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PointClickCare (PCC) Integration with Nonagon N9+ Device and Virtual Exam Platform – Resident Dashboard – Clinical Tab – Weights Vitals

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PointClickCare (PCC) Integration with Nonagon N9+ Device and Virtual Exam Platform – Resident Dashboard – Clinical Tab

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PointClickCare (PCC) Integration with Nonagon N9+ Device and Virtual Exam Platform – Resident Dashboard – Admin – Misc Tab

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§ 411.15 Particular services excluded from coverage.

Link to an amendment published at 88 FR 53345, Aug. 7, 2023.

The following services are excluded from coverage:

(a) Routine physical checkups such as:

(1) Examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptoms, complaint, or injury, except for screening mammography, colorectal cancer screening tests, screening pelvic exams, prostate cancer screening tests, glaucoma screening exams, ultrasound screening for abdominal aortic aneurysms (AAA), cardiovascular disease screening tests, diabetes screening tests, a screening electrocardiogram, initial preventive physical examinations that meet the criteria specified in paragraphs (k)(6) through (k)(15) of this section, additional preventive services that meet the criteria in § 410.64 of this chapter, or annual wellness visits providing personalized prevention plan services.

(2) Examinations required by insurance companies, business establishments, government agencies, or other third parties.

(b) Low vision aid exclusion—(1) Scope. The scope of the eyeglass exclusion encompasses all devices irrespective of their size, form, or technological features that use one or more lens to aid vision or provide magnification of images for impaired vision.

(2) Exceptions.

(i) Post-surgical prosthetic lenses customarily used during convalescence for eye surgery in which the lens of the eye was removed (for example, cataract surgery).

(ii) Prosthetic intraocular lenses and one pair of conventional eyeglasses or contact lenses furnished subsequent to each cataract surgery with insertion of an intraocular lens.

(iii) Prosthetic lenses used by Medicare beneficiaries who are lacking the natural lens of the eye and who were not furnished with an intraocular lens.

(c) Eye examinations for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses for refractive error only and procedures performed in the course of any eye examination to determine the refractive state of the eyes, without regard to the reason for the performance of the refractive procedures. Refractive procedures are excluded even when performed in connection with otherwise covered diagnosis or treatment of illness or injury.

(d) Hearing aids or examinations for the purpose of prescribing, fitting, or changing hearing aids.

(1) Scope. The scope of the hearing aid exclusion encompasses all types of air conduction hearing aids that provide acoustic energy to the cochlea via stimulation of the tympanic membrane with amplified sound and bone conduction hearing aids that provide mechanical stimulation of the cochlea via stimulation of the scalp with amplified mechanical vibration or by direct contact with the tympanic membrane or middle ear ossicles.

(2) Devices not subject to the hearing aid exclusion. Paragraph (d)(1) of this section shall not apply to the following devices that produce the perception of sound by replacing the function of the middle ear, cochlea, or auditory nerve:

(i) Osseointegrated implants in the skull bone that provide mechanical energy to the cochlea via a mechanical transducer, or

(ii) Cochlear implants and auditory brainstem implants that replace the function of cochlear structures or auditory nerve and provide electrical energy to auditory nerve fibers and other neural tissue via implanted electrode arrays.

(e) Immunizations, except for—

(1) Vaccinations or inoculations directly related to the treatment of an injury or direct exposure such as antirabies treatment, tetanus antitoxin or booster vaccine, botulin antitoxin, antivenom sera, or immune globulin;

(2) Pneumococcal vaccinations that are reasonable and necessary for the prevention of illness;

(3) Hepatitis B vaccinations that are reasonable and necessary for the prevention of illness for those individuals, as defined in § 410.63(a) of this chapter, who are at high or intermediate risk of contracting hepatitis B;

(4) Influenza vaccinations that are reasonable and necessary for the prevention of illness; and

(5) COVID–19 vaccinations that are reasonable and necessary for the prevention of illness.

(f) Orthopedic shoes or other supportive devices for the feet, except when shoes are integral parts of leg braces.

(g) Custodial care, except as necessary for the palliation or management of terminal illness, as provided in part 418 of this chapter. (Custodial care is any care that does not meet the requirements for coverage as SNF care as set forth in §§ 409.31 through 409.35 of this chapter.)

(h) Cosmetic surgery and related services, except as required for the prompt repair of accidental injury or to improve the functioning of a malformed body member.

(i) Dental services—(1) Basic rule. Dental services in connection with the care, treatment, filling, removal, or replacement of teeth, or structures directly supporting the teeth.

(2) Exception. Except for inpatient hospital services in connection with such dental procedures when hospitalization is required because of—

(i) The individual’s underlying medical condition and clinical status; or

(ii) The severity of the dental procedures. 577

577 Before July 1981, inpatient hospital care in connection with dental procedures was covered only when required by the patient‘s underlying medical condition and clinical status.

(3) Inapplicability.

(i) Dental services that are inextricably linked to, and substantially related and integral to the clinical success of, a certain covered medical service are not excluded; payment may be made under Medicare Parts A and B for services furnished in the inpatient or outpatient setting. Such services include, but are not limited to:

(A) Dental or oral examination performed as part of a comprehensive workup in either the inpatient or outpatient setting prior to Medicare-covered organ transplant, cardiac valve replacement, or valvuloplasty procedures; and, medically necessary diagnostic and treatment services to eliminate an oral or dental infection prior to, or contemporaneously with, the organ transplant, cardiac valve replacement, or valvuloplasty procedure.

(B) The reconstruction of a dental ridge performed as a result of and at the same time as the surgical removal of a tumor.

(C) The stabilization or immobilization of teeth in connection with the reduction of a jaw fracture, and dental splints only when used in conjunction with covered treatment of a covered medical condition such as dislocated jaw joints.

(D) The extraction of teeth to prepare the jaw for radiation treatment of neoplastic disease.

(ii) Ancillary services and supplies furnished incident to covered dental services are not excluded, and Medicare payment may be made under Part A or Part B, as applicable, whether the service is performed in the inpatient or outpatient setting, including, but not limited to the administration of anesthesia, diagnostic x-rays, use of operating room, and other related procedures.

(j) Personal comfort services, except as necessary for the palliation or management of terminal illness as provided in part 418 of this chapter. The use of a television set or a telephone are examples of personal comfort services.

(k) Any services that are not reasonable and necessary for one of the following purposes:

(1) For the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

(2) In the case of hospice services, for the palliation or management of terminal illness, as provided in part 418 of this chapter.

(3) In the case of pneumococcal vaccine for the prevention of illness.

(4) In the case of the patient outcome assessment program established under section 1875(c) of the Act, for carrying out the purpose of that section.

(5) In the case of hepatitis B vaccine, for the prevention of illness for those individuals at high or intermediate risk of contracting hepatitis B. (Section 410.63(a) of this chapter sets forth criteria for identifying those individuals.)

(6) In the case of screening mammography, for the purpose of early detection of breast cancer subject to the conditions and limitations specified in § 410.34 of this chapter.

(7) In the case of colorectal cancer screening tests, for the purpose of early detection of colorectal cancer subject to the conditions and limitations specified in § 410.37 of this chapter.

(8) In the case of screening pelvic examinations, for the purpose of early detection of cervical or vaginal cancer subject to the conditions and limitations specified in § 410.56 of this chapter.

(9) In the case of prostate cancer screening tests, for the purpose of early detection of prostate cancer, subject to the conditions and limitations specified in § 410.39 of this chapter.

(10) In the case of screening exams for glaucoma, for the purpose of early detection of glaucoma, subject to the conditions and limitations specified in § 410.23 of this chapter.

(11) In the case of initial preventive physical examinations, with the goal of health promotion and disease prevention, subject to the conditions and limitations specified in § 410.16 of this chapter.

(12) In the case of ultrasound screening for abdominal aortic aneurysms, with the goal of early detection of abdominal aortic aneurysms, subject to the conditions and limitation specified in § 410.19 of this chapter.

(13) In the case of cardiovascular disease screening tests for the early detection of cardiovascular disease or abnormalities associated with an elevated risk for that disease, subject to the conditions specified in § 410.17 of this chapter.

(14) In the case of diabetes screening tests furnished to an individual at risk for diabetes for the purpose of the early detection of that disease, subject to the conditions specified in § 410.18 of this chapter.

(15) In the case of additional preventive services not otherwise described in this title, subject to the conditions and limitation specified in § 410.64 of this chapter.

(16) In the case of an annual wellness visit providing a personalized prevention plan, subject to the conditions and limitations specified in § 410.15 of this subpart.

(l) Foot care—(1) Basic rule. Except as provided in paragraph (l)(2) of this section, any services furnished in connection with the following:

(i) Routine foot care, such as the cutting or removal of corns, or calluses, the trimming of nails, routine hygienic care (preventive maintenance care ordinarily within the realm of self care), and any service performed in the absence of localized illness, injury, or symptoms involving the feet.

(ii) The evaluation or treatment of subluxations of the feet regardless of underlying pathology. (Subluxations are structural misalignments of the joints, other than fractures or complete dislocations, that require treatment only by nonsurgical methods.

(iii) The evaluation or treatment of flattened arches (including the prescription of supportive devices) regardless of the underlying pathology.

(2) Exceptions.

(i) Treatment of warts is not excluded.

(ii) Treatment of mycotic toenails may be covered if it is furnished no more often than every 60 days or the billing physician documents the need for more frequent treatment.

(iii) The services listed in paragraph (l)(1) of this section are not excluded if they are furnished—

(A) As an incident to, at the same time as, or as a necessary integral part of a primary covered procedure performed on the foot; or

(B) As initial diagnostic services (regardless of the resulting diagnosis) in connection with a specific symptom or complaint that might arise from a condition whose treatment would be covered.

(m) Services to hospital patients—(1) Basic rule. Except as provided in paragraph (m)(3) of this section, any service furnished to an inpatient of a hospital or to a hospital outpatient (as defined in § 410.2 of this chapter) during an encounter (as defined in § 410.2 of this chapter) by an entity other than the hospital unless the hospital has an arrangement (as defined in § 409.3 of this chapter) with that entity to furnish that particular service to the hospital‘s patients. As used in this paragraph (m)(1), the term “hospital” includes a CAH.

(2) Scope of exclusion. Services subject to exclusion from coverage under the provisions of this paragraph (m) include, but are not limited to, clinical laboratory services; pacemakers and other prostheses and prosthetic devices (other than dental) that replace all or part of an internal body organ (for example, intraocular lenses); artificial limbs, knees, and hips; equipment and supplies covered under the prosthetic device benefits; and services incident to a physician service.

(3) Exceptions. The following services are not excluded from coverage:

(i) Physicians’ services that meet the criteria of § 415.102(a) of this chapter for payment on a reasonable charge or fee schedule basis.

(ii) Physician assistant services, as defined in section 1861(s)(2)(K)(i) of the Act, that are furnished after December 31, 1990.

(iii) Nurse practitioner and clinical nurse specialist services, as defined in section 1861(s)(2)(K)(ii) of the Act.

(iv) Certified nurse-midwife services, as defined in section 1861(ff) of the Act, that are furnished after December 31, 1990.

(v) Qualified psychologist services, as defined in section 1861(ii) of the Act, that are furnished after December 31, 1990.

(vi) Services of an anesthetist, as defined in § 410.69 of this chapter.

(n) Certain services of an assistant-at-surgery.

(1) Services of an assistant-at-surgery in a cataract operation (including subsequent insertion of an intraocular lens) unless, before the surgery is performed, the appropriate QIO or a carrier has approved the use of such an assistant in the surgical procedure based on the existence of a complicating medical condition.

(2) Services on an assistant-at-surgery in a surgical procedure (or class of surgical procedures) for which assistants-at-surgery on average are used in fewer than 5 percent of such procedures nationally.

(o) Experimental or investigational devices, except for certain devices.

(1) Categorized by the FDA as a Category B (Nonexperimental/investigational) device as defined in § 405.201(b) of the chapter; and

(2) Furnished in accordance with the coverage requirements in § 405.211(b).

(p) Services furnished to SNF residents—(1) Basic rule. Except as provided in paragraph (p)(2) of this section, any service furnished to a resident of an SNF during a covered Part A stay by an entity other than the SNF, unless the SNF has an arrangement (as defined in § 409.3 of this chapter) with that entity to furnish that particular service to the SNF‘s residents. Services subject to exclusion under this paragraph include, but are not limited to—

(i) Any physical, occupational, or speech-language therapy services, regardless of whether the services are furnished by (or under the supervision of) a physician or other health care professional, and regardless of whether the resident who receives the services is in a covered Part A stay; and

(ii) Services furnished as an incident to the professional services of a physician or other health care professional specified in paragraph (p)(2) of this section.

(2) Exceptions. The following services are not excluded from coverage, provided that the claim for payment includes the SNF‘s Medicare provider number in accordance with § 424.32(a)(5) of this chapter:

(i) Physicians’ services that meet the criteria of § 415.102(a) of this chapter for payment on a fee schedule basis.

(ii) Services performed under a physician‘s supervision by a physician assistant who meets the applicable definition in section 1861(aa)(5) of the Act.

(iii) Services performed by a nurse practitioner or clinical nurse specialist who meets the applicable definition in section 1861(aa)(5) of the Act and is working in collaboration (as defined in section 1861(aa)(6) of the Act) with a physician.

(iv) Services performed by a certified nurse-midwife, as defined in section 1861(gg) of the Act.

(v) Services performed by a qualified psychologist, as defined in section 1861(ii) of the Act.

(vi) Services performed by a certified registered nurse anesthetist, as defined in section 1861(bb) of the Act.

(vii) Dialysis services and supplies, as defined in section 1861(s)(2)(F) of the Act, and those ambulance services that are furnished in conjunction with them.

(viii) Erythropoietin (EPO) for dialysis patients, as defined in section 1861(s)(2)(O) of the Act.

(ix) Hospice care, as defined in section 1861(dd) of the Act.

(x) An ambulance trip that initially conveys an individual to the SNF to be admitted as a resident, or that conveys an individual from the SNF in connection with one of the circumstances specified in paragraphs (p)(3)(i) through (p)(3)(iv) of this section as ending the individual’s status as an SNF resident.

(xi) The transportation costs of electrocardiogram equipment (HCPCS code R0076), but only with respect to those electrocardiogram test services furnished during 1998.

(xii) Services described in subparagraphs (p)(2)(i) through (vi) of this section when furnished via telehealth under section 1834(m)(4)(C)(ii)(VII) of the Act.

(xiii) Those chemotherapy items identified, as of July 1, 1999, by HCPCS codes J9000–J9020, J9040–J9151, J9170–J9185, J9200–J9201, J9206–J9208, J9211, J9230–J9245, and J9265–J9600, and as of January 1, 2004, by HCPCS codes A9522, A9523, A9533, and A9534 (as subsequently modified by CMS), and any additional chemotherapy items identified by CMS.

(xiv) Those chemotherapy administration services identified, as of July 1, 1999, by HCPCS codes 36260–36262, 36489, 36530–36535, 36640, 36823, and 96405–96542 (as subsequently modified by CMS), and any additional chemotherapy administration services identified by CMS.

(xv) Those radioisotope services identified, as of July 1, 1999, by HCPCS codes 79030–79440 (as subsequently modified by CMS), and any additional radioisotope services identified by CMS.

(xvi) Those customized prosthetic devices (including artificial limbs and their components) identified, as of July 1, 1999, by HCPCS codes L5050–L5340, L5500–L5611, L5613–L5986, L5988, L6050–L6370, L6400–6880, L6920–L7274, and L7362–L7366 (as subsequently modified by CMS) and any additional customized prosthetic devices identified by CMS, which are delivered for a resident’s use during a stay in the SNF and intended to be used by the resident after discharge from the SNF.

(xvii) Those blood clotting factors indicated for the treatment of patients with hemophilia and other bleeding disorders identified, as of July 1, 2020, by HCPCS codes J7170, J7175, J7177–J7183, J7185–J7190, J7192–J7195, J7198–J7203, J7205, and J7207–J7211 (as subsequently modified by CMS) and items and services related to the furnishing of such factors, and any additional blood clotting factors identified by CMS and items and services related to the furnishing of such factors.

(xviii) Those RHC and FQHC services that are described in § 405.2411(b)(2) of this chapter.

(3) SNF resident defined. For purposes of this paragraph, a beneficiary who is admitted to a Medicare-participating SNF is considered to be a resident of the SNF for the duration of the beneficiary‘s covered Part A stay. In addition, for purposes of the services described in paragraph (p)(1)(i) of this section, a beneficiary who is admitted to a Medicare-participating SNF is considered to be a resident of the SNF regardless of whether the beneficiary is in a covered Part A stay. Whenever the beneficiary leaves the facility, the beneficiary‘s status as an SNF resident for purposes of this paragraph (along with the SNF‘s responsibility to furnish or make arrangements for the services described in paragraph (p)(1) of this section) ends when one of the following events occurs—

(i) The beneficiary is admitted as an inpatient to a Medicare-participating hospital or CAH, or as a resident to another SNF;

(ii) The beneficiary receives services from a Medicare-participating home health agency under a plan of care;

(iii) The beneficiary receives outpatient services from a Medicare-participating hospital or CAH (but only for those services that CMS designates as being beyond the general scope of SNF comprehensive care plans, as required under § 483.21(b) of this chapter); or

(iv) The beneficiary is formally discharged (or otherwise departs) from the SNF, unless the beneficiary is readmitted (or returns) to that or another SNF before the following midnight.

(q) Assisted suicide. Any health care service used for the purpose of causing, or assisting to cause, the death of any individual. This does not pertain to the withholding or withdrawing of medical treatment or care, nutrition or hydration or to the provision of a service for the purpose of alleviating pain or discomfort, even if the use may increase the risk of death, so long as the service is not furnished for the specific purpose of causing death.

(r) A home health service (including medical supplies described in section 1861(m)(5) of the Act, but excluding durable medical equipment to the extent provided for in such section) as defined in section 1861(m) of the Act furnished to an individual who is under a plan of care of an HHA, unless that HHA has submitted a claim for payment for such services.

(s) Unless § 414.404(d) or § 414.408(e)(2) of this subchapter applies, Medicare does not make payment if an item or service that is included in a competitive bidding program (as described in part 414, subpart F of this subchapter) is furnished by a supplier other than a contract supplier (as defined in § 414.402 of this subchapter).

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The Centers for Medicare & Medicaid Services (CMS) issued a final rule Monday that updates Medicare payment policies and rates for skilled nursing facilities under the Skilled Nursing Facility Prospective Payment System for fiscal year 2024.

The federal agency estimates that the aggregate impact of the payment policies in the latest rule would result in a net increase of 4.0%, or approximately $1.4 billion, in Medicare Part A payments to SNFs in FY 2024. This estimate reflects a $2.2 billion increase resulting from the 6.4% net market basket update to the payment rates.

The final rule also brings forth updates to the SNF Quality Reporting Program (QRP) and the SNF Value-Based Purchasing (VBP) Program for FY 2024 and future years, including the adoption of a measure intended to address staff turnover.

Experts said that given the rising costs associated with labor and other expenses, the payment rate might be insufficient to meet the needs of the moment.

“While it is nice to see a more significant market basket increase (in the 6.2% range) than the prior years’ 2% and 3% adjustments, it is important to note that much of this increase is making up for last years’ significant under-reimbursement,” Brian Ellsworth, VP public policy and payment transformation for Health Dimensions Group, told Skilled Nursing News.

Moreover, Ellsworth noted that the expenses for the nursing home Industry have gone up. “[The] average hourly nursing wage went up by 17% between 2019 and 2021, so CMS had ample indication that the market basket update needed to be adjusted upward. Adequate payment for nursing staff is of vital importance and will need to be factored into the staffing standards when they come out,” he said.

Ellsworth also recommends that CMS revisit consolidated billing policy to better ensure that patients with high-cost medications get more timely access to skilled nursing. “It is long past due to make some adjustments to that policy,” he said.

Meanwhile, this expert view is backed by nursing home advocates as well, who said that even though they welcome the payment rate increase, it doesn’t go far enough to ensure quality given the tough labor and economic environment.

“The final rule released today does not address the reality of providers’ operating environments, and will, ultimately, limit older adults’ access to much-needed care and services,” said Katie Smith Sloan, president and CEO of LeadingAge, the largest association of nonprofit providers of aging services, including nursing homes. “[The] 4% provided in this rule will surely be offset by the increasing costs of care, which will most certainly continue to rise in the coming year – on top of the expected staffing standards.”

And, Martin Allen, senior vice president of Reimbursement Policy at the American Health Care Association (AHCA), acknowledged that while the Medicare increase will help nursing homes enhance their services and support their caregivers, more must be done, especially if the Biden Administration implements a federal staffing mandate – an effort that AHCA estimates could cost tens of billions of dollars each year. “It is vital to fund government mandates and to ensure Medicare remains a viable program to ensure our nation’s seniors can access the care they need,” Allen said.

Moreover, advocates pointed out that several of the measures stand out as “concerning” on quality reporting and value-based purchasing. Among these measures, they especially noted the staff and resident vaccination measure and the total Nurse Staffing Turnover measure for the VBP as not being practical.

LeadingAge also said that it disagreed with how CMS was defining gaps in employment with a 60 day-timeframe, saying that it was contradictory to the Department of Labor’s guarantee of 12 weeks per year of family/medical leave (FMLA).

“These measures aren’t fair, reasonable or within providers’ control,” Smith Sloan said.

The final 2024 payment rule is expected to be published in the Federal Register on Aug. 7.

Updates to payment rates

The market basket update is based on a 3.0% SNF market basket increase plus a 3.6% market basket forecast error adjustment and minus a 0.2% productivity adjustment, as well as a negative 2.3%, or approximately $789 million, decrease in the FY 2024 SNF PPS rates as a result of the second phase of the Patient Driven Payment Model (PDPM) parity adjustment recalibration, CMS said in its press release.

“After considering the stakeholder feedback received on the FY 2023 SNF PPS proposed rule and to balance mitigating the financial impact on providers of recalibrating the PDPM parity adjustment with ensuring accurate Medicare Part A SNF payments, CMS finalized a PDPM parity adjustment factor of 4.6% in the FY 2023 SNF PPS final rule with a two-year phase-in period, resulting in a 2.3% reduction in FY 2023 and a 2.3% reduction in FY 2024 to the SNF PPS payment rates,” CMS said.

CMS also noted that the impact figures do not incorporate the VBP reductions for certain SNFs subject to the net reduction in payments under the VBP. Those adjustments are estimated to total $184.85 million in FY 2024.

CMS’ other changes include those made to the PDPM ICD-10 Code Mappings, in response to stakeholder feedback.

The federal agency also announced changes to the SNF QRP by adopting two measures in the QRP, removing three measures from the SNF QRP, and modifying one measure in the QRP. In addition, this rule makes policy changes to the QRP and begins public reporting of four measures.

And CMS said that it is also adopting the Discharge Function Score (DC Function) measure beginning with the FY 2025 SNF QRP. This measure assesses functional status by assessing the percentage of SNF residents who meet or exceed an expected discharge function score and uses mobility and self-care items already collected on the Minimum Data Set (MDS).

CMS is removing certain measures as well beginning in FY 2025, including one pertaining to self care score for medical rehab measure. 

Changes to the VBP Program

CMS had also proposed initially to gauge patient satisfaction as part of quality reporting and VBP programs through the CoreQ: Short Stay Discharge measure but decided to nix it in the final rule given that it lacked support during the comment period.

“While we and our members support this type of reporting, the measure as proposed did not provide adequate funding to ensure its success – so it was rightly excluded in the final rule,” Smith Sloan said.

CMS is adopting four new quality measures, replacing one quality measure, and finalizing several policy changes in the SNF VBP Program. The new quality measures are as follows:

• CMS is adopting the Nursing Staff Turnover measure for the SNF VBP program beginning with the FY 2026 program year. This is a structural measure that has been collected and publicly reported on Care Compare and assesses the stability of the staffing within an SNF using nursing staff turnover. Facilities would begin reporting for this measure in FY 2024, with payment effects beginning in FY 2026.
• CMS is adopting the Discharge Function Score Measure beginning with the FY 2027 program year. This measure is also being adopted for the SNF QRP and assesses functional status by assessing the percentage of SNF residents who meet or exceed an expected discharge function score and use mobility and self-care items already collected on the MDS.
• CMS is adopting the Long Stay Hospitalization Measure per 1,000 Resident Days beginning with the FY 2027 program year. This measure assesses the hospitalization rate of long-stay residents.
• CMS is adopting the Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) beginning with the FY 2027 program year. This measure assesses the falls with major injury rates of long-stay residents.
• CMS is replacing the Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM) with the Skilled Nursing Facility Within Stay Potentially

The rule also finalizes a constructive waiver process to ease administrative burdens for CMS related to processing Civil Monetary Penalty (CMP) appeals, the federal agency said in a press release. CMS publishes the final rule consistent with the legal requirements to update Medicare payment policies for SNFs annually.

2024 projected Medicare Part D coverage

CMS also announced that the average total monthly premium for Medicare Part D coverage is projected to be approximately $55.50 in 2024. This expected amount is a decrease of 1.8% from $56.49 in 2023. Stable premiums for Medicare prescription drug coverage in 2024 are supported by improvements to the Part D program in the Inflation Reduction Act that allow people with Medicare to benefit from reduced costs.

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Brian Carpenter, MD 1/31/2023

TELEMEDICINE

ADVERTORIAL

As we move forward in 2023, it’s uplifting to see census returning to near pre-pandemic levels for many providers. Unfortunately, many of these same facilities are still experiencing staffing challenges and the daunting reality of higher-acuity residents. With over 50 percent of U.S. hospitals operating in the red, the trend to discharge patients from the acute setting faster and sicker will surely continue.

An increase in acuity requires more physician access.

Skilled nursing facilities (SNFs) are increasingly shouldering the responsibility of complex hospital discharges, which test staff capabilities and negatively affect quality scores. Some providers have welcomed a higher-acuity strategy as an opportunity to build census, but physician access for these patients remains limited. Newly admitted patients may not see a physician for an assessment on the first day, and long-term care residents may only see a physician once a month. Physician access differs vastly from the acute-care setting, where doctors can be at the bedside 24/7 when needed.

Telemedicine is the only cost-effective means to increase access to physician services.

If the pandemic had a silver lining, it was telemedicine. The U.S. Department of Health and Human Services reported a 63-fold increase in Medicare telehealth utilization in 2020. Better technology, the need for infection control, and regulatory changes in the Coronavirus Aid, Relief, and Economic Security (CARES) Act expanded the opportunity to positively impact SNF outcomes. When deployed correctly, telemedicine is the most effective and affordable way to place a physician at the bedside 24 hours a day. Video-enabled virtual care provides the means to assess, manage, and treat changes in condition, in partnership with an attending nurse. It’s especially effective for nights and weekends.

Today it’s about more, not less.

Despite its promising potential, SNF telemedicine was initially met with a hefty dose of skepticism. Medical directors and attending physicians feared their billable encounters—or even their jobs—could be at risk. Nurses worried physicians would spend less time in the building. Providers worried about liability. And families assumed that telemedicine would replace in-person care for their loved ones.

Fortunately for long term and post-acute care residents, attitudes have shifted dramatically over the past few years. Today, there is broad and growing acknowledgment of telemedicine’s value and data to prove clinical efficacy and improved outcomes.

Telemedicine assists in managing transfers to and from acute settings.

One of the biggest challenges happens when residents need hospital-level services. Transfers at night create the most risk because understaffed emergency departments (EDs) don’t always prioritize SNF residents for treatment. We’ve seen a dramatic difference when an ED transfer workflow includes a tele-physician consult followed by direct communication from the tele-physician to the ED. When an engaged physician speaks directly to an ED physician to advocate on the patient’s behalf, the scenario for the patient changes. Telemedicine makes this possible, even overnight. The result is faster care, appropriate utilization, and less time in the hospital. We manage hundreds of ED transfers each month, and 39 percent of residents return to the SNF without hospital readmission.

Likewise, when patients arrive or return to the SNF, seeing a physician within a few hours can significantly improve the transition of care. Patients and families have shared how comforting it is to see a physician and have questions answered on day one. A video encounter can address medications, pain management, and a care plan to set the patient up for success until they can be seen in person by a physician.

Integration makes a difference.

SNF telemedicine is a two-way conversation initiated by a nurse at the bedside. Nurses use telemedicine more often when the process is easy, integrated into their existing workflow, and intuitive. Our partnership with PointClickCare makes telemedicine accessible directly in the patient chart, and utilization has skyrocketed. One regional organization saw a remarkable 300 percent increase in consultations—94 percent of which resulted in residents receiving treatment without having to leave their facility.

Telemedicine has a positive impact on SNF operations.

For SNFs, the return on investment from telemedicine shows up in myriad ways. Revenue is saved by reducing hospital readmissions and lost bed days. Administrative costs go down with uninterrupted care and fewer expenses tied to hospital transfers. Additional value accrues with improved quality scores, better hospital relationships, and more referrals through high-quality SNF networks. Additionally, numerous organizations see increased nursing satisfaction from this additional level of responsive support, even using their program to help recruit nurses.

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Healthcare providers, including doctors and therapists who treat nursing home patients, will see a key payment factor cut by 4.4% next year.

The Centers for Medicare & Medicaid Services announced the change to the Medicare Physician Pay Schedule conversion factor in a broader physician payment rule published late Tuesday. The conversion factor is part of a CMS formula used to reimburse for Part B care including physician and nurse practitioner services, rehab therapy, lab work and X-rays for Medicare patients in nursing facilities.

Last year, CMS proposed a 3% conversion factor cut, but Congress passed supplemental funding to offset it. It’s a strategy more than 100 healthcare groups are hoping they can win legislative backing for again this year, but the path forward isn’t as clear as in years past.

“Congress has stepped in for the last two years to mitigate the cut and we are lobbying for them to do it again this year,” Advion Executive Vice President Cynthia Morton told McKnight’s Long-Term Care News Tuesday night. “Congress is becoming fatigued with restoring this cut, and so we are concerned that Congress won’t mitigate the entire 4.4% cut that CMS has now finalized.”

That, combined with sequestration cuts triggered by a federal budget-neutrality law, could drive providers out of practice, other medical groups cautioned.

“The rate cuts would create immediate financial instability in the Medicare physician payment system and threaten patient access to Medicare-participating physicians,” The American Medical Association said, calling the rule an “ominous reality unless lawmakers act before Jan. 1.”

In total, physicians could see Medicare payments cut by nearly 8.5% next year, if so-called PAYGO cuts also are factored in.

Morton expressed relief that the broader rule put off plans to reduce payment for codes related to remote therapeutic monitoring.

“CMS had created these codes to move into digital health. Strangely, then they proposed to significantly reduce the value of the codes,” Morton said. “However, in response to concerns raised by Advion and other stakeholders, CMS is NOT finalizing its proposal to create 4 new G-codes (GRTM-1-4).”

Instead of reducing value based on who provides the service, CMS is finalizing the changes to allow any RTM service to be furnished under general supervision.

CMS is also making significant changes to reimbursement for specimen collection and travel allowance payments for clinical labs serving nursing facilities and the home care patients, Morton noted. In 2023, CMS will increase the specimen collection fee from $3 to $10.57 for a specimen collected from a SNF patient or on behalf of a home health agency. CMS is also proposing to adjust the rate for inflation in 2024.

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The need to consider offering at-home services may be accelerating for nursing home operators as the Choose Home Care Act of 2021 was introduced in the House of Representatives on Friday.

The bill was first introduced in July in the U.S. Senate by Sens. Debbie Stabenow (D-MI) and Todd Young (R-IN).

A bipartisan effort, the legislation is intended to give Americans more choice on where to recover following a hospital stay. The bill would create an add-on payment to the traditional Medicare home health benefit for patients 30 days after their hospital discharge.

At the time, LeadingAge, which represents more than 5,000 nonprofit operators, supported Choose Home as it gives older Americans access to a range of affordable care and services to meet their needs.

A spokesperson with the organization renewed that support to Skilled Nursing News on Friday.

The American Health Care Association and National Center for Assisted Living (AHCA/NCAL), which represents more than 14,000 SNF operators, assisted living communities and sub-acute centers, took a different tone.

“AHCA/NCAL strongly supports rational population health framework approaches to offer beneficiaries preferred care options,” a statement sent to SNN said. “However, we adamantly oppose cutting skilled nursing benefit day and coinsurance coverage protections, that have been in place for decades, to finance an untested expansion fo the home health benefit.”

It pointed to a MedPAC report, released in March 2021, that shows that home health aide visits declined from 13.4 visits in 1998 to 1.3 visits in 2019, despite no change in the underlying home health aide benefit.

““We need proposals that add options for Medicare beneficiaries, not limit them,” the statement said. “We hope to work with members of Congress to bring forth a solution that promotes choice, flexibility, and quality for post-acute services as envisioned by the IMPACT Act, and not create additional silos.”

The House companion bill is reportedly cosponsored by Representatives Sanford Bishop, Jr. (D-GA), Brendan Boyle (D-PA), Buddy Carter (R-GA), Dwight Evans (D-PA), Vicente Gonzalez (D-TX), Brian Higgins (D-NY), Clay Higgins (R-LA), Eleanor Holmes Norton (D-DC), Mike Johnson (R-LA), Tom O’Halleran (D-AZ), Tom Suozzi (D-NY) and Paul Tonko (D-NY).

In a statement in support of the piece of legislation, the National Association for Home Care & Hospice and Partnership for Quality Home commended the bill on Friday and said the support it’s received since it was first introduced in July shows how important it is to increase access to safe, cost-effective care at home for Medicare beneficiaries after hospitalization.

An at-home care program was shown to decrease 30-day emergency department (ED) visit escalation, avert $904,000 in ED/hospitalization costs and improve 30-day hospital admittance rates for UnityPoint Health, a Des, Moines, Iowa-based health system that plans to further expand its SNF-at-home to match current patient preference.

During SNN’s RETHINK conference in September, both Carespring Heath Care Management CEO Chris Chirumbolo and Ignite Medical Resorts CEO and Co-Founder Tim Field indicated that they didn’t consider the push to home care to be a threat to their operations in light of the Choose Home Bill’s introduction.

“I think it’s a complement, it’s not a competitor,” Fields said.

Ignite operates a portfolio of 10 short-term rehab facilities in Wisconsin, Illinois, Missouri, Kansas and Oklahoma.

An estimated 35% of nursing home patients could be diverted to home health care if the Choose Home Care Act of 2021 becomes law, according to Keith Myers, chairman and CEO of LHC Group, who spoke on a panel at Home Health Care News’ FUTURE conference last week.

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