SNF/LONG-TERM CARE OPEN-DOOR FORUM REPORTS Here you can read highlights from the SNF/Long-term care open-door forums sponsored monthly by the federal Centers for Medicare and Medicaid Services. To receive notice of upcoming open-door forums, register at www.cms.hhs.gov/opendoor/. Click on a date to read recent forum summaries as reported by our principal editor Anna Rahman. March 4, 2005    March 31,2005    April 27,2005    May 26,2005    June 30,2005   August 30,2005 September 20, 2005    September 29, 2005    November 30, 2005    December 13, 2005    December 21, 2005    January 31, 2006    April 27, 2006    June 6, 2006    July 18, 2006    August 29, 2006    October 12, 2006    November 29, 2006    January 9, 2007    February 15, 2007    March 28, 2007    May 10, 2007    Sept. 13, 2007 Sept. 13, 2007 Forum Highlights: Medicaid Tamper-Resistant Medications: Effective Oct. 1, 2007, CMS will not pay for Medicaid-covered outpatient medications unless the written (and non-electronic) prescription is on a tamper-resistant pad. The law does not apply to prescriptions that are faxed, emailed, or phoned into a pharmacy. The law also includes exceptions for drugs provided in nursing facilities, intermediate care facilities for the mentally retarded, and other specified institutional and clinical settings. As stated in a CMS advisory letter to State Medicaid Directors (go to http://www.cms.hhs.gov/SMDL/downloads/SMD081707.pdf): To be considered tamper resistant on October 1, 2007, a prescription pad must contain at least one of the following three characteristics: one or more industry-recognized features designed to prevent unauthorized copying of a completed or blank prescription form; one or more industry-recognized features designed to prevent the erasure or modification of information written on the prescription by the prescriber; one or more industry-recognized features designed to prevent the use of counterfeit prescription forms. No later than October 1, 2008, to be considered tamper resistant, a prescription pad must contain all of the foregoing three characteristics. For more information, go to http://www.cms.hhs.gov/DeficitReductionAct/Downloads/Tamper.pdf. Or email your questions to Medicaid_integrity_program@cms.hhs.gov. SNF PPS Notice: CMS expects to publish corrections to the SNF PPS notice issued on August 3, 2007. The correction notice, which is expected in the next few weeks, will address a technical error in construction of the market basket and make minor changes to a wage index that affects two areas in New England. Change Request 5532: In response to questions received about CR 5532, which was published on June 29, 2007, CMS confirmed that this change request applies only to Part A services, and not Part B services. A Medlearn article on the topic (go to http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5532.pdf) explains CR 5532 as follows: “For skilled nursing facility (SNF) furnished services, including physical or occupational therapy or speech-language pathology services, to be covered, an initial therapy evaluation must take place within the SNF or your fiscal intermediary or A/B MAC will deny the claim under the SNF benefit.” Change Request 5624: This change request, which takes effect January 2, 2008, publishes Common Working File edits that identify periods when SNF consolidated billing edits should not be applied. CMS advises nursing home providers to review the Business Requirements section of the change request, which is available online at http://www.cms.hhs.gov/Transmittals/downloads/R1289CP.pdf. Change Request 5653: This change request clarifies the Medicare billing requirements for beneficiaries enrolled in Medicare Advantage (MA) Plans. A Medlearn article on the topic (go to http://www.cms.hhs.gov/Transmittals/downloads/R1290CP.pdf) notes that “CR5653 reminds SNFs (and Swing Bed (SB)) providers of the need to submit claims for such beneficiaries enrolled in MA plans and receiving skilled care in order to take benefit days from the beneficiary and/or update the beneficiary’s spell of illness information in Medicare systems.” CMS notes that, for now, SNFs can submit these covered claims with two condition codes—04 and 58. After January 1, 2008, covered claims may be submitted with only condition code 04. Change Request 5757: This change request, to be posted within the month, will list additional Common Working File edits that were incomplete when CR 5624 (described earlier) was published. Q&As: Following the CMS staff reports, the forum was opened to questions from audience members. MAY 10, 2007 Forum Highlights: SNF PPS Rule Change: CMS published in the May 4, 2007 Federal Register a proposed rule that would “update the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs), for fiscal year 2008. In addition, this proposed rule would revise and rebase the SNF market basket, and would modify the threshold for the adjustment to account for market basket forecast error.” You can access the proposed rule online at http://a257.g.akamaitech.net/7/257/2422/01jan20071800/edocket.access.gpo.gov/2007/pdf/07-2180.pdf. NPI Contingency Plan: CMS announced that it is implementing a contingency plan for covered entities (other than small health plans) who will not meet the May 23, 2007, deadline for compliance with the National Provider Identifier (NPI) regulations under the Health Insurance Portability and Accountability Act (HIPAA) of 1996. A CMS press release explains: “The enforcement guidance ...clarifies that covered entities that have been making a good faith effort to comply with the NPI provisions may, for up to 12 months, implement contingency plans that could include accepting legacy provider numbers on HIPAA transactions in order to maintain operations and cash flows.” To apply for an NPI, visit the National Plan/Provider Enumeration System (NPPES) website at https://nppes.cms.hhs.gov/. To view the contingency plan guidance, go to http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/NPI_Contingency.pdf. Invalid SNF Informational Unsolicited Responses: This inadvertent problem is best summarized in CMS’s change request (CR) 5587: “Providers need to be aware that (CMS) has identified an issue with processing outpatient, Part B, and DME (durable medical equipment) claims for beneficiaries who are in a SNF, but whose Medicare coverage for the SNF stay has ended. In October of 2006, Change Request (CR) 4292 was implemented. (This change request) mandated that providers submit ALL SNF non-pay claims after benefits were exhausted to allow CMS to track the beneficiary’s benefit period. “Medicare system changes relating to CR4292 caused outpatient, Part B, and DME paid claims that overlap non-pay SNF claims to be rejected. This is an error and…Medicare contractor(s) will adjust claims or payment recovery actions resulting from this problem. The CWF coding change to fix this problem was effective and in production on January 29, 2007 and CWF will provide a list of claims to the applicable contractors to allow for corrections and payment to be made to providers.” To access CR5587, go to http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5587.pdf. Money Follows the Person: CMS reported on this demonstration project, which is part of a coordinated effort to help states reduce their reliance on institutional care while developing community-based long-term care opportunities, enabling the elderly and people with disabilities to remain in their communities. <,br> In January 2007, 17 states received federal funding for demonstration projects that aim to transition 23,604 individuals out of institutional settings and back into the community over a five-year period. A second round of funding is in the works. For more information, visit CMS’s Money Follows the Person web page at http://www.cms.hhs.gov/DeficitReductionAct/20_MFP.asp. DME Competitive Bidding: CMS published a final rule in the April 10, 2007, Federal Register that aims to “improve the accuracy of Medicare's payments for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) through a new competitive bidding program.” CMS’s CMEPOS Competitive Bidding Implementation Contractor website (http://www.dmecompetitivebid.com/cbic/cbic.nsf/(pages)/home) includes this explanatory fact sheet for SNFs and nursing facilities: The DMEPOS Competitive Bidding Program applies to Skilled Nursing Facilities (SNFs) and Nursing Facilities (NFs) to the extent they furnish competitively bid items under Medicare Part B. SNFs and NFs may elect to participate in the program as “specialty suppliers” that furnish competitively bid items only to their own residents. SNFs and NFs that elect this option must check yes to the question, “Are you a specialty supplier?” on the bid form. SNFs and NFs are required to submit a bid and be awarded a contract in order to provide competitively bid items to their residents under Medicare Part B. SNFs and NFs that elect to be specialty suppliers may not furnish competitively bid items and services to Medicare beneficiaries outside their facilities for purposes of Medicare payment. If a SNF or NF is not selected as a contract supplier, it must use a contract supplier for the competitive bidding area (CBA) to furnish competitively bid items to its residents. For more information, call the Competitive Bidding Program helpline at 877-577-5331 or visit their website at http://www.dmecompetitivebid.com. Q&As: Following the CMS staff reports, the forum was opened to questions from audience members. MARCH 28, 2007 Forum Highlights: National Provider Identifiers (NPI): Medicare and other health plan providers must use their National Provider Identifiers (NPIs) in standard transactions starting May 23, 2007. Medicare will require NPIs on all electronic and paper claims. To apply for an NPI, go to http://www.nppes.cms.hhs.gov or call the enumerator at (800) 465-3203. Providers are advised to leave sufficient time before May 23 to test their NPI and resolve any problems that may arise. Failure to do so may result in delayed payments. According to CMS, “once you obtain your NPI, it is estimated that it will take 120 days to do the remaining work to use it. This includes working on your internal billing systems, coordinating with billing services, vendors, and clearinghouses, testing with payers.” For more information, visit the CMS website http://www.cms.hhs.gov/nationalprovidentstand. Medicare Administrative Contractor Procurement: Section 911 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 mandates that CMS replace the current contracting authority to administer the Medicare Part A and Part B FFS programs with a new Medicare Administrative Contactor (MAC) authority. Fifteen MACs will manage administration of Medicare Parts A and B, replacing the current fiscal intermediaries. The first MAC was awarded on July 31, 2006, in Jurisdiction 3, which covers the states of Arizona, Montana, North Dakota, South Dakota, Utah, and Wyoming. In the next cycle, seven more MACs will be awarded through a request for proposal (RFP) process. The remaining seven MACs also will be awarded through RFPs. Four of these MACs will also manage claims from home health and hospice agencies. The REF for this last group of MACs was publiches in the Federal Register (go to http://www.fedbizopps.gov). For more information, visit the CMS website http://www.cms.hhs.gov/medicarecontractingreform. Comments or questions should be send to section911@cms.hhs.gov. STRIVE: CMS’s Staff Time and Resource Intensity Verification (STRIVE) project has thus far visited 141 nursing homes in eight states to collect staff time and resident-level clinical data regarding health status, medical conditions, services received, and facility resources used to provide care for all types of residents. Ultimately the STRIVE project will collect data from 9,000 residents in 200 nursing homes in 14 states. CMS expects to complete all field work and begin analyzing the data this summer. The results will be used to recalibrate RUGS. Questions about Services for Non-residents: CMS has received questions about nursing homes providing therapy services to non-residents. In response, CMS is working to develop ways—short of a survey and certification letter--to monitor the quality of such services. Post-Acute Care Patient Assessment: CMS is a developing a post-acute care patient assessment to be completed when hospital patients are discharged to post-acute care facilities, including nursing homes, home health agencies, and long-term-care hospitals. The assessment will be an internet-based tool called CARE, for Continuity Assessment Record and Evaluation. CMS has awarded three contracts related to the assessment. Research Triangle International is developing the assessment tool and in January, 2008, will launch and manage the demonstration project to test it. Northrup Grummon will develop the web-based tool. CMS will host a future Open Door Forum to report on the project’s progress. Update: As of March, 2007, CMS is accepting dual use of the UB04 and UB92 forms. No Pay Billing: A transmittal letter is currently under review for clarification of no-pay billing requirements when providers are trying to process their Part B 210 no-payment bill claims when a previously paid 22X claim is already in process. CMS expects approval of the transmittal in about two weeks. Also, some providers trying to bill 22X bill types are receiving an edit for consolidating billing due to previously paid SNF 21X claims. These claims are being rejected in error for consolidated billing. A by-pass to prevent these errors is expected to take effect April 12, 2007. Webcast on “Improving Nursing Home Quality and Payment”: This CMS-sponsored webcast aired on March 23, 2007. This two-hour program was designed to meet three objectives: To inform nursing home staff about the “Advancing Excellence in America’s Nursing Homes” campaign, a two-year, coalition-based initiative concerned with how we care for elderly and disabled citizens. To provide an MDS 3.0 review of resident assessment approaches and tools to assess resident’s depression and pain. To provide information regarding CMS’s national nursing home time study titled Staff Time and Resource Intensity Verification (STRIVE). You can register to view this archived webcast at http://www.cms.internetstreaming.com. The webcast is approved for 2 continuing education credits (CEUs). A Clarification: CMS clarified that Change Request 5405, Transmittal 65, applies to hospitals but not to skilled nursing facilities. A question-and-answer session followed the CMS staff reports. FEBRUARY 15, 2007 Forum Highlights: Post-Acute Care Patient Assessment: CMS is a developing a post-acute care patient assessment to be completed when hospital patients are discharged to post-acute care facilities, including nursing homes, home health agencies, and long-term-care hospitals. CMS hosted a well-attended Open Door Forum on the topic in December. The agency is now in the development phase for the instrument. The next phase entails convening a technical expert panel in March to respond to assessment items currently under consideration. If you have questions or comments about the assessment instrument, please submit them to pat-comments@rti.org. Restorative Nursing: Questions have arisen about restorative nursing and maintenance as they pertain to the MDS. The best reference to consult for answers is the RAI User’s Manual for MDS 2.0, especially Chapter 3, Section P3, pages 191-197. That manual is available online at http://www.cms.hhs.gov/nursinghomequalityinits/20_nhqimds20.asp (scroll down to the “Downloads” section). For state-specific information about restorative nursing, contact your state RAI coordinator. A directory of state coordinators is available in Appendix B of the RAI User’s Manual. SNF Advance Beneficiary Notice (ABN): CMS has completed its evaluation of comments concerning the SNF ABN and is moving toward finalizing the notice, with an implementation date of July 2007. Questions and answers about the SNF ABN are available online at http://www.cms.hhs.gov/bni. If you have questions or comments about the ABN, please submit them to charlayne.van@cms.hhs.gov. Consolidated Billing: CMS learned that some claims submitted in “benefits exhaust” and “no payment” situations have been incorrectly rejected. The agency has now corrected these problems. Some facilities also erroneously received unsolicited responses. CMS corrected this problem in late January. Another system problem, this one pertaining to histories, was fixed in early February, 2007: CMS will now read only SNF claims histories that contain admit dates on or after October 1, 2006. On March 10, 2007, CMS will run a utility on all claims affected by these programming problems. At about that time, CMS also will send a report to contractors to fix the problematic claims. CMS is currently working to correct another problem related to no-pay bills. This problem occurs when providers submit no-pay bills that overlap with previously processed Part-B bill types and they receive an error which their in-patient 210 bill type cannot process. CMS is working on a possible work-around to this problem. The agency will report the final outcome to providers via the Open Door Forum listserv and in a future Medlearn article. With respect to individual questions about no-pay bills, providers should contact their fiscal intermediaries, which are responsible for providing training and education to providers. If a facility is dissatisfied with the intermediary’s response, the provider should contact the CMS regional office. If warranted, the regional office will contact CMS’s central office for assistance. Clarifications Regarding Quality Measures: Questions raised during an earlier Open Door Forum about publicly reported nursing home quality measures prompted CMS to clarify how these measures are derived. Specifically, there was no change in September 2005 to the publicly reported measures on the Nursing Home Compare website. The assessment selection criteria for chronic care measures are unchanged. Assessments for the chronic care measures are selected for the most recent three-month target quarter, not the most recent 180-day period. The only change made in summer 2005 was the addition of the quality measures to the quality indicator report available to facilities through the KEY system. CMS also reported that as of October 2006, facilities with a limited number of chronic care patients are excluded from the requirement to report chronic care measures unless they have at least 30 non-PPS quarterly assessments in the previous year. With this change, it is unlikely that residents who are frequently readmitted to SNFs from other settings will be counted in calculations for the chronic care measures. Finally, CMS reported that the Pay for Performance demonstration will likely use a subset of MDS outcome measures, but these will be calculated in the same way for all participating facilities, so there should be no bias against any one facility. If you have questions about the quality measures, please submit them to robert.connolly@cms.hhs.gov. Q&A Session: CMS representatives answered questions from forum audience members. JANUARY 9, 2007 Forum Highlights: 9th Scope of Work: CMS invites comments on the 9th Scope of Work (SOW) for state Quality Improvement Organizations (QIOs). The 9th SOW takes effect August 1, 2008. Information about the current 8th SOW can be found online at http://www.cms.hhs.gov/QualityIMprovementOrgs/04_9thsow.asp#TopOfPage. During the October 2006 SNF/Long-term-care Open Door Forum, CMS officials reported that the QIO program would likely be revamped with the 9th SOW in accordance with recommendations from a White Paper released by the Institute of Medicine (IoM) on March 9, 2006. That paper can be accessed online at http://www.iom.edu/CMS/3809/19805/33411.aspx. Send comments regarding the 9th SOW to Jacky Harley at Jaqueline.Harley@cms.hhs.gov or contact her at 410-786-5781. The deadline for receipt of comments is January 31, 2007. MDS 3.0: The bulk of the onsite work to develop and test the MDS 3.0 has been completed. Although an implementation date has not been set, CMS expects to complete the national evaluation by the end of 2007 or early 2008. Information about the MDS 3.0 can be accessed online at http://www.cms.hhs.gov/NursingHomeQualityInits/25_NHQIMDS30.asp. That webpage provides this progress report on the MDS 3.0: Phase 1: Town Hall, Stakeholder and Expert Review (Completed) Phase 2: Partnership with Veteran Administration (VA) on Validation Protocol Research (Completed) Phase 3: April 2006 Integration and Alignment Expert Workgroup Review (Completed) Phases 4 & 5: Plans Nursing Home National Onsite Validation Testing and Analysis and Final Revisions (Underway) Revised Draft MDS 3.0:The draft version of the MDS 3.0 dated June 30, 2006, which contains a written introduction to MDS 3.0 and items that are being tested and may be changed after analysis, is also available as a download. It should be noted that many current MDS 2.0 items will not be changed and are not included in this draft. (Working Draft) A draft version of the MDS 3.0, dated June 30, 2006, is available online at http://www.cms.hhs.gov/NursingHomeQualityInits/downloads/MDS30Draft.pdf. Therapy Cap Exceptions: CMS reported that all requests for therapy cap exceptions must be submitted electronically; the agency will not accept manual submissions. Any justifiable therapy cap exception can be submitted. CMS will host an Open Door Forum on therapy cap exceptions in late January or early February, 2007. Buyer Beware: Nursing home providers occasionally contact CMS officials to verify information that they—the providers—have received from consultants or health care articles. Regrettably, time constraints often prevent CMS staff members from responding to such requests; however, providers can consult an authoritative source online: the RAI Users Manual, available at http://www.cms.hhs.gov/nursinghomequalityinits/20_nhqimds20.asp (scroll down to the “Downloads” section). Medicare Contractor Provider Satisfaction Survey (MCPSS): In the first week of January, the 2007 MCPSS was distributed to a new sample of 3500 Medicare physicians and providers. CMS encourages all physicians and providers who are selected to participate to complete and return their surveys. The results and feedback from the survey will be provided to CMS contractors so that they may implement process improvement initiatives. More information about the MCPSS is available online at https://www.mcpsstudy.org/default.asp. RAI Users Manual: Several commercial publishers printed incorrect pages within chapter 3 of the RAI Users Manual. Nursing home providers should consult the June 2006 revisions; the draft version dated May 2006 contains errors. The RAI manual and its updates are available at http://www.cms.hhs.gov/nursinghomequalityinits/20_nhqimds20.asp (scroll down to the “Downloads” section). No Pay Bills: CMS recently published a Spell of Illness chart to help nursing home providers better understand when to submit no-pay claims. You can access the chart online at http://www.cms.hhs.gov/OpenDoorForums/Downloads/SNFspellofillnesscheatsheet010907.pdf. New Surveyor Guidance Regarding Unnecessary Drugs: CMS recently revised the surveyor guidance for F329, Unnecessary Drugs, and the guidance for Pharmacy Services. These changes, which took effect in December, 2006, are reflected in recent revisions to Appendix P and PP of the State Operations Manual: Survey Protocol for Long Term Care Facilities. These appendices can be accessed online at http://www.cms.hhs.gov/transmittals/downloads/R22SOMA.pdf. On December 15, 2006, CMS broadcast a satellite Webcast on the revised guidance. You can view the archived Webcast by first registering online at http://www.cms.internetstreaming.com. Q&As: Following the CMS staff reports, the forum was opened to questions from audience members. NOVEMBER 29, 2006 Forum Highlights: Quality of Care, Survey and Certification Process: CMS issued a new survey guidance on October 15, 2006, pertaining to influenza and pneumonia immunizations. The guidance also adds to Appendix PP of the CMS Manual System a new regulatory tag, F334, for influenza and pneumococcal immunizations. The guidance replaces survey instructions found in the CMS survey and certification letter 06-03, issued on November 17, 2005. The new guidance took effect October 16, 2006. You can access the guidance online at http://www.cms.hhs.gov/transmittals/downloads/R21SOMA.pdf. Unnecessary Drugs: CMS revisions to the survey guidance for F329, unnecessary drugs, are scheduled to take effect December 18, 2006. An advance copy of the survey and certification letter, #06-29, is available from this CMS Survey & Certification webpage: http://www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=4&sortOrder=ascending&itemID=CMS1186880 (scroll down to “Downloads” to access a Zip file containing the letter to surveyors). CMS will broadcast a satellite Webcast on the revised guidance on December 15, 2006, at 1 p.m. (EST). The Webcast is mandatory for nursing home surveyors. You can register online at http://www.cms.internetstreaming.com. Culture Change: CMS is broadcasting a series of four satellite Webcasts on aspects of culture change in nursing homes. The first Webcast, on integrating individual care and quality improvement, was held November 3, 2006, and was mandatory for supervisors of nursing home surveyors. The schedule for upcoming Webcasts in 2007 follows: February: Transforming systems to achieve better clinical outcomes April: Clinical case studies in culture change September: The “how” of culture change You can register for these Webcasts and access archived Webcasts, including the November 3rd program, at http://www.cms.internetstreaming.com. Consolidated Billing: CMS issued on September 29, 2006, Change Request 5283, which lists the 2007 changes to HCPCS (Changes to Healthcare Common Procedure Coding System) codes and Medicare Physician Fee Schedule designations that will “be used to revise CWF edits to allow carriers and FIs to make appropriate payments in accordance with policy for SNF consolidated billing.” You can access the change request online at http://www.cms.hhs.gov/transmittals/downloads/R1068CP.pdf. More information is available from this “MLN Matters Articles” webpage: http://www.cms.hhs.gov/MLNMattersArticles/2006MMAN/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=8&sortOrder=ascending&itemID=CMS1187342. Therapy Caps: CMS issued on November 9, 2006, Change Request 5271, which clarifies contractor instructions related to the therapy cap exception process. You can access the change request online at http://www.cms.hhs.gov/transmittals/downloads/R171PI.pdf. An overview of the upcoming changes, which take effect January 1, 2007, is available from the MLN Matters Article at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5271.pdf. According to this article, “Coverage by Medicare will be limited for outpatient physical therapy (PT), speech-language pathology (SLP), and occupational therapy (OT) services for services received on January 1, 2006 through December 31, 2006. The limits are $1,740 for PT and SLP combined and $1,740 for OT.” Automatic Sprinkler Systems: CMS on October 27, 2006, published a proposed rule in the Federal Register that would require all long-term-care facilities to install and maintain automatic sprinkler systems throughout their buildings as a condition for participating in Medicare and Medicaid. CMS is soliciting public comments concerning the proposed rule and is especially interested in feedback on an appropriate phase-in period for facilities. The comment period closes at 5 p.m. on December 26, 2006. You can access the proposed rule as well as instructions for submitting comments from the Federal Register at http://a257.g.akamaitech.net/7/257/2422/01jan20061800/edocket.access.gpo.gov/2006/pdf/E6-17911.pdf (the proposed rule appears at the bottom right-hand corner of this page). SNF ABN Town Hall Meeting and Q&A Document: CMS hosted on September 26, 2006 a town hall meeting on the advance beneficiary notice (ABN). Now the agency has published the questions and answers from that meeting online at http://www.cms.hhs.gov/BNI/Downloads/SNFABN%20Town%20Hall%20Follow-Up.pdf. For more information about the town hall meeting, go to http://www.cms.hhs.gov/BNI/04_FFSSNFABNandSNFDenialLetters.asp#TopOfPage. No Pay Bills: The “keeper of the keys” on this issue, CMS’s Jason Kerr, was unavailable to present at this forum, but will answer questions about no-pay bills at the next forum. Meantime, you can email your questions to Jason at jason.kerr@cms.hhs.gov. Q&A Session: CMS representatives answered questions from forum audience members. OCTOBER 12, 2006 Forum Highlights: Medicare Contractor Provider Satisfaction Survey (MCPSS): CMS reported results of the MCPSS survey, which was conducted for the first time this year. Overall, the majority of providers were satisfied with their Medicare contractor. Eighty-five percent of the respondents rated their contractor 4-6, with 6 indicating complete satisfaction. The two most powerful predictors of satisfaction were the handling of provider inquiries and claims processing. To read more about the survey results, go to http://www.mcpsstudy.org. The survey will be conducted annually, with the 2006 results serving as a baseline. Results will be used to make improvements to the Medicare program. Questions, comments, and suggestions regarding the survey should be emailed to mcpss@westat.com. Consolidated Billing: Changes to Healthcare Common Procedure Coding System (HCPCS) codes will be posted online at http://www.cms.hhs.gov/SNFConsolidatedBilling/ during the first week in December. Providers should note that flu and pneumonia vaccinations are excluded from the SNF global per diem rate, but are subject to consolidated billing. Hence, SNFs should bill separately for these immunizations. For more information about HCPCS codes for SNF consolidated billing, go to http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5283.pdf. Quality Improvement Organizations (QIOs): CMS is drafting the 9th Scope of Work (SOW) for QIOs, which will take effect August 1, 2008. In this next SOW, CMS intends to revamp the QIO program, largely in response to a White Paper released by the Institute of Medicine (IoM) on March 9, 2006. This paper proposed “a major restructuring of (the QIO program) so that it can become an important national resource integral to strategies of performance measurement, public reporting, and payment incentives.” IoM further recommended that “The QIO program should focus on offering, through its infrastructure in each state, technical assistance to providers and practitioners aimed at building their capacity for quality improvement (http://www.iom.edu/CMS/3809/19805/33411.aspx).” CMS must deliver a preliminary report on the 9th SOW to the agency’s acting administrator by October 27, 2006. Your comments and suggestions are welcome. Email them to jharley@cms.hhs.gov or call Ms. Harley at 410-786-5781. Nursing Home Quality Campaign: CMS officially launched this campaign, which seeks to develop “deep partnerships” with professional organizations involved in long-term care, at a one-day summit on Friday, Sept. 29, at the National Academy of Sciences Building in Washington, D.C. The campaign’s goal is to achieve measurable nursing home quality improvement in eight areas: Reduce pressure ulcer prevalence Reduce the prevalence of physical restraints Reduce the prevalence of pain in short-stay residents Reduce the prevalence of pain in long-stay residents Encourage 90% of nursing homes to set quality improvement targets for the above goals Engage nursing homes in measuring resident satisfaction Measure and reduce staff turnover, particularly turnover among nurse staff Work with culture change advocates to achieve the consistent assignment of nursing aides to residents in a facility The campaign is spearheaded by a coalition of 12 organizations, including CMS. It will run for two years, after which CMS will analyze and publish the outcomes. You can learn more about the campaign, including how your organization can get involved, by visiting the campaign’s website at http://www.nhqualitycampaign.org. MDS Coding: Web-Based Training: CMS recently launched a web-based reference and training tool for the Minimum Data Set (MDS), Version 2.0. Topics addressed include the Resident Assessment Instrument (RAI), the assessment schedule for the RAI, an item-by-item guide to the MDS, a guide to completing the Resident Assessment Protocols (RAPs), submission and correction of the MDS, and the Medicare Skilled Nursing Facility Prospective Payment System. Check it out at http://www.mdstraining.org/upfront/u1.asp#. Immunization Quality Measures: This month, CMS released four new quality measures pertaining to resident immunization for influenza and pneumonia. The new quality measures are: The percentage of long-stay residents who were given influenza vaccination during the flu season The percentage of long-stay residents who were assessed and given pneumococcal vaccination The percentage of short-stay residents who were given influenza vaccination during the flu season The percentage of short-stay residents who were assessed and given pneumococcal vaccination For the influenza vaccination, the target period for MDS record selection is October 2005-March 2006. The target period for pneumococcal vaccination is January 1, 2006 through June 20, 2006. Facilities should have received by now their quality measure reports with the new measures included. Resident exclusions for the flu vaccine include: Resident was not residing in the facility during the flu season Resident was not medically eligible for the vaccine or refused the vaccine Facility was unable to obtain the vaccine For the pneumonia vaccine, residents are excluded if they were offered but refused the vaccine. A User’s Manual Supplement for the vaccinations is available online at http://www.cms.hhs.gov/NursingHomeQualityInits/downloads/NHQIVaccinationSupplement.pdf. Nursing Home Improvement Action Plan: The 2007 Action Plan for (Further Improvement of) Nursing Home Quality is available online at http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/2007ActionPlan.pdf. The report addresses five topics: Consumer awareness and assistance Surveys, standards, and enforcement processes Quality improvement Quality approaches through partnerships Nursing home quality-based purchasing Nursing Home Value-based Purchasing Demonstration: CMS released in June an online preliminary design of this demonstration project, formerly known as the Pay for Performance project. The report is available at http://www.cms.hhs.gov/DemoProjectsEvalRpts/downloads/NHP4P_FinalReport.pdf. In September, CMS retained implementation contractors—Abt Associates and the University of Colorado Health Sciences—for the demonstration project. These contractors currently are refining the preliminary design with an eye toward conducting a two-stage solicitation process. First, they will mail solicitation letters to state Medicaid directors and from the applicants, select 4-5 participant states along with two alternates. In stage two, they will select participant nursing homes from each of the participating states. Your comments, questions, and suggestions are welcome. Email them to nursinghomeqbp@cms.hhs.gov. Consolidated Billing: Web-based Training: In September, CMS posted on its Medicare Learning Network website a web-based module on consolidated billing. To access the module, click here. The course is designed to help providers who need information about the following: Skilled Nursing Facilities (SNFs) SNF consolidated billing "Under arrangement" agreements between SNFs and other providers or suppliers The SNF ABN Town Hall Meeting: CMS’s Town Hall meeting to solicit feedback about the Advance Beneficiary Notice drew an estimated 600 participants on September 20. Questions and Answers: A Q&A session followed the CMS presentations. AUGUST 29, 2006 Forum Highlights: Advance Beneficiary Notice: CMS recently completed and released a draft of the SNF Advance Beneficiary Notice (you can view the draft online at http://www.cms.hhs.gov/BNI/Downloads/SNFABN%20Revised%20Draft.8.24.2006.pdf). Now the agency is inviting feedback on the ABN from providers and other stakeholders. CMS will host a town hall meeting to discuss the ABN draft on September 26, from 1-4 p.m. EST, at CMS’s central office in Baltimore. If you are unable to attend the meeting, you can still participate via teleconference (same day, same time). The toll-free number to call is 1-888-889-6348; the participant passcode is 9413933#. Be aware that this is a listen-only conference call. You will be unable to ask questions or make comments during the meeting. However, you can submit questions or comments prior to the meeting by writing to: CMS MEAG/DCP 7500 Security Blvd. Mail Stop C2-12-16 Baltimore, MD 21244 Attn: Charlayne Van You can also fax your comments and questions to 410-786-8883 or email them to Ms. Van at charlayne.van@cms.hhs.gov. UB04: CMS’s National Uniform Billing Committee (NUBC) is updating the UB-92, which will be replaced by the UB-04. Submitters, including nursing homes, can use the UB-92 form through March 1, 2007. During a transitional period from March 1, 2007 through May 22, 2007, providers that use paper forms for claim submission may submit either the UB-92 or the UB-04 form. Starting May 23, 2007, all institutional paper claims must use the UB-04. CMS recommends that billing staffs start now to become familiar with the new form to ensure a smooth transition with no interruption in bill payments. More information is available online from CMS at http://www.cms.hhs.gov/ElectronicBillingEDITrans/15_1450.asp. DAVE II: CMS contractors reported on progress with DAVE II, the second round of CMS’s Data Assessment Verification project. The project’s goal is to measure and improve the accuracy of the Minimum Data Set (MDS). DAVE staff measure accuracy through reviews conducted by project nurses during onsite visits in nursing homes. Participating facilities constitute a national probability sample; that is, they are randomly selected from all of Medicare’s participating facilities. Within each selected home, project staff review a random selection of recently completed MDS assessments. In this way, DAVE 2 results can be generalized to all MDS assessments. Two types of reviews are conducted in each participating facility. The first is a retroactive medical record review, wherein project nurses complete the MDS based on a resident’s chart information. The nurses complete the MDS for a sample of residents who were 1) recently assessed, 2) recently discharged, and 3) recently re-entered the facility. The project compares the MDS assessments completed by project nurses with those completed by the facility staff to identify any discrepancies. For the second review, project nurses conduct their own MDS assessments of a resident sample and compare their findings to the facility staff findings. For this “two-stage review”, the DAVE staff sits down with the facility staff to discuss and reconcile their MDS assessment findings. During the first quarter, April-June, 2006, DAVE 2 staff visited about 35 facilities in 15 states, completing about 650 medical record reviews and about 58 two-stage reviews. Preliminary results are not being reported for the two-stage reviews at this time due to the small sample size. With respect to the medical record reviews, of the 77 items reviewed across all types of MDS assessments, the discrepancy rate ranged from 0-22%, with an average of about 4%. In other words, on average, the DAVE staff and facility staff agreed on MDS items 96% of the time. However, there were more significant discrepancies on a few of the items. The contractors identified a few common problems. Where there are discrepancies, facility staff have self-reported that they have not read the RAI manual in a long while or have not kept current on updates to the manual. The lesson to draw here: Read the RAI manual. Discrepancies sometimes occurred because facility staff either skipped items by mistake or neglected to validate that an item needed to be changed. What often happens in either instance is that the facility’s computer will automatically report the prior MDS information on the new assessment. Also common were discrepancies in Section G, which addresses support for activities of daily living (ADLs). Areas of confusion often centered around therapy terminology and case mix definitions. Discrepancies in discharge tracking forms and discharge dates also occurred. The confusion seems to stem from the discharge coding requirements noted in the RAI manual and the facility’s bed-hold policies. Eventually, the DAVE II project will publish tip-sheets to help nursing home staff avoid MDS errors. Claims Hold: As noted on the CMS website (go to http://www.cms.hhs.gov/transmittals/downloads/R944CP.pdf), “The Deficit Reduction Act of 2006 requires a one-time hold on Medicare payments for the period of September 22, 2006-September 30, 2006. Payment on claims that would have otherwise been paid on one of these 9 days will be made on the first business day of October 2006.” CMS reported that it will start paying held claims on October 2, 2006. It may take two or three days to process the backlog. MDS 3.0: CMS contractors are expected soon to start validating the latest draft of the MDS 3.0 and complete their evaluation near the end of 2007. The current draft builds on input from long-term-care experts, providers, and other stakeholders. The draft will be validated in 70 facilities in eight states. At the same time, about 20 Veterans Administration facilities will also test the MDS 3.0 draft. The MDS contractors are coordinating their activities with those of CMS’s Staff Time and Resource Intensity Verification (STRIVE) project. No Pay Bills: CMS followed up on prior forum questions pertaining to no pay bills. Three questions were addressed: Question: If a facility has all certified beds but the incoming resident requires intermediate care, not skilled care, must the facility submit a no pay bill? Answer: No. Question: If a SNF resident elects hospice coverage, must the facility submit a no pay bill? Answer: No. Question: If a resident enters for short-term respite care, must the facility submit a no pay bill? Answer: No. Q&As: Following the CMS staff reports, the forum was opened to questions from audience members. JULY 18, 2006 Forum Presentation: This was a special open door forum on survey and certification with a focus on CMS’s quality of care initiatives. CMS’s Long Term Care Task Force: CMS created this task force in 2004 in order to strengthen internal collaboration within the agency and align its long-term care initiatives. One of its first tasks was to publish a nursing home action plan, which addresses four themes: Consumer awareness and information Surveying and monitoring Quality improvement Quality approaches through partnerships The upcoming action plan will address a fifth theme—quality-based purchasing—which will examine how Medicare and Medicaid can use their purchasing power to “better recognize differences (among nursing homes) in quality.” Culture Change: CMS is working to support this national grassroots movement, which aims to change the traditional medical model of care prevalent in nursing homes to a social model that empowers residents and the staff who work most closely with them, primarily nurse aides. CMS recently developed a 79-item questionnaire, called Artifacts of Culture Change, which enables nursing homes to assess their progress toward implementing culture change strategies. The tool is available free online at http://siq.air.org. CMS points out that this is not a regulatory questionnaire whose results surveyors will review; rather it is intended for internal quality improvement purposes. CMS welcomes providers’ feedback on the tool. Email comments to Karen.schoeneman@cms.hhs.gov. Nursing Home Quality Campaign: CMS will officially launch this campaign, which seeks to develop “deep partnerships” with professional organizations involved in long-term care, at a one-day summit on Friday, Sept. 29, at the National Academy of Sciences Building in Washington, D.C. Spokespersons for the campaign are former Speaker of the House Newt Gringrich and former U.S. Senator Bob Kerrey. The campaign’s goal is to achieve measurable nursing home quality improvement in eight areas: Reduce pressure ulcer prevalence Reduce the prevalence of physical restraints Reduce the prevalence of pain in short-stay residents Reduce the prevalence of pain in long-stay residents Encourage 90% of nursing homes to set quality improvement targets for the above goals Engage nursing homes in measuring resident satisfaction Measure and reduce staff turnover, particularly turnover among nurse staff Work with culture change advocates to achieve the consistent assignment of nursing aides to residents in a facility The organizations that worked with CMS in the initial planning of the campaign are: American Association of Homes and Services for the Aging American Health Care Association American Medical Directors Association Alliance for Quality Nursing Home Care National Citizens Coalition for Nursing Home Reform The campaign will run for two years, after which CMS will analyze and publish the outcomes. A campaign website is under construction. Quality Indicator Survey Process: This five-state demonstration started last October in Ohio, Connecticut, Louisiana, Kansas, and California, and will continue through the end of 2006, with an evaluation report due in early 2007. Two teams working in each demonstration state are testing a two-stage survey process, with the second stage investigating compliance issues. Compared to the usual survey process, this new initiative uses a more structured process and a larger resident sample. It does not depart from current law or significantly reinterpret CMS’s guidances to surveyors. In the coming year, the demonstration will be expanded to two states—Kansas and Florida—in an effort to examine training issues. Based on the initiative’s final evaluation, CMS will decide whether to adopt this new survey process nationally. If it does, the process will be phased in over a longer period of time than is customary for most new CMS initiatives. Quality-based Purchasing: Formally known as pay for performance, this demonstration project will test the quality-based purchasing concept in nursing homes before national implementation. CMS will set performance standards based on selected measures of quality improvement. High-performing facilities or those that demonstrate substantial improvement in quality will be eligible to receive payment awards. The program will be budget-neutral, with payment awards based on the estimated savings that accrue to Medicare as a result of improved care in nursing homes. A detailed design report is available online at http://www.cms.hhs.gov/demoprojectsevalrpts/md/list.asp (scroll down to Nursing Home Quality-based Purchasing). CMS currently is selecting states for the demonstration, and then will select facilities within those states. It also is selecting a contractor to implement the demonstration. That contract is expected to be awarded in August 2006. A public meeting to present the plan is in the works and will be announced online. If you have questions or comments about this demonstration project, submit them to nursinghomeqbp@cms.hhs.gov or Ronald.lambert@cms.hhs.gov. Surveyor Guidance on Influenza and Pneumonia Immunizations: CMS expects to release the surveyor guidance on influenza and pneumonia immunizations at the end of August, along with a PowerPoint training program for surveyors. The agency also expects to publish the surveyor guidance on paid feeding assistants in January, 2007. Nursing Home Staffing: About a year ago, CMS on its Nursing Home Compare website began reporting staffing data separately for hospital-based facilities and skilled nursing facilities for short- and long-stay residents, a stratification that allows for a fairer comparison of these facilities. In 2003, CMS embarked on an effort to develop staffing quality performance measures. Phase I of this project ended in 2005; Phase II recently started. In this second phase, CMS’s Office of Clinical Standards and Quality will continue to develop, refine, and test the quality measures established in Phase I. Meanwhile, the Division of Nursing Homes will assess the best and most accurate way to collect nursing home staffing data. Of particular interest is the potential to submit the data electronically based on payroll records. Eventually, CMS expects to conduct a field test that examines the feasibility, burden, and cost of submitting staffing data electronically. Staff Time Study (STRIVE): CMS’s Staff Time and Resource Intensity Verification (STRIVE) project will provide accurate information for updating the RUG-III payment system used by Medicare and some Medicaid agencies. The project also is designed to determine the nurse aide and ancillary staff resources needed to provide quality care to residents. Project staff are visiting nursing homes to collect staff time and resident-level clinical data regarding health status, medical conditions, services received, and facility resources used to provide care for all types of residents, from those receiving immediate post-hospital care to those receiving long-term chronic care. CMS is working collaboratively with federal, state, and private partners to conduct the study. Among its partners is the Association of Nurses in AIDS Care (http://www.anacnet.org/index.php), which offers continuing education units for nursing home staff that volunteer to support the STRIVE project. Nursing Home Compare Website: Starting in October, CMS will include on its consumer education site reports on nursing homes’ life safety and fire safety deficiencies and their automatic fire extinguishing systems. Q&As: Following the CMS staff reports, the forum was opened to questions from audience members. JUNE 6, 2006 Forum Announcements: National Provider Identifiers: CMS reminded health providers to obtain their National Provider Identifier (NPI). NPIs are being issued in accordance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996, which mandated the adoption of standard unique identifiers, or NPIs, for all Medicare healthcare providers. CMS has developed the National Plan and Provider Enumeration System (NPPES—home page: https://nppes.cms.hhs.gov/NPPES/Welcome.do) to assign these unique identifiers. There are three ways to obtain an NPI: You can apply online at https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.instructions. The process takes about 20 minutes. You can fill out a paper application and mail it to NPPES. The paper application is available online at http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/NPIapplication.pdf. Not presently, but eventually you will be able to submit the application through a process known as “electronic file interchange” (EFI), also referred to as bulk enumeration, because a single organization applies for NPIs on behalf of several health providers. For more information about EFI, visit the EFI website at http://www.cms.hhs.gov/NationalProvIdentStand/07_efi.asp. For more information about NPIs, contact NPPES at (800) 465-3203 or visit its home page at https://nppes.cms.hhs.gov/NPPES/Welcome.do. SNF Update Notice for 2007: Rather than issue a new rule with policy changes, CMS will simply update payment rates for nursing homes using the already approved methodology for calculating the wage index, which in turn is used to calculate payment rates. July Open Door Forum: The SNF/Long-term Care Open Door Forum scheduled for July 18 will be devoted to survey and certification, addressing current issues and new initiatives. Please spread to work to staff and colleagues. Forum Presentations: DAVE 2: A representative of Abt Associates, the CMS contractor for the second installment of the Data Assessment Verification project (DAVE 2), reported that DAVE staff in the past eight weeks visited nursing facilities in Arizona, California, Indiana, Massachusetts, New Jersey, New York, Ohio, Virginia, and Tennessee (facilities are selected randomly). Typically, a two-person nurse team is on site at each selected facility for about three days conducting a medical records audit, examining recent MDS assessments, reviewing sample discharge and reentry forms, and conducting their own independent MDS assessment of recently assessed residents so that they can compare their findings to the facility’s staff findings. They discuss their review results with facility staff and provide education and information as needed to resolve discrepancies in MDS coding. They refer facilities to their state REI coordinators for further information. The Abt Associates representative pointed out that DAVE 2 is focused primarily on assessing data accuracy; it is not a payment review. This focus is in contrast to the first DAVE project, which did aim to recoup payments from facilities with significant coding inaccuracies. Data is not yet available from the project, but initial findings will be shared with the long-term-care community and common coding problems will be identified. Additionally, the project will generate educational materials to help facilities improve their data accuracy. The project also will soon launch a website that can be accessed via CMS’s Nursing Home Quality Initiative home page at http://www.cms.hhs.gov/NursingHomeQualityInits/. A fact sheet about DAVE 2 is available online at http://www.cms.hhs.gov/NursingHomeQualityInits/Downloads/MDS20DAVE2FactSheet.pdf. If you have questions, you can also contact Abt Associates at DAVE2@abtassoc.com. STRIVE: CMS’s Staff Time Measurement Study, also known as STRIVE, will start next week in Iowa, with other states scheduled through spring of 2007. This project, like DAVE 2, uses a random sample of nursing facilities. In other words, facilities cannot volunteer to participate. Audit and Recovery Actions: CMS is currently about one year into a three-year demonstration project in California, New York, and Florida that aims to identify whether the use of Recovery Audit Contracts (RACs) will be a cost-effective means of ensuring that Medicare providers receive correct payments and to ensure that taxpayer funds are used for their intended purpose, You can read more about this project in the following Medlearn articles: SE0469 (available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0469.pdf); SE0565 (available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0565.pdf); and SE0617 (available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0617.pdf). If you have questions about the RAC, contact Connie Leonard at connie.leonard@cms.hhs.gov or recoveryauditdemo@cms.hhs.gov. National Provider Indentifiers: All Medicare providers will eventually need a National Provider Indentifier (NPI), though the deadline for obtaining one is unclear at this time. For enrollment purposes and claims processing, facilities do not need an NPI until May of 2007. Word has it, however, that NPIs may be needed before that deadline, and possibly as early as July, 2006, for recertification purposes. SNF/Long-term Care Open Door forum staff will try to verify when NPIs are needed for recertification provider agreements and report back to us. Therapy Caps and KX Modifier: Under the new rules, effective Jan., 2006, regarding therapy caps, providers “must include a KX modifier on the claim identified as a therapy service with a GN, GO, GP modifier when a therapy cap exception has been approved, or it meets all the guidelines for an automatic exception. This allows the approved therapy services to be paid, even though they are above the therapy cap financial limits.” Some providers that purport to have followed these rules report that their claims have nevertheless been denied. CMS reported that a Medlearn Article clarifying the rules will be posted this week or next. More information about the therapy caps exception process is available online at http://www.cms.hhs.gov/mlnmattersarticles/downloads/mm4364.pdf. No Pay Bills: CMS this month posted Change Request (CR) 4292, titled “Benefits Exhaust and No-Payment Billing Instructions for Medicare Fiscal Intermediaries (FIs) and Skilled Nursing Facilities (SNFs).” CMS urges SNFs to review this change request. CR4292 is available from Medicare Learning Network at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4292.pdf. Under “important points to remember,” this article notes that: “CR4292 implements a standard process for billing claims in benefits exhaust and no payment situations. Note: Currently, requirements for billing such claims for SNF providers vary; this instruction implements a standard process. This standard process applies only to SNF residents who are newly admitted to, or are in, Medicare Part A stays on or after October 1, 2006.” Q&As: Following the CMS staff reports, the forum was opened to questions from audience members. The next SNF/Long-Term Care Open Door Forum will be on July 18. APRIL 27, 2006 Forum Highlights: Medicare Learning Network: The Medicare Learning Network announced a new name for its provider education articles: “MLN” (Medicare Learning Network) articles, which replaces the previous name, “Medlearn Matters” articles. The articles can be accessed from http://www.cms.hhs.gov/MLNMattersArticles on the CMS website. To learn more about the name change, access the MLN article on the topic at http://www.cms.hhs.gov/mlnmattersarticles/downloads/SE0620.pdf. Medicare Administrative Contractors: CMS is in the process of replacing Medicare’s fiscal intermediaries and carriers with 15 Medicare Administrative Contractors (MACs), who will handle administration of both the Part A and Part B programs in specified geographic regions. CMS will announce the first MAC contract for Jurisdiction 3 (Arizona, Montana, North Dakota, South Dakota, Utah, and Wyoming) in late June. The next group of contracts will cover Jurisdictions 4 (Colorado, Oklahoma, New Mexico, and Texas), 5 (Iowa, Kansas, Missouri, and Nebraska), and 12 (Delaware, Maryland, New Jersey, and Pennsylvania). On May 3, 2006, a Request for Information (RFI) that includes the draft Scope of Work for these jurisdictions was published on the Federal Business Opportunities website (http://www.fedbizopps.gov/). CMS welcomes your feedback regarding this RFI. For information on how to submit comments and questions, visit www.fedbizopps.gov. This administrative change-over to the MACs consolidates Medicare Part A and B under one authority and thus, is expected to improve customer service. According to a CMS official, providers and beneficiaries should see no other changes as a result of this reform. To learn more about the new MAC reform and the transition to the MACs, visit the Medicare Contracting Reform website at: http://www.cms.hhs.gov/MedicareContractingReform/. Information System Changes: CMS recently undertook a synchronization effort to realign Medicare beneficiary records. CMS reported that is has rectified all records so that providers can now find accurate Medicare eligibility records for beneficiaries. DAVE II: The second round of the Data Assessment Verification project is underway in Massachusetts, New York, Ohio, and California. Though it is too early to identify trends, participating nursing homes have welcomed the exit interview feedback from the DAVE assessment team. CMS contractor Abt Associates is spearheading the second phase of the DAVE project, which aims to assess the accuracy and reliability of the Minimum Data Set information submitted to CMS by nursing homes. The website for the project should be up by next month. SNF/Supplier Arrangements Pertaining to Consolidated Billing Services: CMS addressed the question of what happens when a SNF obtains a bundled service, which is subject to consolidated billing, from an outside supplier and then refuses to pay for all or some of the services provided. In this case, CMS recommends that the supplier contact the SNF to work out the problem; it could, after all, have been an honest mistake by the SNF. If the problem remains unresolved, the supplier might then seek intervention from the CMS regional office. Legal remedies, however, are difficult to obtain. In the worse case scenario, a SNF could be denied Medicare participation, but this is considered “a nuclear option” and rarely occurs. Given this, CMS recommends that suppliers have a clear written agreement that addresses payment before undertaking business with SNFs. More information on about this topic is available online: go to the MLN article at http://www.cms.hhs.gov/transmittals/downloads/r412cp.pdf. More information on the topic is available from CMS at http://www.cms.hhs.gov/snfpps/08_bestpractices.asp. Expedited Notice and Therapy Caps: CMS recently sponsored an Open Door Forum on the new therapy caps. Detailed information about the therapy caps and exceptions to them are available online for the MLN article at http://www.cms.hhs.gov/mlnmattersarticles/downloads/mm4364.pdf. Q&As: Following the CMS staff reports, the forum was opened to questions from audience members. The next SNF/Long-Term Care Open Door Forum will be on June 6. JANUARY 31, 2006 Forum Highlights: Town Hall Meetings: CMS is inviting public commentary on the economic impact of major federal regulations governing the health care industry. Written comments will be accepted through Thursday, Feb. 9. For more information, go to http://aspe.hhs.gov/arrb/index.shtml. Medicare Contractor Provider Satisfaction Survey (MCPSS): CMS is conducting a Medicare Contractor Provider Satisfaction Survey (MCPSS) in order to “garner quantifiable data on provider satisfaction with the performance of Medicare Fee-for-Service (FFS) Contractors….Specifically, the survey will enable CMS to gauge provider satisfaction with key services performed by the 42 Contractors that process and pay the more than $280 billion in Medicare claims each year. CMS will use the results of the survey to improve its oversight and increase the efficiency of administration of the Medicare program. Contractors will use the results to improve the services they offer to providers (CMS website).” A random sample of 25,000 providers will be surveyed through April 2006. The final report is expected in July 2006. For more information, go to http://www.cms.hhs.gov/mcpss. RAI Manual Update: The January 2006 updates to the RAI User's Manual MDS Version 2.0 are now available from CMS’s MDS 2.0 webpage at: http://www.cms.hhs.gov/nursinghomequalityinits/20_nhqimds20.asp. The January updates can be accessed directly from http://www.cms.hhs.gov/NursingHomeQualityInits/downloads/MDS20Update200601.pdf. Medicare Part D: CMS continues to reach out through its regional offices and a network of industry and advocacy organizations to educate providers about the Medicare Part D Prescription Drug Benefit. The new benefits are especially important to the long-term-care population: an estimated 70 percent of long-term-care residents are full benefit patients who are dually eligible for both Medicare and Medicaid. In response to questions about the role of skilled nursing facilities vis-à-vis pharmacies, CMS reported that SNFs may provide comparative plan information to residents, but should not steer residents toward one plan or another. CMS is encouraging pharmacies to contract with all available Part D plans. Also, CMS reported that in 13 states, dually eligible Medicaid managed care patients were “passively enrolled” in Medicare Advantage Plans. In such cases, providers should bill the Medicare plan, not the Medicaid plan. Can states auto-enroll Medicaid patients in Medicare Advantage Plans? No, not unless they are authorized patient representatives under state law. Medicare Second Payor: In response to a question about payor status, CMS reported that Medicare regulations require that entities billing Medicare must verify that Medicare is the primary payor. If billed incorrectly, Medicare can recover its conditional payments. Hence, it is in the best interests of providers to ask beneficiaries or their representatives about their Medicare Secondary Payor status. And this information should be verified every 90 days to play it safe. CCI Edits: According to the CMS website, “CMS developed the Correct Coding Initiative (CCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims.” In January, the CCIs edits were applied to all outpatient therapy services subject to the Medicare CCI. Providers with questions about the initiative or the edits should consult CMS’s National CCI Edits webpage at http://www.cms.hhs.gov/NationalCorrectCodInitEd/. QI/QM Reports: Providers with questions about the technical specifications for nursing home quality indicators (QI) and quality measures (QM) as well as questions about QI/QM exclusions should consult CMS’s “QI/QM Report Information.” Go to http://www.cms.hhs.gov/MinimumDataSets20/05_QualityIndicatorandResidentReports.asp#TopOfPage, and in the “Downloads” section near the bottom of the page, click on “QI/QM Report Information.” Expedited Review/Therapy Caps: CMS reported that no generic notice is needed when a residents hits the therapy cap. This situation is viewed the same way as an exhaustion of benefits. Questions and answers concerning the “expedited determination process for original Medicare” can be accessed at http://www.cms.hhs.gov/BNI/Downloads/ED%20qs&as.pdf. Q&As: Following the CMS staff reports, the forum was opened to questions from audience members. DECEMBER 21, 2005 Forum Highlights: CMS Website Launched: The Centers for Medicare & Medicaid Services (CMS) launched its renovated website on December 13. You can check it out at http://www.cms.hhs.gov. Several web pages within the site have changed, among them the home page for Skilled Nursing Facilities PPS, which is now located at http://www.cms.hhs.gov/snfpps/. Report Request: Nursing homes should be aware that Quality Indicators are updated weekly, not monthly, typically during the evening between Sunday and Monday. Facilities may want to keep this in mind when timing the submission of their data. RAI Manual Update: The RAI User's Manual for the MDS 2.0 has been updated for December 2005. These updates and revisions are now available at http://www.cms.hhs.gov/NursingHomeQualityInits/downloads/MDS20Update200512.pdf. To print Appendix A, please go to the "RAI User's Manual by Chapter" subheading, select the link and print in its entirety. FYI: The home page for the MDS 2.0 manuals and forms is www.cms.hhs.gov/nursinghomequalityinits/20_nhqimds20.asp . DAVE II Update: CMS contractor Abt Associates is spearheading the second phase of the Data Assessment Verification (DAVE) project, which will assess the accuracy and reliability of the Minimum Data Set (MDS) information submitted to CMS by nursing homes. For the project, trained research teams will visit about 60 randomly selected nursing homes across the country starting in spring, 2006. The project, which builds on the original DAVE effort, will examine the impact of MDS discrepancies on quality indicators, quality measures, RUG classifications, and resident care planning. CMS will soon establish an email address for the project and invite comments and questions from long-term-care stakeholders. Expedited Review System: CMS followed up on two questions raised during November’s SNF/Long-term-care Open Door Forum. The first question concerned whether there are different review periods for managed care facilities versus fee-for-service facilities. The answer is yes: Under managed care, Quality Improvement Organizations (QIOs) have 48 hours to make a determination after receiving a timely request for expedited review; with respect to fee-for-service facilities, the QIOs have 72 hours to make a determination. The second question concerned whether glucose monitoring for a SNF resident receiving Part B services would trigger the expedited determination right. The answer is found on page 28 of the “EXPEDITED DETERMINATION (ED) PROCESS FOR ORIGINAL MEDICARE: Questions and Answers (Q&As)” file, which is available at http://www.cms.hhs.gov/BNI/Downloads/ED%20qs&as.pdf. This file notes that “the expedited process is not used for the following services that are usually provided once or not for any prolonged duration. If one or any combination of services on the list below are the only covered services provided, expedited notice will not be required when coverage of these services ends: 1. SNF provides diagnostic x-ray tests (including portable x-ray), diagnostic laboratory tests, and other diagnostic tests either directly or under arrangement.” The CMS representative explained that diagnostic laboratory tests include glucose monitoring. Q&As: Following the CMS staff reports, the forum was opened to questions from audience members. DECEMBER 13, 2005 Open Door Forum on the Special Time Study, or STRIVE Study: How much staff time and other facility resources are needed to provide nursing home care to individual residents? This question is at the heart of a government-funded staff time study that recently got underway and even more recently was the topic of a December 13th Special Open Door Forum sponsored by the study’s funder, the Centers for Medicare and Medicaid Services (CMS). The study, known as STRIVE, for Staff Time Resource Intensity Verification, aims to enhance the efficiency and accuracy of the Resource Utilization Group (RUG) III system. The last such time study was conducted in 1997. The new study has profound implications for nursing home payments. The RUG system, first introduced in 1990, groups residents by clinical characteristics that have been shown to affect the amount of staff time and other resources needed to care for the residents. Each of the various resident groups or ‘RUGs’—at present there are 44 of them, but that number will increase to 53 in January—are then assigned a weight, or a Case Mix Index (CMI), which reflects the relative costliness of caring for the residents. Prepayments to nursing homes are based on these weighted RUGs. Nearly 50 percent of states use a version of the RUG classification system to pay for Medicaid nursing home care. In the Open Door Forum, representatives of the CMS contractor, the Iowa Foundation for Medical Care (IFMC), explained that the STRIVE study will be conducted in 15 volunteer states, in 240 facilities, and will include about 12,000 residents. In each participating state, a stratified, random sample of facilities will be selected. The sample will be stratified to ensure that special populations, such as Medicare patients and residents on ventilators and respirators, are represented. Facility recruitment is expected to start in the new year, with data analysis completed in March, 2007. The study will collect data pertaining to staff time and other resources needed to care for residents, resident characteristics, and facility characteristics. Nursing home staff will use pocket PCs to record their activities throughout the day. Resident characteristics will be based largely on recent Minimum Data Set (MDS) assessments. Facility data will include staffing levels, administration and ownership, demographics, and name, type, and size of the nursing units. A PowerPoint presentation that outlines the STRIVE study is available online at www.qtso.com. IFMC welcomes input from long-term-care stakeholders. Send your comments and questions by email to STRIVE@IFMC.org. (Back to top) NOVEMBER 30, 2005 Forum Highlights: Special Time Study: The Centers for Medicare & Medicaid Services (CMS) will hold a special Open Door Forum on December 13 to discuss the agency’s recently implemented national nursing home staff time measurement (STM) study, the “Staff Time and Resource Intensity Verification (STRIVE) Project.” The STRIVE project will provide accurate information for updating the RUG-III payment system used by Medicare and some Medicaid agencies. The study will collect staff time and resident-level clinical data regarding health status, medical conditions, services received, and facility resources used to provide care from a large sample of nursing homes. CMS has contracted with the Iowa Foundation for Medical Care (IFMC) to collect data and provide analysis for the STRIVE project. The special Open Door Forum will begin with an update of the time study project by IFMC and its subcontractors and will then be opened to comments and questions. To participate, call 1-800-837-1935 and at the prompt, key in the reference conference ID number, 2654075. RUG-53 Educational Material: CMS has posted online educational materials to help facilities make the transition from the RUG-44 classification system to the new RUG-53 system, which will take effect January 1, 2006. Go to http://www.cms.hhs.gov/providers/snfpps/, and in the “Highlights” section, click on “RUG-53 Educational Material.” This opens a zip file, which includes three documents: The Crosswalk document shows the services, conditions, and requirements that apply for each of the 53 RUG groups. The SNF PPS Refinement documents discuss the 9 new groups, software updates, payment implications, and other areas related to RUG-53. There are two versions of the SNF PPS Refinement; one for Skilled Nursing Facilities and the other for Hospital Swing Beds. The Crosswalk and the SNF PPS Refinement files should be used together for training and educational purposes. The documents were not created to be stand-alone material New Swing Bed Manual: On the same webpage, http://www.cms.hhs.gov/providers/snfpps/, again in the “Highlights” sections, providers can access the new Swing Bed Manual, which was revised in November. Consolidated Billing Annual Update Available: CMS has posted online the SNF Consolidated Bill Annual Update for 2006. Go to http://www.cms.hhs.gov/providers/snfpps/snffi/ and scroll down to the bottom right and click on “2006 SNF CB Annual Update” to open the zip file. The file contains the complete list of HCPCS codes that are excluded from SNF CB for claims submitted to Fiscal Intermediaries for payment. Minor Surgery and Part B therapy inclusions are also included with this file. The codes are listed within an Excel file so that providers can conveniently sort them. Teleconference for the Correct Coding Initiative (CCI): CMS will sponsor a teleconference on the correct coding initiative on December 15 from 2 p.m. to 4 p.m. Pre-registration is required. To register, go to http://jsp.premiereglobal.com/webrsvp/questionnaire.jsp?1133455156716. (The conference code is 4976223.) A December 6th teleconference on the same topic is already fully subscribed. The Medicare CCI edits take effect January 1, 2006, and will apply to all outpatient services furnished by skilled nursing facilities, comprehensive outpatient rehabilitation facilities, outpatient physical therapy and speech-language pathology providers, and home health agencies. To review the CCI edits that apply to Medicare Part B services go to http://www.cms.hhs.gov/providers/hopps/cciedits/. For more information about new, deleted and revised codes in the ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) go to http://www.cms.hhs.gov/medlearn/icd9code.asp. Therapy Caps: CMS issued a change request—CR4115—on therapy caps in November. Caps are statutory limitations on the therapy services (PT, OT, speech language pathology) that a Medicare patient can receive in one year. Currently, there is no limitation on therapy services, but a cap will be instituted in January unless Congress takes action before then. For more information about the therapy caps, go to http://www.cms.hhs.gov/providers/therapy/#status, and scroll down about 7/8th of the page, to the “Therapy Cap Status” headline in the left-hand column. The resources provided in this section include an “Outpatient Therapy Caps” PowerPoint demonstration. Personal Computer Upgrades Needed?: CMS will update its recording software in January, 2006, a change that may require nursing facilities to upgrade their computers so that they can access their quality indicator reports (the software change will not affect facilities’ ability to transmit MDS data). The minimum specifications needed to support the new reporting software are available online at http://www.cms.hhs.gov/medicaid/survey-cert/sc0522.pdf. According to a CMS-sponsored survey of nursing facilities, about one-third of nursing home computers are too old to support the new reporting software. Dehydration Codes: In October, CMS moved from one ICD-9-CM code for dehydration (276.5) to three separate codes (276.50, 276.51, 276.52). The change specifications are expected to take effect next week. Any one of the three new specifications will trigger a dehydration RAP. For more information, consult the Medlearns article at http://www.cms.hhs.gov/medlearn/matters/mmarticles/2005/MM4005.pdf. Consolidated Billing Change Request: Change Request 3910, the “Common Working File (CWF) Skilled Nursing Facility (SNF) Consolidated Billing (CB) Edits for Evaluation and Management (E&M) Services Billed to Fiscal Intermediaries (FIs) by Hospitals”, was published on November 11, 2005. The change, which takes effect January 1, 2006, revises the claims processing procedures to follow when a hospital bills for "facility charges" (overhead expenses) in connection with clinic services of hospital-based physicians. For more information, consult CR 3910 online at http://www.cms.hhs.gov/manuals/pm_trans/R740CP.pdf. RAI Users Manual: The updated RAI Users Manual is available online at http://www.cms.hhs.gov/quality/MDS20/. Scroll to the bottom of the page to access the manual by chapter. No Pay Bills: In response to numerous questions about no pay bills, CMS has developed a change rule for submitting these bills. The change rule is currently under review. Q&As: Following the CMS staff reports, the forum was opened to questions from audience members. The next SNF/Long-term Care Open Door Forum is scheduled for December 21. (Back to top) SEPTEMBER 29, 2005 Forum Highlights: Hurricane Relief: CMS officials confirmed that emergency relief policies adopted by the agency (under its 1135 waiver authority) for Hurricane Katrina apply equally to Hurricane Rita, including the waiver of the three-day prior hospital stay as a requirement for skilled nursing home care. Q&A’s about CMS’s emergency relief measures applicable to SNFs can be accessed online here. Other pertinent Q&A’s can be accessed at http://www.cms.hhs.gov/katrina/. Consolidated Billing: CMS has identified for correction several billing codes. The codes are listed online at http://www.cms.hhs.gov/providers/snfpps/default.asp. Corrections should take effect no later than December 1, 2005, and possibly as early as November 3, 2005. CMS discovered the errors after if found it had denied some professional services in error as improperly subject to consolidated billing. Contractors may resubmit claims after the coding errors are corrected. Pay for Performance Demonstration: CMS’s open door forum held September 20th on the nursing home Pay for Performance (PFP) pilot program offered CMS and its contractors a chance to present their plans for the demonstration project as well as elicit feedback from the long-term-care community regarding those plans. Representatives of Abt Associates, the CMS design contractor, reported that the PFP initiative would aim to improve nursing home care by offering financial incentives to facilities that deliver high quality care or demonstrate significant improvements in care quality. Current plans call for a three-year demonstration project starting in late 2006 or early 2007 and involving 150 to 200 hospital-based or freestanding facilities in three to four states. The project would be budget neutral in that total incentive payments would be equal to the total estimated savings from quality-of-care improvements in a given year. Facility participation in the demonstration would be voluntary; no facility would experience a reduction in payment as a result of participation. For more information about this open door forum, go to http://www.cms.hhs.gov/researchers/demos/nhp4p/default.asp. To view the power point presentation prepared by Abt Associates for this forum, go to http://www.cms.hhs.gov/researchers/demos/nhp4p/nhp4p.pdf. Transition from RUG-44 to RUG-53: This transition begins January 1, 2006. CMS will post educational materials on its website to help providers and fiscal intermediaries through this transition, or "RUG Refinement," which aims “to improve the ability of the existing RUG-III classification system to explain non-therapy ancillary (NTA) costs.” Related changes to the RAI Manual and Swing Bed Manual also will be posted on CMS’s website. For more information, visit CMS’s “SNF Prospective Payment System” contents page at http://www.cms.hhs.gov/providers/snfpps/rugrefine.asp. MDS Section W: Starting October 1, nursing home providers must complete for all residents the new Section W of the Minimum Data Set, which pertains to influenza and pneumococcal immunizations. A 2-1/2 hour satellite webcast covers all the details. Go to http://www.cms.hhs.gov/quality/MDS20 to access the webcast. No Pay Bills: In response to numerous questions about no pay bills, CMS is developing a change rule for submitting these bills. At present, the agency is testing various scenarios to arrive at a standardized rule. Facilities that have not submitted no pay bills for several years should wait to submit them until the change rule is published. Facility Reviews: CMS also expects to publish soon a change rule that addresses facility reviews. Medicare Modernization Act: CMS is now publicizing Medicare’s new drug benefit plans. Beneficiaries can enroll in the plans starting November 15. For more information about the plans, go to http://www.medicare.gov/medicarereform/drugbenefit.asp. (Back to top) SEPTEMBER 20, 2005: Special Forum on Nursing Home Pay for Performance Forum Highlights: The open door forum held September 20st on the nursing home Pay for Performance (PFP) pilot program offered CMS (the Center for Medicare and Medicaid Services) and its contractors a chance to present their plans for the demonstration project as well as elicit feedback from the long-term-care community regarding those plans. Representatives of Abt Associates, the CMS design contractor, reported that the PFP initiative would aim to improve nursing home care by offering financial incentives to facilities that deliver high quality care or demonstrate significant improvements in care quality. Current plans call for a three-year demonstration project starting in late 2006 or early 2007 and involving 150 to 200 hospital-based or freestanding facilities in three to four states. The project would be budget neutral in that total incentive payments would be equal to the total estimated savings from quality-of-care improvements in a given year. Facility participation in the demonstration would be voluntary; no facility would experience a reduction in payment as a result of participation. Abt Associates has not yet selected the quality measures (QMs) that will be used to reward incentive payments, but is considering several types, including QMs based on the Minimum Data Set (MDS), facility staffing levels, state survey results, and avoidable hospitalizations. Measures based on processes of care, satisfaction, quality of life, and staff interaction may also be used. Abt Associates also reported that several questions have yet to be addressed, among them: How much will each QM count toward a facility’s overall performance score? How will CMS coordinate with state Medicaid programs to administer the PFP program? How should the incentive pool be determined? How should performance be linked to incentive payments? How will states be selected for the demonstration project? CMS and Abt Associates invite and welcome feedback from all long-term-care stakeholders. Email questions, comments, concerns, and suggestions to nursinghomep4p@cms.hhs.gov. For more information about this open door forum, go to http://www.cms.hhs.gov/researchers/demos/nhp4p/default.asp. To view the power point presentation prepared by Abt Associates for this forum, go to http://www.cms.hhs.gov/researchers/demos/nhp4p/nhp4p.pdf. (Back to top) AUGUST 30, 2005 Forum Highlights: CMS in Hurricane-Affected Areas: To reach CMS regional offices serving hurricane-affected areas call either the Atlanta office, staff contact Colleen Carpenter, at 404-562-7242, or the Dallas office, staff contact Paula Hammond, at 214-767-6427. Expedited Review Process: CMS has updated its list of questions and answers pertaining to the expedited review process for beneficiaries in original Medicare, which took effect July 1, 2005. Go to http://www.cms.hhs.gov/medicare/bni/EDqsandas.pdf to review the Q&As. If you still have questions, email them to: BIPAexpeditedreviews@cms.hhs.gov. According to the CMS website, “Home Health Agencies, Skilled Nursing Facilities, Comprehensive Outpatient Rehabilitation Facilities and Hospices with beneficiaries in Original Medicare are (now) required to notify beneficiaries of their right to a new expedited review process when these providers anticipate that Medicare coverage of their services will end.” Therapy Caps: Dr. Dorothy Shannon reported that caps on therapy services are scheduled to take effect in January 2006. Caps are statutory limitations on the therapy services (PT, OT, speech language pathology) that a Medicare patient can receive in one year. Currently, there is no limitation on therapy services, but a cap will be instituted in January unless Congress takes action before then. For more information, consult publication 100-04, Chapter 5, Section 20, of the Medicare Benefit Policy Manual, available online at http://www.cms.hhs.gov/manuals/pm_trans/R515CP.pdf. Therapist Qualifications: A CMS change request pertaining to the “qualifications required for staff providing services billed as physical therapy and occupational therapy services incident to the services of a physician or nonphysician practitioner” took effect in June. The change request prompted revisions to sections 220 and 230 in Chapter 14 of the Medicare Benefit Policy Manual. According to a CMS Medlearn article, the manual revision “adds reference information and clarifies current policy concerning physician visits and certification. In addition, it defines the qualifications of therapists.” This Medlearn article, available online at http://www.cms.hhs.gov/medlearn/matters/mmarticles/2005/MM3648.pdf, is a good place to start to learn more about this CMS change request. Influenza and Pneumococcal Immunizations Soon to be Required: A proposed CMS rule would require nursing homes to offer short- and long-stay residents influenza and pneumococcal immunizations starting October 1, 2005, before the start of the flu season. The public comment period for the draft rule has closed, and the final rule—Section W of the CMS’s RAI Version 2.0 Manual—is expected to take effect October 1. Under the new rule, facilities must provide residents or their representatives the opportunity to refuse the immunizations. At the same time, they must make sure the decision-makers are educated about the benefits of immunization. A draft of Section W is available online at http://www.cms.hhs.gov/quality/mds20/SectionW.pdf. Register for Satellite Broadcast and Webcast on Nursing Home Immunizations: This broadcast will be held Thursday, Sept. 8, from 1 p.m.-3 p.m. EDT. Registration is free, and you can register at http://cms.internetstreaming.com/. Section W Supplemental Items: Effective October 1, 2005, Section W will be added to: the Minimum Data Set (MDS) Assessment Form, the RAI Manual Version 2.0, MDS All Forms, and the Medicare PPS Assessment Form (MPAF). Correct Coding Initiative (CCI): Effective January 1, 2006, Medicare CCI edits will be applied to all outpatient services furnished by skilled nursing facilities, comprehensive outpatient rehabilitation facilities, outpatient physical therapy and speech-language pathology providers, and home health agencies. To review the CCI edits that apply to Medicare Part B services go to http://www.cms.hhs.gov/providers/hopps/cciedits/. A Medlearn article on the edits (available at http://www.cms.hhs.gov/medlearn/matters/mmarticles/2005/SE0545.pdf) advises affected providers to “begin immediately to prepare their systems with any necessary software, educate their staff and management about the 2006 CCI application to their claims, and watch for forthcoming information from CMS and their local contractor (carrier or fiscal intermediary), after October 1, 2005.” Q&As: Following the CMS staff reports, the forum was opened to questions from audience members. (Back to top) JUNE 30, 2005 Forum Highlights: SNF Proposed Rule Change: As reported on its website, CMS in May “proposed refinements to the RUG-III system that included the addition of 9 new RUG groups, and an adjustment to the nursing case mix weights…As part of our ongoing analysis of case mix refinements, we have updated our analyses to use 2001 data, the most recent available. In addition, CMS has corrected a mathematical error associated with the therapy case mix weights shown in the NPRM.” The final rule is due July 29, 2005. Comments may be submitted until July 12. To read more, go to http://www.cms.hhs.gov/providers/snfpps/snfpps_rates.asp. Expedited Appeals Process: CMS reports on its website that “beginning July 1, 2005, Home Health Agencies, Skilled Nursing Facilities, Comprehensive Outpatient Rehabilitation Facilities and Hospices with beneficiaries in Original Medicare will be required to notify beneficiaries of their right to a new expedited review process when these providers anticipate that Medicare coverage of their services will end.” CMS’s Open Door Forum in June on this topic drew a record audience of more than 2,000 long-term-care providers and professionals. If you missed that forum but have questions about the new process, here are online sources you can consult: CMS’s Beneficiary Notices Initiative Page at http://www.cms.hhs.gov/medicare/bni/ Questions and Answers Related to the New Process at http://www.cms.hhs.gov/medicare/bni/EDqsandas.pdf Expedited Review Process PowerPoint Presentation at http://www.cms.hhs.gov/opendoor/schedule.asp; scroll to the PowerPoint under the Highlights section. Medlearn Matters article on the new process at http://www.cms.hhs.gov/medlearn/matters/mmarticles/2005/SE0538.pdf Pay for Performance: Ron Lambert of CMS reported that the agency will embark on a demonstration project designed to evaluate possible quality measures to use in a nursing home pay for performance program. CMS recently met with its MDS Coalition to get input for the demonstration project. In the next few months, CMS will draft a design for the demonstration project and report back to its MDS stakeholder group, possibly in September. Requirements for Signing Non-physician Orders: Do physicians have to verify and sign orders by nurse practitioners? CMS is reissuing a Questions-and-Answer advisory to address this question. A Medlearn article on the topic should be posted to the CMS website on July 1. Go to http://www.cms.hhs.gov/medlearn/matters and search for article SE0418. Medical Director Requirements: As noted on its website, CMS “has completed (its) to produce new surveyor guidance for nursing home deficiency tag F501, Medical Director. The new guidance includes Interpretive Guidelines, an Investigative Protocol, and Severity guidance for deficiencies cited at F501. We are delaying final issuance until November 2005 to allow surveyors to be trained in the new guidance and to permit facilities and medical directors to study the significantly revised and expanded guidance.” An advanced copy of the guidance is available at http://www.cms.hhs.gov/medicaid/survey-cert/sc0529.pdf. Electronic Health Records: In a prior Open Door Forum, an audience member raised a question about federal requirements for maintaining electronic health records. For guidance on this issue, CMS recommends providers consult the State Operations Manual (http://www.cms.hhs.gov/manuals/107_som/som107_appendixtoc.asp). Of particular interest is the section on Clinical Records, Section 483.75(l) of the Interpretative Guidelines for Long Term Care Facilities. To review this section, go to http://www.cms.hhs.gov/manuals/107_som/som107ap_pp_guidelines_ltcf.pdf and scroll to page 307. The next SNF/Long Term Care Open Door Forum is tentatively scheduled for July 28. (Back to top) APRIL 27, 2005 Forum Highlights: CMS staff invited providers to offer feedback, ideas, and suggestions regarding all CMS long-term-care activities so that the agency can be as responsive as possible to the provider community. A proposed rule change for skilled nursing facilities (SNFs), originally slated for release on April 22, is not yet ready. The final rule change is now due July 29. Information and updates regarding the rule change can be found at http://www.cms.hhs.gov/providers/snfpps. Proposed revisions to the RAI Manual, originally scheduled to take effect May 1, 2005, have been retracted based on comments and inquiries from providers. New proposed revisions are expected to be posted online by May 23, with an effective date of June 15, 2005. Visit http://www.cms.hhs.gov/quality/MDS20 for continued updates regarding the revisions. CMS is developing a supplemental set of questions for the MDS on influenza and pneumococcal vaccines. These new MDS data specs will be effective October 1, 2005. The specs are expected to be posted online by next week. Also in early May, CMS will post draft manual changes for this new section, called Section W. A final downloadable version of the manual changes should be available online in June. For more information, go to http://www.cms.hhs.gov/medicaid/mds20/whatsnew.asp. Fourth quarter quality measures have been posted to CMS’s Nursing Home Compare website. The next update will be in July. Providers who want to learn more about the Medicare prescription drug benefit can do so by visiting the CMS site on the topic, http://www.cms.hhs.gov/medicarereform/pdbma/. From the “Provider Information” section (go to http://www.cms.hhs.gov/medicarereform/pdbma/provider.asp), visitors can access issue papers on the drug benefit as well as a wealth of other pertinent information. For a two-page brochure called “The Facts about Medicare Prescription Drug Plans” go to http://www.medicare.gov/Publications/Pubs/pdf/11065.pdf. Nursing homes may want to keep copies of this brochure handy for staff, residents and family members. Copies of the brochure can also be ordered from Medicare regional office campaign teams. Regarding a provider question during a previous open forum about benefit period renewal citations and continuation of stay, CMS staff member Jason Kerr referred providers to the Medicare Benefit Policy Manual at http://www.cms.hhs.gov/manuals/102_policy/bp102c03.pdf. This chapter on Duration of Covered Inpatient Services states that “the period is renewed when the beneficiary has not been in a hospital or SNF for 60 days.” CMS staff answered questions from the audience. The next SNF/Long-term-care Open Door Forum is scheduled for May 26.(Back to top) MAY 26, 2005 Forum Highlights: CMS published its “FY 2006 SNF PPS Notice of Proposed Rulemaking” in the Federal Register on May 19th. Among the proposed provisions are RUG refinements and a change in structure for the wage index. To access the proposed changes, go to http://www.cms.hhs.gov/providers/snfpps/ and scroll down to the “Highlights” box. The comment period ends July 12. All comments must be submitted in writing to CMS. Also now available for review online is Section W, the MDS 2.0 supplemental items on influenza and pneumococcal immunization, and the final report on Quality of Life in Nursing Homes, a study conducted by University of Minnesota gerontologist Rosalie Kane and her colleagues on behalf of CMS. Access these materials at http://www.cms.hhs.gov/quality/nhqi/. CMS and the Centers for Disease Control will sponsor a web and satellite broadcast on increasing influenza and pneumococcal immunization rates in nursing homes on September 8, from 1 – 2:30 p.m. (EDT). CMS invites your suggestions for increasing nursing home staff participation in this broadcast. Send suggestions to robert.connolly@cms.hhs.gov. The Swing Bed Manual has been updated. Access it online at http://www.cms.hhs.gov/providers/snfpps/sbmanual.asp. The therapy section (about physical therapy, occupational therapy, speech-language pathology, and audiology) of the Medicare Benefit Policy Manual has been modified; go to http://www.cms.hhs.gov/medlearn/therapy/ to view the Medicare Benefit Policy Manual power point for details. CMS is developing a Change Request to discuss no-pay bills, a response to questions from nursing home providers about the topic. CMS will host an Open Door Forum on the Expedited Review Process on June 20, 2 – 4 p.m. (EDT). The next SNF/Long Term Care Open Door Forum is scheduled for June 30. (Back to top) MARCH 4, 2005 General News: CMS’s current focus on pressure ulcer prevention apparently stems from the fact that pressure ulcer prevalence rates did not improve following the launch of the national Nursing Home Quality Initiative, though other quality measures, such as pain rates, did. CMS will soon start a pilot project to prevent pressure ulcers. The project will target nursing home surveyors. In March or April, CMS expects to issue to nursing homes clinical “guidance” regarding urinary incontinence and catheter use. In the long term, CMS is very interested in moving the industry toward electronic health records for nursing home residents. This change would enhance the exchange of information between nursing facilities and CMS. Minimum Data Set (MDS) 3.0 Report: No date has been set for its release, though national testing is expected some time in 2006. Goals for the new MDS are to enhance the validity and reliability of the items, decrease provider burden, and increase residents’ voices in the assessment (look for resident interview questions). Four regional Veteran’s Administration teams, in Los Angeles, Atlanta, Boston, and Philadelphia, are working with CMS to validate MDS items pertaining to eight areas: pain; falls; mood; behavior; customary routines (quality of life); symptoms; diagnoses; and delirium. You can access a draft of the MDS 3.0 at www.cms.hhs.gov/quality/MDS30. (Back to top) MARCH 31, 2005 Forum Highlights: CMS is in the midst of conducting a background check pilot program in nursing home in seven states. Background checks are conducted on nursing home employees with direct contact with residents. Initiated in January 2005 in consultation with the Department of Justice, the pilot is expected to wrap up in September 2007. CMS is developing a supplemental set of questions for the MDS on influenza and pneumococcal vaccines. These new MDS data specs will be effective October 1, 2005. For more information, go to http://www.cms.hhs.gov/medicaid/mds20/whatsnew.asp. Visit www.medqic.org to access a repository of protocols, assessments, literature reviews, and more information on improving care quality in nursing homes. Quality Partners of Rhode Island is sponsoring The St. Louis Accord, a two-day conference (June 8 and 9) in St. Louis, Missouri, that “will bring together an action-oriented team of committed individuals from each state to create and develop strategies to bring person-directed care to their nursing homes. It will focus on achieving the expectation outlined by the Centers for Medicare & Medicaid Services (CMS) in the 8 SoW for culture change along with an overview of Culture Change by experts in the field.” For more information and to register, go to http://www.riqualitypartners.org/st_louis_accord/index.php. The availability of new QI reports for nursing homes has been delayed for a month. The new reports will be accessible starting in mid-May. New revisions to the RAI Manual will take effect May 1, 2005. You can view and download the revisions at http://www.cms.hhs.gov/quality/mds20/RAIMay2005Update.pdf. The next Long-term-care/SNF Open Door Forum is tentatively scheduled for April 22, 2005. (Back to top)