Recently, HCFA issued Transmittal 381 in which Support Surfaces in Skilled Nursing facilities under Part A is clearly defined. Section 2203.2 of the transmittal classifies support surfaces as routine or ancillary based on intermidiary application of DMERC screening policy instructions. The transmittal also makes it possible for SNF's to make an ancillary charge for support surfaces that fall into Group 2 or 3 of the DMERC guidelines. In addition to the Air Fluidized Beds and the Fully Integrated Low Air Loss Therapy Beds, Low Air Loss Therapy Mattress replacements are specifically mentioned in the transmittal as an example of a support surface classified as ancillary. What remains open for intermidiary interpretation is the medical necessity for such products. This HCFA policy addresses payment only.
Based on how medical necessity has been interpreted in the past with the use of the Fully Integrated Low Air Loss Beds, we can provide the following information which will be helpful in determining how your patients can benefit from this therapeutic adjunct, and how you can be reimbursed for it.
PRE-QUALIFIERS
1) The patient must have had a minimum of three days hospital stay.
2) The patient must be admitted to the Skilled Nursing Facility within 30 days of discharge from the hospital.
3) Medicare Part A will reimburse for 100 days per spell of illness.
DOCUMENTATION REQUIREMENTS
1) Skilled level of care forms must be included with billing forms to document the medical necessity of this, or any item for which you are seeking reimbursement. Each intermidiary has it's own documentation requirements.
2) There must be a written plan of treatment for pressure ulcers.
3) Adequate, concise progress notes must be documented. This documentation should be done on a daily basis, and the wound(s) should be re-measured and re-assessed at least twice per week. It is recommended that in conformance to WOCN guidelines for assessment, your personnel not " down grade " the stage of an ulcer. Instead you should note the progress by documenting the changes in color, shape, size drainage, etc. It is important to remember that a Stage IV ulcer is always a Stage IV ulcer until it is resolved, it does not become a Stage III ulcer.
4) The patient's medical history and condition are important to document. Include information on other treatments that were tried in the SNF or the Hospital, but were ineffective.
5) Some form of evaluation must be used to document such contributing factors as immobility, incontinence, etc. A formal documentation tool such as the Gosnell, Braden or Norton systems are recommended.
6) Pressure ulcer assessment which will indicate stage, size, color, odor, location(s0, etc. must be used.
7) A written order from a physician must be made.
8) An expected outcome which would result from the use of this intervention must be given. In other words, a measurable outcome must be identified.
CONDITIONS THAT ARE COVERED
1) Multiple Stage II (except when limited to the heels), Stage III or Stage IV pressure ulcers on more than one turning surface.
2) Post flap or graft surgery. Some intermidiaries may cover for a limited time if there is potential of the surgery failing, or if re-surgery would be required. This type of case would account for the least lengthy use of a support surface.
3) Medicare will not reimburse for pain management, prevention or comfort.
THE FINANCIAL IMPACT OF USING SPECIALTY SUPPORT SURFACES
The utilization of Specialty Support Surfaces in the Skilled Nursing Facility could increase the profitability of the facility. If you are currently using the full frame bed systems, under the Resource Utilization Group (RUG), for instance, an imediate increase in cash flow would result by beginning to utilize the more cost effective mattress replacement systems, thereby resulting in a decrease in the costs that are associated with the full frame systems. Obviously, when the daily cost is decreased in relation to the current daily rate, higher profits are the result. If you are not using any specialty beds, or only on a limited basis, then a mixture of several different types of products will help to increase your daily rate, although this will not be realized until some point in the future.
Many Skilled Nursing facilities have created a positive reputation for themselves in their communities, as well as increased their market share, by showing that they are not only willing to take the more challenging cases, but are able to heal these patients consistently and in a timely fashion.
Another point that is noteworthy is the "Prudent Purchaser Clause" , which Medicare has set forth with regard to the reimbursement of ancillary services. The Prudent Purchaser Clause states that SNF's have a responsibility to not drive up costs, but to select alternatives that are lower in cost, and still get the job done. Low Air Loss mattress replacement systems allow you to be on the cutting edge of both therapeutic capability and financial responsibility.
