CMS Fiscal Year 2024 Skilled Nursing Facility Prospective Payment System Final Rule

On July 31, 2023, CMS released the FY 2024 Skilled Nursing Facility Prospective Payment System Final Rule — CMS-1779-F. The rule is expected to increase Medicare A payments by 4.0%, or $1.4 billion, to SNFs in FY 2024. In addition, the final rule includes updates to the SNF Quality Reporting Program (QRP) and the SNF Value-Based Purchasing (VBP) program for FY 2024 and future years. Information on the FY 2024 final rule can be found here. Information on the Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program can be found here.

CMS Optional State Assessment (OSA) For RUGS Needed For Billing Effective 10/1/2023

Prior to October 1, 2023, the MDS provided a HIPPS score and a RUG score. Effective October 1, 2023, Section G (Functional Status) is removed from the MDS, causing facilities to be unable to generate a RUG score. If you need a RUG for insurance billing, you will need to complete an OSA to get one. Until CMS releases a replacement, they are allowing states to have Section G and GG running simultaneously for the Optional State Assessment (OSA). Using the OSA makes information available to maintain legacy RUG systems for facilities. If you have questions or need additional information on this change, please contact Stephanie Kessler or Tracy Montag.

2024 Medicare Parts A & B Premiums and Deductibles               

Medicare announced the premiums, deductibles and coinsurance amounts for 2024. The SNF Part A daily coinsurance is increasing to $204. The Part B annual deductible has increased to $240. The 2024 Medicare Part A and B Premiums and Deductibles Fact Sheet can be found here.

UPMC Health Plan Will Reinstate Initial Prior Authorization Requirement for Skilled Nursing Facilities              

Effective October 1, 2023, UPMC Health Plan will reinstate the initial prior authorization requirement for CRM.030 Skilled Nursing Facilities Services that was previously waived due to the COVID-19 public health emergency. Information on CRM.030 Skilled Nursing Facilities Services can be found in their Policies and Procedures manual on their website.

Novitas — Electronic Billing EDI Smart Edits            

Novitas continues to roll out Smart Edits, with the last round being implemented on September 14, 2023. It is recommended providers routinely check the Smart Edits web page for updates and more information. If you have trouble understanding these edits and getting your claims to transmit successfully, please contact one of our Medical Billing Managers, Gina Alifano or Lacy Albright. 

Medicaid 180 Day Exception Requirements for Claims Beyond 365 Days

Medicaid requires that a 180 Day Exception Request Detail Page be submitted with 180 day packets for claims beyond 365 days. This form requires the date that the Medicaid application was submitted and the proof of that submission (fax confirmation sheet, mailing proof or Compass proof). We ask that you please keep this in mind and have this information saved so it can be provided to us in the event we need it. If you have questions regarding this requirement, you can contact your Medical Billing Manager, Lindsay Esterline. 

PCC Corner

PCC Level of Care Functionality:

PCC uses the Level of Care and census entries to determine if a no-pay or a benefit exhaust claim needs to be generated when billing claims. The census entry triggering the Start of the Medicare Benefit Period, the utilization of the 100 days in the benefit period and the Level of Care, PCC will automatically create a monthly Benefit Exhaust claim and allow for a Monthly No Pay Claims to be generated using the Monthly No Pay Bills on Demand functionality.

PCC will create monthly Benefit Exhaust claims, as applicable, and will create a discharge No Pay Claims when a resident is discharged from the facility. Benefit Exhaust Claims and Discharge No Pays are generated when monthly UBs are generated.

PCC will automatically create a skilled level of care for all Medicare A admissions. Levels of Care related to other payers (Managed Care, Insurance, etc.) must be manually entered upon admission. Since No Pays and Benefit Exhaust claims are not produced for Medicare Advantage (Medicare Replacement) payers, the Level of Care will not automatically be created. Still, it can be entered so that the Level of Care report reflects the current skilled or non-skilled level of residents.

It is important to review the Level of Care setup when census entries are made so that census changes are reflected in the Level of Care as needed based on the payer(s) included in the census changes. For example, when a resident is cut from Medicare, a new level of care should reflect that the resident is no longer at a skilled level of care.

Any provider with PCC questions may contact Paula Hynum.

Questions about these updates? Need support to meet requirements?

Contact Stefanie Knaub, RKL Senior Living Services Partner, at 717.590.8648.