The SNF PPS final rule - finally - Health Care Financing Administration's regulations affecting skilled nursing facility-based prospective payment system and consolidated billing - Editorial

Nursing Homes, Oct, 1999 by Jade Gong

* Overall management and evaluation of the care plan

* Observation and assessment of the patient's changing condition

* Patient education services

* Insertion and irrigation of suprapubic catheters

Anecdotally, many long-term care providers felt that the coverage criteria had been too restrictive and their ability to apply clinical judgment had been eliminated. Hopefully, the restoration of these examples will allow Medicare patient days to return to pre-PPS levels.

* MDS clarifications

Although the MDS was a familiar care-planning document to nurses prior to SNF PPS, it took on new meaning under SNF PPS. All nurses and other clinical staff must have a clear understanding of the following policy issues in order to effectively operate under SNF PPS:

Grace days: HCFA has clarified that all 8 days of the first assessment, including the grace days, are acceptable as the assessment reference date. Further, HCFA clarifies that they expect that many patients falling into the rehabilitation groups will have assessment reference dates falling on grace days. Nevertheless, HCFA does discourage the routine use of grace days for every Medicare admission.

Other Medicare Required Assessment (OMRA): HCFA has clarified that an OMRA is required 8 to 10 days after all rehabilitation therapy is discontinued. An OMRA is done only for those residents who continue to receive a skilled level of care. HCFA explains that if a beneficiary remains in skilled care following rehabilitation therapy, there must be a documented clinical reason for this continued stay. Use of 14-day look-back: HCFA clarified that the use of a "look-back" period in making RUGs-III assignments is considered a clinical proxy of the need for skilled care. There had been some concern about using a look-back period in qualifying a person for skilled care, when the service that was captured during this look- back period was discontinued prior to admission to the SNF (such as an IV medication administered in the previous 14 days). Providers should now feel comfortable using the look-back period to qualify patients for skilled care.

* Delay in new MDS Section U requirement

HCFA had intended to impose a new requirement for the collection of patient-specific medication information in a new MDS section, now referred to as Section U.

HCFA is now in the process of streamlining this section of the MDS to minimize the burden on SNFs, and the requirement has therefore been delayed until October 1, 2000.

* Therapy clarifications

The final rule contains many clarifications regarding the provision and tracking of therapy services under SNF PPS. However, two issues warrant specific mention. First, HCFA is requiring a physician signature on the plan of treatment prior to billing Medicare for these services (fax signatures are acceptable). In addition, HCFA has clarified that actual minutes of therapy provided should be recorded; these minutes should not be rounded up to intervals of 10 or 15 minutes.

* New payment rates for October 1, 1999