Department of Medical Assistance Services

1. 1 Department of Medical Assistance Services

2. 2 INTENSIVE REHABILITATION SERVICES July-August 2004

3. TRAINING OBJECTIVES Learn the qualifications of the rehab therapists Learn and apply the intensive rehab program criteria Gain knowledge of all medical record documentation requirements To understand the purpose of utilization review and the appeals process Proper utilization of Medicaid eligibility options and billing guidelines

4. 4 TRAINING OVERVIEW Rehabilitation Criteria Rehabilitation Services Documentation Requirements Interdisciplinary Team Requirements Utilization Review Appeals Process

5. 5 COMMONLY USED ACRONYMS IR - Intensive Rehab DMAS - Department of Medical Assistance Services CMS – Centers for Medicare and Medicaid Services PA - Preauthorization POC - Plan of Care DME - Durable Medical Equipment

6. 6 DMAS WEB SITE www.dmas.virginia.gov The home page includes: Recipient information Provider information-including all Medicaid manuals Administration and Business information DMAS e-mail notification for subscription

7. 7 DMAS WEB SITE (cont.) Learning Network-allows access to training presentations Provider Search-to locate provider in a particular location Search Forms-allows provider to print DMAS required forms

8. 8 GENERAL INFORMATION Provider Memo dated 3-22-2004 provides information regarding: Plastic ID Cards MediCall-24 hour access Internet-Automated Response System (ARS) Additional helpful provider information

9. 9 FREEDOM OF CHOICE Virginia Medicaid recipients have the right to choose a participating rehabilitation provider

10. 10 MEDALLION If the recipient is enrolled in MEDALLION, the ordering physician must be the MEDALLION care physician (PCP), or there must be a referral for the service from the MEDALLION PCP.

11. 11 MEDALLION (cont’d) The PCP referral may be obtained in writing or orally and must be documented in the recipient’s medical record. NOTE: For more information, refer to Supplement A of the Virginia Medicaid Rehabilitation Manual

12. 12 COVERED SERVICES Medically necessary rehab services are a covered service for Medicaid recipients. Medical necessity is: services ordered by a physician treatment plan of care accepted medical standards of practice (not experimental or investigational) safe and cost-effective level of care

13. 13 PROVIDERS OF SERVICE Intensive rehab services may be provided by: A freestanding rehab hospital, or A Comprehensive Outpatient Rehab Facility (CORF), or An acute care hospital that has a Medicare-exempt physical rehab unit

14. 14 PREAUTHORIZATION All requests for preauthorization must be received by WVMI within 72 hours (calendar days) of the IR/CORF admission. WVMI: (804) 648-3159 or (800) 299-9864 Requests received after 72 hours will be denied up to the day of the request. Requests may be telephonic or on paper (DMAS-351 and DMAS-361 forms)

15. 15 INTENSIVE REHAB ADMISSION CRITERIA (INCLUDING CORF) A recipient is deemed appropriate for IR/CORF if both of the following criteria are met: Interdisciplinary coordinated team approach Services cannot be carried out in a less intensive setting

16. 16 INTENSIVE REHAB ADMISSION CRITERIA (INCLUDING CORF) [Continued] In addition, recipient’s must also meet all of the following criteria: The recipient requires rehab nursing for patient/family education, and The recipient requires at least two of four therapies (PT/OT/SLP/Cognitive)

17. 17 INTENSIVE REHAB ADMISSION CRITERIA (INCLUDING CORF) [Continued] Criteria continued: Recipient is able to actively participate in therapy on a daily basis, and The medical condition is stable and compatible with an active rehab program, and Meets Interqual criteria for preauthorization purposes

18. 18 INTERQUAL CRITERIA-2004 Frequent Issues: Specific Diagnoses - “Deconditioning” cannot be used as a primary diagnosis At least 2 disciplines > 3h/d > 5d/wk Discharge planning - when all appropriate rehab goals are met, patients must be promptly discharged

19. 19 INAPPROPRIATE ADMISSIONS Admissions for evaluation and/or training solely for vocational or educational purposes or developmental or behavioral assessments are not covered IR/CORF services Admissions for evaluation for the same condition as a previous rehab admit is a non-covered IR/CORF service

20. 20 SPECIAL IR ADMISSIONS DMAS may negotiate individual contracts with in-state or out-of-state IR facilities for recipients with special rehab needs. For example: Ventilator-dependent recipients Out-of-state placements (when the service is not available within Va.)

21. 21 SPECIAL IR ADMISSIONS(Continued) Preauthorization through DMAS is required prior to admission for ventilator-dependent or out-of-state placements. Contact the DMAS’ Facility and Home Based Services Unit in Richmond, Va. Phone: 804-225-4222

22. 22 THERAPY GUIDELINES FORMEDICAID REIMBURSEMENT IMPROVEMENT OF FUNCTION Therapy will result in significant and practical improvement in the recipient’s level of functioning within a reasonable period of time.

23. 23 THERAPY GUIDELINES FORMEDICAID REIMBURSEMENT MAINTENANCE THERAPY Therapy will NOT result in significant practical improvement or the skills of a licensed therapist are not required to carry out the treatment to maintain or monitor patient function. Medicaid reimbursement will NOT be made for maintenance therapy.

24. 24 CONDITIONS OF DISCHARGE Discharge from IR/CORF must be considered when one of the following conditions exists: No further potential for improvement is demonstrated The skills of a qualified therapist are no longer required The recipient has reached his/her maximum level of progress

25. 25 CONDITIONS OF DISCHARGE (cont’d) Limited motivation on the part of the recipient or caregiver Recipient has an unstable medical condition that limits participation Progress toward goals cannot be achieved within a reasonable period of time Interqual discharge criteria no longer met

26. 26 THERAPEUTIC FURLOUGH DAYS DMAS will not reimburse for intensive rehabilitation services for days when a recipient is on an overnight therapeutic furlough. Such days must not be billed on the UB-92 invoice.

27. 27 IR TRANSFERS - READMITS When a recipient requires transfer to acute care for: > than 24 hrs = d/c recipient from IR < than 24 hrs = d/c is not required Note: For re-admissions > than 24 hrs., each team member must re-evaluate the recipient’s functional status (Rehab Manual, Ch. IV, page 5)

28. 28 PROSTHETIC - ORTHOTIC SERVICES Coverage is available for prosthetic and orthotic services when recommended as part of an approved IR/CORF program when the following criteria are met: Physician ordered Physician-approved treatment or discharge plan

29. 29 DURABLE MEDICAL EQUIPMENT AND SUPPLIES DME required for home use or to facilitate the recipient’s discharge home may be covered under the DME and Supplies program. Note: refer to the DMAS agency web site for the DME Manual requirements. www.dmas.virginia.gov Provider Manual section

30. 30 DOCUMENTATION REQUIREMENTS Physician Rehab Nursing PT OT SLP Cog. Rehab Psychology Social Work Therapeutic Rec. Interdisciplinary Team

31. 31 DOCUMENTATION REQUIREMENTS PHYSICIAN History and Physical Examination Admission Orders - Plan of Care (medications, rehab therapies, treatments, diet, and other required services such as psychology, social work, therapeutic rec., etc.) NOTE: 60 day renewal orders - plan of care must include all of the same components as the admission orders

32. 32 DOCUMENTATION REQUIREMENTS PHYSICIAN (continued) Admission certification on DMAS-127 form 60-Day Recertification on DMAS-128 form Physician 60-Day Plan of Care Review on the DMAS-126 form Identification of a discharge plan and discharge disposition

33. 33 DOCUMENTATION REQUIREMENTS PHYSICIAN (continued) Progress notes to be written at least every 30 days Progress notes include changes in the recipient’s condition, and Recipient response to treatment

34. 34 DOCUMENTATION REQUIREMENTS PHYSICIAN (continued) Discharge summary to be completed within 30 days of the recipient’s discharge from IR/CORF stay Discharge order upon discharge from IR/CORF stay Any therapies discontinued prior to discharge require a physician order

35. 35 DOCUMENTATION REQUIREMENTS PHYSICIAN (continued) All physician documentation must be signed and dated by the physician Physician signature may include written signatures, written initials, computer entry, or rubber stamp initialed by physician

36. 36 DOCUMENTATION REQUIREMENTS NURSING Rehab nursing involves patient and family education and training. Education and training includes skilled nursing care and therapeutic rehab activities the patient has learned in the rehab sessions that will be carried over onto the nursing care unit.

37. 37 DOCUMENTATION REQUIREMENTS NURSING (Continued) Admission evaluation - documentation of the patient’s deficits and need for rehabilitative nursing services NOTE: A registered nurse (RN) or a licensed practical nurse (LPN) under the supervision of a registered nurse must complete, sign, and fully date the evaluation

38. 38 DOCUMENTATION REQUIREMENTS NURSING (Continued) Plan of Care (POC) - documentation of individualized, measurable goals with time frames for achievement and nursing interventions used to achieve patient goals NOTE: A registered nurse (RN) or a licensed practical nurse (LPN) under the supervision of a registered nurse must complete, sign, and fully date the POC

39. 39 DOCUMENTATION REQUIREMENTS NURSING (Continued) Biweekly Review of the POC - documentation that demonstrates review of the recipient’s response to the nursing plan of care/treatment plan Note: a registered nurse (RN) must review the patient’s response to the POC at least every two weeks

40. 40 DOCUMENTATION REQUIREMENTS NURSING (Continued) Weekly progress notes - documentation of nursing care provided, patient and/or family education, changes in patient’s condition, patient’s response to nursing interventions, and any modifications to the patient’s goals. NOTE: A registered nurse (RN) or a licensed practical nurse (LPN) under the supervision of a registered nurse must complete, sign, and fully date all progress notes

41. 41 DOCUMENTATION REQUIREMENTS REHABILITATIVE THERAPIES All rehabilitative therapy services must be ordered by a physician. The following slides will review documentation for the following therapies: PT, OT, SLP, Cognitive, and Therapeutic Recreation

42. 42 DOCUMENTATION REQUIREMENTS REHABILITATIVE THERAPIES Admission Evaluation Must be completed by a registered or licensed therapist and must include: Diagnoses of the recipient History of any previous treatment Prior/current functional status Medical findings Clinical signs/symptoms Therapist’s recommendations

43. 43 DOCUMENTATION REQUIREMENTS REHABILITATIVE THERAPIES Plan of Care Is developed by a qualified therapist and must include: Recipient measurable goals Time frames for goal achievement Interventions, modalities, treatments Frequency and duration of therapies

44. 44 DOCUMENTATION REQUIREMENTS REHABILITATIVE THERAPIES Progress Notes Must be written at least every 2 weeks and include: Frequency and duration of the therapies Recipient response to treatment Review of the plan of care

45. 45 DOCUMENTATION REQUIREMENTS Progress Notes-continued (PT/OT/SLP) Supervisory 30 day on-site review and documentation is required by a licensed therapist when the therapy is provided by an LPTA, COTA, SLP (without license), or speech-language assistants

46. 46 DOCUMENTATION REQUIREMENTS Psychology and Social Work Services Both services must be ordered by the physician prior to implementation The following slides will review documentation for these two services

47. 47 DOCUMENTATION REQUIREMENTS Psychology Services Admission Evaluation Must be written by a licensed psychologist, LPC, or LCSW and must include: History Diagnoses Identified needs/problems

48. 48 DOCUMENTATION REQUIREMENTS Psychology Services Plan of Care Is developed by a qualified therapist and must include: Recipient measurable goals Time frames for goal achievement Interventions Frequency and duration of services

49. 49 DOCUMENTATION REQUIREMENTS Psychology Services Progress Notes Must be written at least every 2 weeks and include: Frequency and duration of the services Recipient response to interventions Review of the plan of care

50. 50 DOCUMENTATION REQUIREMENTS Social Work Services Admission Evaluation Must be written by a social worker and must include: Patient social history Diagnoses Identified needs and problems

51. 51 DOCUMENTATION REQUIREMENTS Social Work Services Plan of Care Is developed by a social worker and must include: Recipient measurable goals Time frames for goal achievement Interventions Frequency and duration of services

52. 52 DOCUMENTATION REQUIREMENTS Social Work Services Progress Notes Must be written at least every 2 weeks and include: Frequency and duration of the services Recipient response to interventions Review of the plan of care

53. 53 DOCUMENTATION REQUIREMENTS Discharge Summary Each discipline must complete a discharge summary within 30 days after a recipient’s discharge. The summary must document the recipient’s progress (functional outcome), identify goals that were met/not met, and state the recommendations for follow-up care.

54. 54 DOCUMENTATION REQUIREMENTS Discharge Planning Is an integral part of the recipient’s plan of care developed by the team disciplines. The discharge plan must be addressed during the admission evaluation and must be reviewed/revised relative to the recipient’s/family’s response to rehab.

55. 55 INTERDISCIPLINARY TEAM The interdisciplinary (ID) team provides a comprehensive approach to the intensive rehabilitation program The ID team must prepare written documentation of the ID plan of care within 7 days of admission

56. 56 INTERDISCIPLINARY TEAMContinued Documentation must include, but is not limited to: Needs of the recipient Measurable, recipient oriented goals Approaches used to meet the goals The discipline(s) responsible for the goals Time frames for goal achievement

57. 57 INTERDISCIPLINARY TEAMContinued The ID team must identify a discharge plan which must include, but not limited to: Anticipated improvements in functional goals Time frames for goal achievement Recipient’s discharge destination Modifications needed at the recipient’s home for d/c and an alternate d/c plan(s)

58. 58 INTERDISCIPLINARY TEAMContinued ID team must be held at least every 2 weeks to review the plan of care Documentation must include: Progress made toward established interdisciplinary goals Revisions/changes to goals Discharge plan

59. 59 INTERDISCIPLINARY TEAMContinued Documentation must demonstrate a coordinated team approach Each discipline must be present at the team conference held at least every two weeks A review by the team disciplines of each others’ progress notes does not constitute a team conference

60. 60 DMAS UTILIZATION REVIEW

61. 61 PROVIDER UTILIZATION REVIEW (UR) Utilization review (UR) ensures high quality care as well as the appropriate provision of services. IR/CORF providers must comply with all documentation requirements in order to receive Medicaid reimbursement for the services provided.

62. 62 PROVIDER UR PLAN DMAS requires 100% UR of all Medicaid recipients in an IR/CORF setting. The annual facility UR Plan must identify: Committee organization and meetings Admission & ongoing review process Medical care evaluation (MCE) studies

63. 63 DMAS UTILIZATION REVIEW The purpose of UR is to ensure: Services are medically necessary Rehab criteria is met High quality care is provided Services provided as ordered

64. 64 DMAS UTILIZATION REVIEW(cont’d) DMAS is responsible for validation of: Appropriateness of care provided Adequacy of services Necessity of continued participation Feasibility of recipient’s needs being met in alternate settings Verification of documentation requirements

65. 65 DENIAL OF REIMBURSEMENT Payment to the rehab provider may be retracted when the provider has failed to comply with established Federal (42 CFR) and State (VAC) regulations or Medicaid policy requirements as outlined in the Virginia Medicaid Rehabilitation Manual.

66. 66 MEDICAL RECORDS Medical records must be retained for not less than 5 years after the recipient’s discharge date from IR. The records must contain complete documentation, be readily accessible, legible, and organized to facilitate prompt retrieval.

67. 67 APPEAL PROCESS RECIPIENT PROVIDER

68. 68 APPEAL PROCESS Recipient Appeals If the denied rehab service has not been provided to the recipient, the denial may be appealed only by the recipient or his/her legally appointed representative Recipient appeals must be submitted within 30 days to DMAS Division of Appeals

69. 69 APPEAL PROCESS Provider Appeals The rehab provider has the right to request reconsideration of DMAS utilization review retractions. The request for reconsideration and all supporting documentation, must be submitted to DMAS within 30 days of the denial notification.

70. 70 APPEAL PROCESS Provider Appeals (cont’d) First Level Appeal - to the DMAS Supervisor of the Facility and Home Based Services Unit Second Level Appeal - to the DMAS Division of Appeals (IFFC Hearing) Third Level Appeal - to the DMAS Division of Appeals (Formal Hearing)

71. Department of Medical Assistance Services Intensive Rehabilitative Services: Eligibility Verification and Billing July-August 2004 www.dmas.virginia.gov

72. 72 As a Participating ProviderYou must - Accept as payment in full, the amount paid by Medicaid Bill any and all other third-party carriers Determine the patient's identity Verify the patient's age Verify the patient's eligibility Maintain records for minimum 5 years

73. . The new VA Medicaid card, unlike previous card does not have any periods of eligibility listed. When eligibility is verified, you will also receive information on HMO enrollment for the client. I want to share some information with you from WVMI, our prior authorization contractor. 467 pre-authorizations were received for the month of September 2003. 206 of those pre-authorizations were for clients who were not eligible for VA Medicaid or were enrolled in a VA Medicaid HMO. 44% of those claims should not have been sent to VA Medicaid. These figures show the impact failing to verify eligibility can have on your practice.. The new VA Medicaid card, unlike previous card does not have any periods of eligibility listed. When eligibility is verified, you will also receive information on HMO enrollment for the client. I want to share some information with you from WVMI, our prior authorization contractor. 467 pre-authorizations were received for the month of September 2003. 206 of those pre-authorizations were for clients who were not eligible for VA Medicaid or were enrolled in a VA Medicaid HMO. 44% of those claims should not have been sent to VA Medicaid. These figures show the impact failing to verify eligibility can have on your practice.

74. 74 In order to receive reimbursement for clients enrolled in a VA Medicaid HMO, you the provider must participate with the HMO.In order to receive reimbursement for clients enrolled in a VA Medicaid HMO, you the provider must participate with the HMO.

75. 75 Important Contacts MediCall Automated Response System Provider Call Center Customer Service Provider Enrollment Commonwealth Mailing

76. 76 MediCall 800-884-9730 800-772-9996 804-965-9732 804-965-9733 MediCall- toll free. Which by our last statistics was giving a 95% answer rate for all calls received.MediCall- toll free. Which by our last statistics was giving a 95% answer rate for all calls received.

77. 77 Automated Response SystemARS Web-based eligibility verification option Free of Charge Information received in “real time” Secure Fully HIPAA compliant We now have an ARS user’s guide on our web site. You can find it listed under “What’s New”.We now have an ARS user’s guide on our web site. You can find it listed under “What’s New”.

78. 78 Provider Sign-up for FreeWeb-based Eligibility Option First Health Services Corporation virginia.fhsc.com

79. 79 ARS User Guide Available Located on the DMAS web-site under the “What’s New” section General information on ARS eligibility verification Instructions on the using the system “FAQ”(frequently asked questions) section

80. 80 ARS- Information Available Medicaid client eligibility Service limit information Claim status Prior authorization Provider check log

81. 81 PROVIDER CALL CENTER Claims, covered services, billing inquiries: DEPARTMENT OF MEDICAL ASSISTANCE SERVICES 600 East Broad Street, Suite 1300 Richmond, Virginia 800-552-8627 804-786-6273

82. 82 Billing Inquiries

83. 83 Provider Enrollment New provider numbers or change of address: First Health – PEU P. O. Box 26803 Richmond, VA 23261 888-829-5373 804-270-5105 804-270-7027 - Fax

84. 84 Requests for DMAS Forms and Manuals: DMAS Order DeskCOMMONWEALTH MARTIN1700 Venable StreetRichmond, Virginia 23222

85. 85 Billing on the CMS-1450

86. 86 MAIL CMS-1450 FORMS: Department of Medical Assistance Services Hospital P. O. Box 27443 Richmond, VA 23261-7443

88. CMS-1450 FORM:Use ONLY the originalRED and WHITE InvoicePhotocopies are not acceptable!

92. Locator 4:Enter the code as appropriate:  111 Original Inpatient Hospital Invoice 117 Adjustment Inpatient Hospital Invoice 118 Void Inpatient Hospital Invoice 131 Original Outpatient Invoice 136 Adjustment Outpatient Invoice 138 Void Outpatient Invoice 741 Original Outpatient Rehab Agency Invoice 746 Adjustment Outpatient Rehab Agency 746 Void Outpatient Rehab Agency Invoice

94. Locator 6 Enter the beginning and ending dates reflected by this invoice (include both covered and non-covered days). Use both “from” and “to” for a single day. If the total days of service exceed 31 days use additional billing invoices. Claims submitted which exceed the 31-day limitation will be denied, “Limit of 31 Days Per Billing Invoice Exceeded.”

95. Locator 6 The billing period may overlap calendar months as long as the 31-day billing limitation is not exceeded and does not cross over the provider’s fiscal year for cost settlement. Do not include furlough days.

100. Locator 15: Sex

108. Locator 23: Medical Record Number (Optional)

112. Locator 39-41 82 No Other Coverage- If the enrollee has no insurance coverage other than Medicaid. 83 Billed and Paid- If the provider has received payment from the primary carrier(s), code 83 must be entered, and the amount covered by the primary carrier entered under the amount section of the locator.

113. Locator 39-41 85 Billed and Not Paid- primary insurance carrier has excluded this service, or the benefits may be exhausted. Code 85 must be entered. Using Code 85 will require an attachment containing: the name of the insurance, the date of denial, and the reason for denial or non-coverage.

119. Locator 47: Total Charges (by Revenue Code)

136. Locator 85: Provider Representative

137. Locator 86: Date

138. 138 Medicare Crossover Claims

139. 139 Medicare Primary Billing Instructionsfor CMS-1450 (UB-92) The word “CROSSOVER” must be entered in Block 11 of the UB-92 to identify Medicare crossover claims. Coordination of Benefits (COB) codes 83 and 85 must be accurately printed in Blocks 39-41 of the UB-92.

140. 140 Medicare Primary Billing Instructionsfor CMS-1450 (UB-92) The first occurrence code 83 indicates that Medicare paid and there should always be a dollar value associated with this code. The A1 indicates Medicare deductible and code A2 indicates Medicare coinsurance.

141. Medicare Primary:Blocks 39-41 Line a 83 = Billed and Paid (enter amount paid by Medicare or other insurance). Line a A1 = Deductible Payer A. (enter Medicare Deductible Amount on the EOMB). Line a A2 = Co-Insurance Payer A. (enter Medicare Co-Insurance amount on the EOMB).

142. 142 Medicare Primary Billing Instructionsfor CMS-1450 (UB-92) Note: Complete all information in Locators 39a through 41a first (payments by Medicare or payments by other insurance) before entering information in 39b through 41b locators etc.

143. 143 Medicare Primary Billing Instructionsfor CMS-1450 (UB-92) COB code 85 is to be used when another insurance carrier is billed and there is no payment from that carrier. For the deductibles and co-insurance due from any other carrier(s) (not Medicare) the code for reporting the amount paid is B1 for the deductibles and B2 for the coinsurance.

144. 144 Medicare Primary Billing Instructionsfor CMS-1450 (UB-92) Block 77 on the UB-92 is not required. The 10/28/03 Medicaid Memo erroneously listed this as a required field. Block 80 must be left blank for UB-92 Medicare Part B paper claims. If applicable, an ICD-9-CM procedure code should be entered in Block 80 for Medicare Part A claims.

145. REMITTANCE VOUCHERSections of the Voucher APPROVED - for payment. PENDING - for review of claims. DENIED - no payment allowed. DEBIT (DR)-Adjusted claims creating a positive balance. CREDIT (CR) - Adjusted/Voided claims creating a negative balance.

146. REMITTANCE VOUCHERSections of the Voucher FINANCIAL TRANSACTION EOB DESCRIPTION ADJUSTMENT DESCRIPTION/REMARKS- STATUS DESCRIPTION REMITTANCE SUMMARY- PROGRAM TOTALS.

147. 147