CMS Has New Updates that May Impact Patient Post-Acute Transitions

Numerous updates from CMS include post-acute transfers to skilled nursing.

In the last week there have been a lot of updates that have come from the Centers for Medicare & Medicaid Services (CMS), so I thought it would be imperative to provide a news brief on what is going on as it relates to post-acute transitions to skilled nursing, as well as patients who require durable medical equipment (DME) or home health.

CMS Increases Scrutiny on Nursing Homes

CMS has decided to conduct off-site (i.e., remote) targets on nursing and skilled nursing facilities (SNFs) to make sure they are accurately assessing and coding individuals with schizophrenia. There is concern that nursing homes may be erroneously diagnosing patients with schizophrenia and potentially over-utilizing antipsychotic medications. Facilities that are found to have inaccurate coding during these audits for schizophrenia are at risk of having their Medicare Quality Star Rating downgraded. Health systems or organizations that are involved in coding for SNFs may want to consider an internal audit of their patients diagnosed with schizophrenia or those who have received antipsychotic medications to make sure their cases were accurately coded and represented.

Additionally, CMS has stated that they will be publicly reporting on Medicare’s Care Compare website all nursing centers/SNFs that have disputed their survey citations.

Face-to-Face Requirements for DMEPOS

CMS has lightened some of the regulations around ordering durable medical equipment (DME) or prosthetics, orthotics, and supplies (DMEPOS). As of Jan. 17, they added an additional 10 orthoses that will require a face-to-face encounter. There must be clear documentation in the medical record that demonstrates the intent for the equipment and a written order prior to delivery of the equipment, each as a condition of payment. This makes the grand total about 63 items that now require a face-to-face visit prior to ordering DMEPOS. The majority of face-to-face items are logical, such as items that need to be fitted or sized custom to the patient, primarily in conjunction with orthopedic needs. As well as powered wheelchairs, this equipment not only requires a face-to-face encounter, but also prior authorization.

Many should remember that last year, CMS lightened the requirements for ordering DME; however, I am sure DME providers were reluctant to loosen the documentation requirements. Most non-electric equipment simply requires a physician order with a description of the item. Additional documentation such as physical therapy notes are no longer required. Thus, case managers should discuss with their DME suppliers opportunities to remove some of their burdensome documentation requirements to obtain DME.

Additional Funding for Rural Home Health Providers

As part of the Consolidated Appropriations Act of 2023, Section 4137, home health companies will receive an additional 1 percent of payment amounts for any patients they serve in a “low population density” category. Although this may seem like a great thing, the definition is broken down by counties, and county designations vary significantly across state lines. However, hopefully the additional payment will encourage additional home health services across the rural U.S.