Senior Living Focus: COVID-19, SNFs, MDS, and Billing Guidance
Today’s blog post on skilled nursing facilities is by CLA’s Deb Freeland and Jillian Martin
During these challenging times, the senior living community is focused on caring for residents and keeping those residents safe. It is also a time that facilities continue to focus on compliance and billing to ensure there is timely revenue inflow to pay for the care provided. The Minimum Data Set (MDS) is the beginning point for determining the revenue to be received for each skilled nursing facility (SNF) resident.
MDS Assessments
One of the first things facilities should continue to focus on is the timely completion of the MDS assessments. While every effort should be made to maintain the MDS schedule, the Centers for Medicare & Medicaid Services (CMS) has relaxed the requirements for submission under the current circumstances. If a facility is unable to open and complete their MDS timely, they must reach out to their state Resident Assessment Instrument (RAI) coordinator and their Medicare Administrative Contractor to notify them of the inability to complete the MDS timely. Facilities should keep in mind that payment would only be received timely with MDS completion and transmission.
ICD-10 Coding and Patient-Driven Payment Model (PDPM) Rate Calculation
In addition to timely completion of the MDS assessments, SNFs need to be aware of new ICD-10 coding. Effective April 1, 2020, Centers for Disease Control and Prevention (CDC) added a diagnosis code for 2019-nCoV acute respiratory disease to the PDPM grouper that can be utilized for the primary category. In addition, CMS added other ICD-10 diagnosis codes related to COVID-19. Facilities should include specific COVID-19 diagnoses on MDS assessments and claims beginning April 1, 2020 to receive appropriate payment for the services offered.
Providers need to code the nursing component correctly on the MDS in order to obtain the correct PDPM rate. Some patients admitted either with an active diagnosis or presumptive diagnosis of COVID-19 may meet the criteria for infection isolation to be placed in the Extensive Services 1 nursing component under PDPM. All four criteria as outlined in the MDS manual must continue to be met in order to code infection isolation.
- The resident has active infection with highly transmissible or epidemiologically significant pathogens that have been acquired by physical contact or airborne or droplet transmission.
- Precautions are over and above standard precautions. That is, transmission-based precautions (contact, droplet, and/or airborne) must be in effect.
- The resident is in a room alone because of active infection and cannot have a roommate. This means that the resident must be in a room alone and not cohorted with a roommate regardless of whether the roommate has a similar active infection that requires isolation.
- The resident must remain in his/her room. This requires that all services be brought to the resident (e.g. rehabilitation, activities, dining, etc.)
CMS addressed isolation requirements by stating: “with regard to the question about isolation, at this time. Providers should continue to code isolation on the MDS following the relevant coding guidelines outlined in the MDS RAI manual.” This is effective April 1, 2020.
If a resident does not meet the requirements to code for active infection isolation, there are some additional resident characteristics to consider for the PDPM nursing component:
- Diagnosis of COPD and documentation indicating shortness of breath when lying flat;
- Fever and one of the following, pneumonia, vomiting, weight loss, or feeding tube;
- Respiratory therapy for seven days;
- Respiratory failure and oxygen therapy while a resident;
- Pneumonia;
- Oxygen therapy while a resident; and,
- IV medication while a resident.
The Non-Therapy Ancillary (NTA) component of the PDPM rate may also be impacted by COVID-19. Residents being treated for active or presumptive infection with COVID-19 may qualify for the following points based on the diagnoses, note and/or hospital information. Items to be considered include: ventilator or respirator post-admin code (4 points); isolation post-admit code (1 point); and cardio-respiratory failure and shock (1 point).
Medicare Compliance
Despite the various waivers, SNFs must still comply with certain Medicare requirements for proper reimbursement and to avoid the appearance of fraud or abuse, such as:
- Medicare certifications must be completed for all residents accessing their Medicare A benefit.
- Only providers can diagnose
- Residents accessing their Medicare A benefit must continue to meet daily skilled requirements evidenced by chart documentation indicating a need for skilled nursing and/or therapy services.
Wondering how to work on MDS assessments and coding during this challenging time? CLA can help with this and more, allowing you to focus on caring for your residents. Access CLA’s COVID-19 resources page or reach out to Deb and Jillian. Stay safe!
Jennifer Boese is the Director of Health Care Policy at CLA. She is a highly successful public policy, legislative, advocacy and political affairs leader, including working in both the state and federal government as well as the private sector. She brings over 20 years of government relations and public policy knowledge with her to CLA. Well over half of her career has been spent dedicated to health care policy and the health care industry, affording her a deep understanding of the health care market and environment, health care organizations and health care stakeholders. Her role at CLA is to provide thought leadership, policy analysis and strategic insights to health care providers across the continuum related to the industry's ongoing transformation towards value. A key focus of that work is on market innovations and emerging payment models. Her goal is to help CLA clients navigate and thrive in an increasingly dynamic health care environment.
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