SAM and Medicare PPS

1
SAM and Medicare PPS

• Understanding and Using Medicare Prospective
  Payment System Functions in SAM.

2
Introduction

• This presentation will show you how to use SAMs
  OASIS and billing functionality to create,
  transmit, manage, and adjust Requests for
  Anticipated Payments and Final Claims according
  to specifications published by HCFA.
• After this presentation you should be able to
  create RAPS, final claim EOEs, and perform
  adjustments suggested by SAM including Partial
  Episode Payments, Low Utilization Payment
  Adjustments, Significant Change In Condition and
  Outlier Adjustments.

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SAM PPS Topics

• Entering Medicare Plan of Care
• Entering OASIS Assessment
• OASIS Summary
• Creating Invoices for PPS
• The new PPS RAP service item
• The new PPS EOE service item
• The RAP Invoice and Claim
• The EOE Invoice and Claim
• PPS Billing Log
• Adjusting your RAPs and EOEs
• Payments, Applying Cash and Adjustments
• PPS and the OASIS Potential Problem Log
• PPS and the Account Log
• PPS and the Sales Report
• PPS and the Medicare Episode Report
• PPS and the Aging Report
• PPS and the Utility Census Report
• PPS and the General Ledger
• Steps in PPS Billing

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Entering Medicare Plan of Care
Medicare PPS Billing begins with a Medicare Plan
of Care for the patient entered in SAM. Without
a Medicare Plan of Care, this patient will not be
considered for PPS billing. The Medicare Payer
must be assigned a Medicare payer class.
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Entering OASIS Assessment
In addition, a OASIS Assessment associated with
the Plan of Care is required.
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OASIS Summary
Once the OASIS Assessment is completed, pressing
the Summary button will display the PPS
information. We have not yet created the RAP or
EOE, this is reference information only, however,
it does show us that we have completed the
information necessary on the assessment for PPS
billing.
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Setting Client/Payer Requirements
You can set the client/payer relationship
requirements to require Signed Plan of Care (and
billable visit). If this option is turned On
for the client/payer relationship, the RAP will
not be created unless a billable visit exists for
the certification period. In addition, The EOE
will not be created unless all Plan of Cares and
Verbal Orders for the certification period have a
Received Signed date.
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Creating PPS Invoices

• Before you generate PPS Invoices, make sure you
  have the following
• A Medicare or Episodic Insurance payer.
• Branch ID entered for the office.
• Clients associated with the Medicare or Episodic
  Insurance payer.
• First skilled billable visit (on the cert begin
  for 60 RAPs)
• Plan of Care for the Medicare or Episodic
  Insurance payer (no overlapping plans of care for
  same payer.)
• A Start of Care, Resumption of Care, Recert or
  follow-up OASIS Assessment for the patient.
• The OASIS Assessment is associated with the
  appropriate Plan of Care.
• The OASIS Assessment has a status of locked or
  exported.
• You can click the summary button on the OASIS
  Assessment and get the PPS Episode amount with no
  assessment errors reported.
• If the Medicare client is Medicare Secondary
  Payer, placing MSP in the client's Bill
  Notes field will cause all RAP and EOE claims to
  be created with occurrence code 1 '05,
  occurrence date 1 RAP date, and the remark will
  read "Services provided by our agency are not
  associated with previous MSP."

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Creating PPS Invoices
Once the Medicare Plan of Care and OASIS
Assessment are complete we are ready to create
PPS invoices/claims. On the Create Invoices
screen, click the PPS Option, and Click the
Create Invoices button. You may create PPS
Invoices at any time. You may also optionally
select to create PPS invoices for one client.
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The new PPS RAP Service Item
When a PPS RAP invoice is created, SAM creates a
PPS RAP service item for either the date of the
first billable visit or the start of episode date
if no billable visit is found. The invoice
description shows the percentage of payment
requested, the HHRG and HIPPS codes, as well as
the wage index and case mix weight.
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The new PPS EOE Service Item
When a PPS EOE invoice is created, SAM creates a
PPS EOE service item for the End of Episode date.
The invoice description shows the percentage of
payment previously requested, the HHRG and HIPPS
codes, as well as the wage index and case mix
weight.
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The RAP Invoice
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The RAP Claim

• Source of admission on the claim will be set to
  a 9 meaning unavailable, unless the information
  has been entered for the patient in Care Manager.
  The claim must be edited in SAM with the true
  source of admission if it was not entered for the
  patient.
• B Transfer from another HHA
• C Readmission to same HHA
• 1 Physician referral
• 2 Clinic referral
• 3 HMO referral
• 4 Transfer from a hospital facility
• 5 Transfer from a SNF
• 6 Transfer from another healthcare facility
• 7 Emergency room
• 8 Court/Law Enforcement
• 9 Information unavailable
• SAM sets the RAP service item date (locator
  46) equal to the first billable visit's date. 
  The first billable visit for an initial RAP (60)
  is a skilled visit with a status of "confirmed",
  "verified" or "closed."  This is also the
  patients start of care date.
• The first billable visit for a subsequent RAP
  (50) is a skilled or unskilled visit with a
  status of "confirmed", "verified" or "closed"
  within the certification period.  If no billable
  visit is found, the date will be set to the
  certification begin date.  On the UB92 claim,
  locator 6 (statement period covers dates) will be
  set equal to the RAP service item date.  On
  subsequent RAP claims, locator 6 dates will
  reflect the certification begin date. 

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The EOE Invoice
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The EOE Claim

• On EOE claims, locator 6 dates will reflect the
  certification period.
• The date in locator 6 on the EOE UB92 must match
  the date in locator 6 of the RAP UB92. For this
  reason, it is important that the date of the
  first billable visit be known at the time the RAP
  is created. If this is not the case, BOTH the
  RAP and EOE claims must be edited and
  resubmitted. If you need to edit the claims,
  check with your clinical staff to make sure that
  the OASIS Assessment and scheduled visit
  information are correct. If not, they may need
  to make adjustment to the assessment(s) or
  schedule before you recreate the RAP/EOE claims.
  Source of admission on the claim will be set to a
  9 meaning unavailable, unless the information
  has been entered for the patient in Care Manager.
  The claim must be edited in SAM with the true
  source of admission if it was not entered for the
  patient.
• Patient status will be a 30 if the cert end
  date is the end of episode. Otherwise, the
  patient status will be set to a 06 to represent
  a discharge or transfer before the cert end date.
  A transfer in SAM is a type of discharge. Do
  not use the transfer patient status as this means
  transfer within the organization and not to
  another agency.
• This claim contains line items for visits and
  supplies closed at the time the episode is
  detected to be over.
• SAM will default to code 270 for Medicare
  Supplies. If those supplies are wound care, the
  claim must be edited and the code for the wound
  care supplies changed to 623.

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EOE Claim
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SAM PPS Billing Log
During the invoicing process, several situations
will be detected and logged.
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SAM PPS Billing Log Entry Types

• A billing log report will be displayed on the
  screen. This log will report any errors or
  warnings regarding the creating of the PPS
  invoices. This report will sort entries based on
  the Plan of Care certification begin date. The
  billing log is saved as N\pps.log and is
  appended to each time the Create PPS Invoices
  option is selected.
• An additional billing log in Microsoft Excel
  format (n\ppslog.xls) is also created which will
  contain all of the information last appended to
  the billing log (n\pps.log) (only current
  information.) This will allow you to easily sort
  the file by name, messages, etc. Long messages
  such as OUTLIERS or SCICS are truncated to
  254 characters in the .xls file.
• List below are just a few of the type of errors
  that SAM might report in the billing log.
• Although a PPS RAP was created, no billable visit
  exists.
• No OASIS record information found for the Plan Of
  Care.
• OASIS not found with assessment reason of Start
  of Care, Resumption of Care, Recert follow-up.
• Plan of Care for has no mailed date for cert
  begin.
• OASIS document is not locked or exported.
• Although the episode has ended, the week the
  episode ended within has not been closed so a PPS
  EOE service item and final claim will not yet be
  created.
• You can use this checklist to trouble shoot any
  problems reported on the billing log
• What is the payer set for the client/payer
  relationship to the Medicare payer?
• Are all of the Medicare visits on that payer set?
  
• Is the Plan of Care for that payer set?
• Is the OASIS Assessment associated with the
  correct plan of care?
• Are all of the OASIS Assessments associated with
  the correct plan of care?
• Do you have a first skilled billable visit
• For a 60 RAP must be equal to the cert begin
  date
• For a 50 RAP must be within cert period
• Have you discharged the patient from the payer
  prior to the first billable visit?

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SAM PPS Billing Log Entry Types

• RAP created for patient name on date falls within
  previous episode for patient. PEP coding is
  required.
• You do not need to adjust your claim. Medicare
  is aware of PEPs and will pay accordingly. You
  will only be paid short if a LUPA occurs or if
  another agency picks up your patient within your
  original cert period. After you receive your
  payment for the episode, you will need to adjust
  your EOE service item to match the remittance.
• Patient is qualified for OUTLIER payment.
• You do not need to adjust your claim. Medicare
  counts your visits on your EOE claim, and adjusts
  your payment accordingly if you have reached the
  threshold amount for an outlier. After you
  receive your payment for the episode, you will
  need to adjust your EOE service item to match the
  remittance.
• Patients original condition has changed (SCIC).
  The original HIPPS code is FIRST_HIPPS. As of
  SCIC_DATE, the new HIPPS code is HIPPS with a
  Case Mix Weight of CMW. A SCIC adjustment may be
  appropriate.
• Only adjust the claim if the SCIC will cause the
  episode amount to increase.
• Adjust the EOE claim before transmitting
• Adjust the current EOE detail line (0023 line) to
  reflect the number of days (in the days/units
  field) appropriate (from the pps log) for the
  original HIPPS code.
• Add a new line as follows description PPS
  EOE, code 0023, HCPCS/rate new HIPPS code
  (from pps log), date of service date of SCIC
  (from pps log), days/units days for new HIPPS
  code (from pps log).
• Skilled billable visit for patient not found on
  or after date. RAP PPS bill was created BUT be
  sure a billable visit was done.
• Adjust the claim to reflect the date of the
  skilled billable visit in locator 46 (serv date)
  to be equal to locator 6 (statement period covers
  dates) from date before you transmit the RAP
  claim.
• The episode patient for the date plan of care has
  only x visits and qualifies as a LUPA. The RAP
  payment for this episode was . The EOE payment
  for this episode is . The total episode
  payment should be REDUCED by .
• Medicare will pay the episode at the LUPA rate.
• Adjust the RAP as usual to reflect the take
  back.
• Adjust the EOE, making the episode equal to the
  payment.

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Adjusting the PPS Service Items
If for any reason you need to make a adjustment
to the RAP or EOE, you will want to adjust the
PPS Service Items. Find the PPS RAP and/or EOE
service item by date, client, and payer.
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Adjusting the PPS Service Items (cont.)
Adjust the service items so that the final value
of the two equals the correct total episode
amount and select the PPS Adjustment Type (this
will be used for reporting).
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Payment, Applying Cash and Adjustments

• When you get a remittance, add that as a payment
  in SAM and record the EFT , Check or
  Remit as the payment number.
• If there is a payment for a RAP, apply the cash
  to the RAP invoice.
• If there is a recoup for a RAP, apply a negative
  cash application to the RAP invoice AND adjust
  the RAP service item to 0.
• If there is a payment for an EOE, (at this point
  it should be payment for the entire episode) 1)
  apply the cash to the EOE invoice and then 2)
  adjust the EOE service item to match the amount
  paid for the EOE.
• If you follow this process, you should be able to
  balance the SAM payment/cash app report to your
  remittance advice.
• When you are making the RAP / EOE service item
  adjustments be sure to categorize them correctly
  (LUPA, SCIC, etc.), these adjustments are
  reported on the Medicare Episode report.
• The final claim (EOE) must be submitted 60 days
  after the paid date of the RAP or 120 from the
  SOC date (whichever is greater), or the RAP will
  be auto cancelled also known as a take back.
  In this case, the take back will be shown on
  your remittance. Apply a negative cash
  application to the RAP invoice do not make any
  adjustment to the RAP so it will stay on your
  Invoice Aging report. Resubmit the RAP claim,
  wait 3 days and then submit the EOE claim.

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PPS and the OASIS Potential Problem Log
The OASIS Potential Problem Log report may be run
to flag potential problems with your OASIS
assessments that might affect your PPS Billing.
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PPS and the OASIS Potential Problem Log (cont.)
You may optionally select any combination of the
following problems to be reported.
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PPS and the Account Log
A patient discharged before the end of a plan of
care would have the following adjustment advice
(PEP).
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PPS and the Account Log (cont.)
A patient with 4 or fewer visits when the end of
episode is detected will have the following
adjustment advice (LUPA).
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PPS and the Sales Report

• The Sales report can be used to show PPS sales
  activity for Medicare. On the report selection
  screen, choose your Medicare payer. Then
  un-select all but service type items. Enter
  the service dates that cover the episode dates
  for the sales you wish to see.
• You can select to report Medicare visits and
  service items and choose Show Only PPS Sales.
  This will report sales values only on the PPS
  RAP and EOE service items, giving you a valid
  sales figure.
• The report will show all PPS RAP, PPS EOE, and
  all adjustments to these. It will also indicate
  what type of adjustment was done (PEP, LUPA,
  SCIC, Outlier).
• By exporting this to Excel, the adjustment
  description can be used to create sums for PEP,
  LUPA, SCIC, and Outlier adjustments.
• This report also offers Excel Output Options for
  reporting By County and Age, Client, Visits,
  Hours OT by Payerclass and Clients, Employees,
  Visits, Hours by Skill to assist in your
  Medicare reporting.

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PPS and the Sales Report
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PPS and the Medicare Episode Report

• This report is invaluable for your Medicare cost
  reporting.
• You may enter a average cost per visit per
  skill and SAM will produce a report of all of
  the information regarding the episode and
  calculated Gross Margin.
• In addition, if you export this report to Excel,
  all of the OASIS M00 answers that affected the
  episode are included in the Excel file.
• If you select to Exclude visits outside the date
  range SAM will generate the following .xls files
  specifically designed to help you with your
  Medicare cost reporting.
• Visit totals summarizes number of visits by MSA
  code, RAP adjustment type, EOE adjustment type,
  and skill.
• MSA SN patients summarizes number of SN visits
  by MSA code, patient name, and patient number.
• MSA PT patients summarizes number of PT visits
  by MSA code, patient name, and patient number.
• MSA OT patients summarizes number of OT visits
  by MSA code, patient name, and patient number.
• MSA ST patients summarizes number of ST visits
  by MSA code, patient name, and patient number.
• MSA MS patients summarizes number of MSW visits
  by MSA code, patient name, and patient number.
• MSA HA patients summarizes number of HHA visits
  by MSA code, patient name, and patient number.

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PPS and the Medicare Episode Report
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PPS and the Aging Report
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PPS and the Utility Census Report

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PPS and the General Ledger

• The General Ledger reports will show cost and
  sales from Medicare visits and supplies as well
  as the service items and adjustments that
  represent the RAP and EOE sales.
• Your Glaccount table in SAM should be updated to
  place the RAP and EOE service items into NEW
  accounts in your general ledger.

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Steps in SAM PPS Billing

• Make sure that the Medicare Payer is set to bill
  by Calendar and payer class Medicare.
• Create patient type client in SAM and associate
  to a Medicare Payer. Turn On requirement
  Signed Plan of Care (and billable visit) if
  desired.
• Admit the patient to the agency using Care
  Manager.
• Create a plan of care, or at least a plan of care
  shell in SAM (patient, payer, cert begin and end
  dates, physician, and ICD9 codes).
• Create an OASIS assessment and link it to the
  Plan of Care.
• Use PPS option of Create Invoices function to
  create PPS RAP service item, invoice, and claim.
• When the patient is discharged or the cert end
  has passed, the PPS option of Create Invoices
  function can be used to create PPS EOE service
  items, invoices, and claims.
• View PPS billing log or clients account log for
  any adjustment advice and perform the proper
  adjustments to the PPS RAP and PPS EOE service
  items so that the SAM aging will be accurate.
• Review the final claim for correctness. Pay
  close attention to revenue codes on supplies.
• Apply cash and use your aging as you normally do.

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Summary

• Remember, before you can bill via PPS in SAM, an
  OASIS must be attached to the patients plan of
  care.
• If you have ideas about how SAMs PPS functions
  can be more useful to your organization, email us
  your suggestion at helpdesk_at_riversoft.net