Therapy hours could go down and depression to go up at SNFs.
A depression diagnosis is often hard to make. Clinical depression can be demonstrated in many ways and requires the subjective findings of a clinician. Some clinically depressed individuals seem to withdraw, while others can become irritable or even agitated. Eating and sleeping patterns can be affected. Clinical depression may cause a person either to sleep or eat to excess or almost refuse to eat or not be able to sleep. In skilled nursing homes, patients may have symptoms of depression that are situational or impacted by medications.
Under the old Resource Utilization Group (RUG) system, skilled nursing facilities (SNFs) had reimbursement driven mainly by the number of minutes of physical, occupational, and speech therapy services provided.
Now, SNFs can increase their Medicare payments dramatically just by claiming that all their patients are depressed.
Let’s look at an example of how this works. We took a sample claim for a nursing home we know well and assumed a 31-day stay. We assumed a patient had a hip replacement. We also assumed that they were cancer-free.
The patient is morbidly obese, so they have an NTA of 1 to 2. We also assume their function score is 6 to 14. (If you need some of these terms explained, contact me).
If this patient is not depressed, the Medicare per diem is $599.59. With the same patient, if depression is present, the per diem payment is $647.41. This is a whopping 7.98 percent increase in payment.
In addition to the potential for abuse of the depression diagnosis, there’s the fact that the diagnosis is subjective, and based on the opinion of the clinician. What if SNFs hire clinicians to diagnose all their patients as depressed? The appeals are much harder for Medicare to fight since they are based not on hours of therapy, but a clinical finding.
Will the Zone Program Integrity Contractors (ZPICs) and Recovery Audit Contractors (RACs) hire their own psychiatrists to dispute a diagnosis of depression? Will SNFs be under-reimbursed because they fail to make a proper diagnosis? Will some nurses and Minimum Data Set (MDS) coordinators simply click the boxes on their electronic medical record (EMR) forms to denote depression?
We are left with many more questions than answers, and here in South Florida, I expect therapy hours to go down and depression to go up at SNFs.
As I discussed recently, we have a go-live date for the Medicare Change of Status Notice of Feb. 14. Before reading on, stop and take
The Centers for Medicare & Medicaid Services (CMS) released the Final Rule for the 2025 Medicare Physician Fee Schedule on Nov. 1, which included a
Please log in to your account to comment on this article.
Join Beth Wolf, MD, CPC, CCDS, for an in-depth webcast on the FY2025 spinal fusion MS-DRG updates. Discover key changes in DRG classification, understand impacts on documentation and CMI, and learn strategies to ensure compliance.
Join Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, as she presents effective strategies to strengthen collaboration between CDI, coding, and quality departments in acute care hospitals. Angela will also share guidance on implementing cross-departmental meetings, using shared KPIs, and engaging leadership to foster a culture of collaboration. Attendees will gain actionable tools to optimize documentation accuracy, elevate quality metrics, and drive a unified approach to healthcare goals, ultimately enhancing both patient outcomes and organizational performance.
Optimize your outpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to outpatient CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. You will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.
Enhancing outpatient clinical documentation is crucial for maintaining accuracy, compliance, and proper reimbursement in today’s complex healthcare environment. This webcast, presented by industry expert Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, will provide you with actionable strategies to tackle complex challenges in outpatient documentation. You’ll learn how to craft detailed clinical narratives, utilize advanced EHR features, and implement accurate risk adjustment and HCC coding. The session also covers essential regulatory updates to keep your documentation practices compliant. Join us to gain the tools you need to improve documentation quality, support better patient care, and ensure financial integrity.
Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.
Healthcare organizations face complex regulatory requirements under the No Surprises Act and Price Transparency rules. These policies mandate extensive fee disclosures across settings, and confusion is widespread—many hospitals remain unaware they must post every contracted rate. Non-compliance could lead to costly penalties, financial loss, and legal risks. Join David M. Glaser Esq. as he shows you how to navigate these regulations effectively.
Protect your facility from unwanted audits! Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, and take a deep dive into both the CMS and AMA guidelines for reporting post operative pain blocks. You’ll learn how to determine if the nerve block is separately codable with real life examples for better understanding. Becky will also cover how to evaluate whether documentation supports medical necessity, offer recommendations for stronger documentation practices, and provide guidance on educating providers about documentation requirements. She’ll include a discussion of appropriate modifier and diagnosis coding assignment so that you can be confident that your billing of post operative pain blocks is fully supported and compliant.
During this RACmonitor webcast Dr. Ronald Hirsch spotlights the areas of the OIG’s Work Plan and the findings of their most recent audits that impact utilization review, case management, and audit staff. He also provides his common-sense interpretation of the prevailing regulations related to those target issues. You’ll walk away better equipped with strategies to put in place immediately to reduce your risk of paybacks, increased scrutiny, and criminal penalties.
Copyright © 2024 RACmonitor. Powered by MedLearn Media.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
