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Still not sure on ending PPS with no rehab?

First HAPPY THANKSGIVING TO EVERYONE! I just started doing the MDS/PPS for medicare residents at our facility which just became medicare certified and still am not sure on 1 thing (1 of alot!) but my DON said since we are all new to this, Billing, PPS assessments and everything we would start with just one Med A at a time for awahile. Well within 1 week I now have 3. I do their MDS/PPS schedules, care plans and work the floor at times do all the assessments and charting among everthing else that gets thrown at me. 2 of our MED A are being skilled for behavior and med changes that were current residents but had been sent to a Psych Hospital for issues and returned on MED A, since they are not getting any rehabs, they are fairly independant but need almost constant monitoring I am wandering when I/ or I tell the Dr I feel they have stabalized and no longer require daily skilled services do I just stop doing the PPS's and they go back and continue their OBRA schedule? I know when they are in a rehab group and that is dc'd but still continue to need skilled services I need to do a OMRA, BUT what do I do when they were never in a rehab group to start with to end me doing their PPS, you see when they are off of medicare A the other MDS nurses take them back over, right now if they are my residents I do their their OBRA and Medicare PPS..Also what type and when is a notice suppose to be given the the resident or family letting them know they can no longer be skilled? Am I suppose to be giving anything to billing while I have the medicare A residents. No oone has ever told me and since we are all new to this It seems very disorganized to me. Billing doesn't seem to have much of clue either..Thanks ahead of time for the help. I am in Colorado


Specializes in LTC.

Happy Thanksgiving! Sounds like you haven't enjoyed your day much. Stop worrying about work and have a glass of wine. To answer your question - first of all, you really should not be covering residents coming back from a mental health stay under med A. The feds do not see that as an "acute" hospital stay. I attended a Medicare seminar not too long ago, and they told us that 90% of the time those charts get denied in review. When you are covering for other things that are not therapy related, be sure you have the proper documentation to back up what you are covering for. Most of the time you can cover residents returning from the hospital for the presumption of coverage if they had an IV, as long as you have the proper documentation. If they can't continue to be covered, be sure to cut them by day 5, and issue a cut letter ond day 2. New residents coming in that are being covered for things other than therapy such as skin issues need excellent documentation by the nursing staff. Be sure you have measurements of wounds weekly, and daily notes. The cut letters are on the Medicare site one the internet. There are 5 different ones. They are generic. Be sure you put your facility letter head on each one. You must give a cut letter to residents when they are cut from part A medicare 3 days before they are cut. You also must give them one when they have a partial cut in benefits. For example - if they are recieving PT and OT, and they are only cut form OT, you must give a cut letter for the OT when it is cut. This is a new rule, and there is a special form for this. There is also special language that you have to put on the form that is available on the internet, also on the Medicare Site. You can keep track of the billing days for med A, but the billing dept. is responsible for actually doing the billing. There is a Exel Spread sheet for PPS Medicare days that you can download from from the AANAC site. If you are not a member I can e-mail it to you. You should not be giving out the letters to the residents. I am a firm believer that this is a Social Service function. I dont think that nursing should mix medicine with money. I also have a form that I have made up for the computer that I keep track of my medicare A residents stay on. It has their name, Medicare#, ARD dates, Billing Dates, Why they are in the facility, Date of admit, Hosp stay dates, and ICD-9 codes on it. I keep one of these filled on on each med A resident, and on the private insurance resident too, since most of them require medicare MDS's. I keep them in a note book, and when we have our weekly medicare meetings I have easy access to what we have. If you would like a copy of that I can e-mail you the shell to that as well.

Good luck!catherinebuc4434@aol.com

CapeCodMermaid, RN

Specializes in Gerontology, Med surg, Home Health.

Be careful if you're only skilling for behaviors and med changes post psych admission. We had a couple of people from Medicare tell us they don't often pay for that since it's not really a skill and there is no sig. change. Make sure all the behaviors and interventions are documented although I'm not sure that'll be enough since it's not really a skill.


Specializes in ER CCU MICU SICU LTC/SNF.

'agree w/ both replies.

here is what cms says regarding a psych stay...

"while a 3-day stay in a psychiatric hospital satisfies the prior hospital stay requirement, institutions, which primarily provide psychiatric treatment, cannot participate in the program as snfs. therefore, a patient with only a psychiatric condition who is transferred from a psychiatric hospital to a participating snf is likely to receive only noncovered care. in the snf, the term "noncovered care" refers to any level of care which is less intensive and skilled than the snf level of care which is covered under the program." http://www.cms.hhs.gov/manuals/downloads/bp102c08.pdf p8

however, if the resident was in the hospital for a new onset of behavioral issues, a claim may be paid, probably for just a few days. see chapter 6 of the medicare program integrity manual http://www.cms.hhs.gov/manuals/downloads/pim83c06.pdf p29, #12 under hipps codes indicating classification into the lower 18 rug-iii group. documentation is crucial.

the beneficiary should be notified no less than 2 days prior to termination of coverage. the types of notices can be found here ... http://www.cms.hhs.gov/bni/01_overview.asp#topofpage

a clinical person should decide when a resident no longer requires skilled services, that be a therapist (for rehab services) or the nurse-in-charge of nursing care. the pps coordinator and billing person should then be notified of the anticipated d/c date and the reason why (a weekly medicare meeting would be beneficial). it would be ideal for the billing person to send the notice so he can explain the payment consequences and refer the beneficiary to the responsible clinician regarding clinical issues.


Specializes in Hosp, SNF.

"they are recieving PT and OT, and they are only cut form OT, you must give a cut letter for the OT when it is cut. This is a new rule, and there is a special form for this." VeryBerryRn, can you site where this came from, and the special form I am stupid and can not find it on the Web, thaks so much !! Nadine

CapeCodMermaid, RN

Specializes in Gerontology, Med surg, Home Health.

This must be a VERY new rule since I've never heard of it. If someone is on PT and OT and you dc the OT, you don't have to give a cut letter because the person would still be skillable.

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