Dually eligible beneficiaries are individuals who qualify for both Medicare and Medicaid, making them eligible for a broad range of healthcare services. These beneficiaries typically have limited income and resources, qualifying them for additional support to cover healthcare costs that Medicare does not fully pay. Here’s a detailed guide to understanding the benefits, billing practices, and key considerations for healthcare providers dealing with dually eligible beneficiaries.

Who Are Dually Eligible Beneficiaries?

Dually eligible beneficiaries are those who qualify for Medicare Part A (hospital insurance), Part B (medical insurance), or both, and receive full Medicaid benefits or assistance with Medicare premiums and cost-sharing through specific Medicare Savings Programs (MSPs). The primary MSP categories include:

• Qualified Medicare Beneficiary (QMB): Covers Part A and Part B premiums, deductibles, coinsurance, and copayments.
• Specified Low-Income Medicare Beneficiary (SLMB): Covers only Part B premiums.
• Qualifying Individual (QI): Covers only Part B premiums for individuals who are not eligible for any other Medicaid benefits.
• Qualified Disabled Working Individual (QDWI): Covers Part A premiums for certain individuals under 65 who have returned to work.

Medicare is generally the primary payer for services, with Medicaid covering additional costs that Medicare does not, such as long-term care or home-based services.

Billing Prohibitions and Requirements

Healthcare providers must be particularly mindful when billing dually eligible beneficiaries, especially those under the QMB program. Key points include:

• Billing Prohibitions: Providers cannot bill QMB beneficiaries for Medicare Part A and B cost-sharing, such as deductibles, coinsurance, and copayments. Even if Medicaid does not fully cover these amounts, the provider must accept the Medicare and Medicaid payments as payment in full.
• Assignment Requirement: Providers must accept assignment, meaning they agree to accept the Medicare-approved amount as full payment for services provided to dually eligible beneficiaries.
• Advance Beneficiary Notice (ABN): In some cases, providers may issue an ABN if they expect Medicare to deny a service as not medically necessary. However, providers cannot charge the beneficiary up front and must follow specific guidelines if they plan to shift financial responsibility to the patient.

Important Resources

For further details and guidelines, healthcare providers can refer to:

• Medicare Claims Processing Manual, Chapter 1
• Medicare & Medicaid Basics
• CMS Qualified Medicare Beneficiary (QMB) Program

Understanding these rules ensures compliance and helps providers avoid penalties while ensuring that dually eligible beneficiaries receive the care they need without undue financial burden.

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Transitional Care Management (TCM) services play a crucial role in ensuring that patients who are discharged from inpatient care facilities receive the appropriate follow-up care necessary to transition smoothly back into their community settings. These services are vital for preventing readmissions, improving patient outcomes, and managing the complexities that often accompany post-discharge care.

What Are Transitional Care Management (TCM) Services?

TCM services are designed to support patients during the 30-day period following their discharge from an inpatient setting. This period begins the day the patient is discharged and continues for the next 29 days. The goal is to bridge the gap between the care received in the hospital and the care provided once the patient returns to their home or another community setting, such as a skilled nursing facility or assisted living.

Key components of TCM services include:

1. Interactive Contact:
   • Healthcare providers must establish contact with the patient or their caregiver within two business days of discharge. This contact can be made via phone, email, or face-to-face interactions. The purpose is to address any immediate health concerns and ensure that the patient understands their care plan.
2. Face-to-Face Visit:
   • A face-to-face visit is required within a specified timeframe depending on the complexity of the patient’s condition. For moderate complexity, this visit must occur within 14 days; for high complexity, it must occur within 7 days.
3. Medication Reconciliation:
   • Medication reconciliation and management are critical components of TCM services. This process ensures that any changes in medication regimens are clearly communicated and understood by the patient and their caregivers, reducing the risk of medication errors.

Who Can Provide TCM Services?

TCM services can be provided by a range of healthcare professionals, including physicians and non-physician practitioners (NPPs) such as nurse practitioners, physician assistants, and clinical nurse specialists. These services can also be delivered by clinical staff under the general supervision of a physician or NPP, ensuring a comprehensive approach to managing the patient’s transition from hospital to home.

Billing and Coding for TCM Services

When billing for TCM services, it’s important to follow the specific guidelines set out by CMS to ensure proper reimbursement. Only one healthcare provider can bill for TCM services for a patient during the 30-day period, and the face-to-face visit cannot be billed separately from the TCM code. Additionally, TCM services cannot be billed if they fall within a global surgery period.

The Importance of TCM in Reducing Readmissions

Effective TCM services are essential for reducing hospital readmissions, particularly for patients with complex medical needs. By ensuring timely follow-up and addressing potential issues early, healthcare providers can help prevent complications that could lead to a return to the hospital. This not only improves patient outcomes but also reduces overall healthcare costs.

For more detailed information on billing and coding for TCM services, you can refer to the CMS Transitional Care Management Services Guide and other related resources provided by the Medicare Learning Network.

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Navigating Medicare’s billing requirements can be complex, especially when it comes to the Skilled Nursing Facility (SNF) 3-Day Rule. This rule is critical for ensuring that Medicare covers SNF services, and understanding it can help prevent denied claims and unexpected costs for patients. Here’s what you need to know about the SNF 3-Day Rule and how it affects billing practices.

What is the SNF 3-Day Rule?

The SNF 3-Day Rule is a Medicare requirement that stipulates a patient must have a medically necessary inpatient hospital stay of at least three consecutive days to qualify for Medicare-covered SNF services. This inpatient stay must occur immediately before the patient is admitted to a SNF, and it does not include the discharge day or any pre-admission time spent in the emergency department or under outpatient observation.

This rule applies not only to traditional hospitals but also to Critical Access Hospitals (CAHs) that offer swing bed services, which allow them to provide SNF-level care following an acute care stay.

Why is the 3-Day Rule Important?

The 3-Day Rule is designed to ensure that only those who truly need intensive post-hospital care in a SNF receive it under Medicare coverage. Without meeting this requirement, patients may face out-of-pocket expenses if they seek SNF care. For example, if a patient is discharged from the hospital after only two days, they would not meet the 3-Day Rule, and Medicare would not cover their subsequent SNF stay.

Additionally, during the COVID-19 Public Health Emergency (PHE), CMS temporarily waived the 3-Day Rule to provide more flexibility in patient care. However, with the end of the PHE on May 11, 2023, the standard 3-Day Rule requirements are back in effect.

Applying the 3-Day Rule in Practice

• Inpatient Days: Only full inpatient hospital days count toward the 3-Day Rule. The day of discharge, time spent in the emergency department, or time under outpatient observation does not count.
• Swing Bed Services: Hospitals and CAHs offering swing bed services must also adhere to the 3-Day Rule for Medicare to cover the SNF services provided.

For a patient to qualify for SNF services under Medicare:

• The patient must have stayed in the hospital as an inpatient for at least three consecutive days (excluding the discharge day).
• The SNF admission must occur within 30 days of the qualifying hospital stay, unless it’s medically inappropriate to admit them sooner.

What Happens if the 3-Day Rule Isn’t Met?

If a patient does not meet the 3-Day Rule, Medicare will not cover the SNF services. This makes it essential for hospitals, CAHs, and SNFs to clearly communicate the number of inpatient days to patients and their representatives to prevent any misunderstandings regarding coverage.

For example, if a patient is admitted to the hospital on April 16 and discharged to a SNF on April 18, the hospital stay would not satisfy the 3-Day Rule, as the patient was only in the hospital for two days (April 16 and April 17). In this case, the SNF services would not be covered by Medicare, and the patient may need to pay out of pocket.

Communicating Coverage and Financial Responsibility

Hospitals and SNFs must work closely together to ensure accurate communication regarding a patient’s inpatient status and the implications for SNF coverage. Patients and their representatives should be made aware of their potential financial liability if the 3-Day Rule is not met.

In some cases, certain Medicare Shared Savings Program Accountable Care Organizations (ACOs) or CMS Innovation Center models offer waivers for the 3-Day Rule. For example, the Comprehensive Care for Joint Replacement Model and the Bundled Payments for Care Improvement Advanced Model allow eligible patients to bypass the 3-Day Rule under specific circumstances.

Additional Resources

For further details on the 3-Day Rule and SNF billing, you can refer to these resources:

• Medicare Benefit Policy Manual
• CMS SNF 3-Day Rule Waiver Guidance
• Medicare Claims Processing Manual

Understanding these rules and properly applying them in practice can help healthcare providers ensure compliance and prevent unnecessary financial burdens for patients.

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What Are Chronic Care Management Services?

CCM services focus on the comprehensive management of patients with two or more chronic conditions that are expected to last at least 12 months or until the patient’s death. These conditions place the patient at significant risk of death, acute exacerbation, decompensation, or functional decline. Examples of chronic conditions include diabetes, hypertension, heart failure, asthma, and chronic kidney disease.

CCM services typically include:

• Structured Recording of Patient Health Information: Maintaining accurate and up-to-date patient health records is vital for ongoing care.
• Comprehensive Care Plan: Developing, implementing, and updating a patient-centered care plan that addresses all health issues, with a focus on managing chronic conditions.
• Care Coordination: Ensuring that all healthcare providers involved in a patient’s care are informed and coordinated, including referrals, transitions between healthcare settings, and communication with community-based services.
• Access to Care: Providing patients with 24/7 access to care and health information, ensuring continuity of care and addressing urgent needs promptly.

Who Can Provide CCM Services?

CCM services can be provided by a variety of healthcare practitioners, including:

• Physicians
• Nurse Practitioners (NPs)
• Physician Assistants (PAs)
• Clinical Nurse Specialists (CNSs)
• Certified Nurse Midwives (CNMs)

These services are often provided by clinical staff under the general supervision of a billing practitioner, meaning the practitioner oversees the services but does not need to be physically present when they are delivered.

Billing and Coding for CCM Services

CCM services are billed using specific Current Procedural Terminology (CPT) codes that correspond to the complexity and duration of the services provided. Some of the relevant CPT codes include:

• 99490: Non-complex CCM services, at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month.
• 99487: Complex CCM services, first 60 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month.
• 99491: CCM services provided personally by a physician or other qualified healthcare professional, first 30 minutes, per calendar month.

Healthcare providers must ensure accurate and compliant billing practices, as improper billing can lead to denied claims or audits.

Patient Eligibility and Consent

Before initiating CCM services, healthcare providers must confirm that patients meet the eligibility criteria—having two or more chronic conditions—and obtain the patient’s consent. This consent must inform the patient of the nature of CCM services, their cost-sharing responsibilities, and their right to stop services at any time.

The Role of CCM in Reducing Healthcare Disparities

CCM services are particularly important in addressing healthcare disparities, especially for patients in rural or underserved areas. By providing continuous care and support, CCM can help manage chronic conditions more effectively, reducing the need for more costly interventions such as emergency room visits or hospital admissions.

For more detailed information on billing and guidelines, healthcare providers can refer to the CMS Chronic Care Management Services Guide.

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Who Are Dually Eligible Beneficiaries?

Dually eligible beneficiaries are those who qualify for Medicare Part A (hospital insurance), Part B (medical insurance), or both, and receive full Medicaid benefits or assistance with Medicare premiums and cost-sharing through specific Medicare Savings Programs (MSPs). The primary MSP categories include:

• Qualified Medicare Beneficiary (QMB): Covers Part A and Part B premiums, deductibles, coinsurance, and copayments.
• Specified Low-Income Medicare Beneficiary (SLMB): Covers only Part B premiums.
• Qualifying Individual (QI): Covers only Part B premiums for individuals who are not eligible for any other Medicaid benefits.
• Qualified Disabled Working Individual (QDWI): Covers Part A premiums for certain individuals under 65 who have returned to work.

Medicare is generally the primary payer for services, with Medicaid covering additional costs that Medicare does not, such as long-term care or home-based services.

Billing Prohibitions and Requirements

Healthcare providers must be particularly mindful when billing dually eligible beneficiaries, especially those under the QMB program. Key points include:

• Billing Prohibitions: Providers cannot bill QMB beneficiaries for Medicare Part A and B cost-sharing, such as deductibles, coinsurance, and copayments. Even if Medicaid does not fully cover these amounts, the provider must accept the Medicare and Medicaid payments as payment in full.
• Assignment Requirement: Providers must accept assignment, meaning they agree to accept the Medicare-approved amount as full payment for services provided to dually eligible beneficiaries.
• Advance Beneficiary Notice (ABN): In some cases, providers may issue an ABN if they expect Medicare to deny a service as not medically necessary. However, providers cannot charge the beneficiary up front and must follow specific guidelines if they plan to shift financial responsibility to the patient.

Important Resources

For further details and guidelines, healthcare providers can refer to:

• Medicare Claims Processing Manual, Chapter 1
• Medicare & Medicaid Basics

The post Understanding Medicare & Medicaid for Dually Eligible Beneficiaries appeared first on BFLOW .

Chronic Care Management (CCM) services are essential in the ongoing care of patients with multiple chronic conditions, offering continuous support and coordination of care to improve health outcomes and reduce healthcare costs. The Centers for Medicare & Medicaid Services (CMS) recognizes CCM as a critical service and provides reimbursement for these non-face-to-face services under the Medicare Physician Fee Schedule (PFS).

What Are Chronic Care Management Services?

CCM services focus on the comprehensive management of patients with two or more chronic conditions that are expected to last at least 12 months or until the patient’s death. These conditions place the patient at significant risk of death, acute exacerbation, decompensation, or functional decline. Examples of chronic conditions include diabetes, hypertension, heart failure, asthma, and chronic kidney disease.

CCM services typically include:

• Structured Recording of Patient Health Information: Maintaining accurate and up-to-date patient health records is vital for ongoing care.
• Comprehensive Care Plan: Developing, implementing, and updating a patient-centered care plan that addresses all health issues, with a focus on managing chronic conditions.
• Care Coordination: Ensuring that all healthcare providers involved in a patient’s care are informed and coordinated, including referrals, transitions between healthcare settings, and communication with community-based services.
• Access to Care: Providing patients with 24/7 access to care and health information, ensuring continuity of care and addressing urgent needs promptly.

Who Can Provide CCM Services?

CCM services can be provided by a variety of healthcare practitioners, including:

• Physicians
• Nurse Practitioners (NPs)
• Physician Assistants (PAs)
• Clinical Nurse Specialists (CNSs)
• Certified Nurse Midwives (CNMs)

These services are often provided by clinical staff under the general supervision of a billing practitioner, meaning the practitioner oversees the services but does not need to be physically present when they are delivered.

Billing and Coding for CCM Services

CCM services are billed using specific Current Procedural Terminology (CPT) codes that correspond to the complexity and duration of the services provided. Some of the relevant CPT codes include:

• 99490: Non-complex CCM services, at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month.
• 99487: Complex CCM services, first 60 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month.
• 99491: CCM services provided personally by a physician or other qualified healthcare professional, first 30 minutes, per calendar month.

Healthcare providers must ensure accurate and compliant billing practices, as improper billing can lead to denied claims or audits.

Patient Eligibility and Consent

Before initiating CCM services, healthcare providers must confirm that patients meet the eligibility criteria—having two or more chronic conditions—and obtain the patient’s consent. This consent must inform the patient of the nature of CCM services, their cost-sharing responsibilities, and their right to stop services at any time.

The Role of CCM in Reducing Healthcare Disparities

CCM services are particularly important in addressing healthcare disparities, especially for patients in rural or underserved areas. By providing continuous care and support, CCM can help manage chronic conditions more effectively, reducing the need for more costly interventions such as emergency room visits or hospital admissions.

For more detailed information on billing and guidelines, healthcare providers can refer to the CMS Chronic Care Management Services Guide.

Image Prompt Suggestion:

“A healthcare provider in a clinical setting, reviewing a patient’s comprehensive care plan on a computer. The scene shows the provider focusing on detailed patient information, with a calendar and medical charts in the background, emphasizing the continuous and coordinated nature of Chronic Care Management services.”

• H1: Comprehensive Guide to Chronic Care Management (CCM) Services
• H2: What Are Chronic Care Management Services?
• H2: Who Can Provide CCM Services?
• H2: Billing and Coding for CCM Services
• H2: Patient Eligibility and Consent
• H2: The Role of CCM in Reducing Healthcare Disparities

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Key Points of CR 13610:

1. Manufacturer Exit Scenarios

This update addresses situations where a wheelchair manufacturer discontinues operations—whether through business closure or bankruptcy—resulting in the wheelchair no longer being available on the market. When aftermarket parts are unavailable, making the existing equipment inoperable, beneficiaries may need to replace their wheelchairs entirely. This update allows Medicare to consider such equipment as “lost” under federal regulations, thus permitting the issuance of replacement equipment.

2. Replacement Equipment and Claims Processing

Under the new guidelines, when a manufacturer exits the business and no aftermarket parts are available, Durable Medical Equipment (DME) suppliers can process claims for replacement wheelchairs. Suppliers must include the appropriate Healthcare Common Procedure Coding System (HCPCS) code for the replacement equipment along with specific HCPCS modifiers such as RA (Replacement of a DME Item) and KH (Initial Claim, Purchase, or First Month Rental) when applicable. This ensures that the claim is processed correctly and the replacement equipment is provided under the new 13-month capped rental period, starting from the date the new equipment is furnished.

3. Prior Authorization Requirements

Suppliers are required to submit a Prior Authorization Request (PAR) before furnishing the new wheelchair to the beneficiary and submitting a claim for processing. This step is crucial to ensure that the replacement equipment meets Medicare coverage criteria and that the claim will be reimbursed. Suppliers must include a narrative stating that the replacement is due to the manufacturer exiting the business, which should be submitted through the proper electronic claim formats or noted on the CMS-1500 claim form.

4. Exemptions and Clarifications

It’s important to note that this replacement policy does not apply if repair parts are available from sources other than the original manufacturer. The policy also does not apply if the wheelchair does not yet require repairs or replacement parts. Suppliers must ensure that these conditions are met before processing a replacement claim under this new directive.

Impact on Beneficiaries and Providers

This update is significant for both beneficiaries who rely on power or manual wheelchairs and the providers who supply and maintain this equipment. By allowing for the replacement of wheelchairs when the manufacturer exits the market and no parts are available, CMS is ensuring that beneficiaries continue to have access to the mobility aids they need. For providers, this update clarifies the process for submitting claims in these specific circumstances, helping to avoid claim denials and ensuring timely reimbursement.

Conclusion

CMS’s CR 13610 provides clear and essential guidance for managing the replacement of wheelchair equipment in scenarios where the manufacturer exits the business. By adhering to these guidelines, DME suppliers can ensure compliance with Medicare requirements while continuing to meet the needs of their patients.

For more detailed information and to stay updated on further changes, DME suppliers should consult the official CMS documentation or contact their Medicare Administrative Contractor (MAC).

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Key Updates for FY 2025:

1. Hospice Payment Rates

For FY 2025, the hospice payment update percentage is based on the inpatient hospital market basket, which is set at 3.4%. However, this percentage must be reduced by a multifactor productivity (MFP) adjustment of 0.5 percentage points, resulting in a final hospice payment update of 2.9%. This update applies to the payment rates for all levels of hospice care, including Routine Home Care, Continuous Home Care, Inpatient Respite Care, and General Inpatient Care.

Hospice providers who do not submit the required quality data will face a reduction in their payment rates. Specifically, the payment update percentage for these providers will be reduced by 4 percentage points, resulting in a net decrease, with an update rate of -1.1%. This emphasizes the importance of timely and accurate quality data submission to avoid significant financial penalties.

2. Hospice Cap Amount

The hospice cap amount for FY 2025 has been updated to $34,465.34, reflecting a 2.9% increase from the FY 2024 cap amount of $33,494.01. This cap applies to the aggregate amount that a hospice provider can be reimbursed for services rendered within the cap year, which spans from October 1, 2024, to September 30, 2025.

3. Hospice Wage Index

The hospice wage index is adjusted annually to account for local variations in wages. For FY 2025, CMS continues to implement a 5% cap on any decreases to a geographic area’s wage index. This cap helps mitigate significant negative impacts on hospice providers in areas where wage index adjustments could otherwise result in substantial payment reductions. CMS has also incorporated revised delineations from the Office of Management and Budget (OMB) into the hospice wage index, ensuring that wage index values are reflective of current geographic and economic realities.

4. Labor and Non-Labor Shares

The labor and non-labor shares used to wage-adjust hospice payments for each level of care have been revised. For instance, the labor share for Routine Home Care (days 1-60) is now 66.00%, with the corresponding non-labor share at 34.00%. These adjustments ensure that hospice payments more accurately reflect the cost of providing care.

Importance for Hospice Providers

These updates underscore the necessity for hospice providers to remain vigilant in their billing practices, particularly in the areas of wage index coding and quality data submission. Failure to comply with CMS requirements can result in significant payment reductions, which could impact the financial viability of hospice services.

Conclusion

CMS’s CR 13707 brings several critical changes for FY 2025, with a focus on ensuring fair and accurate payment adjustments for hospice services. By staying informed and compliant with these updates, hospice providers can optimize their reimbursement processes and continue delivering high-quality care to their patients.

For more detailed information and guidance on these changes, hospice providers should refer to the official CMS documentation or consult their Medicare Administrative Contractor (MAC).

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What is Disposable Negative Pressure Wound Therapy (dNPWT)?

Disposable Negative Pressure Wound Therapy (dNPWT) is a therapeutic technique used to promote wound healing by applying continuous or intermittent negative pressure to the wound site. This method is particularly beneficial for treating complex wounds such as ulcers, grafts, and surgical incisions. The use of dNPWT can significantly reduce the risk of infection, enhance the healing process, and improve patient outcomes, making it a critical tool in wound care management.

Key Highlights of CR 13244:

1. Introduction of Separate Payments for dNPWT Devices:

Under the new policy, CMS will make separate payments for dNPWT devices provided to patients under home health care. This change is designed to address the growing need for advanced wound care solutions and to ensure that providers are adequately reimbursed for the costs associated with these specialized devices.

2. Impact on Home Health Agencies (HHAs):

Home Health Agencies (HHAs) offering wound care services will need to adjust their billing practices to comply with the new payment structure. The separate payment for dNPWT devices will be distinct from the standard payments for home health services, requiring precise documentation and coding to secure reimbursement.

3. Billing and Coding Requirements:

To ensure proper payment, HHAs must accurately report the use of dNPWT devices on their claims. The claims should reflect the specific Healthcare Common Procedure Coding System (HCPCS) codes associated with the dNPWT devices, as well as any other relevant information that CMS may require. HHAs must stay informed about the latest coding updates and guidelines to avoid payment delays or denials.

4. Enhancing Patient Care and Outcomes:

By recognizing the value of dNPWT devices through separate payments, CMS aims to improve access to these advanced wound care treatments. This policy change is expected to enhance patient care by ensuring that more patients can benefit from effective wound management solutions, ultimately leading to better healing outcomes and a reduction in wound-related complications.

Preparing for the Changes:

As the January 1, 2024, implementation date approaches, HHAs should take proactive steps to prepare for the changes introduced by CR 13244. This includes training staff on the new billing requirements, updating internal systems to accommodate separate payments for dNPWT devices, and ensuring compliance with all CMS guidelines.

Staying ahead of these changes will be crucial for HHAs to maximize their reimbursement opportunities and continue providing high-quality care to their patients.

Conclusion:

The introduction of separate payments for Disposable Negative Pressure Wound Therapy devices under CMS’s Change Request 13244 is a positive step toward recognizing the importance of advanced wound care in the home health setting. By adequately compensating providers for these specialized services, CMS is supporting the delivery of better patient outcomes and reinforcing the value of innovative medical technologies.

For more information and detailed guidance on implementing these changes, HHAs should consult the official CMS documentation or reach out to their Medicare Administrative Contractor (MAC).

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