Interim Final Rule and Surveyor Guidance for Long-Term Care Facility Testing Requirements

CMS has released guidance outlining details on how to comply with the new interim final rule requiring COVID-19 testing of staff and residents.

Testing Guidance

CMS is requiring facilities to conduct three types of testing: 

  1. Symptomatic Testing: Test any staff or residents who have signs or symptoms of COVID-19 (facility must continue screening all staff, residents and other visitors).
  2. Outbreak Testing: Test all staff and residents in response to an outbreak (defined as any single new infection in staff or any nursing home onset infection in a resident) and continue to test all staff and residents that tested negative every 3-7 days until 14 days has passed since the most recent positive result. An admit already confirmed does not constitute a facility outbreak.
  3. Routine Testing: Test all staff based on the extent of the virus in the community, using CMS’ published county positivity rate under “COVID-19 Testing”, in the prior week as the trigger for staff testing frequency as outlined in the table below:
  • Facilities are guided to monitor their county positivity rate every other week (e.g. first and third Monday of every month).
  • Staff and residents who have recovered from COVID-19 and are asymptomatic do not need to be retested for COVID within 3 months after symptom onset.
  • CMS provided guidance on staff who refuse to test:
    • Staff who refuse and have signs or symptoms must be prohibited from entering until the return to work criteria are met. CLICK HERE to review the CDC Criteria for Return to Work.
    • Asymptomatic staff who refuse testing should follow occupational health and local jurisdiction policies.
  • Facilities must maintain records of all testing for compliance and must be able to provide to surveyors.
  • Facilities that do not comply with the testing requirements will be cited for noncompliance with new F-tag, F-886.

CMS has also revised the focus surveys for nursing homes to ensure compliance with testing requirements, infection prevention standards, and compliance for infection preventionists.

OCR Alert – Phishing Scam Targeting Compliance Officers

The Office of Civil Rights (OCR) issued an alert on August 6, 2020 reporting postcards are being sent impersonating the OCR to coerce compliance officers into visiting a website regarding HIPAA risk assessments.  This is a marketing ploy to trick the victim into engaging in services under the guise of a directive from OCR.  A risk assessment is a requirement of HIPAA as defined in §164.308(a)(1); however, it does not specifically state how often it is needed or how it is to be done.  Best practice is to conduct risk assessments annually or when significant changes or threats occur within or to the environment.

It is recommended by OCR that all covered entities alert their workforce about this misleading communication.  For more information and an example of the postcard, CLICK HERE.

CMS FY 2021 SNF PPS Final Rule Released

Strengthening Medicare

CMS projects that aggregate Medicare program payments to SNFs will increase by $750 million, or 2.2 percent, for FY 2021 compared to FY 2020. This estimated increase is attributable to a 2.2 percent market basket increase factor, adjusted by a 0.0 percentage point productivity adjustment.

Updates to PDPM Clinical Diagnosis Mappings

In this final rule, in response to these stakeholder recommendations, CMS is finalizing changes to the ICD-10 code mappings, effective October 1, 2020.

SNF Value-Based Purchasing (VBP) Program

CMS made no changes to the measures, SNF VBP scoring policies, or payment policies in this final rule.  CMS announced performance periods and performance standards for the FY 2023 program year.

CLICK HERE to view the SNF PPS Final Rule.

CLICK HERE to view the SNF PPS Final Rule Fact Sheet.

CMS Physician Fee Schedule CY 2021 Proposed Rule Released

CY 2021 PFS Ratesetting and Conversion Factor

With the budget neutrality adjustment to account for changes in Resource Value Units (RVUs), CMS reports the proposed CY 2021 PFS conversion factor is $32.26, a decrease of $3.83 from the CY 2020 PFS conversion factor of $36.09.  CMS’ increases in RVU for Evaluation and Management (E/M) services codes in CY 2020 final rule are to take effect 1/1/2021. These increases are a positive for primary care physicians and some physical therapy and occupational therapy evaluation codes. However, the significant cuts to frequently used therapy intervention codes result in an overall 7-9% decrease in reimbursement for therapy services. CMS proposes these cuts to therapy as well as other critical care provisions in order to meet the budget neutrality requirements.

Advocacy efforts are underway to #fightthecut and protect our beneficiaries’ access to therapy, especially during this health care emergency.

Contact your congressman through your respective association below:

NASL

APTA

AOTA

ASHA

Additionally, comments can be sent directly to CMS here by October 5, 2020.

Medicare Telehealth

CMS is proposing to make permanent some telehealth provisions related to physician visits that have been extended as part of the public health emergency. Currently, a finite list of therapy services is reimbursable when provided via telehealth for as long as the public health emergency exists, and there is no proposal to make these therapy telehealth provisions permanent.

CLICK HERE to view the Physician Fee Schedule CY 2021 Proposed Rule.

CLICK HERE to view the Physician Fee Schedule Proposed Rule Fact Sheet.

MDS Updates

On Oct 1 MDS version 1.17.2 will be used. Updates include assessment changes that will support the calculation of PDPM payment codes for state Medicaid programs and on OBRA assessments when not combined with the 5-day SNF PPS assessment. This will specifically affect the OBRA comprehensive (NC) and OBRA quarterly (NQ) assessment item sets, which was not possible with item set version 1.17.1.

The updated item sets will not have a revised RAI manual released.  Contact your state’s RAI coordinator for item set questions.

For more information, visit MDS 3.0 Technical Information page.

Emergency Declarations

Watch for more information from CMS regarding possible additional waivers for beneficiaries in Louisiana and Texas due to Hurricane Laura and in California due to the wildfires following declarations of public health emergency in those locations.

CLICK HERE for more information on the waivers when they become available.

CLICK HERE to read the press release regarding Hurricane Laura relief.

COVID-19 Waiver Claims Review

Providers have begun receiving non-medical additional document requests for claims utilizing the benefit period waiver in response to the COVID-19 public health emergency. These reviewers are being flagged with a “7COVD” code and have primarily been reported under Wisconsin Physician Services (WPS).

These suspended claims may be the result of a billing issue. As such, review the proper guidelines below for how claims involving the waiver for the 60-day wellness period should be billed.

According to this Medicare Learning Network memo, to bill for the benefit period waiver:

  • Submit a final discharge claim on day 101 with patient status 01, discharge to home
  • Readmit the beneficiary to start the benefit period waiver

For admission under the benefit period waiver:

  • Complete a 5-day PPS Assessment. (the interrupted stay policy does not apply.)
  • Follow all SNF PDPM assessment rules.
  • Include the HIPPS code derived from the new 5-day assessment on the claim.
  • The variable per diem schedules begins from day 1.

For SNF benefit period waiver claims, include the following:

  • Condition code DR- identifies the claim as related to the PHE
  • Condition code 57 (readmission) – this will bypass edits related to the 3-day stay being within 30 days
  • COVID100 in the remarks – this identifies the claim as a benefit period waiver request

What’s GG Got to Do With It?

Despite the many adaptations and additional considerations that have been adopted in the battle against COVID-19, healthcare providers in skilled nursing facilities (SNFs) maintain their primary focus of quality patient rehabilitation and care. In the midst of planning and delivering care in a pandemic, some may ask, Does data collection really matter right now?  What’s GG got to do with it? The answers are Yes and everything!

CMS has indicated the value of data collection of our patient’s functional abilities (i.e. Section GG) by signaling it as a key comparison of quality across post-acute settings, an indicator of resource use impacting reimbursement, and critical to guiding patient-centered care planning. Although CMS stated exceptions and extensions were granted because data collection may be greatly impacted by the response to COVID-19, beginning July 1, SNFs are expected to report their quality data to meet the SNF QRP requirements for the third quarter of 2020. (Download CMS’ SNF QRP Tip Sheet)

Knowing this data eventually will be publicly posted, the question now becomes Does it reflect our exhausting efforts to deliver care during this public health emergency? That answer is yet to be determined, but it is never too late for a review and refresh of Section GG content as well as considerations for coding and patient identification in the current environment.

Accuracy of Section GG coding depends not only upon the healthcare professional’s familiarity with the objective scales, but also with each item’s definition, intent and parameters for coding. For example, walking items may be completed within separate sessions. A single walking item may include a brief rest, as long as the resident does not sit down. These considerations may assist in completing a thorough assessment in isolation. CMS provides training videos on the SNF QRP Training webpage for instructional purposes.

Facilities can use Section GG data to capture potential changes in function that may require skilled intervention by completing interim assessments. It is the role of the interdisciplinary team to identify potential impacts of isolation on a patient’s biopsychosocial wellbeing and intervene as appropriate.

Finally, review the submission requirements for the SNF-QRP, so a technicality does not overshadow the successful outcomes your teams are creating. Avoid dashes, utilize the activity not attempted codes as necessary, incorporate at least one goal into the patient’s care plan and submit the completed data for at least 80% of your Medicare A claims.

The interdisciplinary team should champion the role of data collection, even in a pandemic, to ensure that we are facilitating the appropriate plan of care, capturing the true picture of the resident’s needs and maintaining the highest quality of rehabilitation and care. Our patients are counting on us!

SNF PDPM Interrupted Stay Issue

CMS reports a new issue is affecting some inpatient hospital and skilled nursing facility (SNF) claims when an interrupted stay is billed at the end of the month. The system incorrectly assigns edits U5601-U5608 (overlapping a hospital claim).

If you billed the interrupted stay correctly, and your claim is rejected, modify your billing so the claim spans past the last day of the interrupted stay:

  • Bill two months at a time, or
  • Bill a month plus the days in the following month that span the interrupted stay plus 1 day

According to CMS, adjusting the statement covered from and through dates to encompass the entire interrupted stay will allow your claim to process and pay correctly. Medicare Administrative Contractors will finalize any suspended claims that meet the criteria, so you can make corrections and resubmit your claim.

If CMS rejected an inpatient hospital claim, the hospital should ask the SNF to modify their claim. Until October 5, a SNF cannot submit an adjustment to a paid claim; they must cancel the paid claim and all subsequent claims in the same stay and resubmit them in sequential order.

CMS will correct the system in the future.

To read the full report in the MLN, CLICK HERE.

Section GG Correlation to Clinical Documentation

External reviewers have begun targeting Section GG as a focal point of pre/post-pay medical review audits. ​Because the PDPM function score is derived from Section GG data, and that score correlates to a case mix group for payment, reviewers will seek supportive documentation for decision making related to coding on the MDS. ​

  • Therapy evaluations, recertifications, and discharge documents serve as clinical support of that decision making. ​
  • Section GG coding should be reflective of the patient’s clinical characteristics. ​
  • Objective data within the therapy evaluation/discharge should correlate to the section GG scores. ​
  • Example:  Bathing noted as Min assist by OT would be scored as 3 – Partial/Moderate Assistance.

Ensuring accurate data information at the beginning of the stay is the first key to successful outcomes. Accurate coding on sections I, C, and K of the MDS are critical. ​This clinical classification serves as a predictor of resource needs (therapy needs) from CMS and establishes an admission (baseline) for the patient that may be used as parameters in the future for patient progression.

Consider implementing proactive internal audits that review supportive documentation for MDS coding and continue to educate staff on proper coding to strengthen medical review success.

To access our tools for success, please CLICK HERE.

HHS Releases Detailed Provider Relief Fund Reporting Guidance

The U.S. Department of Health and Human Services (HHS) has provided more detailed Provider Relief Fund (PRF) reporting guidance. HHS reports they will be releasing more detailed reporting instructions by August 17, 2020. 

These reporting instructions will provide directions on reporting obligations applicable to any provider that received a payment from the following CARES Act/PRF distributions:

General Distributions:

  • Initial Medicare Distribution
  • Additional Medicare Distribution
  • Medicaid, Dental & CHIP Distribution

Targeted Distributions:

  • High Impact Area Distribution
  • Rural Distribution
  • Skilled Nursing Facilities Distribution
  • Indian Health Service Distribution
  • Safety Net Hospital Distribution

According to HHS, the reporting system will become available to recipients for reporting on October 1, 2020.

  • All recipients must report within 45 days of the end of CY 2020 on their expenditures through the period ending December 31, 2020.
  • Recipients who have expended funds in full prior to December 31, 2020 may submit a single final report at any time during the window that begins October 1, 2020, but no later than February 15, 2021.
  • Recipients with funds unexpended after December 31, 2020, must submit a second and final report no later than July 31, 2021.
  • Detailed PRF reporting instructions and a data collection template with the necessary data elements will be available through the HRSA website by August 17, 2020.

To read the guidance in its entirety,CLICK HERE.

For the CARES Act Provider Relief Fund FAQs, CLICK HERE.

CMS Directs Additional Resources to Nursing Homes in COVID-19 Hotspot Areas

The Centers for Medicare & Medicaid Services (CMS) announced they will provide a targeted approach for additional resources to nursing homes in COVID-19 hotspot areas. 

CMS reports that plans include the following:

  • Deployment of Quality Improvement Organizations (QIOs) to nursing homes in the hotspot areas.
  • Implementation of an enhanced survey process tailored to meet the specific concerns of hotspot areas.
  • Coordination of federal, state and local efforts to leverage all available resources to these facilities.

CMS reports the purpose of these efforts is to target facilities with known infection control issues by providing resources and support that will help them improve quality and safety and protect vulnerable Americans.

To view the press release from CMS, CLICK HERE.

CMS Provides Updates on Both Diagnostic Testing and SNF Benefit Period Waiver

In the July 17th MLN Matters Special Edition Article, Medicare Fee-for Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19), CMS provided updates on both diagnostic testing and SNF benefit period waiver.

Medicare Coverage of COVID-19 Testing for Nursing Home Residents and Patients

CMS instructed Medicare Administrative Contractors and notified Medicare Advantage plans to cover coronavirus disease 2019 (COVID-19) laboratory tests for nursing home residents and patients.

Starting on July 6, 2020, and for the duration of the public health emergency, consistent with sections listed in the CDC guidelines titled, “Interim SARS-CoV-2 Testing Guidelines for Nursing Home Residents and Healthcare Personnel,” original Medicare and Medicare Advantage plans cover diagnostic COVID-19 lab tests.

Diagnostic Testing

  • Testing residents with signs or symptoms of COVID-19
  • Testing asymptomatic residents with known or suspected exposure to an individual infected with SARS-CoV-2, including close and expanded contacts (e.g., there is an outbreak in the facility)
  • Initial (baseline) testing of asymptomatic residents without known or suspected exposure to an individual infected with SARS-CoV-2 as part of the recommended reopening process
  • Testing to determine resolution of infection

Original Medicare and Medicare Advantage Plans don’t cover non-diagnostic tests. 

Skilled Nursing Facility (SNF) Benefit Period Waiver – Provider Information

In the MLN Medicare Fee-For-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19) article, CMS provided clarification in three areas on the SNF Benefit period waiver:   

  1. The waiver authorizes a one-time renewal of benefits for an additional 100 days of Part A SNF coverage without first having to start a new benefit period (this waiver will apply only for those beneficiaries who have been delayed or prevented by the emergency itself from commencing or completing the process of ending their current benefit period and renewing their SNF benefits that would have occurred under normal circumstances).
  2. Beneficiaries who exhaust their SNF benefits can receive a renewal of SNF benefits under the waiver except in one particular scenario: that is, those beneficiaries who are receiving ongoing skilled care in a SNF that is unrelated to the emergency, as discussed in the article.
  3. To bill for the benefit period waiver: submit a final discharge claim on day 101 with patient status 01, discharge to home and readmit the beneficiary to start the benefit period waiver.  

For more information, CLICK HERE.

COVID-19 Point-of-Care Testing Supplies to Be Distributed to Nursing Homes in the Coming Weeks

Distribution Information

  • Shipping of testing supplies was initiated the week of July 20th and will continue over the following 14 weeks. 
  • Testing distribution is being prioritized based on epidemiological hotspot data. 
  • Facilities must have a Clinical Laboratory Improvement Amendments (CLIA) Certificate of Waiver in order to receive the testing equipment.
  • CMS reports they will expedite review of CLIA waivers for COVID-19 testing.
  • For more information on how to obtain a CLIA waiver, CLICK HERE.
  • To be eligible, in addition to having a current CLIA Certificate of Waiver, the nursing home must meet certain epidemiological criteria. 
  • For the list of nursing homes receiving instruments and tests in the first wave, CLICK HERE.

Testing Information

  • Each facility will receive at least one diagnostic test instrument (from manufacturers QUIDEL or BD) and approximately 400 tests to get started (these numbers will be adjusted for the size of the facility).
  • Additional antigen tests can be ordered at $25/test through a concierge service from the respective manufacturer.
  • The test instruments have the capacity to perform 15-20 antigen tests within an hour with near immediate results.
  • CMS indicated the Medicare program does not reimburse for surveillance testing, but if a patient tests positive, the test may be billed as diagnostic.
  • Facilities were encouraged to work with other facilities or to potentially share equipment until supply needs for each facility can be met.
  • CMS reported that they are aware of the likelihood of false negatives with rapid testing; however, the quick result can prove beneficial to the facility for infection control compared to the current lag time of results from the lab.
  • Additionally, on-site rapid testing may prove beneficial not only due to results obtained more quickly, but it is also more cost effective (the cost of on-site tests is $25 as opposed to the $100-$150 per test cost for current laboratory tests).

For CMS’ FAQ document regarding COVID-19 testing platforms and tests, CLICK HERE.

To access the press release from HHS regarding testing, CLICK HERE.

Fax Phishing

Alexander Bain invented the “Electric Printing Telegraph” in 1843 which became the world’s first faxing device.  One hundred seventy-seven years later, we still use fax, and so do hackers.  Faxing is so commonly used in our industry that we sometimes forget to be cautious.  Hackers use it to send phishing emails which entice users to click on links that download malicious codes.  In some instances, you are required to enter your credentials, giving the hacker the opportunity to steal them. 

To avoid becoming a victim of fax phishing, see the example email below with tips to stay safe.

Documenting the Picture for Skilled Need During a Health Care Emergency and Beyond

​During times of pandemic and national emergency, when flexibilities or waivers are allowed by CMS, supportive documentation is crucial to justify the need for our skilled care. Throughout the public health emergency, many providers have utilized the available waivers for SNFs, including “skilling in place.”  With use of these waivers the following should be considered:

  1. Physician involvement, skilled nursing notes, and therapy evaluations and treatments should demonstrate medical necessity and skilled interventions relative to specific patient care needs. ​
  2. A signed physician certification will not suffice; the documentation needs to clearly support the order. 
  3. ​The patient assessment, physician documentation,  justification for the reason why the patient should be skilled in place versus discharged to the hospital, and hospital notes that document rationale for not admitting a patient or discharging early should all be obtained and recorded.
  4. Consistent and thorough documentation related to the care being delivered and why the particular care being provided is appropriate to the patient’s diagnosis, illness, or condition should be included.
  5. Strong facility processes, ongoing communication, and frequent medical record spot checks are the most effective ways to ensure that your records can best support the patient-centered care that is provided through the health care emergency and beyond. ​

After the emergency declaration is rescinded, it is very likely that CMS, either through the Office of the Inspector General (OIG) or contractors, will look to ensure that Medicare dollars were spent appropriately without fraud, waste or abuse. ​ When evaluating the use of the waivers, it is important to focus on CMS’ goal to take “aggressive actions and exercise regulatory flexibilities to help healthcare providers contain the spread of 2019 Novel Coronavirus Disease (COVID-19).” ​ Documentation will be critical to explain the rationale for the use of the waivers as well as clinical decision making for application.

In conclusion, a thorough interdisciplinary treatment record is crucial to support the specialized services provided during this health care emergency. ​ As we continue to provide excellent resident-centered care, we should ensure that we demonstrate the complexity, sophistication, and medical necessity of the services that we provide in our documentation. ​Documentation is paramount to fortify defensibility following this pandemic and to ensure our residents continue to have access to quality care.

CMS Releases Enhanced Enforcement Actions Based on Nursing Home COVID-19 Data and Inspection Results

CMS released a memorandum addressing COVID-19 survey activities, enhanced enforcement, and engagement of Quality Improvement Organizations (QIOs).  CMS also released a state-by-state report on COVID-19 cases for residents and staff along with numbers of infection control focused surveys completed. The memorandum includes guidance related to

  • Focused Infection Control Nursing Home Surveys and CARES Act Supplemental Funding 
    • States that have not completed focused infection control surveys in 100% of their state’s nursing homes by July 31, 2020 will be required to submit a corrective action plan outlining the strategy for completion of these surveys within 30 days. 
    • Access to CARES Act allocations will be impacted by state performance on completing the nursing home infection control focused surveys. 
  • COVID-19 Survey Activities 
    • Requiring states to implement the following COVID-19 survey activities. States that fail to perform these survey activities timely and completely could forfeit up to 5% of their CARES Act allocation, annually. 
  • Expanded Survey Activities 
    • Emphasizes Nursing Homes Re-opening Recommendations, which indicates that once a state has entered Phase 3 of the reopening process, states may use their discretion as to whether and how they decide to expand survey activity beyond the current survey prioritization.
  • Enhanced Enforcement for Infection Control Deficiencies 
    • For all infection control deficiencies at a scope and severity of D or above, CMS will impose a directed plan of correction that will include the use of root cause analysis. 
  • Support From Quality Improvement Organizations (QIOs) 
    • Nursing homes can take advantage of weekly National Nursing Home Training that focuses on infection control, prevention and management to help prevent the transmission of COVID-19.Nursing homes can locate the QIO responsible for their state here

Read the memo from CMS here.

COVID-19 Data and Inspection Results Available on Nursing Home Compare

The Centers for Medicare and Medicaid Services (CMS) initiated posts of COVID-19 nursing home data which will be updated weekly.

In addition, results of targeted inspection surveys and reports are available on Nursing Home Compare. CMS plans to post the results of the inspections monthly as they are completed.

Available Links