Language Fundamentals leadership recently took part in a Medicare training session led by Alicia Cantinieri of Zimmet Healthcare Services Group.   Alicia provided an informative & interactive seminar that included the most important SNF Industry Medicare updates.

Among the important topics covered were:

Importance of Accurate Diagnosis Coding – Under PDPM accuracy of primary and secondary diagnosis is paramount.  Refining systems for accurate diagnosis coding is highly recommended.

Upcoming changes regarding NYS Case Mix – The system for MDS Case Mix in New York State is in need of an update. Section G of the OBRA assessment is scheduled to be eliminated in October 2023.  This will affect the calculation of a RUG-III score in states like New York that rely on this information.   Solutions include implementing an Optional State Assessment or using PDPM. No clarification has been provided yet.

BIMS – It is important to have documentation as to why a BIMS is repeated on a patient. Surveyors do frequently ask for the patient’s most recent BIMS.  Additionally, CMS has the ability to perform targeted audits based on BIMS scores.

Skilled Care & Documentation – The technical definition of skilled care has not changed.  7 days of skilled nursing care or 5 days of skilled rehab.  It is important to remember the criteria with regard to the plan of treatment. Documentation that supports the skilled intervention by a licensed professional (RN, PT, OT, SLP) is critical to protect from a poor audit result.

Accuracy of MDS information – MDS information is also used in many avenues, including QM, 5-star, care compare, legal cases, and more.  Therefore, the impact of the MDS accurately reflecting the clinical condition of the resident is more important than ever.

SLP Component – coding SLP-related comorbidities is an area where many SNFs miss reimbursement opportunities. Having expertise in the PDPM Assessment of the SLP Component will prevent lost reimbursement.

Claim Denials – According to ZHSG, the most common reasons for denied claims include:

  • Clinical Eligibility (7 day/week: Nursing, 5/Therapy)
  • Nursing RUG drivers and “end splits”
  • Nursing documentation must support all drivers
  • Speech variables
  • Function scoring / Variance from Section G
  • NTA drivers: Medical necessity, administration, documentation
  • ICD‐10 assignment or omission

While we understand that SNF operators are now heavily focused on staffing issues, Medicare audits primarily related to the 1135 waiver are likely to have negative implications. It is important to dedicate resources and attention to the accuracy of reimbursement and supportive documentation.

If you have any questions about how to improve the accuracy of reimbursement at your SNF, especially the speech component, please don’t hesitate to contact us.