the MDS) will determine which of the 10 clinical categories the patient will be assigned. Once the clinical category and any comorbidities are taken into account, the patient will be categorized further based on 5 criteria: Nursing, Occupational Therapy, Physical Therapy, Speech Therapy, Non Therapy Ancillary (NTA). These 5 items are the basis of PDPM.
Things to Review with Staff
|1||Ensure staff is proficient in ICD-10 coding and that all codes are accounted for appropriately.
ADL software will display appropriate Diagnosis codes throughout the EMR
|2||Make sure relevant staff is familiar with Section GG of the MDS|
|3||Calculates a residents LACE score to predict the rate of readmission or death within 30 days of discharge|
|4||Make sure comorbidities are captured upon admission|
|5||Make sure HIV/AIDS codes are accurate for the increased rate adjustment|
|6||Reduce burden of multiple assessments – Scheduled MDS assessments will decrease from a minimum of 5 in 100 day stay
to 1 completed at the beginning of care
|7||MDS I8000 Active Diagnosis – Make sure to capture accurate and detailed medical diagnosis|
|8||PDPM scores will be accessible within various places in the EMR as reference|
|1||MDS new category I10020B for Primary Diagnosis will determine clinical categories|
|2||Providers will be required to complete an IPA with an ARD by 10/07/2019 for all Medicare Part A residents
(10/01/19 is Day 1 so schedule accordingly)
|3||Each should discipline justify and support the level of service provided.
ADL will alert user when assessments are due and ensure that proper ICD-10 codes are used based on conditions and orders
|4||Re-certification tracker of all active ICD-10 codes will keep you in compliance|
As of November 1, 2014, the Centers for Medicare and Medicaid Services (CMS) effected their mandate requiring long-term care providers to conduct electronic pharmacy transmissions via the National Prescription Drug Programs (NCPDP) 10.6 Script protocol.
ADL has been certified by pharmacy software vendors to be in compliance with the new protocol.