Medicare Compliance & Reimbursement

CMS announces a change in its stance on default rates

If you forget to do a minimum data set, you can simply bill Medicare at the default rate for the days covered by the assessment, right?

Not according to recent transmittals issued by the Centers for Medicare & Medicaid Services. Transmittals 196 and 1252 state that the facility must submit an MDS that's accepted into the state repository before billing the Medicare program, observes Ronald Orth, president of Clinical Reimbursement Solutions LLC in Milwaukee.

"More specifically, Transmittal 196 says there are only two situations where you can bill the default rate without an MDS," Orth adds. One is when you did not do a 5-day MDS for a resident who is discharged or expires on or prior to day eight of the SNF admission. The other one is in "demand bill situations where the facility doesn't continue the PPS scheduled assessments," Orth adds.

In the past, however, SNFs "have always billed the default rate for time periods associated with an MDS" that wasn't done, Orth says.

"The interpretation was that you could bill the default rate if an MDS was not completed for whatever reason," agrees Marilyn Mines, director of clinical services for FR&R Healthcare Consulting in Deerfield, IL.

Example: In the past, if staff realized on day 35 of a SNF resident's stay that they did not complete a 14-day PPS assessment, the facility would bill the default rate for days 15 to 30. "Now CMS is saying that's not appropriate," Orth says.

Instead: You have to complete the late MDS using a current assessment reference date and transmit it before billing the default rate. If the resident has been gone from the facility more than seven days, you won't have information to code the MDS for the lookback, Orth notes.

Survival strategies: "If you missed an MDS and the resident is still in the building, do the MDS until CMS provides further clarification on this issue," counsels Orth.

"To prevent a missed assessment, monitor your assessment schedule very closely," Orth advises. And "as part of your weekly Medicare meetings, verify that all the assessments have been done and that the team is up to date."

Watch for warning messages from the state in real time showing an out-of-sequence assessment, Orth adds. "The key is to make sure the team didn't miss any assessments as the cause of the warning message."

Orth notes that CMS' current stance on billing the default rate contradicts two FIs' SNF manuals he has reviewed, as well as "MDS Web-based training the agency has in place," all of which state that "if you haven't completed an assessment, bill the default rate for those days."

Stay tuned: CMS says it is still reviewing the issue and [...]