Introduction to medicare part A 1 When a resident no longer meets skilled level of care criteria, has benefit days left in their benefit period, and will be staying in the skilled nursing facility und

Introduction to medicare part A 

1 When a resident no longer meets skilled level of care criteria, has benefit days left in their benefit period, and will be staying in the skilled nursing facility under Medicaid payment, which beneficiary notice(s) should be issued? 

There is one notice required, the NOMNC, CMS 10123.

There are two required notices, the NOMNC, CMS 10123 and the ABN CMS R 131.

There are two required notices, the ABN, CMS R131, and the standard claim appeal notice, which can be met with either the SNFABN, CMS 10055 (2018), or one of the CMS approved denial letters.

There are two notices required, the NOMNC, CMS 10123 and the SNFABN, CMS 10055 (2018).

2 Which of the following scenarios would be considered "proper notice" when issuing the NOMNC, CMS 10123?

The resident is informed that Medicare services are ending today and facility staff can coordinate plans with her to return home tomorrow. The facility representative explains the right to expedited appeal, shows her the telephone number, and has her sign and date the form.   

The resident is informed that Medicare services are ending in two days and facility staff can coordinate plans with her to return home. The facility representative explains the right to expedited appeal and the process for obtaining the appeal, and has her sign and date the form after she voices understanding and has no further questions.

The resident is not capable of understanding the appeal process, so the physician may document the resident's inability to understand, then order discharge from skilled services in two days, thereby waiving the requirement for beneficiary signature on the CMS 10123.

The resident is not capable of understanding the appeal process and the daughter is unavailable, so the business office may leave a message on the daughter's home phone and put a copy of the NOMNC in the resident's medical record and ask the nurse to give it to the daughter at the next care plan meeting.

3 If a resident leaves the facility for an overnight stay to attend a family wedding on October 22, which of the following is true?

If the resident is well enough to attend a wedding, a denial letter should be issued as of that day.

The facility should bill for the day the resident was out, the day is counted against the 100-day benefit count and PPS MDS schedule is not adjusted.

The facility should not bill for October 22, and the variable per diem adjustment schedule should be adjusted to omit that day.

4 The facility should bill for October 22, deduct one day from her 100-day benefit period, and her PPS MDS schedule should be unchanged.

A resident was admitted to the skilled nursing facility after a three-day qualifying hospital stay. In this case, there is a planned six-week delay in skilled therapy. Which of the following items is not mandatory related to how the resident qualifies for coverage under Medicare Part A?

The delay in therapy must be identified on discharge from the hospital.

The need for the delay must be based on standards of medical practice.

The resident must be receiving skilled nursing services.

The amount of time before starting therapy must be predictable.

5 After the first recertification, where does counting begin to determine the next physician’s recertification date?

No counting is required. The next recertification is due on or before the 44th day.

The signature date of the first recertification and continues no later than 30 days.

The admission date and continues every 30 days thereafter.

The next recertification can be signed at any time and backdated if necessary

6 When must the initial certification of need for skilled services be signed?

On the day of admission

By day 7 of the resident’s stay

As soon as possible after admission

By day 14 of the resident’s stay

7 What is considered a direct skilled nursing service?

Anytime a service is performed daily by or under the direct supervision of a nurse.

Daily assessment and treatment of two stage 2 pressure ulcers.

Daily application of dressings involving prescription medications and aseptic techniques.

Daily changes of dressings for uninfected post-operative or chronic conditions.

8 Upon readmission to the facility, it was found that that the resident was signed up for a Medicare Advantage plan. What should the facility do during the admission process?

Deny admission to the facility.

Realize that the resident did not have Original Medicare and that the facility would not be managing SNF benefits.

Skip the secondary payer screening and assume there are no other secondary payers available for the resident.

Skip the prior stay investigation and assume there was no previous stay

9 When the facility has determined that a resident no longer meets the criteria for skilled Medicare A coverage and they have Medicare A days available in their current benefit period, which of the following statements indicates the correct course of action?

A SNF ABN is not required since her benefits are not exhausted.

A Generic Notice is required to be given no less than two days prior to the last day of coverage.

The Detailed Notice is required to be given at the same time as the Generic Notice.

The SNF ABN and Detailed Notice is required within 48 hours. 

10 When a resident exhausts a benefit period, what service could prevent the 60-day count from beginning?

The resident discharges home with Home Health.

The resident has a G-tube with daily flushes only.

The resident is receiving blood glucose monitoring three times a day.

The resident is receiving Part B therapy five days a week.

11 Which of the following would have prevented a resident from being covered under the presumption of coverage?

If the resident had classified into the NA (12+ points) case-mix group for the NTA component on the 5-day assessment.

If the resident had been admitted to the SNF after three days at home following hospitalization.

If the resident did not require therapy on readmission to the SNF.

If the resident had received IV fluids in the hospital prior to admission.

12 The facility staff sets and completes the 5-Day assessment with an ARD of day 12 of the Medicare A stay. How does this ARD selection affect payment?

ZZZZZ default rate is paid for the 5-Day payment period.

ZZZZZ default rate is paid for the first 4 days of the Medicare stay.

ZZZZZ default rate is paid starting on day 12.

There is no impact on the payment.

13  long term resident transitioned to Medicaid on December 1, after completion of 100 days on Medicare Part A for a PEG tube with 100% caloric intake. All beds in the facility are Medicare certified. On March 1, the resident had a three-day stay in the hospital with sepsis, pneumonia, and multiple stage 3 pressure ulcers. Can the resident receive Medicare A coverage?

Yes, the resident is eligible for full coverage.

Yes, the resident is eligible, but only for the diagnoses from the latest hospital stay.

No, the resident is not eligible for Medicare A coverage.

No, the resident is not eligible because Medicaid is always primary.

14 George Jackson is an 89-year-old resident being re-admitted from the hospital after a right leg, below the knee, amputation, due to diabetes mellitus. He has Medicare Part A benefit days available. He will not be ready for skilled rehabilitation for prosthesis training until the stump heals. In the meantime, Mr. Jackson’s nurse will be developing his care plan after assessing his care needs, which include skin care, oral medications, a diabetic diet, an exercise program to preserve muscle tone and body condition, and observation to detect signs of deterioration in his condition or complications resulting from his restricted, but increasing, mobility. Which of the following statements are true?

He should be issued a denial letter on admission, since he doesn’t require a skilled level of care.

Because of the complexities of his non-skilled services, he can be covered for daily development and management of the care plan until the care plan is essentially set.

He cannot be covered on Medicare Part A skilled services since he is not ready for skilled rehab at the time of discharge from acute care.

He does not meet skilled Medicare coverage criteria. The facility needs to issue a Notice of Medicare Non-Coverage beneficiary notice upon reentry back into the facility.

15 If the need for skilled services is not certified by a physician or other authorized healthcare provider per regulations, what will happen?

The facility can appeal to the QIN-QIO Quality Improvement Organization.

The MAC may pay any claim submitted for services.

The services are not coverable under Medicare Part A.

An affidavit from the resident can be substituted.

16 Which of the following is not authorized to sign the certification of skilled care?

Physician Assistant

Clinical Nurse Specialist

Medical Doctor

Registered Nurse

17 The Patient-Driven Payment Model (PDPM) is comprised of which components?

PT, OT, respiratory therapy, recreational therapy, nursing, and a non-case-mix component

Therapy, non-therapy nursing, non-therapy ancillary, and a non-case-mix component

PT, OT, SLP, respiratory therapy, nursing, and a non-case-mix component

PT, OT, SLP, non-therapy ancillary, nursing, and a non-case-mix component 

18  Medicare A resident finished therapy on October 26, but stayed on skilled Medicare A for nursing.  What assessment(s) are required due to the discontinuation of therapy? 

No assessments are required, the 5-day will continue to pay for the entire Medicare part A stay, unless an Interim Payment Assessment (IPA) is completed.

An Interim Payment Assessment (IPA) is required to reset the rate the end of therapy services.

A Part A PPS Discharge assessment is required, a resident cannot continue skilled services for nursing only. 

A Part A PPS Discharge is required at the end of therapy treatment and a new 5-Day is set to capture nursing-only skilled services.

19 What is the relationship between the MDS and SNF PPS reimbursement?

Payment is made for each of the services identified on the MDS.

The MDS is an optional tool for calculating reimbursement.

The MDS is a clinical tool with a minor role in reimbursement.

The MDS responses help to predict the cost of the care based on resident characteristics

20 Which of the following would be a qualifying hospital stay for a resident to begin a skilled nursing facility benefit period?

Three nights in a foreign hospital that qualifies as an “emergency hospital".

Three midnights in a certified hospital, regardless of whether the resident was admitted as an inpatient or spent the time as an outpatient or in observation status.

There is no requirement for a qualifying hospital stay for original Medicare Part A. They may be admitted directly from home.

21 One midnight as an outpatient in an emergency room and two midnights as an inpatient in a Medicare certified hospital.

Which of the following is true about Medicare Part A skilled level of care requirements?

Coverage of nursing care or therapy to perform a maintenance program does not depend on the presence or absence of an individual’s potential for improvement from the nursing care or therapy, but rather on the beneficiary’s need for the professional services of a licensed nurse or rehabilitation therapist.          

Coverage of nursing care or therapy depends entirely on an individual’s potential for improvement from the nursing care or therapy.  When the resident is not capable of further improvement, skilled care must end.

Coverage of nursing care or therapy to perform a maintenance program is not allowed under Part A coverage.  The resident must be discharged from Part A and then evaluated for Part B.

Coverage of nursing care to perform a maintenance program does not turn on the presence or absence of an individual’s potential for improvement from the nursing care, but rather on the beneficiary’s secondary pay source.

22 Which is true of Medicare Part A reimbursement?

The 5-day PPS assessment will establish a HIPPS code for payment of the first 30-day of the Medicare stay. The SNF must submit an Interim Payment Assessment (IPA) every 30 days thereafter for continued reimbursement. 

No PPS assessments are required for Medicare Part A reimbursement under PDPM.

The 5-Day PPS assessment will establish the PDPM HIPPS code for billing of the entire Medicare Part A stay, unless an Interim Payment Assessment (IPA) is completed. 

If the SNF does not complete the required PPS Part A Discharge assessment, then they must bill default for the entire Medicare stay. 

23 After reviewing the ADR response, the MAC totally denied the claim. Which is the least likely reason for the claim to be denied?

Lack of documentation to support the MDS and/or the level of care.

Inaccurate or missing information on the UB-04.

The physician’s certification is not signed and dated by the MD, NP, PA, or CNS.

She did not make any progress for three days during the claim period.

24 When a resident is admitted with Medicare Part A as primary payer, which of the following components is mandated by regulations?

Physician certification for extended care services.

Notice of exclusion from Medicare benefits.

A copy of the hospital discharge summary.

Explanation of benefits from Medicare for the hospital stay.

25 If a resident has Original Medicare, which of the following would qualify the resident for Medicare Part A coverage after a 3-day qualifying stay?

The resident required physical therapy a minimum of five days a week.

The resident requires wound care dressing changes every three days.

The resident exhausted benefits on a previous Part A stay and did not have a 60-day break in skilled level of care.

The resident receives Occupational Therapy two days a week and restorative nursing for range of motion five days a week.

26 A resident’s physical therapy (PT) evaluation indicates that she will be able to benefit from skilled rehab services. In the absence of other skilled services, how often will PT sessions have to be provided to qualify for as a skilled level of care for Medicare Part A?

3 days per week

4 days per week

5 days per week

7 days per week

27 A long-term care resident with chronic renal failure and brittle insulin dependent diabetes mellitus (IDDM) returns from a 12-day hospital stay.  Upon readmission the assessment nurse determined that the resident has a decline in activities of daily living, and is unstable with his blood sugars. It has been 45 days since he exhausted his Medicare benefit. Which assessment is most likely to be completed upon return to the facility?

An initial assessment. 

A Medicare 5-day assessment.

A significant change assessment.

A quarterly assessment. 

28 Josephine Harkins, 75, was admitted to Shady Acres skilled nursing facility on October 28, following an acute CVA stroke. She received Medicare Part A coverage for rehab for left-sided hemiplegia until December 2, using 35 days of her 100-day benefit period. Last week, on January 6, she fell while walking across a street with her daughter and sustained a left hip fracture. She was admitted as an inpatient to the hospital and underwent an open reduction and internal fixation (ORIF) on January 7, and developed post-op urinary tract infection (UTI) and pneumonia. The UTI is resolved. She is being readmitted to Shady Acres tomorrow, January 21.

Which of the following would be necessary on readmission from the hospital?

Verifying Medicare benefits.

A secondary payer screening.

A prior stay investigation.

Verifying that level-of-care criteria are met.

29 After eight weeks of rehab therapy, a resident with post-open reduction and internal fixation (ORIF) surgery is able to ambulate independently with a front-wheeled walker and manages her own ADLs. 29 During the course of her therapy, she developed pneumonia, and daily IV antibiotics will be administered for two weeks. She also continues to receive physical therapy due to decline in mobility as a result of the onset of pneumonia. The facility has received an ADR for the claim period covering the antibiotic therapy.  Which of the following represents an appropriate licensed nurse’s note in support of daily skilled services for this resident during antibiotic therapy period?

IV antibiotic infusing in left forearm. Ambulated with physical therapy without adverse reaction.  VS 120/80- 98-72-16. Medicated for pain. Tolerated meals well; no complaints of nausea.

A & O x 3. Respirations even & unlabored. Crackles in bases bilaterally to auscultation. IV antibiotics administered for pneumonia without s/s of adverse reaction. VS = 120/80 98-72-16. Ambulates to bedroom with mod-assist of one person, weight bearing as tolerated with front wheeled walker. Medicated for left hip pain, 6 on scale of 10, two times this shift with relief to 3/10 for 4 hours each episode.

A & O x 3. No s/s SOB, no s/s respiratory distress. Transfers with assist of 1, no s/s related to adverse effects of IV antibiotics. VS 120/80- 98-72-16.  Medicated for left hip pain rated 6 on scale of 10 with good effect. Patient teaching provided.

Alert and oriented. No respiratory distress. Family at bedside. Patient teaching provided. Patient able to identify medications and the potential side effects. No complaints of pain.

30 Which scenario will not qualify a resident for Medicare Part A skilled therapy after a 3-day qualifying hospital stay?

The resident’s level of function is diminished due to the surgery.

The resident has an infection requiring daily IV antibiotic therapy.

The resident requires nursing services for application of dressings involving prescription medications and aseptic techniques.

31 The resident needs therapy only four days per week. As a part of the ADR response, the facility staff should include which of the following?

Only the information requested by the MAC since the MAC reviewer has identified what is missing.

Information requested in the ADR, plus information from earlier billing periods to remind the reviewer of the history of the case.

Information requested in the ADR plus any additional information that will support payment for services during the billing period in question.

Information from all Medicare stays this resident had at the facility.

32 What is a common reason for Medicare coverage to be denied?

There are missing orders calling into question medical necessity.

The resident has a G-tube with daily flushes only.

The resident has a new colostomy and the stoma is healing.

The admission paperwork was not completed

33 A Medicare Part A beneficiary exhausts his Medicare benefit on July 15 and transitions to long-term care. On October 9th he suffers an acute episode, transitions to the hospital where he is admitted, and a discharge return anticipated assessment is completed. After a 10-day stay as an inpatient in the hospital, he returns to the nursing facility to continue his recovery from complications of renal failure. He is receiving five days of physical therapy for a decline in mobility and change in incontinence. Which assessment is most likely to be completed upon return to the facility? 

A Medicare 5-day assessment, dually coded with a significant change. 

A Medicare 5-day assessment.

A significant change assessment.

A quarterly assessment.

How do you manage key Medicare processes within the facility?

Conduct chart reviews after the facility receives a high error rate from the FI/MAC.

Have the therapists manage the Medicare program in the facility.

Technical and clinical criteria are reviewed by the business office manager only.

Ensure the IDT audits supporting documentation for Medicare services in a pre-billing audit.

34 How do you manage key Medicare processes within the facility?

Conduct chart reviews after the facility receives a high error rate from the FI/MAC.

Have the therapists manage the Medicare program in the facility.

Technical and clinical criteria are reviewed by the business office manager only.

Ensure the IDT audits supporting documentation for Medicare services in a pre-billing audit.

35 In response to an additional development request (ADR) by a Medicare Administrative Contractor (MAC), what is the best course of action for the facility staff?

Have the medical records clerk prepare the response and ensure that the director of nursing review the ADR prior to the designated timeframe.

Assign the medical records clerk to respond to the ADR and ensure that the requested documents are sent to the MAC within the designated timeframe.

Have the director of nursing and biller review the ADR prior to the designated timeframe.

Provide an interdisciplinary response to the request, with final review by a clinician with expertise in Medicare Part A coverage.

36 Who is responsible for putting together the necessary information for an additional development request (ADR)?

The Administrator and Business Office Manager.

The Business Office Manager

It is an interdisciplinary effort.

Therapy and the Business Office Manager