Skilled Nursing Reimbursement Basics Flashcards
What is the MDS?
Minimum Data Set. Determines the approparite RUG level and amount of money for the client
What did the 1997 Balanced Budget Act change?
Changed Reimbursement to a prospective payment system and mandated that the MDS would drive the payment.
CMS (Center for Medicare and Medicaid Services created RUGS(Resource Utilization groups) for patients using Part A services
Who qualifies for Medicare?
- Must have paid into Medicare or be married to someone who paid into medicare for at least 10 years
- 65+ years
- Disabled for 2 years and receiving SSDI
- End stage renal disease
How does one qualify for skilled care under medicare Part A
- 3 day qualifying hospital stay (3 midnights)
- 30 day window after release from hospital
- Needs skilled level of care
- Practical matter test
- Diagnoses
______ days= one benefit period
100 days
Medicare pays for 100% of _______ days of treatment/stay
20 days
T/F For the last 80 days of a benefit period, the client/patient has to pay co-payment or use co insurance
True. The first 20 days are 100% covered by Medicare Part A, after they have a daily co-pay of 161.00
T/F Services are provided 5-7 days/week
True
T/F The initial evaluation is included as therapy minutes
False
Explain the reimbursement basics for Part A in skilled nursing
- Paid per diem based on RUG level. (Determined by the MDS)
- Uses 7 day look pack period(Assessment Reference Periods) to capture therapy services provided
- Assessment Reference Date (ARD) is the last day of the assessment reference period and reimburses based off those 7 days
- 66 different categories for reimbursement
What things do RUGS determine?
Resource Utilization Group
- Combination of minutes of all therapies, frequency of therapy and disciplines involved
- Each minute of therapy counts, not units
- Needs to be hands on therapy time
- Divide minutes by the number of people co-treating
List all of the documents that need to be included in a patient file in order to be reimbursed
- Evaluation
- Justification of Daily Services
- Progress Report
- Supervisory visits (# of visits a COTA can do before the OT has to physically be there.. 10 visits or 30 calendar days)
- Re-evaluation
- Discharge Summary
How are DME and AD paid for in skilled nursing? Which equipment is included?
Part of Medicare Part A
Part of consolidated billing, no separate charge
Basic mobility and safety devices included in per diem rate
T/F If you want Part B insurance, you must buy into the system with monthly payments
True (121.80/month)
T/F Part B covers patients residing in a long term care setting
True
