Questions and answers from the American Association of Nurse Assessment Coordinators (AANAC). (AANAC's PPS Review).

Editor's Note: Record keeping for the Medicare Prospective Payment System (PPS) has always been a daunting prospect. Rescue is at hand in the form of the American Association of Nurse Assessment Coordinators (AANAC). Consisting of nurses who have been designated as the PPS point persons in their facilities, AANAC is dedicated to helping facilities achieve accurate and timely resident assessment and appropriate Medicare reimbursement. One of AANAC's principal features is an online chat group for members who exchange observations, questions and answers about PPS-related problems. AANAC experts review all questions and peer review the answers to ensure that members receive accurate information. Here, and published quarterly in Nursing Homes/Long Term Care Management, is a sampling of common questions submitted to AANAC and their answers.

Q: We admitted a resident who was supposed to be covered under an HMO, so only an admission MDS was done. After the resident was discharged, the billing company found out the resident was covered under Medicare. They want me to do the 5-day and 14-day PPS assessments. The resident was admitted in September 2001 and discharged October 2, 2001. Can I still do the 5-day and 14-day PPS assessments? Or do we just get paid at the default rate?

A: Since it is not permitted to go back and reconstruct MDSs after the window for the ARD is passed, the MDSs will be late, and you will have to accept the default rate. The ARD may be set back in time only from within the assessment window. Once the window is passed, you can no longer set the ARD back in time. In other words, for the 5-day assessment, you have until day 8 to set the ARD on any day from day 1 through day 8. After day 8, you can no longer set the ARD back in time. CMS's Dana Burley at the AANAC Fall 2001 Conference in Pittsburgh verified this rule.

Q: Historically, when we have had patients who needed blood transfusions, we have sent them to the ambulatory treatment center or to a medical floor of the acute hospital. Administration is now telling us we have to do our own since we cannot bill separately for blood transfusions. Is this correct?

A: Yes, because blood transfusions are not on the short list ofitems excluded from consolidated billing. That means that blood transfusions for Part A residents must appear on the UB-92 claim form and may not be billed separately to Medicare under Part B by the SNF or by a contracted provider of the transfusion, or in any other way. This is similar to the way rehab therapy is billed on the UB-92 claim form and may not be billed to Part B or be billed directly by the rehab company to Medicare. Just as the rehab company bills the facility, so must the contracted provider of the transfusion bill the facility for its services.

The cost of providing the transfusion is considered to be a part of the Medicare Part A per-diem payment to the facility. The only solution to the problem, other than providing the service yourself, is to negotiate reasonable rates with a contracted provider of the transfusions.

Q: Our FI says that we can't count a physician's visit for the MDS unless the doctor writes a progress note. Is that right?

A: A number of questions have come up recently about what qualifies as a physician visit for MDS item P7 purposes. AANAC asked the folks at CMS for the official word on this, and here it is: A physician progress note is required. It is not sufficient for a nurse to document the visit in a nurse's note. The presence of an order written by the physician in the absence of a progress note is also not sufficient.

Just a reminder: Remember that the RAI manual instructions are "To record the number of days during the last 14-day period a physician has examined the resident...." So, it's not the "visit" that counts; it is the examination. When an examination takes place, the standard of practice is for the examiner to document it.

Q: How should we code any of the walking ADLs when the resident does not ambulate in room or hallway, but does walk with therapy in a room off the unit?

A: Since the resident does leave the unit for therapy, follow the Section G coding instructions regarding how the resident got there, either ambulating or, if he or she doesn't ambulate, once in the wheelchair. If he or she is assisted to therapy off the unit in a wheelchair and then walks with therapy in the therapy room, code for the assistance he or she receives in the wheelchair to get to therapy.

With thanks to Rena R. Shephard, RN, BA, FACDONA, AANAC president and president of RRS Healthcare Consulting Services, San Diego, California.