Skilled Nursing Facilities

Type of nursing home
Skilled nursing facilities (SNF). Long-term care hospitals (LTCHs). Inpatient rehabilitation facilities (IRFs). Home health agencies (HHAs).
Type of care does Skilled Nursing Facilities provide
Activities of daily living (ADLs). Personal care services (custodial care). Rehabilitation services.
Medicare Part A eligibility criteria
Immediately after acute inpatient hospitalization of 3 days or more. 100 days of SNF-covered services per benefit period (spell of illness)
3. Describe what Consolidated Billing (CB) is and how it works
Includes bills from outside vendors
Laboratory
X-ray
Pharmacy
Excludes emergency services; inpatient services; extensive procedures; and certain high-cost, low probability-ancillary services
4. Assessment (Standard assessments for admissions and readmissions)
Standard assessments for admissions and readmissions
Other assessments
Start of therapy (SOT)
Change of therapy (COT)
End of therapy (EOT)
Significant change in status assessment (SCSA)
5. Define and explain the three components of structure of payments
Base rate
SNF case-mix group
Adjustments
Base Rate
Per diem
Known as federal base rate or federal per diem
CMS calculates using past cost reports from base year
Adjustments to base rate (per diem)
Geographic factors and inflation
Other mandated by regulation or statute
Patient case-mix based on complexity of resource intensity of residents’ conditions
6. What adjustments to the base rate can be adjusted and for what purpose?
Labor costs (wage index) and nonlabor costs
CMS takes into consideration when setting percentages
Pricer takes into consideration when determining payment
Inflation CMS takes into consideration when setting base rate
7. What is Resource Utilization Groups (RUG)
Homogeneous groups with similar health characteristics and requirements for use of resources
8. What key data to classify resident into RUG? Explain modes of therapy (Individual concurrent, group).
Nursing component.
Therapy component.
Noncase-mix-adjusted component and noncase-mix therapy component.
Nursing Component
Intensity of nursing patients expected to require
Case mix adjusted for all RUGs
Therapy components
Reflects amount of therapy services provided or expected to be provided
Case-mix adjusted for rehabilitation RUGs
Constant non-rehabilitation RUGs
Non-case mix adjusted components
Room & board, linens, and administrative costs
Constant amount for all RUGs
Explain difference of RUG upper category groups and related placement criteria
52 RUG upper category groups
Rehabilitation Plus Extensive Services (9)
Rehabilitation (14)
Extensive Services (3)
Special Care High (8)
Special Care Low (8)
Clinically Complex (10). Criteria
At least 45 minutes of therapy per week
“Presumption of coverage” — Medicare covers 52 upper category services covered if correctly classified by MDS data
Describe lower RUG category groups and placement criteria
14 RUG lower category groups
Behavioral Symptoms and Cognitive Performance (4)
Reduced Physical Function (10).
Criteria
Do not receive at least 45 minutes of therapy per week
Medicare coverage is determined on an individual basis
Explain three steps to payments for SNFs
Step One: Adjustment for geographic factors (base rate adjusted by area wages)
Base rate:
~70% adjusted for area wages (multiplied by wage index) plus ~30% nonlabor related portion (FY 2015 is 69% and 31%)
Step Two: Adjusted for case-mix
Geographic-adjusted base multiplied by RUG weight (CMS provides table that perform this task)
Step Three: Multiple geographic and case-mix adjusted base rate by number of days to equal SNF payment
What is pricer
Software program that has logic to calculate SNF PPS payments
Pricer’s data items
Federal rates for rural and urban area and nursing and therapy indices for each RUG
Applicable wage index
Changes to labor and nonlabor portions
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