But an increase in rates will not benefit providers unless they follow the right procedures. By minding their P's and Q's, SNFs can assure they receive the most appropriate payment for Medicare patients.

1. PREPARATION

Preparing your key staff takes ongoing inservices that target actual case studies. Select case studies that had or could have had a negative financial impact on your facility. Discuss these cases as a clinical team, in terms of admission issues and procedures, nursing and rehabilitation care, documentation and billing. Talk about the challenges, how the staff responded and how they resolved the issues. Do not forget to involve the evening and night-shift staff in these discussions.

To optimize learning, assign a different clinician to be responsible for presenting a "Case Study of the Week." Following the in-service, ask the responsible clinician to prepare a summary of the case and send it to the attending physician, SNF medical director or physician/nursing facilityist (the long-term care equivalent of a physician hospitalist). Include a short note that entices the physician to read the study.

Preparation also involves establishing monitoring systems to keep staff current on PPS changes. Ask your clinical team if they are as prepared as they felt they had been before PPS implementation. Be sure that clinicians are current on the Final Rule¹ published on July 30, 1999, which supplanted all previous rules and regulations. Appointing one clinician to search the Internet to stay abreast of Medicare PPS regulations provides a way for the facility staff to remain vigilant about updates.

2. PRE-ADMISSION

A key ingredient for success in the pre-admission screening process is the composition of the admission team. Admission decision-makers must understand RUG III categories and be able to quickly review a medical record to make an accurate determination of the most appropriate RUG category for a particular patient. Using a pre-admission screening tool will help you identify clinical indicators on the MDS that result in a patient's RUG classification.

During the pre-admission screening process, set the most appropriate assessment reference date to capture the best and most relevant information for RUG determination. Sometimes it only takes one check in a field on the MDS to trigger a higher RUG classification. The following case illustrates this point:

A male patient was hospitalized with a diagnosis of congestive heart failure and was discharged to a SNF. After the patient was assessed in the SNF, the case manager determined he would fall into the Special RUG category (SSB) because he had a fever of 102 degrees, and received oxygen and respiratory therapy treatments daily during his hospital stay. Upon further investigation of the medical record, the case manager determined that the patient had IV Lasix while in the emergency room, thus bumping him up to an Extensive Group (SE). That one check changed his RUG category and increased the federal payment by $38 per day.

After admission, be sure that your clinical team has a daily team huddle, i.e., a brief stand-up meeting, to verify each patient's RUG classification and to ensure that all Medicare patients continue to meet the skilled criteria. These meetings also serve as a means for validating the pre-admission screening process. If you frequently find discrepancies between the RUG classification estimated during the pre-admission process and the actual RUG classification found on the five-day assessment, you have an excellent agenda for your next PPS inservice training.

3. QUALIFYING FOR MEDICARE

Medicare basics for SNF eligibility as described in Transmittal 2622 still apply under PPS. Your pre-admission screening tool also should include a Medicare SNF eligibility check (Table).

To be eligible for Medicare payment in a skilled nursing facility, Medicare beneficiaries must have a qualifying three-day hospital stay within the last 30 days. Patients also must be a Medicare Part A beneficiary, have a benefit period remaining and meet the criteria for inpatient services in a skilled nursing facility. To obviate any questions about the patient's eligibility at a later date, be sure that your admission orders provide a diagnosis and state the reason that the patient requires skilled care. The diagnosis should be directly related to the medical necessity resulting in the admission decision. Otherwise, the Health Care Financing Administration may deny payment for services provided without a supporting diagnosis. For an illustration, see HCFA's Memorandum A-99-20,3 which reads:

"A Medicare beneficiary was classified into the RUA RUG III group. The beneficiary's deficits were impaired strength and endurance related to a medical condition, e.g., pneumonia. On medical review, the reviewer determines that the beneficiary had no medically reasonable and necessary requirement for rehabilitation therapy services, because his deficits would be expected to spontaneously improve as the beneficiary resumes normal activities. There was no documentation to indicate that there were any medical conditions to support the need for rehabilitation therapy services. In this case, the reviewer would disallow all rehabilitation therapy services and adjust payment for the entire payment period. The reviewer would reclassify the bill from RUA to the CA1 group based on his pneumonia diagnosis. The bill would be adjusted for the entire payment period."

4. PHYSICIAN ORDERS

Physicians who are unfamiliar with prospective payment and how to conservatively manage ancillary services can be a major threat to a SNF's profitability under PPS. In addition to individualized physician education by your medical director, use a Care Management Model to coordinate the multitude of procedures that assure optimal reimbursement under Medicare PPS.

The care manager's role includes coordinating the processes and procedures related to proper physician orders, certifications and re-certifications throughout a patient's stay in the SNF. The care manager also leads the daily staff meetings, keeps all team members informed and oversees the delivery of clinical services to ensure that patients meet their goals in a reasonable amount of time. The care manager may be a nurse manager, a case manager or another clinician assigned to this role. Typically, this person is not the same person as the MDS coordinator, whose focus should be on the accuracy of the MDS.

5. QUALITY

The MDS is the instrument common to both Medicare compliance audits and SNF surveys. Therefore, its accuracy and timeliness of completion are a basic measurement of quality in the facility. The best way to ensure quality is to use retrospective quality improvement processes, which result in action plans to close any gaps between expected performance and actual performance. At a minimum, be sure you are completing the following quality measurement processes:

* Conduct a pre-lock audit of all MDS forms. A nurse who was not involved in preparing the MDS should complete the audit. Highlight any discrepancies within the MDS as well as areas that simply do not make clinical sense. Investigate and clarify the discrepancies before submitting the MDS.

* Review survey results over a period of two to three years to detect trends. By reviewing survey results historically, you can clearly see repeated citations for issues. Trigger these areas for procedural changes and educational priorities for the facility.

* Conduct patient and employee satisfaction surveys. Reasons for quality care issues will become evident when staff have an opportunity to provide input anonymously.

Being successful and profitable under Medicare involves doing the little things well, day after day, week after week. In other words, minding your P's and Q's. *

References

1. Health Care Financing Administration, Department of Health and Human Services, Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities Update; Final Rule and Notice, Federal Register. July 30, 1999, Vol. 64, No. 146, p. 41684-41701.

2. Health Care Financing Administration, Department of Health and Human Services. Coverage of Services. HIM 12, Chapter 2, Transmittal No. 262. December 1987.

3. Health Care Financing Administration, Department of Health and Human Services. Payment Safeguard Review of Skilled Nursing Facility Prospective Payment Bills. Program Memorandum Intermediary, Transmittal No. A-99-20. May 1999.

Diana Johnson is clinical consultant, and Dr. Kathleen M. Griffin is national director of post-acute and senior services, for Health Dimensions Consulting Group, a member organization of the Benedictine Health System, Scottsdale, Ariz. They can be reached at (800) 972-7871, or fax (651) 636-1019.