By Sophie A. Campbell, MSN
Where does the physician “fit” into the reimbursement requirements and regulations for skilled nursing facilities (SNFs)? The involvement of the physician as a member of the interdisciplinary team is critical in assisting the provider to meeting these regulatory requirements and is essential for compliance and accurate reimbursement for the provider facility (also referred to as the provider). Reimbursement for care and services delivered to a resident in a SNF is a benefit that residents of the SNF are entitled to, if they meet the criteria. Meeting the criteria involves more than just the care of the clinical condition of the resident. It involves every level of service delivery in the facility, including the physician.
Providers of skilled nursing services must comply with both the Prospective Payment System (PPS) eligibility criteria and the Medicare technical eligibility criteria. The PPS criteria are focused on the resources used in the care of the resident. The PPS reimbursement is an all-inclusive per diem rate. The only resident services that are excluded from the consolidated billing per diem are those that are specifically listed as exclusions. These exclusions are updated regularly by the Centers for Medicare and Medicaid Services (CMS) and must be reviewed by the business office, admissions team and members of the interdisciplinary team involved in care of the resident, which includes the physician. It is the responsibility of the provider facility team to keep the physician informed when there are changes.
For example, the modified barium swallow for the resident with swallowing concerns is not listed as an exclusion. Thus, when the SNF resident requires this diagnostic test, the cost of the MBS is billed to the facility and becomes included in the per diem reimbursement rate that the provider receives. This per diem rate also includes many other items such as laboratory, radiology, pharmacy, medical supplies and ambulance trips to and from the hospital for ER visits. Some services required by the resident may be requested to be completed at the acute care facility prior to transfer where they may be billed directly to Medicare, while other diagnostic services must be provided in the SNF. It is important for the physician to be aware of the diagnostic and other services that are included in the per diem reimbursement rate for the facility when writing orders for services for the resident.
The Medicare technical eligibility criteria have been consistent since the implementation of the Medicare system. Many of these technical eligibility criteria are reviewed prior to the admission of the resident to ascertain Medicare eligibility. The involvement of the physician related to these criteria is critical to ensuring Medicare reimbursement. One criterion is the three-day qualifying stay. This requires three consecutive midnights as an inpatient at the qualifying hospital prior to the admission to the SNF. Physician orders written for direct admissions to the hospital when a resident is transferred from the SNF to the hospital is one method to avoid the potential of the long observation stays or emergency room stays that may impact the qualifying stay requirement. This direct admission order eliminates the potential for an observation stay or a stay in the emergency room that will not be included in the qualifying stay, resulting in Medicare ineligibility for the resident.
Another technical eligibility criterion is the requirement for admission of the resident to the SNF within 30 days of the original qualifying stay. The resident may be discharged home and then to the SNF and still be eligible for Medicare Part A benefits as long as the transfer to the SNF occurs within 30 days of the discharge from the qualifying hospital stay. This allows for a physician to admit the resident from his/her office to the extended care facility within 30 days of the hospital stay and for the resident to remain eligible for Medicare benefits.
This is also a resident benefit during the SNF stay of the resident. The resident may be eligible for the remainder of his Medicare Part A benefit days if Medicare skilled services are initiated within 30 days of the last covered day. The benefit days are related to the original qualifying stay. For example, consider a resident who had been discharged from the acute care hospital to home following a CVA. The spouse returns the resident to the physician’s office for a follow up appointment in two weeks post discharge. The physician realizes that the resident would benefit from therapy treatment services. The resident may be admitted to the SNF for therapy treatment services at this time (and any time within 30 days of the hospital discharge) and remain eligible for Medicare Part A benefits for the services since the qualifying stay criterion had been met, as well as the 30 day transfer requirement. Additionally, when a resident in a SNF has been discharged from skilled services but has skilled services initiated again within 30 days, the resident will remain eligible for the remainder of the 100 skilled Medicare days allowable. For example, a resident who has achieved therapy treatment short-term goals that were set and demonstrates decline within 30 days after the discharge from therapy treatment services, may receive a physician’s order to resume therapy treatment services within 30 days of the last treatment day and remain eligible for Medicare Part A benefits through the 100 allowable days.
A resident in extended care who exhausts all 100 allowable Medicare Part A benefit days may receive another 100 day skilled benefit period if the “break in the spell of illness” criterion has been met. This break in the spell of illness requires that the resident maintain 60 calendar days without inpatient hospital admissions (ER visits are allowable) and without receiving any skilled services (as defined by Medicare). The litmus test for this break in the spell of illness is to determine whether the services being provided to the resident meet the criteria that would allow billing to Medicare, if Medicare benefit days were unlimited. If the service being provided to the resident could be billed to Medicare because it meets the definition of a skilled service as set by Medicare, the break in the spell of illness has been interrupted and the 60-day calendar must be restarted after the delivery of the service has been completed.
For example, suppose that a physician orders therapy treatment services for five days per week and these services are ordered following the exhaustion of the 100-day allowable benefit period. This level of skilled service delivery meets the definition of a skilled service for Medicare and the 60-day break in the spell of illness calendar is stopped. However, if the therapy treatment services are ordered by the physician four days per week, this will not interrupt the 60-day break in the spell of illness calendar because this level of service does not meet the definition of a Medicare skilled service.
All skilled services in the care and treatment of the resident that are billed to Medicare must be ordered by a physician. Thus, a physician may be asked for orders for restorative nursing programs as part of the rehabilitation low classification when otherwise physician orders would not be requested for restorative nursing programs. Skilled services must be delivered to the resident on a daily basis. The provider has the opportunity to include as skilled services specific combinations of physician visits and order changes because these are related to the condition of the resident. However, the criterion that determines a physician visit is the documentation of progress note by the physician in the medical record.
The technical eligibility criteria for Medicare also state that the physician must be involved in, and approve of, the residents’ plan of treatment and must certify that the resident requires skilled care and services throughout the benefit period. The involvement and approval of the physician in the plan of treatment includes the timely signature of the therapy Plan of Treatment forms, timely signature of telephone and verbal orders and orders for services that will be billed to Medicare. The certification of skilled services includes the timely documentation of the skilled services required by the resident, estimated length of stay and potential discharge plan based on current information.
Some providers may utilize a specific standardized form for this process. While the form is not a requirement, the form requires only the timely signature and dating by the physician. “Timely” signature by the physician is specifically addressed in Medicare regulation for the certifications and recertifications of skilled need for services and must meet these requirements. “Timely” signature of the physician for the plan of treatment is defined as the signature prior to the billing to Medicare for the services delivered as the result of those treatment plans and “timely” signature of orders and notes by the physician must adhere to specific guidelines related to the type of order written. “Timely” involvement of the physician in the plan of care involves review of orders and visits and demonstration of physician involvement per standard of practice.
Additional demonstration of involvement in the residents’ plan of treatment includes supportive progress notes by the physician in the medical record for the services that have been ordered for the resident and are being billed to Medicare. Physicians are reminded that, when any signature is requested on medical record forms, Medicare also requires a dating of the signature to verify the “timeliness” of the signature according to regulation or standard of practice.
While the Medicare benefit system has adjusted the eligibility criteria that must be met by the providers in order to be reimbursed for care and services to the beneficiary, these adjustments have not had an impact on the reimbursement to physicians for the services that they provide. Physicians have continued to bill Medicare for the care and services delivered to residents in skilled nursing facilities in the same manner that they have always done. The involvement of the physician in the compliance with Medicare reimbursement criteria ensures accurate and timely reimbursement to the provider facility and is essential to their financial survival. The survival of the SNF is as critical to the care continuum in the community as the role of the physician is to the provider reimbursement.
Sophie A. Campbell, MSN, RN, is a manager and health care consultant at Parente Randolph, LLC in Harrisburg,Pa.