Category: COVID-19

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Implementation Strategies: Trauma-Informed Care During the COVID-19 Pandemic

The COVID-19 pandemic introduces unique considerations related to patient-specific care plans, the execution of trauma-informed care (TIC) and the implementation of protocols to prevent disease transmission allowing for the continued provision of quality care.  In order to incorporate TIC, each patient’s unique history, specifically those relevant to the current environmental demands, should be addressed with strategic care planning. 

Interdisciplinary teams must help alleviate the unintended consequences of social isolation and source control strategies (i.e. face mask use) while in pursuit of infection control.  Now, more than ever, we must be familiar with our residents and newly admitted patients, their histories, potential triggers and preferences in order to develop and employ patient-specific TIC successfully. 

Consider the following strategies:

  1. Determine the health literacy of each resident/patient and provide education concerning infection control and prevention at their level of understanding to the diminish potential for new trauma
  2. Adapt protocols as necessary and modify care plans accordingly to prevent re-traumatization.
  3. Provide patients reassurance as often as necessary that protocols in place are in their best interest.
  4. Address needs for a sense of normalcy by developing new routines, roles, and habits. 
  5. Mitigate the psychosocial effects of isolation through creative implementation of activities to promote socialization and engagement.
  6. Utilize technology to facilitate connections with family and friends, when possible.

There are no shortages of avenues for success with TIC, but communication is critical for them all.  At its core, TIC requires communication with the patient and their designated representative for historical knowledge and care plan updates. It takes each member of the interdisciplinary team offering specific insight resulting from their familiarity with the patient, to develop a thorough and comprehensive care plan for the individual that accomplishes preventing traumatization or re-traumatization.  Do not diminish the explicit value each member brings as their contribution may very well be the one to enable positive patient outcomes. 

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Will Your Documentation Stand Up in a Post-Pay Review Following the COVID-19 Pandemic?

The current SNF coverage decisions, under the COVID-19 Section 1135 Waivers, allow providers to render skilled services to LTC residents, considered “skilling in place.” It is important to note that the previous requirements for skilled care need as defined in Chapter 8, Section 30 of the Medicare Benefit Policy Manual remain unchanged.

The quality of our documentation should not change regardless of payer; however, when an 1135 waiver is evoked, extensive care should be taken to document the reasoning for the initiation of the Part A benefit (e.g., change in condition) and why the qualifying event (e.g., 3 day hospital stay or wellness period) was waived. According to CMS FAQs regarding the waivers, if “continued skilled care need…is unrelated to the COVID-19 emergency, then the beneficiary cannot renew his or her SNF benefits.”

Relation to the emergency may include:

  • early hospital discharge due to resource need or
  • avoiding hospital transfer due to exposure risk.

Documentation is our defense when under review—as we continue to provide care to our residents, educate nursing and therapy to demonstrate the complexity, sophistication, and medical necessity of the services provided throughout the episode of care. Our services have a positive impact on many areas of the patient’s life. It’s important that the work we do with each of them carries over onto paper to fortify defensibility following this pandemic and to ensure our patients continue to have access to quality care. 

Review the Medicare Part A waive memo here.

Review CMS FAQs for 1135 waivers here. (SNF Services may be found on pages 34-35)

AHCA Waiver Application Decision Making Flowcharts:

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Coronavirus Scams

There are increasing reports of scams and phishing attempts referencing COVID-19. These attacks many times appear as innocent emails looking for assistance or providing information regarding the COVID-19 crisis. Bad Actors are taking advantage of this crisis to prosper or do damage.  Their criminal actions are becoming more and more sophisticated and look very official as though coming from government agencies and health organizations.

It is critical to remain vigilant with all email correspondence and websites, but particularly those referencing COVID-19 updates, maps, donations, notifications etc.

To avoid becoming a victim, follow the guidelines below:

  • Never click on links or open attachments within unexpected emails.
  • If you receive a suspicious email appearing to come from a legitimate organization such as CDC, WHO, FEMA etc., confirm its legitimacy.  Make sure links direct you to the official site by hovering over the link.  Report suspicious email to your company’s Information Security Department.
  • If you visit a website or receive a pop-up window directing you to a phone number for support desk assistance, DO NOT call the number, instead contact your company’s Information Security Department.
  • Never share your password with anyone.

Trends noted to date include:

  • Malicious Websites – sites referencing coronavirus or COVID-19 in the URL. Thousands of new websites have recently been registered to distribute malware when the user accesses the site.
  • Spam – emails trying to grab your attention to sell information or goods now in high demand such as masks, hand sanitizers, COVID-19 drugs, etc.
  • Phishing – emails posing to be from legitimate organizations such as Center for Disease Control (CDC), the World Health Organization (WHO), Federal Emergency Management Agency (FEMA), etc. These emails contain malicious links, and some are collecting personal information.
  • Fake Charities – emails and websites asking for donations for studies, healthcare professionals, victims, or other activities related to COVID-19
  • Fake internal HR or IT communications such as coronavirus surveys pretending to be from your company’s HR or IT department – these sites are attempting to obtain your User ID and password or other personal information.
  • Fake notification of infection – beware of emails reporting you have been exposed to an infected individual, particularly ones asking for personal information to proceed.

 Always Think Before You Click.

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COVID-19: Answering the Call

Because our patients and residents typically are older, often have underlying chronic medical conditions and live in a community together, they are at the highest risk of being affected by COVID-19. During this unprecedented time, our residents rely on the members of their interdisciplinary team to ensure that their health and safety needs are met.

With a team approach of collaboration, communication and demonstration of the value and essence of our skilled professions, we will answer the call to protect this vulnerable population in the pursuit of No Patient Left Behind. Whether it’s clinical considerations in the recovery wake of a COVID-19 diagnosis or ensuring they are supported to continue to attain and maintain the highest level of practicable function within this modified environment, nursing facilities are equipped to meet the needs of the residents who call our facilities home.

Each member of the interdisciplinary team – including therapy, nursing and administrative team members – has specific skills that can help meet the residents’ needs. Collaborative efforts to integrate each team member’s contributions allow for greater positive impact on the care provided.  Timely and effective communication of changes in function should be ongoing between nursing and therapy to identify emerging conditions and potential symptoms of COVID-19.  Each patient is unique and requires screenings relative to their specific diagnoses, history and risks. It is our imperative to ensure dignity, quality of life and the highest level of independence possible. Members of the care team have been empowered to own their distinct role in resident-centered advocacy, which ultimately leads to successful outcomes.

Any member of the interdisciplinary team can lead the advocacy efforts for each resident by observing changes in the resident’s ability, ensuring timely notification, developing a resident-specific plan of care and thoroughly planning for the next level of care. Care delivery must be adapted by team members to occur in bundled sessions with enhanced in-room treatment techniques. By working together, we can help curb the potential anxiety and psychosocial effects perpetuated by a world in pandemic and affirm that no patient is left behind.

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Medical Review Audits Suspended

Reliant has worked closely with the National Association for the Support of Long Term Care (NASL) to raise awareness of the activity associated with Medicare’s medical review process during this pandemic, including pre-pay targeted probe and educate (TPE) activity and post-pay recovery audit contractor (RAC) reviews. At this time, Novitas, First Coast and CGS have suspended TPE activity until further notice. Our contacts indicate current pre-pay TPEs will be released and paid in the coming weeks.

According to an FAQ released on 3/30/2020, CMS indicates suspension of most Medicare Fee-For-Service (FFS) medical reviews during the emergency period due to the COVID-19 pandemic. The FAQ states that both pre-payment medical reviews such as the reviews for TPE and post-payment reviews conducted by the MACs, Supplemental Medical Review Contractors (SMRCs) and Recovery Audit Contractors (RACs) are suspended for the duration of the Public Health Emergency (PHE).

The FAQ also notes that “no additional documentation requests will be issued for the duration of the PHE for the COVID-19 pandemic.” Current post-payment review by the MACs, SMRCs, and RACs will be suspended and released from review as well. CMS is suspending these medical review activities for the duration of the PHE, but could conduct medical reviews “during or after the PHE if there is an indication of potential fraud.”

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Medicare Advantage Plans Prior Authorization Suspended

In response to the COVID-19 pandemic, Medicare Advantage plans are issuing temporary suspensions in prior authorization requirements for post-acute settings and revising policies to improve patient access to care.

UnitedHealthcare (UHC) is suspending prior authorization requirements for post-acute settings through May 31, 2020, with the waiver applying to skilled nursing facilities (SNFs), long-term care facilities (LTCFs), and acute inpatient rehabilitation (AIR).  In addition, UHC will reimburse physical, occupational and speech therapy telehealth services provided by qualified health care professionals when rendered using interactive audio/video technology, emphasizing state laws and regulations apply.

Cigna has indicated a similar suspension for commercial and Medicare Advantage plans, noting it will make it easier for hospitals to transfer patients to long-term acute-care hospitals (LTACHs) and other sub-acute facilities to help manage the demands of increasingly high volumes of COVID-19 patients

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Medicare Accelerated and Advanced Payments Now Available

On March 28, 2020, the Centers for Medicare & Medicaid Services (CMS) expanded the current Accelerated and Advance Payment Program to a broader group of Medicare Part A providers and Part B suppliers. This program expansion, which includes changes from the recently enacted Coronavirus Aid, Relief and the Economic Security (CARES) Act, is one way CMS is working to lessen the financial hardships of providers facing extraordinary challenges related to the COVID-19 pandemic and ensures the nation’s providers can focus on patient care.

Eligibility qualifications state the provider/supplier must:

  • Have billed Medicare for claims within 180 days immediately prior to the date of signature on the provider’s/supplier’s request form
  • Not be in bankruptcy
  • Not be under active medical review or program integrity investigation
  • Not have any outstanding delinquent Medicare overpayments

Medicare will start accepting and processing the Accelerated/Advance Payment Requests immediately. CMS anticipates that the payments will be issued within seven days of the provider’s request.   

Access CMS’ step by step guide for eligibility and processes here.

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COVID-19 Medicare Waivers

CMS is empowered to take proactive steps through 1135 waivers and rapidly expand the Administration’s aggressive efforts against COVID-19. As a result, the following blanket waivers are available: 

  • Three-Day Stay Waiver: CMS is waiving the requirement at Section 1812(f) of the Social Security Act for a 3-day prior hospitalization for coverage of a skilled nursing facility (SNF) stay, providing temporary emergency coverage of SNF services without a qualifying hospital stay for those who need to be transferred as a result of the effect of a disaster or emergency.
  • SNF Part A 100-Day Benefit Waiver: For certain beneficiaries who recently exhausted their SNF benefits, it authorizes renewed SNF coverage without first having to start a new benefit period.
  • MDS Completion and Submission Waiver: CMS is waiving 42 CFR 483.20 to provide relief to SNFs on the timeframe requirements for Minimum Data Set assessments and transmission.

Read the Coronavirus 1812(f) waiver.

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New Targeted Plan for Healthcare Facility Inspections

On March 23, 2020 CMS released guidance to state survey agencies further prioritizing and suspending most federal and state surveys and delaying revisit surveys for the next three weeks beginning March 20.

CMS has released this survey tool to review infection prevention and control practices. Providers are encouraged to perform a self-assessment utilizing this same tool. Surveyors will review for:

  • Overall effectiveness of the Infection Prevention and Control Program (IPCP) including policies and procedures
  • Standard and transmission-based precautions (with the understanding that certain essential supplies are scarce, and facilities should not be penalized for not having certain supplies if they are unable to obtain them)
  • Quality of resident care practices, including those with COVID-19 (laboratory-positive cases), if applicable
  • Surveillance plan
  • Visitor entry and facility screening practices
  • Education, monitoring and screening practices of staff
  • Facility policies and procedures to address staffing issues during emergencies, such as transmission of COVID-19

Click here for the Survey Prioritization Fact Sheet.

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PPE Guidance from CDC and CMS

The CDC issued guidance for optimizing the PPE supply, specifically facemasks, gowns and eye protection, including suggestions on what to do in case of shortages.

CMS recommends reaching out to a health care coalition (HCC) in your area for emergency response assistance. Click here for an interactive map with contact information.

Additionally, AHCA has warned providers to beware of COVID-19 scams selling PPE or other supplies. To aid in differentiation between legitimate businesses and scams, the Federal Trade Commission (FTC) has provided general guidance on COVID-19-related scams.

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March Clinical Appeals

Denial Reason Code W7020- NCCI Edit Update

In February, CMS rescinded the National Correct Coding Initiative (NCCI) Edits which restricted the billing of CPT codes 97530 and 97150 on the same day as billing of PT/OT evaluation codes (97161, 97162, 97163, 97164, 97165, 97166) retroactively to January 1, 2020. Nonetheless, many providers have experienced line item denials due to the edit enacted for the short duration. These line item denials are reflected by reason code W7020. To resolve, CMS will be correcting the NCCI edit, beginning April 6, 2020. Medicare Administrative Contractors (MACs) will automatically reprocess claims, without provider action.  When reconciling payments,

  • Review Part B line items for denial of HCPCs 97530 and 97150, in the presence of evaluation codes 97161, 97162, 97163, 97164, 97165, 97166.
  • If line item denials are identified, determine if reason code W7070 is appended.
  • If confirmed, flag impacted claims for review for automatic reprocessing following CMS correction of the edit, beginning April 6, 2020.
  • CMS has indicated provider action is not required.
  • Follow up with your MAC should reprocessing not occur or occur with errors.

SNF Claims Incorrectly Cancelled

From January 26 through February 16, 2020, a software issue caused SNF claims to be incorrectly cancelled with a message that there was no three-day qualifying hospital stay. This issue has been corrected. If your claims were incorrectly cancelled, re-bill them in sequential order to receive payment.

  • Claims need to process in date of service order for each stay for the Variable Per Diem (VPD) to calculate correctly.
  • Submit claims in sequence and wait at least 2 weeks before billing subsequent claims.
  • Some of the affected claims with older dates of service will require a timely filing exception; enter “Resubmission due to non-qualifying stay” in the remarks field.

Click here for more information.

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HIPAA Privacy & COVID-19

In this unprecedented time with worldwide infection of COVID-19, there are provisions within the HIPAA Privacy Rule to address use and disclosure of patient information in a public health emergency to aid in prevention and control of the spread of disease. While this provision addresses use and disclosure to authorized public health authorities, Covered Entities and Business Associates must continue to safeguard patient information from impermissible uses and disclosures.

Refer to the bulletin released by the Office of Civil Rights (OCR) in February 2020 at this link OCR HIPAA Privacy and COVID-19 for more information regarding HIPAA Privacy Rule relating to infectious disease control.