The Department of Veterans Affairs (VA) Community Nursing Home (CNH) Fee Schedule operates under a framework similar to Medicare’s Prospective Payment System (PPS), as detailed in Chapter 6 of the Medicare Claims Processing Manual. This system dictates how the VA reimburses community nursing homes for the care they provide to veterans. Generally, the VA payment is the lower amount between the billed charges and what is stipulated in the CNH Fee Schedule. This also incorporates policies on interrupted stays and offers increased payments for veterans with HIV/AIDS. However, there are specific exceptions to these general rules within the VA system, which are outlined below.
For further details on the standard Medicare PPS billing requirements, you can refer to the Medicare Claims Processing Manual, Chapter 6.
Key Differences in the VA CNH Fee Schedule:
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Patient Driven Payment Model (PDPM) Modifications: The VA utilizes PDPM-based pricing software but with specific adjustments:
- Days 1-100: For the initial 100 days of care in a CNH, the VA applies a 0.93 multiplier to the physical therapy (PT), occupational therapy (OT), speech-language pathology (SLP), nursing, and non-case-mix components of the PDPM calculation. This adjustment is in addition to any other applicable adjustment factors.
- Days 101+: Beyond the first 100 days, the therapy components (PT, OT, and SLP) are removed from the calculation, or their adjustment factor is set to zero. The nursing and non-case-mix components are then multiplied by 1.25.
- Non-Therapy Ancillary Component: This component follows the standard PDPM structure, set at 3.0 for the first three days of care. For days 1-100, it reverts to 1.0, and for days 101+, it is adjusted to 1.25.
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Limited Special Service Pricing: Unlike some systems, the VA PDPM-based PPS does not include separate, special service pricing for specific care needs. This means there are no additional payments for services like bed hold, memory care, behavioral health services, care for HIV/AIDS (despite the general enhanced payment mentioned earlier), respite care, ventilator care, tracheostomy care, or isolation/private rooms. The base PDPM rate covers these services.
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Exclusion from Certain Medicare Programs: The VA system operates independently of several Medicare programs. Specifically, the VA does not participate in sequestration (automatic spending cuts), quality reporting programs, or value-based purchasing programs that are part of Medicare.
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Separately Billable Services: Certain services covered under VA CNH authorizations are not bundled into the nursing home PPS. For these services, nursing homes must submit separate claims for reimbursement:
- Physician Services: If a physician provides services that are federally mandated or separately authorized by the VA, these services should be billed on a fee-for-service basis. Reimbursement will be at the lower of the billed charges or the Medicare Physician Fee Schedule. Unless the physician has a Veterans Care Agreement with the VA, the nursing facility is responsible for submitting these claims.
- Physical Therapy (PT), Occupational Therapy (OT), and Speech-Language Pathology (SLP): If a veteran requires PT, OT, or SLP therapy beyond the first 100 days of their CNH stay (day 101+), the provider must obtain prior authorization from the VA. Once authorized and delivered, these services are billed fee-for-service using specific procedure codes: G0151, G0152, G0153, G0157, G0158, G0159, G0160, and G0161. Reimbursement will be the lower of billed charges or the VA Fee Schedule.
- Escort Services: When a veteran needs an escort to a medical appointment, providers must first secure prior authorization from the VA. Approved escort services are billed fee-for-service using procedure code G0156. Payment will be the lesser of billed charges or the VA Fee Schedule.
This explanation clarifies the VA CNH Fee Schedule and its deviations from the standard Medicare PPS, providing essential information for healthcare providers and those involved in veteran care.
