Government Source Documents

As a nurse leader, staying current with government regulations is always a challenge. That is why we do the hard work for you, monitoring government websites, looking for important updates and information. Click on the titles below to find a brief description of important government regulations most relevant to you.

For expert analysis and commentary on these government regulations, check out the DNS Navigator our monthly e-newsletter and search for specific LTC topics in the Resource Library.

In the August 2018, Skilled Nursing Facility Prospective Payment System (SNF PPS) final rule, CMS announced that the RUGs-IV Case Mix System will be replaced by the PDPM effective 10/1/2019. Here is a list of government resources related to the PDPM.

SNF PPS Final Rule FY2019

The Final Rule contains the regulations regarding the components of the PDPM system that will be implemented 10/1/2019.

SNF PPS Payment Model Research – PDPM Resources – general information page

SNF PDPM Technical Report

The SNF PDPM Technical Report discusses the additional analyses conducted, many in response to stakeholder feedback on the ANPRM, in development of the proposed PDPM.

SNF PDPM ICD-10 Diagnosis and Procedural Code Crosswalk

This SNF PDPM ICD-10 Diagnosis and Procedural Code Crosswalk assist to show how the PDPM would use ICD-10 diagnosis and procedural codes in order to classify SNF residents into one of ten PDPM Clinical Categories, which would then be used to further classify the resident for payment purposes under PDPM. These files provide a crosswalk between the ICD-10 diagnosis and procedure codes and the ten PDPM clinical categories.

SNF PDPM Classification Walkthrough, Version 2

SNF PDPM Grouper Tool, Version 3

SNF PDPM NTA Comorbidity Mapping, Version 2

The three files listed above help stakeholders in understanding the process by which SNF residents would be classified into PDPM payment groups. The first file provides a narrative step-by-step walkthrough that would allow stakeholders to manually determine a resident’s PDPM classification based on the data from an MDS assessment. The second file is a spreadsheet-based grouper tool which can be used to test certain combinations of MDS items used to classify residents under the proposed PDPM, and observe their impact on the resident’s PDPM classification. These files should be used in conjunction with the discussions found in the FY 2019 SNF PPS NPRM and accompanying files to better understand the process for resident classification under PDPM. The third file is a mapping, referenced in the narrative walkthrough file, between ICD-10-CM codes and the comorbidities used for resident classification under the NTA component.

SNF PDPM Provider Specific Impact Analysis

To assist stakeholders in understanding the potential impacts of the proposed PDPM, CMS provided this provider-specific impact analysis file, which details the estimated impact of the PDPM model discussed in the FY 2019 SNF PPS NPRM on Medicare Part A payments to each SNF in the country.

Minimum Data Set 3.0 Cognitive Function Scale

This report explains the retrospective cohort study conducted to develop the Cognitive Function Scale used as a basis for the cognitive scoring in the PDPM.

The State Operations Manual (SOM) contains the primary survey-and-certification rules and guidance for LTC providers from the Centers for Medicare and Medicaid Services Internet-Only Manual System.

CMS Quality Safety & Oversight Policy and Memos

CMS Quality Safety & Oversight memoranda, guidance, clarifications and instructions to State Survey Agencies and CMS Regional Offices.

CMS Quality Safety & Oversight Administrative Information Memos

CMS Quality Safety & Oversight memoranda, guidance, clarifications and instructions to State Survey Agencies and CMS Regional Offices.

Dementia Care Focused Survey

Committed to enhancing the quality of life for people with dementia, CMS has partnered with federal and state agencies, nursing homes, other providers, advocacy groups, and care givers to identify and implement initiatives including public reporting, state-based coalitions, research, training and revised surveyor guidance. The partnerships’ initial focus was antipsychotic medications.

Adverse Drug Event Trigger Tool

Based on findings of medication-related adverse events, CMS created the "Adverse Drug Event Trigger Tool" as a resource document containing necessary information for evaluating high-risk medications. This tool is a crosswalk that lists: common potentially preventable adverse drug events; risk factors related to those events; triggers – signs, symptoms, or clinical interventions that could indicate that the adverse drug event has occurred; and probes that would assist surveyors in evaluating systems around high-risk medications. Providers can use it as a risk management tool

Life Safety Code Resource Page – CMS

The LSC is a set of fire protection requirements designed to provide a reasonable degree of safety from fire; CMS partners with State Agencies to assess compliance. This page and attached resources detail LSC regulations, compliance information, as well as the certification process.

LTC Survey Pathways - Updated 10-03-2017 (zip file)

Effective Nov. 28, 2017, surveyors conducting surveys using the new survey process will follow a series of tools in addition to the interpretive guidance in Appendix PP of the State Operations Manuals. These tools include Critical Element Pathways that address specific care areas, and facility task tools that address specific facility systems.

Nursing Homes Reform of Requirements New Survey Process Resources

This CMS website includes links to many resources related to the survey process that is effective Nov. 28, 2017. These include the Long Term Care Survey Process (LTCSP) Procedure Guide, a crosswalk between the old and new F-tags, and an entrance conference worksheet and provider matrix.

CMS e-Learning website

CMS has developed several training courses for surveyors that help nursing homes understand survey requirements. These include the Emergency Preparedness Basic Surveyor Training Course and the LTC Survey Process SME Videos, which cover multiple areas of revised Appendix PP/State Operations Manual guidance that goes into effect Nov. 28, 2017.

RAI User’s Manual

This page contains the complete RAI Manual in one document with bookmarks for ease of navigation.

MDS 3.0 Forms and Item Sets

This link provides complete files of MDS forms for SNF, NF and Swing Bed Facilities under the Appendix H tab.

QTSO: CASPER Reporting Manual

This link provides access to manuals from QTSO, which maintains the MDS submissions and CASPER reporting systems. Available manuals provide guidance on how to successfully submit MDS files, how to find management reports to monitor your facility’s submission status, and how to access CASPER QM reports.

The MDS 3.0 Quality Measures User’s Manual v 11, effective April 1, 2017, is a key resource for managing your facility's quality outcomes through Quality Measure (QM) tracking and trending.  CMS uses QMs for survey management, payment, and measuring quality resident care.  The manual contains the key definitions and the methodology for how the nationally reported QMs are computed. CMS also issued an errata to the V11 manual that addresses an error pertaining to N015.01, Percent of High-Risk Residents With Pressure Ulcers (long stay).

CMS created the Five-Star Quality Rating System to help consumers, their families, and caregivers compare nursing homes more easily. The Nursing Home Compare Web site features a quality rating system that gives each nursing home a rating of between 1 and 5 stars. Nursing homes with 5 stars are considered to have much above average quality and nursing homes with 1 star are considered to have quality much below average. The Five-Star Quality Rating System Technical Users' Guide provides in-depth descriptions of the ratings and the methods used to calculate them.

Duration of Inpatient Services, Chapter 3, Medicare Benefit Policy Manual

Chapter 3, “Duration of Inpatient Services,” explains what a benefit period is, what counts as an inpatient day, and the impact of leaves of absence, as well as the impact of discharge or death on the first day of entitlement or participation.

Coverage of Extended Care (SNF Part A) Services, Chapter 8, Medicare Benefit Policy Manual

Chapter 8, “Coverage of Extended Care (SNF) Services Under Hospital Insurance,” is the primary resource for information about Medicare Part A skilled coverage and level-of-care information.

Part B Therapy / Covered Medical & Other Health Services, Chapter 15, Medicare Benefit Policy Manual

Chapter 15, “Covered Medical & Other Health Services,” provides a wealth of information about coverage of Part B services, including Part B (aka outpatient) rehabilitation therapy services. This chapter reviews conditions of coverage and payment for Part B physical therapy, occupational therapy, and speech-language pathology services. 

General Exclusions From Coverage, Chapter 16, Medicare Benefit Policy Manual

Chapter 16, “General Exclusions from Coverage,” reviews the basic items and services that Medicare won’t pay for under certain conditions. For example, Medicare doesn’t cover personal comfort items, routine services and appliances, or custodial care.

General Overview, Chapter 1, Medicare General Information, Eligibility & Entitlement Manual

Chapter 1, “General Overview,” offers basic information about Medicare program benefits, including Part A and Part B; the administration of the Medicare Program; and the role of Medicare contractors, including Medicare Administrative Contractors.

Deductibles, Coinsurance & Payment Limits – Plus Benefit Periods, Chapter 3, Medicare General Information, Eligibility & Entitlement Manual

Chapter 3, “Deductibles, Coinsurance Amounts, and Payment Limitations,” explains annual deductibles and coinsurance amounts. However, this chapter also reviews how a benefit period starts and ends, the definition of a SNF for ending a benefit period, and the definition of inpatient for ending a benefit period.

Physician Certification & Recertification (Cert/Recert), Chapter 4, Medicare General Information, Eligibility & Entitlement Manual

Chapter 4, “Physician Certification and Recertification of Services,” reviews who can sign the cert/recert for Medicare Part A SNF services, certification content and timing requirements, recertification content and timing requirements, the rules involving delayed certs/recerts; and the disposition of certs/recerts.

Definitions, Chapter 5, Medicare General Information, Eligibility & Entitlement Manual

Chapter 5, “Definitions,” explains key definitions related to the Medicare program. These include but are not limited to the definition of: Provider agreements; A skilled nursing facility; A distinct dart of an institution as a SNF; Transfer agreements; and Hospital providers of extended-care services.

Disclosure of Information, Chapter 6, Medicare General Information, Eligibility & Entitlement Manual

Chapter 6, “Disclosure of Information,” reviews the rules related to privacy and the disclosure of information evolving from the Privacy Act of 1974 and the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. For example, it provides guidelines for how Medicare contractors should handle requests for beneficiary-specific information from providers, physicians, and suppliers.

General Billing Requirements, Chapter 1, Medicare Claims Processing Manual

Chapter 1, “General Billing Requirements,” explains an array of basic information, including but not limited to: The formats for submitting claims to Medicare; Jurisdictions for claims; Provider assignment to Medicare administrative contractors; Provider participation; Termination of provider agreements; The basic process for filing a request for payment, including the rules for billing frequency; Billing noncovered charges on institutional claims; Part A and Part B timely filing limits and exceptions; MAC claims processing timeliness; How to handle billing when a patient is a Medicare Advantage enrollee for a portion of the billing period; duplicate claims; SNF Part A and Part B adjustment billing; SNF claims subject to expedited determinations; and Services paid on the Medicare Physician Fee Schedule for SNF Part B claims (22x and 23x bill types).

Administration & Registration Requirements, Chapter 2, Medicare Claims Processing Manual

Chapter 2, “Administration and Registration Requirements,” explains basic information, including but not limited to: General administration and registration rules, including health insurance claim numbers (HICN) and SNF verification of prior hospital stay information for determining deductible and benefit period status; Information required to determine whether to bill Medicare or another payer; and Providers obtaining/verifying the HICN and entitlement status, including the rules for accessing eligibility data from systems maintained by CMS and the Medicare administrative contractors.

Part B Outpatient Rehabilitation, Chapter 5, Medicare Claims Processing Manual

Chapter 5, “Part B Outpatient Rehabilitation and CORF/OPT Services,” includes information about the annual Part B therapy caps, as well as instructions on functional reporting and HCPCS coding requirements, including reporting service units and using timed codes. In addition, the chapter has an appendix with relevant ICD-10 codes.

SNF Inpatient Part A Billing and Consolidated Billing, Chapter 6, Medicare Claims Processing Manual

Chapter 6, “SNF Inpatient Part A Billing and SNF Consolidated Billing,” provides nuts-and-bolts information on SNF PPS billing and consolidated billing.

SNF Part B Billing, Chapter 7, Medicare Claims Processing Manual

Chapter 7, “SNF Part B Billing (Including Inpatient Part B and Outpatient Fee Schedule),” reviews the three situations where SNFs are allowed to submit claims for Part B services; billing for inpatient SNF Services paid under Part B; billing for outpatient SNF services; determining how much to charge before billing is submitted; general payment rules and application of Part B deductible and coinsurance; HCPCS codes; billing formats and frequency; guidelines for submitting corrected bills; and billing requirements for an array of services, such as bone mass measurements, supplies (e.g., surgical dressings), and durable medical equipment.

Preventive and Screening Services, Chapter 18, Medicare Claims Processing Manual

Chapter 18, Preventive and Screening Services,” reviews the coverage and billing rules for multiple preventive services, including the pneumococcal pneumonia, influenza virus, and hepatitis B vaccines, as well as various screening services such as mammography screening.

Completing & Processing the CMS-1450 or UB-04, Chapter 25, Medicare Claims Processing Manual

Chapter 25, “Completing and Processing the Form CMS-1450 Data Set,” provides a field-by-field look at the coding requirements for creating an accurate institutional Part A/B bill to submit to Medicare administrative contractors.

Common Working File (CWF) Technical Basics, Chapter 27, Medicare Claims Processing Manual

Chapter 27, “Contractor Instructions for the CWF,” explains how the Common Working File operates from a technical perspective and explains the meaning of various codes, such as SNF consistency error codes.

Appeals of Claims Decisions, Chapter 29, Medicare Claims Processing Manual

Chapter 29, “Appeals of Claims Decisions,” walks through the administrative appeals process. Topics include but are not limited to: Who may appeal; Steps in the appeals process, as well as a detailed review of each level: redetermination, reconsideration, administrative law judge hearing, departmental appeals board/appeals council, and U.S. District Court review; Where to appeal; Time limits for filing appeals and good cause for extension of the time limit for filing appeals; Amount-in-controversy requirements; Appointment of representative and assignment of appeal rights; Fraud-and-abuse issues; Guidelines for writing appeals correspondence; and Disclosure of information.

Financial Liability Protections: ABN, SNF ABN, NOMNC, Chapter 30, Medicare Claims Processing Manual

Chapter 30, “Financial Liability Protections,” explains multiple aspects of financial liability protections for patients, including but not limited to: Limitation on liability when claims are disallowed; The rules for determining financial liability when claims are disallowed; Requirements, including content and delivery rules, for Form CMS-R-131, the Advance Beneficiary Notice of Noncoverage (ABN); Requirements, including content, delivery, and signature rules, for Form CMS-10055, the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN); Indemnification procedures for claims falling within the limitation on liability provision; and Expedited determinations of provider service terminations , including the requirements for the Notice of Medicare Non-Coverage (NOMNC) and the Detailed Explanation of Non-Coverage. This section includes an example of an expedited determination scenario in a SNF.

Reopening & Revision of Claim Determinations and Decisions, Chapter 34, Medicare Claims Processing Manual

Chapter 34, “Reopening and Revision of Claim Determinations and Decisions,” explains the opportunities providers have to request a remedial action from Medicare contractors to change a final determination or decision that resulted in either an overpayment or an underpayment, even though the determination or decision was correct based on the evidence of record. Reopenings are separate and distinct from the appeals process. Topics include but are not limited to time frames to reopen claim determinations and what is good cause for reopening.

Medicare Improper Payments, Chapter 1, Medicare Program Integrity Manual

Chapter 1, “Medicare Improper Payments: Measuring, Correcting, and Preventing Overpayments and Underpayments,” provides an overview of the Centers for Medicare and Medicaid Services’ program integrity and provider compliance activities using review contractors, i.e., Medicare administrative contractors (MACs) , Comprehensive Error Rate Testing (CERT) contractors, recovery auditors, program safeguard contractors (PSCs), zone program integrity contractors (ZPICs), and the supplemental medical review contractor (SMRC). Topics addressed include but are not limited to: the operation of the Medicare Improper Payment Prevention program, including program goals, the contractors that are involved, and the types of claims they handle; contractor medical director requirements; and contractor medical review manager requirements.

Medical Review Process Basics (ADRs, etc.), Chapter 3, Medicare Program Integrity Manual

Chapter 3, “Verifying Potential Errors and Taking Corrective Actions,” lays out the basic requirements that review contractors must use in conducting prepayment and postpayment reviews of provider claims.

Benefit Integrity (ZPICS, PSCs), Chapter 4, Medicare Program Integrity Manual

Chapter 4, “Benefit Integrity,” offers an in-depth look at the Medicare Fraud Program, giving examples of fraud (e.g., billing noncovered or nonchargeable services as covered items) and providing details on operational requirements for program safeguard contractors and zone program integrity contractors.

SNF PPS Part A Medical Reviews, Chapter 6, Medicare Program Integrity Manual

Chapter 6, “Medicare Contractor Medical Review Guidelines for Specific Services,” provides a detailed review of how Medicare contractors should conduct medical review of SNF PPS claims.

Comprehensive Error Rate Testing (CERT), Chapter 12, Medicare Program Integrity Manual

Chapter 12, “The Comprehensive Error Rate Testing (CERT) Program,” explains the basic operating structure of the CERT Program, which produces a national Medicare fee-for-service (FFS) improper payment rate by evaluating a random sample of Medicare FFS claims to determine if they were paid properly under Medicare coverage, coding, and billing rules.

Local Coverage Determinations (LCD), Chapter 13, Medicare Program Integrity Manual

Chapter 13, “Local Coverage Determinations,” explains the difference between a national coverage determination and a local coverage determination, which is a decision by a Medicare administrative contractor (MAC) whether to cover a particular item or service on a MAC-wide basis. The chapter then details the rules that MACs must follow in creating and using LCDs.

Exhibits (Sample Letters & Instructions), Medicare Program Integrity Manual

“Exhibits” provides an array of supporting documentation used in program integrity activities, ranging from consent settlement documents to postpayment additional documentation request sample letters.

The OIG has developed a series of voluntary compliance program guidance documents directed at various segments of the healthcare industry, such as hospitals, nursing homes, third-party billers, and durable medical equipment suppliers, to encourage the development and use of internal controls to monitor adherence to applicable statutes, regulations, and program requirements. 

Access the OIG Corporate Compliance Guidance 2000.

Access the OIG Corporate Compliance Guidance 2008.

BFCC-QIOs

Beneficiary and Family Centered Care (BFCC)-QIOs are regional organizations that support beneficiaries by providing more expeditious review of such things as complaints. This page includes look-up contact information for the BFCC-QIOs.

QIN-QIO

Quality Innovation Network (QIN)-QIOs are designed to improve healthcare services through education, outreach, sharing practices that have worked in other areas, using data to measure improvement, working with patients and families and convening community partners for communication and collaboration. This page includes look-up contact information for the QIN-QIOs.

Find additional information on QIOs here.

Quality Assurance and Performance Improvement (QAPI)

Tools and resources for Quality Assurance & Performance Improvement (QAPI) programs.

Nursing Home Compare

The Nursing Home Compare database provides your facility's rating overall, as well as for survey, staffing, and QMs.

Centers for Disease Control

The Centers for Disease Control and Prevention (CDC) provides data statistics about nursing homes, services and residents.

ICD-10

The CDC provides full information on ICD-10-CM codes and guidelines, with links.

OSHA

The US Department of Labor's Occupational Safety and Health Administration (OSHA) provides major requirements and guidelines for health care facilities.

IMPACT Act

CMS provides an overview of the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act). Passed in 2014 the IMPACT Act requires standardized data reporting for all facilities in the post-acute continuum of care. It is designed to improve patient safety, satisfaction, and outcomes, as well as reduce costs.

Staffing: Payroll Based Journal: PBJ

CMS provides an overview of Payroll Based Journal (PBJ), the system for facilities to submit staffing and census information, as required by Section 6016 of the Affordable Care Act (ACA).

Staffing: Department of Labor

The US Department of Labor's Wage and Hour Division provides full information on state labor laws.

Federal Register, Ch. 42 for LTC Facilities

The Code of Federal Regulations (CFR) is the codification of rules that are published in the Federal Register by the Centers for Medicare and Medicaid Services and other government agencies. It is the actual regulation from which CMS bases and issues Medicare and Medicaid program guidance, such as all of the manuals in the Internet-Only Manual System. FDsys has set up a searchable on-line version of the CFR as a reference tool. Most information pertinent to SNFs and NFs is located in: Volume 42, "Public Health," Chapter IV, "Centers for Medicare and Medicaid Services, Dept. of Health and Human Services.

* Part 483, "Requirements for States and Long-Term Care Facilities," Subpart B. These sections cover the basic requirements of Medicare/Medicaid participation: from resident rights and resident assessment to the actual Conditions of Participation.

* Part 409, "Hospital Insurance Benefits," Subparts A - H. These sections cover such issues as the skilled level-of-care requirement, the "daily basis" criteria, and plan-of-care requirements.”

Medicare and Medicaid Reform of Requirements for Long-term Care—Final Rule and Correction

On Oct. 4, 2016, CMS issued a final rule revising the requirements that an institution has to meet in order to qualify to participate as a skilled nursing facility (SNF) in the Medicare program, or as a nursing facility (NF) in the Medicaid program. On July 13, 2017, CMS issued a correction to correct technical and typographical errors.

PPACA (Affordable Care Act)

This bill was enacted after being signed by the President on March 23, 2010.

CMS Innovations Center - ACO, Bundled payment demonstration projects

CMS provides an overview of the Innovation Center, which develops new payment and service delivery models. Specific demonstrations of these models are required to be conducted by CMS, which provides a map of the demonstrations across the US.

Link to State Regulations

The University of Minnesota provides a complete list of links to state nursing home regulations.

State Medicaid Resource

Medicaid.gov provides resources by state, including the Innovation Accelerator Program (IAP), Medicaid State Technical Assistance, Medicaid and CHIP Program Portal, MAC Learning collaboratives, and Eligibility & Enrollment Final Rule Webinars.

State Nurse Practice Acts

The National Council of State Boards of Nursing (NCSBN) provides a link to all State Nurse Practice Acts.