Senior Living Health Care: Billing trends alert

Feb 24, 2016
Audit Health care

The Centers for Medicare & Medicaid (CMS) introduced new assessment requirements to better align skilled nursing facilities’ (SNF) billing and Medicare payments. Beginning with the start of therapy (SOT) and end of therapy (EOT) assessments in 2011 and the change of therapy (COT) assessment in 2012, SNFs have been required to complete appropriate assessments and claims to capture accurate information. Since those changes have occurred, the percentage of billed service days in rehab ultra high, the highest paid rehab resource utilization group (RUG) has increased by 50 percent. Per the Office of Inspector General report in 2015, rehab ultra high and rehab very high comprise more than 75 percent of the total billed days in 2013 and are growing.

While calculation for therapy use and payment will most likely be changing in the future, SNFs are cautioned to accurately report and bill therapy services. Most troublesome are the calculations of the payment days when therapy changes.

SOT: When therapy starts between scheduled assessments, facilities can do an SOT assessment. Therapy has to have been provided a minimum of five days to set the assessment reference date for the SOT assessment. Payment for the rehab category starts the day therapy started.

EOT: Facilities must report the end of therapy with an EOT assessment within three days after all therapy ends and the beneficiary continues to need skilled nursing services. Payment changes the day after the last therapy was provided.

COT: For beneficiaries receiving therapy and scoring in the rehab categories, facilities are required to assess the amount of therapy provided every seven days. If there has been a change in the level of therapy provided, the facility must complete the COT assessment. Payment at the new category goes back seven days to reflect the change.

Excellent communication between the billers, the minimum data set (MDS) team and the therapy team has to be established to capture the correct payments. This is especially important when an unscheduled assessment (SOT, EOT and COT) occurs at the end of the month or the beginning of the month. The assessments may not be completed for up to eight days after the beginning of the month, but reflect back to the previous month.

For example, a the resident was in the rehab very high category, but on day six in the look-back period, she missed one day of therapy, and on the review day (day seven), requalified into the rehab high category. The assessment was completed with an assessment reference date (ARD) of March 4. Payment changes went back to February and had to be captured on the February claim. If the February claim was submitted for payment, the biller must wait for the original claim to be adjudicated and then submit an adjustment claim. Payment can be delayed for more than a month in some instances.

SNFs are being reviewed to ensure that appropriate claims are generated that reflect the services provided. CMS is working to monitor the SNF billing practices for changes in therapy and is targeting a claims review for SNFs that rarely bill for changes in therapy or who frequently use therapy assessments incorrectly. Providers are encouraged to include RUG status in the morning meeting and to invite the billers to participate in those meetings. Therapists are encouraged to manage the therapy services on a daily basis and to communicate to the clinical and billing team when there may be a need to add a therapy change assessment.

For more information, contact Joan McCarthy at +1 312 634 3479.

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