Reimbursement QuickTIP: Get Paid for the Care and Services you Provide


During the COVID-19 pandemic, post-acute care leaders have had their days filled with sparse staffing, infection control surveys, sick residents and staff, and distraught families. Now that vaccines are rolling out to our residents and employees, we can begin to look beyond making it through the day and think about the overall health of our organization beyond COVID-19.

Now is the time to turn your focus to reimbursement as you prepare for the “new normal.” Although the CARES Act provided some financial support for extra costs during the Federal and State Public Health Emergencies (PHE), as of today, the PHE 1135 waiver is still in place, which supports changes for some Medicare procedural rules. While there are numerous waivers in place, the three-day hospital stay remains waived and the new benefit period rule is waived in some circumstances.

The clinical reimbursement processes in some skilled nursing facility (SNF) settings are not consistently optimizing residents’ access to the Medicare benefit under these waivers.

(See below for a complimentary checklist from Pathway Health to assist in identifying opportunities to advocate for your residents with Medicare to access their SNF benefit when appropriate.)

Tips on how to access Medicare during the PHE 1135 waiver:

  • Identify a change in condition or close exposure (from a COVID-19 positive staff or resident) for the resident.
  • Assess the change and decide if the resident meets one of the Medicare clinical criteria for coverage per the Medicare Benefit Policy Manual – Chapter 8 Coverage of Extended Care (SNF) Services under Hospital Insurance:
  • Skilled therapy
  • Skilled nursing
  • Observation and assessment
  • Management of a care plan
  • Teaching and training
  • Confirm that the resident has Medicare and has days available to use.
  • Obtain physician orders and certification for a skilled stay.
  • Begin discipline-specific assessments for Medicare stay (like a new admission).
  • Schedule a Significant Change/5-day MDS.

Another challenge is managing the residents’ diagnoses reimbursement coverage changes over the course of their stay. We are all aware that the resident’s primary diagnosis drives payment in many of the Patient Driven Payment Model (PDPM) components. During this PHE, staff may not have focused on effective diagnosis management. However, managing diagnoses is a key activity for PDPM and other payor success.

Leadership Considerations: Use a Best Practice Approach for Diagnosis Management

The diagnosis management process goes beyond identifying a primary diagnosis for PDPM. It also involves entering the correct diagnoses on the MDS and the billing claim for Medicare. Once a Medicare stay ends and a resident remains in the facility, the diagnoses need to be reviewed and potentially reorganized, which may impact your reimbursement. It is also important to note that the secondary payor must have correct codes on the claim as well. Consider the following:

  • Identify the correct diagnosis for the SNF admission. Validate that the primary diagnosis works for PDPM.
  • Clarify with the provider if needed.
  • Review all transfer documents and request documents from the hospital as needed to identify all active comorbidities, including:
  • Operative reports
  • Consult reports
  • Diagnostic test reports
  • Before completing the 5-day MDS, review notes from providers and discipline-specific assessments to identify all of the resident’s active conditions and interventions.
  • Clarify with the provider if documentation is needed.
  • Monitor provider documentation for changes in the diagnosis list over the course of the Medicare stay. Remember to sequence the remaining diagnoses based upon the primary diagnosis and severity of illness.
  • Consider an Interim Payment Assessment (IPA) MDS if the resident gets a new diagnosis or intervention that would increase PDPM payment.
  • Compare the provider-documented diagnoses to the MDS and Claim prior to billing to confirm that diagnosis codes are supported.


Complimentary Resource: Checklist for Medicare Reimbursement Systems
This complimentary Medicare Reimbursement QuickTIP is a great checklist designed for leaders! Use this with your team to review current Medicare processes during the COVID-19 pandemic, including your COVID-19 coding processes, billing and MDS outcomes.


Pathway Health’s reimbursement professionals are available to assist you in your reimbursement optimization journey. Contact us for details on the affordable Reimbursement SnapShot review which outlines areas of opportunity.


Karolee Alexander
Director of Reimbursement and Clinical Consulting