Revised SNF ABN

CMS is releasing a newly revised SNF ABN (SNF Advance Beneficiary Notice of Non-coverage), along with new, concise, easy to follow, and detailed instructions to complete the form.  CMS will be discontinuing the 5 SNF denial letters and the Notice of Exclusion from Medicare Benefits. (NEMB-SNF). The requirement for Notice has not changed, nor have the guidelines- only the form.

SNFs must issue a liability notice to FFS Medicare beneficiaries, prior to providing an item or service that is usually paid for by Medicare, but may not be paid for because the service is not medically reasonable and necessary, or it is custodial care. The ABN form is to help the beneficiary decide whether or not he/she wants the care that may not  be paid for by Medicare, in which case they would be financially responsible.

For Medicare Part B, SNFs should continue to use the ABN Form CMS R-131.

The revised SNFABN will be mandatory for use on May 7, 2018, however, it is recommended that the revised SNFABN be used as soon as possible. The revised form and instructions are under downloads at the following link:

https://www.cms.gov/Medicare/Medicare-General-Information/BNI/FFS-SNFABN-.html

If you have any questions please contact Barbara Blatt, Appeals Management Coordinator at bblatt@preftherapy.com.

 


 

 

Permanent Medicare Part B Therapy Cap Repeal

Background
The Medicare Part B therapy cap was initiated by the Balance Budget Act of 1997 and has been extended by legislation several times throughout the years. The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 extended the therapy cap exceptions process through 12/31/17 and included a targeted manual medical review for therapy services exceeding $3,700 for PT/ST (combined) and $3,700 for OT. Unfortunately, further legislation to extend the therapy cap did not occur prior to it expiring on 12/31/17. Over the years, grass roots efforts from PAC providers and therapy companies like PTS were coordinated urging Congress to permanently repeal the arbitrary therapy cap. Ongoing efforts were continued into 2018 after the exceptions process to the therapy cap expired.
What You Need To Know
Last week, as part of the bipartisan budget deal legislation, the therapy cap was permanently repealed and signed into law with a retroactive effective date of Jan 1st, 2018. After over 20 years, we will no longer have to advocate for continued legislation to extend the therapy caps exception process!
As part of this therapy cap repeal:
  • The KX modifier will continue to be required on claims over $2,010 for PT/ST and $2,010 for OT (for tracking purposes).
  • The targeted manual medical review threshold has been lowered from $3,700 to $3,000 for PT/ST services and a separate $3000 threshold for OT services.
While PTS never allowed the arbitrary therapy cap and threshold to impact the delivery of medically necessary services to our residents, we are very pleased that Congress and the White House has passed this legislation.
As your Rehabilitation Partner, Preferred Therapy Solutions continues to collaborate with your facility.
If you have any questions, please contact Maria Maggi, Vice President of Compliance: mmaggi@preftherapy.com

 

MedPAC Holds January Public Meetings

Background
On Thursday, January 11, 2018, the Medicare Payment Advisory Commission (MedPAC) met as scheduled for their first public meeting of 2018 in Washington, DC. The purpose of this and other public meetings of MedPAC is for the commissioners to review the issues and challenges facing the Medicare program and then make policy recommendations to Congress.

During this meeting, MedPAC staff assessed payment adequacy and updating payments for skilled nursing facilities and home health services as well as voting to replace the Merit-based Incentive Payment System (MIPS) with a more voluntary approach under a new program.

What You Need to Know
After reviewing the summary of the January MedPAC meeting, we identified the following as being of interest to SNF providers:

> MedPAC projects SNF Medicare FFS margins to be 9% for FY 2018.

> As part of their Draft 2018 Recommendations to Congress, MedPAC voted to approve to following:

  • Elimination of the market basket update for SNFs for FY2019 and FY2020;
  • Direct the Secretary to implement a redesigned prospective payment system (PPS) inFY2019 for SNFs; and

Direct the Secretary to report to the Congress on the impacts of the revised PPS and make any
additional adjustments to payments needed to more clearly align payments with costs in FY2021.

> If Congress chooses to adopt these recommendations, MedPAC projects:

  • A $750 million to $2 billion decrease in payments for FY 2019;
  • A reduction in the disparity of Medicare margins between providers;
  • Increased access to services for medically complex beneficiaries; and
  • A variable impact on individual providers based on their mix of cases and current practice patterns.

Preferred Therapy Solutions (PTS) will continue to monitor the activity and recommendations made by MedPAC. What is clear based on their January meeting is that MedPAC supports replacing the current SNF-PPS with a re-designed payment model which more closely aligns payment with cost. This further supports our belief that the Resident Classification System (RCS-I) will be implemented this October. PTS has fully analyzed RCS-I and is prepared to meet the challenges we will all face under this new payment model.

As your Rehabilitation Partner, Preferred Therapy Solutions continues to collaborate with your facility. If you have any questions, please contact Maria Maggi, Vice President of Compliance: mmaggi@preftherapy.com

 

SNF QRP- Full Confidential Feedback Reports Now Available

The Skilled Nursing Facility Quality Reporting Program (SNF QRP) Confidential Feedback Reports/Quality Measure Reports containing the assessment and claims-based IMPACT Act measures are now available via the Certification and Survey provider Enhanced Reports (CASPER) Reporting System.
Assessment-based quality measures:
• Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay)
• Application of Percent of Long-Term Care Hospital (LTCH) Patients with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function
• Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay)
Claims-based quality measures:
• Total Estimated Medicare Spending Per Beneficiary Measure
• Discharge to Community-Post Acute Care– SNF QRP
• Potentially Preventable 30-Day Post Discharge Readmission Measure
Please note- CMS has discovered an error in some of the MSPB measure calculations contained in the SNF October 2017 Confidential Feedback/QM reports. The error affects the risk adjustment of the measure. CMS has corrected this issue and the data has been loaded into the Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system. These facility level quality measures reports are on-demand, user-requested reports in your CASPER folder in QIES. Providers should request an updated version of the report to review the corrected MSPB measure calculation.
Courtesy of NASL
As your Rehabilitation Partner, Preferred Therapy Solutions continues to collaborate with your facility.
If you have any questions, please contact Maria Maggi, Vice President of Compliance:
mmaggi@preftherapy.com

 

Updated Editing of “Always Therapy” Services CR 10176

Background
On July 27, 2017, CMS issued a Change Request (CR 10176) which impacts claims processing of “Always Therapy” service codes. This change request became effective 1/1/2018 and this PTS Alert is intended to insure our valued partners are prepared to comply with the claims processing requirements for “Always Therapy” services.
CR 10176 implements revised editing of Part B “Always Therapy” services to require a therapy modifier in order for the service to be accurately applied to the therapy cap. While this is not a change or enactment of a new policy, the guidelines presented in CR 10176 will improve enforcement of existing instructions which could result in the return/rejection of claims if appropriate therapy modifiers are not included.
What You Need To Know
Providers should expect the following:
• MAC’s will return/reject claims which contain an “always therapy” procedure code, but do not also contain the appropriate discipline-specific therapy modifier of GN (Speech Therapy), GO (Occupational Therapy), or GP (Physical Therapy).
• MAC’s will return/reject claims if any service line on the claim contains more than one occurrence of a GN, GO, or GP therapy modifier.
• MAC’s who are returning/rejecting such claims will use Group Code CO and Claim Adjustment Reason Code (CARC) 4 on the related remittance advice.

As your Rehabilitation Partner, Preferred Therapy Solutions continues to collaborate with your facility.
If you have any questions, please contact Maria Maggi, Vice President of Compliance:
mmaggi@preftherapy.com

REVISED CPT CODING FOR 2018

As part of the final Medicare Physician Fee Schedule (MPFS) released in November 2017, certain CPT codes commonly used by therapy were modified or deleted. In addition, 3 new CPT codes became effective January 1, 2018. The chart below summarizes the changes to the CPT codes:

CPT Code

Description

Status

Comment

97532
Development of Cognitive Skills
Deleted
No longer effective after 12/31/17
G0515
Development of Cognitive Skills
Added
Effective 1/1/18 for Medicare payers
97127
Development of Cognitive Skills
Added
Effective 1/1/18 for non-Medicare payers
97762
Orthotic and Prosthetic Check-Out
Deleted
No longer effective after 12/31/17
97760
Orthotic Management and Training
Modified
Effective 1/1/18, only to be used
for initial encounter
97761
Prosthetic Management and Training
Modified
Effective 1/1/18, only to be used
for initial encounter
97763
Orthotic and Prosthetic Management
and Training
Added
Effective 1/1/18, to be used for subsequent encounter

 

As your Rehabilitation Partner, Preferred Therapy Solutions continues to collaborate with your facility.
If you have any questions, please contact Maria Maggi, Vice President of Compliance:
mmaggi@preftherapy.com

 

CMS Update on Comprehensive Care for Joint Replacement Model, cancels Episode Payment Models and Cardiac

As your Rehabilitation Partner, Preferred Therapy Solutions continues to provide our customers with CMS updates. Below is an update released by CMS on November 30. If you have any questions, please contact Maria Maggi, Vice President of Compliance: mmaggi@preftherapy.com
Source:  Centers for Medicare & Medicaid Services
CMS NEWS
FOR IMMEDIATE RELEASE
November 30, 2017
Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries
CMS finalizes changes to the Comprehensive Care for Joint Replacement Model, cancels Episode Payment Models and Cardiac Rehabilitation Incentive Payment Model
Today, the Centers for Medicare & Medicaid Services (CMS) finalized the cancellation of the mandatory hip fracture and cardiac bundled payment models that were to be operated by the CMS Innovation Center and implemented changes to the Comprehensive Care for Joint Replacement (CJR) Model. These changes will offer greater flexibility and choice for hospitals in providing care to Medicare patients.
“While CMS continues to believe that bundled payment models offer opportunities to improve quality and care coordination while lowering spending, we believe that focusing on developing different bundled payment models and engaging more providers is the best way to drive health system change while minimizing burden and maintaining access to care. We anticipate announcing new voluntary payment bundles soon,” said CMS Administrator Seema Verma.
In the final rule, CMS is reducing the number of mandatory geographic areas participating in CJR from 67 areas to 34 areas. As part of the agency’s ongoing commitment to addressing the unique needs of rural providers, CMS is also making participation voluntary for all low volume and rural hospitals participating in the model in all 67 geographic areas. This regulation also includes an Interim Final Rule with Comment Period, in which CMS is establishing and seeking comment on a final policy to provide flexibility in determining episode costs for participant hospitals located in areas impacted by extreme and uncontrollable circumstances, such as the major hurricanes of 2017.
CMS is also finalizing the cancelation of the hip fracture and cardiac bundled payment and incentive payment models – the Episode Payment Models and the Cardiac Rehabilitation Incentive Payment Model – that were scheduled to begin on January 1, 2018. Not pursuing these models gives CMS greater flexibility to design and test innovations that will improve quality and care coordination across the in-patient and post-acute care spectrum.
Moving forward, CMS expects to increase opportunities for providers to participate in voluntary initiatives rather than large mandatory bundled payment models. The changes in the final rule will help position the agency to engage in future voluntary efforts.
For a technical fact sheet on the changes in this final rule and interim final rule with comment period, please visit: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-11-30.html.
For more information on the Comprehensive Care for Joint Replacement Model, please visit: https://innovation.cms.gov/initiatives/cjr.
The final rule and interim final rule with comment (CMS-5524-F and IFC) can be downloaded from the Federal Register at https://www.federalregister.gov/public-inspection.
###
Get CMS news at cms.gov/newsroom, sign up for CMS news via email and follow CMS on Twitter @CMSgovPress

Jimmo Update

Early in February 2017, and noted in our news alert in August, HHS was tasked to create a website referencing the Jimmo Settlement, to clarify how claims are adjudicated according to Medicare policy.
This web page is now available at the following link:

https://www.cms.gov/Center/Special-Topic/Jimmo-Center.html

As a reference, this CMS web page serves to provide access, in one location, to various public documents related to the Jimmo Settlement Agreement, including a FAQ document.
Source: CMS Website
As your Rehabilitation Partner, Preferred Therapy Solutions continues to collaborate with your facility.
If you have any questions, please contact Maria Maggi, Vice President of Compliance:
mmaggi@preftherapy.com

TPE – TARGETED PROBE & EDUCATE: A CMS MEDICAL REVIEW STRATEGY

                                         TPE – TARGETED PROBE & EDUCATE:  A CMS MEDICAL REVIEW STRATEGY

On 8/14/17, CMS announced that it will expand Targeted Probe and Educate (TPE) program to all MAC jurisdictions later in 2017 in order to identify potential Medicare fraud and improper payments. The TPE program began in 2014 as a means for CMS to review clinical documentation, combining a sample of claims with education, to help reduce errors in the claims submission process. Believing the results of that tactic were so successful, CMS initiated a targeted probe in one MAC jurisdiction in 2016, and then expanded into three MAC jurisdictions in July 2017.

TPE will focus on claims that carry the greatest financial risk to the Medicare fund, and/or on those providers who have the highest claim error rates and irregular billing practices when compared to their peers. In simple terms, this means that TPE claim selection will be provider specific, rather than being based on all providers billing a particular service. This selection will be accomplished by mining data from Medicare claims.
The TPE process will consist of a maximum of 3 rounds:
Round 1: Includes a review of 20-40 claims, followed by one-on-one, specific education based on the issues. Providers with moderate/high error rates will continue on to another targeted review.
Round 2: Includes 20-40 more claims, followed by further one-on-one education. Providers with high error rates after round two, continue on to a final round.
Round 3: Same process as noted above. Providers with a consistently high error rate after the third round will be referred to CMS for additional action, which may include the following:  100% Prepay Probe, Extrapolation of error rates to determine overpayment, or referral to the Recovery Audit Contractor (RAC).

What are some of the “red flags” that might be construed as indicative of “false claims”?
• Short qualifying hospital stays with extended RUG utilization
• Increase in Ultra High billing without evidence that the SNF population has changed
• Weak Primary Medical Diagnosis coding, especially when Ultra High and Very High RUGs are billed
• RUA or RVA scores for more than 30 days• High percentage of assessments falling exactly on or within 10 minutes of the RV and RU threshold
• PT, OT or ST claims with poor or missing treatment diagnosis codes to support the billed services

It is therefore most essential to establish strict protocols, and/or revise your existing procedures to ensure on-going and proper review of all billing and coding to reduce the risk of a targeted probe.


As your Rehabilitation Partner, Preferred Therapy Solutions continues to collaborate with your facility. If you have any questions, please contact Maria Maggi, Vice President of Compliance: mmaggi@preftherapy.com

Jimmo vs. Sebelius

Last week, CMS announced the release of its Jimmo-specific website is expected in the next couple of weeks.

 

In February, the court in Jimmo vs. Sebelius approved a Corrective Statement to be used by the Centers for Medicare and Medicaid Services (CMS) to affirmatively disavow the use of an “Improvement Standard” for Medicare coverage. The government will use the statement as part of its Corrective Action Plan, which was ordered by the Court to remedy noncompliance with the Jimmo Settlement.

 

CMS will be publishing the Corrective Statement on the new webpage dedicated to Jimmo. The webpage will also include Frequently Asked Questions and Jimmo-related documents and resources. The Corrective Action Plan also includes additional training for Medicare contractors and adjudicators. The Plan must be fully implemented by September 4, 2017.

 

Source: NASL

As your Rehabilitation Partner, Preferred Therapy Solutions continues to collaborate with your facility.
If you have any questions, please contact Maria Maggi, Vice President of Compliance:
mmaggi@preftherapy.com

CMS Cancels Episode Payment Models

The Center for Medicare and Medicaid Services (CMS) has sent a proposal to the Office of Management and Budget (OMB) to eliminate the Episode Payment Models that were originally slated to begin July 1, 2017, but through several delays, was moved to January 1, 2018.

The proposed rule, titled “Cancellation of Advancing Care Coordination through Episode Payment and Cardiac Rehabilitation Incentive Payment Models; Changes to Comprehensive Care for Joint Replacement Payment Model” is recommending the three new cardiac care mandatory bundles, along with the new one for non-replacement surgery following a hip fracture be canceled. It is also recommending that the number of geographic areas participating in the current mandatory Comprehensive Care for Joint Replacement (CJR) bundle be decreased from 67 areas to 34. In addition, CMS proposes to allow CJR participants in the 33 remaining areas to participate on a voluntary basis.


As your Rehabilitation Partner, Preferred Therapy Solutions continues to collaborate with your facility.
If you have any questions, please contact Maria Maggi, Vice President of Compliance: mmaggi@preftherapy.com

CMS Posts Provider-Specific Impact Analysis for Reviewing RCS-1 Proposal

On Friday July 21st, the Centers for Medicare and Medicaid Services (CMS) posted a provider-specific impact analysis of the potential financial implications of the proposed RCS-1 payment system. This analysis provides simulated Medicare Part A payments under RCS-1 and CMS notes “…the provider and resident data is for fiscal year 2014 and represent estimated payments under RCS-1, assuming no changes in provider behavior or resident case-mix.”

Additional details about CMS’ SNF PPS research is available here. Download the Provider Specific Impact Analysis zip file here.

As expected, some facilities have projected gains under RCS-1 while others have projected losses. This same scenario presented itself prior to the implementation of RUG-IV and just as there was no need to worry then, there is no need to worry now. Preferred Therapy Solutions, along with many other industry analysts, believe that any projected negative impact can and will be minimized with proper planning and preparation.

Preferred Therapy Solutions has thoroughly reviewed RCS-1 and is prepared to implement strategies for success. This impact analysis from CMS will further enhance facility-specific strategic planning and be a great resource as we partner together to prepare for RCS-1.

As your Rehabilitation Partner, Preferred Therapy Solutions continues to collaborate with your facility. If you have any questions, please contact Matt Nash, PT / Vice President of Strategic Development: mnash@preftherapy.com

CMS Releases Multiple Proposed Rules

On 4/27/17, the Centers for Medicare and Medicaid (CMS) released a proposed rule and an advance notice of proposed rulemaking for the SNF setting:

  • Medicare Program: Prospective Payment System & Consolidated Billing for Skilled Nursing Facilities (SNF PPS) for FY 2018
  • Medicare Program: Prospective Payment System & Consolidated Billing for Skilled Nursing Facilities: Revisions to Case-mix Methodology (Advance Notice of Proposed Rulemaking)

What is in the SNF PPS Proposed Rule? 

  • The SNF PPS payment update is 1% for FY2018, which is an increase in payments of $390 million in FY2018
  • There are several changes to the quality measures required by the IMPACT Act.
  • Revises SNF Quality Reporting Program (SNF QRP)
  • SNF Value-Based Purchasing Program for FY 2019: proposals related to implementation of the program
  • Clarifies the regulatory requirements for team composition for surveys conducted investigating a complaint
    • Clarifies that “interdisciplinary team must include a registered nurse” is applicable to certain surveys, but not to those surveys conducted to investigate complaints or to monitor compliance on-site
  • Performance period for the National Healthcare Safety Network (NHSN) Healthcare Personnel (HCP) Influenza Vaccination Reporting Measure in the ESRD Quality Incentive Program For Payment Year
  • Soliciting comments on:
    • Potential changes to recently finalized Requirements for Long-Term
    Care Facilities that would result in a burden reduction if modified or eliminated
    • Potential CMMI models or other demonstration projects that would reduce cost and increase quality of care for SNF, or more generally
    Post- Acute Care patients
    • CMS flexibilities and efficiencies

What is the SNF Revisions to the Case-mix Methodology?
CMS is proposing to replace the current RUG case-mix system with a new one based on their payment research called the Resident Classification System. CMS intends to propose these case-mix refinements in next year’s SNF PPS Proposed Rule (for FY2019).  CMS is using this Advance Notice of Proposed Rulemaking to solicit comments on potential revisions. CMS asks for comments on many aspects of the model including complementary policies, lead time needed for software developers, etc. CMS includes a discussion of individual versus group and concurrent therapy and wants to place limits on the percent of time patients can be in group or concurrent therapy.

Preferred Therapy Solutions is currently reviewing the proposed rule to determine the impact it will have on our valued partners. As in years past, PTS will continue to work with industry leaders and advocates to provide feedback to CMS on the proposed rule. In addition, PTS will be analyzing the “Revisions to Case-Mix Methodology” advanced notice of proposed rulemaking. Although it will not impact our industry this upcoming fiscal year, the proposed revisions to SNF case-mix are significant and PTS wants to take advantage of the additional time afforded by CMS to review and comment.

Courtesy of NASL

As your Rehabilitation Partner, Preferred Therapy Solutions continues to collaborate with your facility.
If you have any questions, please contact Maria Maggi, PT / Vice President of Compliance
mmaggi@preftherapy.com

ABN, Form CMS-R-131 Renewal The Advance Beneficiary Notice of Non-coverage

(ABN), Form CMS-R-131, and form instructions have been approved by the Office of Management and Budget (OMB) for renewal. While there are no changes to the form itself, providers should take note of the newly incorporated expiration date. The effective date for use of this ABN form is 60 days from this announcement. More information on the ABN and the ABN form instructions can be found at: FFS ABN – Centers for Medicare & Medicaid Services.

As your Rehabilitation Partner, Preferred Therapy Solutions continues to collaborate with your facility and Interdisciplinary Team to support and coordinate ADR and appeals activity. If you have any questions, please contact Barbara Blatt, PT Appeals Management Coordinator bblatt@preftherapy.com

 

 

Center for Medicare and Medicaid Services Delays Effective Date of New Bundled Payment Models

On March 21st, 2017, the Center for Medicare and Medicaid Services (CMS) released an interim final rule that further delays the effective date of the Advancing Care Coordination through Episode Payment Models (EPM’s), the Cardiac Rehabilitation Incentive Payment Model, and changes to the Comprehensive Care for Joint Replacement Model from July 1, 2017 to October 1, 2017.

These models currently mandate bundled payment programs in select service areas for heart attacks and bypass surgery, as well as new coverage for surgical hip and femur fractures. In the interim final rule, CMS notes it may be less burdensome to participants to implement the EPM’s and changes to CJR based on a calendar year and is considering a further delay of the effective date to January 1, 2018.

This additional delay would also allow time for CMS to make potential modifications to the programs and insure participants have a clear understanding of any changes that are made. CMS is accepting stakeholder comment until April 19, 2017. At this point, it is unclear what modifications may be made, but there is the potential CMS will remove the mandatory nature of the EPM model. CMS believes this may lead to more engaged healthcare providers. Medicare’s Bundled Payments for Care Improvement (BPCI) initiative and the original CJR models will remain intact.

With ongoing uncertainty surrounding these programs, Preferred Therapy Solutions will continue to monitor the situation and keep our valued partners updated.

As your Rehabilitation Partner, Preferred Therapy Solutions continues to collaborate with your facility and Interdisciplinary Team to support and coordinate ADR and appeals activity. If you have any questions, please contact Maria Maggi, PT / Vice President of Compliance mmaggi@preftherapy.com

 

MedPAC Highlights Report for Developing a Unified PAC Payment System

During the September 10 public meeting, the Medicare Payment Advisory Commission (MedPAC) research staff presented an initial report, “Mandated Report: Developing a Unified Payment System for Post-Acute Care (PAC).”

The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014, requires MedPAC to submit to Congress a report, no later than June 30, 2016, replacing Medicare’s four PAC payment systems for long-term care hospitals, inpatient rehabilitation facilities, nursing homes and home health providers.  The report must evaluate and recommend features of a new unified PAC prospective payment system (PPS) based on patient characteristics (such as cognitive ability, functional status, and impairments) instead of according to the setting where the Medicare beneficiary is treated.  The Act also requires data from the Center for Medicare and Medicaid Services’ (CMS) Post-Acute Payment Reform Demonstration (or other data), to be evaluated.

(more…)

Audit & Appeal Fairness, Integrity and Reforms in Medicare Act of 2015 (“AFIRM Act”)

On June 3, the Senate Finance Committee approved the Audit & Appeal Fairness, Integrity and Reforms in Medicare Act of 2015 (“AFIRM Act”). The bill aims to expedite the Medicare appeals process by streamlining certain appeals functions and increasing funding for the Office of Medicare Hearings and Appeals (OMHA) and the Departmental Appeals Board (DAB), the third and fourth levels of the Medicare appeals process. The legislation was reported out of the Committee by a voice vote, and now heads to the Senate floor.

(more…)