Are Your Stars in Alignment?

As stated on the CMS website, CMS created the Five-Star Quality Rating System to help consumers, their families, and caregivers compare nursing homes more easily and to help identify areas about which you may want to ask questions.

The Nursing Home Compare Web site features a quality rating system that gives each nursing home a rating of between 1 and 5 stars. Nursing homes with 5 stars are considered to have much above average quality and nursing homes with 1 star are considered to have quality much below average. There is one Overall 5-star rating for each nursing home, and a separate rating for each of the following three sources of information:

Health Inspections – The health inspection rating contains information from the last 3 years of onsite inspections, including both standard surveys and any complaint surveys. This information is gathered by trained, objective inspectors who go onsite to the nursing home and follow a specific process to determine the extent to which a nursing home has met Medicaid and Medicare’s minimum quality requirements. The most recent survey findings are weighted more than the prior two years. More than 180,000 onsite reviews are used in the health inspection scoring nationally.

Staffing – The staffing rating has information about the number of hours of care provided on average to each resident each day by nursing staff. This rating considers differences in the levels of residents' care need in each nursing home. For example, a nursing home with residents who had more severe needs would be expected to have more nursing staff than a nursing home where the resident needs were not as high.

Quality Measures (QMs) – The quality measure rating has information on 11 different physical and clinical measures for nursing home residents. The rating now includes information about nursing homes' use of antipsychotic medications in both long-stay and short-stay residents. This information is collected by the nursing home for all residents. The QMs offer information about how well nursing homes are caring for their residents’ physical and clinical needs. More than 12 million assessments of the conditions of nursing home residents are used in the Five-Star rating system.









REMINDER: PBJ reports must be submitted by November 14, 2016 for Quarter 3, 2016

All staffing data must be submitted to Medicare for payroll based journal reporting to capture staff and contracted hours during this time frame. The files must include the specific information required by Medicare such as employee specific id, discipline, days and hours worked in an xml format.

As a facility you must log on and obtain a Medicare issued identification number for your facility. Once you have your ID, a provider can then format an upload of the contracted therapy hours to submit to you include in your reporting. This avoids you having to manually enter or collect the contracted hours.

Not reporting your PBJ information can have a significant impact on your 5 STAR rating. The rating for staffing is based on two case-mix adjusted measures:

  1. Total nursing hours per resident day (RN+LPN+ nurse aid hours)
  2. RN hours per resident day

These hours are then calculated based on a formula that includes resident census to obtain each facility staffing rating. This rating is then converted and compared to percentile cut points to achieve your 5 STAR rating for staffing.

Providing accurate and timely reporting will ensure you receive an accurate rating.

5 STAR is comprised of 3 components: health inspections, staffing and quality measures with more stars indicating better quality. Therefore, is critical you submit your PBJ report before the cut -off date of November 14, 2016 to achieve your staffing star!

Section GG Success Plan

Although part of the MDS, Section GG brings many unique challenges to our teams. Understanding the definitions and coding requirements require a solid plan for education and training. Strategies for Success:

1.Educate, Educate, Educate - anyone who will be responsible for the assessment, observation and documentation in the medical record. This step is critical to ensure that Section GG coding accurately reflects the resident’s performance level and goals.

a. Identify a Trainer

b. Provide guides for terminology and scoring

2.Collaborate - develop an interdisciplinary process to collect information on the resident’s performance through interdisciplinary tracking forms and software integrations.

a. Identify a Team Leader – to ensure compliance with look back periods and monitor the documentation required during this period

b. Identify Therapy Leader responsible for collecting and reviewing the clinical information on current status and anticipated goals with the interdisciplinary team

3.Process Management – identify roles and responsibilities within the process

a. Pre-Admission screening review of information to assist with accurate functional goals

b. Admission communication that is effective for timely completion of evaluations

c. Evaluation process incudes Section GG items for completion in therapy and nursing assessments

d. Daily encounter notes should be completed

e. Post admission meeting within 48-72 hour to develop goals for discharge

f. Pre-discharge meeting to review performance for the last 3 days prior to discharge

4.Documentation – identify documentation methods used to collect data

a. Therapy evaluations, notes and discharge summaries

b. Skilled nursing notes

c. Review of all shift notes during the 3 day look back period – review number of episodes

d. Interdisciplinary team meeting documentation


a. Develop guides for definitions – most usual performance

b. Develop guides for coding – dependent definition

By incorporating these steps into your Section GG transition, you will ensure your team is coding an accurate description of the functional performance of the resident within Section GG

October 1 Brings New Requirements

October 1 is an important day in the world of Long Term Care as a new Section on the MDS becomes mandatory call Section GG and ICD10 coding transition period comes to an end.

Section GG is required on all admissions starting October 1 that have a Medicare Part A payer. Section GG is a 3 day look back period that allows for the facility to determine the resident’s “most usual” performance and then code the mobility and self- care items accordingly. To establish “most usual” performance, there should be a strong collaboration between nursing and therapy. Integration of software programs, tracking methods, discussion protocols and decision trees for coding are all beneficial tools to assist in this process.

Once the admission assessment is completed on the 5- day assessment and “most usual” performance with goals are coded, if the resident is a planned discharge, Section GG must be completed at that time as well. The discharge assessment uses the last 3 days of their skilled stay to determine “most usual” performance which correlates to goal achievement.

Collaboration and training are critical elements for a successful transition to Section GG. Education provided to the facility staff and therapy at the same time to ensure conformity of message and process as well as a solid understanding of the coding criteria and goal setting on the admission assessment will assist with a successful transition.

ICD10 transition is complete as of October 1 and the expansion to more specific diagnosis coding is complete. Diagnosis must include items such as laterality and more specific detail as provided in ICD10. Denials are now possible due to improper coding using the ICD10 system as of October 1, 2016.

Collaboration between facility and therapy is important to ensure correct codes are submitted on the UBO4 form and processes such as Triple Check can assist with submission of clean claims.

What is your risk?

Providers cannot eliminate all risk, but can minimize risk through proactive approaches that involve training and policy development. Medicare audits have increased 1000% in the last 5 years! Are you ready for that level of scrutiny? To help analyze your risk, identifying WHO is responsible for the following areas and establish a schedule of review to build your compliance foundation:

  • MDS coding and accuracy? Avoids payment returns and supports billing process
  • Training? How often? What topics? Keeps everyone knowledgeable and focused on current guidelines
  • Audits? How often? Opportunity for improvement plans resulting in improved processes
  • Review of Provider agreements and Federal guidelines for coverage guideline updates? Prevents errors in billing for services outside of the coverage guidelines
  • Database content? Who monitors this? How often? Protects the integrity of your organization

Audits such as new survey protocols focusing on MDS accuracy, new analytics and increased ability to data mine are occurring in conjunction with active interagency reporting, so establishing internal audits to confirm practices helps safe guard your organization from a negative outcome.


Are you protecting the privacy of the MDS Data?

As a facility submitting MDS data to CMS, you must abide by the Federal and State regulations with respect to maintaining resident data. The Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument 3.0 version 1.13 states that “all contractual agreements, regardless of their type, involving the MDS data should not violate the requirements of participation in the Medicare and/or Medicaid program, the Privacy Act of 1974 or any applicable state laws.”

Effective 6-17-2013 the privacy act statement for health care records was implemented. This form provides to the Resident the advice required by the Privacy Act of 1974 and is NOT a consent form. This form does provide permission to release Health Care Information.
This form is found on Pages 1-16, 1- 17 and 1- 18 of the RAI manual at and should be included as a part of your admission packet.

NOTE: “providers may request to have the Resident or his or her Representative sign a copy of this notice as a means to document that notice was provided. Signature is NOT required.”
All Residents and or their Representatives MUST be supplied with a copy of the notice. Including this form in your admission packet ensures you are in compliance with the Medicare Regulation outlined in Chapter 1.8, Protecting the Privacy of the MDS Data.

What is a Compliance Program?

Although there are many definitions and descriptions of a compliance program at its most basic level it is a method for an organization to ensure that there are methods identified for prevention, detection, collaboration and enforcement of all applicable federal and state laws governing the organization.
An effective compliance program is an ongoing process. It is a system for doing the right thing through policies and procedures that are developed within the organization. By how is that defined?
According to the Compliance 101 resource, the OIG’s top 10 list of reasons to implement a compliance program are as follows:

  1. Adopting a compliance program concretely demonstrate to the community at large that a provider has a strong commitment to honesty and responsible corporate citizenship
  2. Compliance programs reinforce employees’ innate sense of right and wrong
  3. An effective compliance programs helps a provider fulfill its legal duty to government and private payors.
  4. Compliance programs are cost -effective
  5. A compliance program provides a more accurate view of employee and contractor behavior relating to fraud and abuse.
  6. The quality of care provided to patients is enhanced by an effective compliance program
  7. A compliance program provides procedures to promptly correct misconduct.
  8. An effective compliance program may mitigate any sanction imposed by the government.
  9. Voluntarily implementing a compliance program is preferable to waiting for the OIG to impose a Corporate Integrity Agreement (CIA).
  10. Effective corporate compliance programs may protect corporate directors from personal liability.

Now that you know why you need a compliance program, what does that look like and where do you start? There is not a standard compliance program out there that is appropriate for all organizations but the foundation is a commitment to meeting the 7 seven essential elements that an effective compliance program is structured around and identifying barriers you may encounter.
As you start to examine your compliance program, the first step would be to ask have you reviewed and updated your policies and procedures and provided your employees with standards of conduct? If so, when? Establishing these items will provide a code of conduct for good decision making throughout the organization.

CMS Expands Mandatory Bundling Program to Cardiac Care, Including Rehab

The Centers for Medicare and Medicaid Services (CMS) has announced the latest in its move toward value-based payment systems—this time through the introduction of a mandatory bundling program for care associated with bypass surgery and heart attacks, including provisions that would incentivize the use of cardiac rehabilitation.

The demonstration plan announced by CMS would affect hospitals in 98 randomly selected metropolitan areas and would work much like the Comprehensive Care for Joint Replacement (CJR) model implemented this year. Similar to CJR, the new bundling plan would reimburse providers a set amount for an entire episode of care, from admission to 90 days after the patient is discharged. Medicare would create targets for spending, and if the total spending is less than the Medicare target, the hospitals may be eligible to receive additional payment from Medicare. If hospitals spend more than the Medicare target, they could be required to pay back Medicare for some portion of the difference. And like CJR, the cardiac bundling plan is mandatory for hospitals in those areas.

Also included in the cardiac demonstration proposed rule: a proposal to extend the CJR bundling provisions beyond hip and knee arthroplasty to include patients undergoing care for hip and femur fractures. The project would launch July 1, 2017, and last for 5 years.

"Just like CJR, the model is mandatory and extends to metropolitan statistical areas [MSAs] that include the 67 areas already covered in CJR," said Roshunda Drummond-Dye, APTA director of regulatory affairs. "If PTs want to formally collaborate with hospitals to share in incentive payments, they must negotiate contractually. But the bottom line is, if they are included in one of the identified MSAs and they treat patients within 90 days from discharge from the hospitals after a heart attack, bypass, or hip surgery, the care they provide will count toward the bundle."

The cardiac program also includes an initiative that would promote the use of cardiac rehabilitation during the 90-day period after discharge. According to a fact sheet from CMS, the initial payment would be $25 per cardiac rehab service for each of the first 11 services paid for by Medicare. After 11 services are paid for by Medicare for a beneficiary, the payment would increase to $175 per service. "Clinical studies have found completing a rehabilitation program can lower a patient’s risk of heart attack or death," CMS writes. "Increasing the use of cardiac rehabilitation services has the potential to improve patient outcomes and help keep patients healthy and out of the hospital."

Drummond-Dye says that the expanding use of bundling programs is part of a larger shift toward value-based payment models—and something PTs need to be tuned into.

"One key proposal that uniquely affects PTs is the provision to make CJR and other bundled payment models qualify as alternative payment models under [the Medicare Access and CHIP Reauthorization Act, or MACRA]," Drummond-Dye said. "At first glance, this is good news for our providers, as this gives them more opportunities to participate in alternative payment models and quality programs under MACRA—it's something that APTA advocated for in our comments, and, essentially, CMS listened."

Meanwhile, APTA advises that PTs stay on top of patient data and evidence to make the bundling models work for them.

"It is imperative that PTs know the composition of the patient population they treat and have clinical evidence on the outcomes of their care for this patient population," Drummond-Dye said.

 APTA intends to provide comments on the cardiac bundling demonstration by the September 24 deadline, and continues to track implementation of CJR.

The APTA CJR webpage contains extensive information on both the nuts-and-bolts of the program and the considerations physical therapists should weigh when making practice decisions. The online resource also includes links to evidence-based clinical information and community programs, as well as a free webinar on the system.


Posted by News Now Staff

Labels: Health Care Headlines

New study finds: Medicare eligibility ups rehab use among seniors

In the year after seniors hit Medicare eligibility, there is close to a 10% increase in those seeking rehabilitation care services, according to a new analysis.

In comparing pre-Medicare trauma patients versus those at age 65, researchers at the Center for Surgery and Public Health at Brigham and Women's Hospital also found a 6.4% decline in uninsured seniors.

Becoming a Medicare beneficiary means more patients have access to skilled nursing facilities, researchers said, allowing them to seek out rehab care that would otherwise be ignored. Medicare coverage restrictions based on hospital stay length were also associated with increased inpatient and skilled nursing care.

Researchers used regression discontinuity models and examined patient data from the National Trauma Data Bank between 2007-2012 to conduct the study. A total of 305,198 patients were analyzed, with slightly over a total of 40% receiving rehabilitation care.

"As a nation, it's imperative that we continue to study the impact of ongoing healthcare reform, particularly when it comes to the effect that health insurance status has on access to rehabilitation,"  Adil Haider, M.D., MPH, FACS, lead author of the study and Kessler Director of the Center for Surgery and Public Health, said. "Whether it's discharge to a skilled nursing facility, acute inpatient facility, or care provided at home, rehabilitation is a key step in the healing and recovery process and every patient deserves equitable access."


More individuals could be blocked from Medicare, Medicaid under new bill

Individuals affiliated with fraudulent healthcare companies would face tougher government scrutiny under a bill introduced in the House on Tuesday.

The “Fighting Medicare Fraud Act, 2016,” introduced by Reps. Lois Frankel (D-FL) and William Keating (D-MA), would give the Department of Health and Human Services greater ability to exclude individuals linked to companies penalized for fraud from participating in federal healthcare programs.

That increased ability would close a “loophole” that allows employees to resign before a company receives a penalty and “potentially launch a new Medicare fraud scheme,” the bill's authors said. Current laws only exclude individuals who are still employed by the company, so the HHS Office of Inspector General is blocked from excluding individuals who voluntarily leave, Kirk Ogrosky, an attorney with Washington-based law firm Arnold & Porter, told Bloomberg BNA.

The bill would expand the OIG's exclusion abilities to individuals who had ownership, control interest, or an officer or managing position with a fraudulent company who knew or “should have known” about fraudulent conduct.

“We need to ensure taxpayer dollars are committed to providing vital services for our seniors, not lining the pockets of fraudulent businesses and CEOs,” said Keating in a statement on the bill. “This common-sense legislation stops the cycle of deceit amongst the worst actors — toughening the consequences felt by those who illegally exploit our elderly population while strengthening the Medicare system in the process.”

The proposed legislation would also make stealing Medicare, Medicaid or Children's Health Insurance Plan numbers a federal offense carrying a possible prison sentence of up to 15 years.

Medicare Advantage and Part D organizations would also be required to report incidents of potential fraud and abuse within 60 days of identification under the bill. Research has indicated that instances of fraud and abuse in those programs “may be unreported,” the bill's authors said.

The bill has been referred to the House Energy and Commerce and Ways and Means committees. Similar legislation was introduced in 2013, but never received a full House vote.