SNF PPS
Can be freestanding facilities, hospital-based units, or swing beds in acute-care hospitals.
What is a Skilled Nursing Facility? (SNF?)
Patients with multiple acute and chronic diseases may require inpatient care in one of these for extended periods.
What are Long-Term Care Hospitals?
Provide intense multidisciplinary services to inpatients in order to restore or enhance patients' function after illness or injury.
What are Inpatient Rehabilitation Facilities (IRFs)?
A provider that renders skilled care to people in their homes, typically people who are homebound.
What is a Home Health Agency?
Predetermined rate for a 60-dy episode of home health care
Home health resource group (HHRG)
Covers the cost of SNF services for Medicare beneficiaries.
What is Medicare Part A?
Pays for up to 90 days of hospital services within the benefit period in LTCHs.
What is Medicare Part A?
Must be licensed under applicable state laws to provide skilled nursing care to inpatients 24hours per day.
What are Inpatient Rehabilitation Facilities?
The payment system implemented on Oct 1, 2000 for Home Health Agencies.
What is the home health prospective payment system (HHPPS)?
Services provided after acute illness
What is Post-acute care (PAC)?
Immediately after an acute-care inpt hospitalization of at least 3 days (3 midnights).
What is when is a Medicare beneficiary eligible for SNF services?
For days 61-90 in the LTCH, this payment is also required.
What is a daily coinsurance payment?
This collects the information that drives payment in IRFs.
IRF PAI Inpatient Rehabilitation Facility Patient Assessment Instrument
60-day periods of care
What are the periods of care covered under Medicare Part A and Medicare Part B.
This act was aimed at standardizing data submission for PAC (post acute care) areas, in Sept. 2014
IMPACT Improving Medicare Post-Acute Transformation Act of 2014
Pays a daily rate for each day of care
What is a per diem reimbursement methodology?
CMS requires this to be 25 days or more.
What is the ALOS?
Once upon admission and again at discharge
What is the requirement for completion of the IRF PAI fo Medicare patients.
When the provider reviews medical record documentation and verifies that the home health services are medically necessary.
What is certification?
means daily
per diem
SNF is required to pay for outpatient services that a resident may receive from outside vendors. Outside vendors who provide services to SNF residents with Part A benefits, submit their bills to the SNF, not to Medicare.
What is consolidated billing? (CB)
A case-rate system that categorizes patients with similar clinical characteristics and resource intensity into groups for payment.
What is LTCH PPS?
Rather than reporting a principal diagnosis, the IRF PAI must report this, the cause of the problem that led to the condition requiring rehabilitation admission.
What is the etiologic diagnosis?
Data collection tool to measure patient outcomes using data in this comprehensive assessment that underlies the pt's care plan
Has to be completed at certain times during the patient's care.
the Outcome Assessment Information Set (OASIS)
Facility submits one total bill to the the MAC (Medicare Administrative Contractor) covering the services, such as laboratory, x-ray, and pharmacy, received by the patient, client or resident during admission to the facility, including services from outside vendors
What is consolidated billing?
An extensive database of the resident's clinical data; comprehensive assessments required by CMS which must be completed in certain time frames and submitted to CMS. They are part of the clinical record.
What is the Minimum Data Set (MDS)?
The groups that patients are classified to based on diagnosis and adjustments for geographic factors & resource consumption to determine required payment.
MS-LTC-DRGs (Medicare Severity-Long-Term Care Diagnosis-Related Groups)
These were developed so that the IRF PPS could be implemented for inpatient rehabilitation services.
What are Case-Mix Groups?
Used to reflect details of skilled nursing and therapy services in home care claims
What are HCPCS G-codes?
Before an IRF can receive payment from Medicare and Medicaid, it must meet a compliance percentage of the inpatients requiring intensive rehabilitation services in one of the 13 qualifying conditions.
What is the 60 percent rule?