The Prospec1ve Payment System May What is SNF PPS? HIPPS & MDS 3.0 4/17/17. Wilhide Consul1ng, Inc. (c) 1. Source: Source:

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1 Source: The Prospec1ve Payment System May 2016 Current RAI Manual, Chapter 2 & 6 ( resources Chapter 2: 2.8: The SNF PPS Assessment Schedule 2.9: MDS Medicare Assessments for SNFs 2.10: Combining Medicare Scheduled and Unscheduled Assessments 2.11: Combining Medicare Assessments and OBRA Assessments 2.12: Medicare and OBRA Assessment Combina1ons 2.13: Factors Impac1ng the SNF Medicare Assessment Schedule 2.14: Expected Order of MDS Records 2.15: Determining Item Set for MDS Records Judy Wilhide Brandt judy@judywilhide.com JudyWilhide.com 1 2 Chapter 6: 6.1: SNF PPS Background Source: 6.2: Using the MDS in the Medicare Prospec1ve Payment System 6.3: RUG-IV Overview 6.4: Rela1onship between the assessment and the claim 6.5: SNF PPS Eligibility Criteria 6.6: RUG-IV 66-Group Model Calcula1on Worksheet for SNFs 6.7: SNF PPS Policies 6.8: Non-compliance with the SNF PPS Assessment Schedule What is SNF PPS? Original Medicare A Not: Medicare Health Plan Medicare Advantage State Dual-Eligible HMO Private insurance Tricare We transmit PPS assessments on Original Medicare A only. 3 judywilhide.com 4 Two Basic Types of PPS Assessments: HIPPS & MDS 3.0 Scheduled Unscheduled Prescribed range of days from which to select. Penal;es for improper selec;on. Prescribed scenarios that facility must correctly iden;fy in which the assessment is required. Penal;es for improper selec;on. HIPPS Code will be calculated by Grouper. 5 6 Wilhide Consul1ng, Inc. (c) 1

2 Comple1on/Submission of PPS-only assessments Other uses of scheduled PPS assessments Must be completed (Z0500b) no later than (A2300) + 14 days Must be submihed no later than comple1on (Z0500b) + 14 days There is no financial penalty for late comple1on or transmission! Quality Measures OBRA & Scheduled PPS assessments used for calcula1ng Short and Long Term measures Survey Public Repor1ng Five Star SNF QRP Scheduled PPS Assessments & SNF PPS Discharge used to calculate MDS based SNF-QRP measures Ini1al assessment will be used to calculate risk adjustments and exclusions for SNF-QRP 7 8 Type Scheduled PPS Assessments /Grace Day Window Payment Days 5 day Day Day Day Day Day 1 First Medicare day 2-43 Thu Fri Sat Sun Mon Tue Wed /1/14 5/2/14 5/3/14 5/4/14 5/5/14 5/6/14 5/7/14 Thu Fri Sat Sun Mon Tue Wed /8/14 5/9/14 5/10/14 5/11/14 5/12/14 5/13/14 5/14/14 Thu Fri Sat Sun Mon Tue Wed /15/14 5/16/14 5/17/14 5/18/14 5/19/14 5/20/14 5/21/14 Thu Fri Sat Sun Mon Tue Wed /22/14 5/23/14 5/24/14 5/25/14 5/26/14 5/27/14 5/28/14 Thu Fri Sat Sun Mon Tue Wed /29/14 5/30/14 5/31/14 6/1/14 6/2/14 6/3/14 6/4/14 Thu Fri Sat Sun Mon Tue Wed /5/14 6/6/14 6/7/14 6/8/14 6/9/14 6/10/14 6/11/14 Thu Fri Sat Sun Mon Tue Wed /12/14 6/13/14 6/14/14 6/15/14 6/16/14 6/17/14 6/18/ Thu Fri Sat Sun Mon Tue Wed /19/14 6/20/14 6/21/14 6/22/14 6/23/14 6/24/14 6/25/14 Thu Fri Sat Sun Mon Tue Wed /26/14 6/27/14 6/28/14 6/29/14 6/30/14 7/1/14 7/2/14 Thu Fri Sat Sun Mon Tue Wed /3/14 7/4/14 7/5/14 7/6/14 7/7/14 7/8/14 7/9/14 Thu Fri Sat Sun Mon Tue Wed /10/14 7/11/14 7/12/14 7/13/14 7/14/14 7/15/14 7/16/14 Thu Fri Sat Sun Mon Tue Wed /17/14 7/18/14 7/19/14 7/20/14 7/21/14 7/22/14 7/23/14 Thu Fri Sat Sun Mon Tue Wed /24/14 7/25/14 7/26/14 7/27/14 7/28/14 7/29/14 7/30/14 Thu Fri Sat Sun Mon Tue Wed /31/14 8/1/14 8/2/14 8/3/14 8/4/14 8/5/14 8/6/14 Thu Fri /7/14 8/8/14 11 Can I combine a PPS MDS with an OBRA Discharge MDS? It is important to note that when the OBRA and Medicare PPS assessment 1me frames coincide, one assessment may be used to sa1sfy both requirements. In such cases, the most stringent requirement for MDS comple1on must be met. (2-1) A scheduled PPS must be on a Medicare benefit day. Discharge must be a Medicare benefit day (2-64) If Discharge is a"er last covered day, may not combine. 12 Wilhide Consul1ng, Inc. (c) 2

3 Examples Planned discharge Last Covered Day is Day 15, resident discharges on day 16. Day 15 is a required. must be day 15. OBRA Discharge must be day 16. CANNOT COMBINE Unplanned discharge Resident emergently discharges to the hospital on day 7. 5 day/obra discharge combina1on allowed on day 7. A2400C (Medicare end) is whichever occurs first: Date SNF benefit exhausts or Date of last day covered as recorded on NOMNC or Date payer source changes from Medicare A to another payer (regardless if the resident was moved to another bed or not) or Date resident was discharged from the facility. A2400 does not include stays billable to Medicare Advantage HMO plans. Always = A1600 entry date 13 Never dashes on ANY discharge What is a PPS Discharge? (NPE) J1800 & J1900: Falls since entry or last OBRA/PPS MDS Part A PPS Discharge (NPE) GG DC Func1onal Status M0210, M0300, M0800 Current & Worsened Pressure Ulcers Part A stay ends & resident stays in SNF RA or RNA & planned PPSDC/OBRA Discharge (ND) When is PPS DC Required? NOT required when Part A stay ends in death May (MUST) be combined with OBRA DC when Part A stay ends and resident physically discharges from SNF on or one day aqer last Part A day (A2400C) You shall rise and show respect to the aged. GG Discharge Fxl Abili1es Falls At least 3 days Pressure Ulcers Any except 03 Cogni1ve Paherns, Mood, Behaviors, Fxl Status, Bowel/Bladder, Diagnoses, Pain, Other Health Condi1ons, Swallowing/ Nutri1on, PU dimensions, Meds, Special Tx, Restraints, Discharge Plan Wilhide Consul1ng, Inc. (c) 3

4 Unplanned OR To acute hospital OR Part A stay < 3 days PPS DC/OBRA Discharge (ND) First forced combina1on in MDS history Falls Pressure Ulcers Cogni1ve Paherns, Mood, Behaviors, Fxl Status, Bowel/Bladder, Diagnoses, Pain, Other Health Condi1ons, Swallowing/ Nutri1on, PU dimensions, Meds, Special Tx, Restraints, Discharge Plan OBRA Discharge and PPS Discharge must be combined when both are due. A2400C = A2000 Discharge Date A2400C one day prior to A2000 Discharge Date PPS DC doesn t always have Discharge Fxl Abili1es Sec1on GG PPS DC always has items to calculate QRP Falls w/major injury and QRP new/worsened pressure ulcers Reminder: You just have to remember to do the stand-alone PPS Discharge! Factors Impac1ng the SNF PPS Schedule Sec1on 2.13 Resident Expires Before or On the Eighth Day of SNF Stay If beneficiary dies before or on 8 th day of SNF stay, should prepare & submit a PPS MDS as completely as possible. If PPS MDS not completed, provider must bill the default rate for any Medicare days. Medicare Short Stay Policy may also apply. Must also complete a Death in Facility Tracking Resident Discharged Before or On the Eighth Day of SNF Stay If beneficiary is discharged from the SNF or transferred to another payer source before or on the eighth day of the covered SNF stay, the provider should prepare a Medicare-required assessment as completely as possible and submit the assessment as required. Discharged from the SNF = leaves the cer1fied bed Transfers to another payer source = remains in the cer1fied bed but no longer billing Part A for the stay. Resident Discharged Before or On the Eighth Day of SNF Stay If there is not a PPS MDS in the QIES ASAP system, the provider must bill the default rate for any Medicare days. If Part A stay ends & beneficiary remains in the facility, a Part A PPS Discharge assessment is required. When physically discharged, must also complete an OBRA Discharge assessment which may be combined with a PPS assessment if all requirements for both are met Wilhide Consul1ng, Inc. (c) 4

5 Short Stay If beneficiary dies, is discharged from the SNF, or discharged from Part A level of care on or before the eighth day of covered SNF stay, the resident may be a candidate for the short stay policy. The short stay policy allows the assignment into a Rehabilita1on Plus Extensive Services or Rehabilita1on category when a resident received rehabilita1on therapy and was not able to have received 5 days of therapy due to discharge from Medicare Part A. See Chapter 6, Sec1on 6.4 for greater detail. Resident is AdmiLed to an Acute Care Facility and Returns If a Medicare Part A resident is admihed to an acute care facility and later returns to the SNF (even if the acute stay facility is less than 24 hours and/or not over midnight) to resume Part A coverage, the Medicare assessment schedule is restarted with a PPS 5 day assessment Resident Is Sent to Acute Care Facility, Not in SNF over Midnight, and Is Not AdmiLed to Acute Care Facility If a resident is out of the facility over a midnight, less than 24 hours, and is not admihed to an acute care facility, the Medicare assessment schedule is not restarted. The day the resident was absent at midnight is not a covered Part A day. This the midnight rule. The Medicare assessment schedule must then be adjusted to skip the day in calcula1ng when the next Medicare assessment is due. Scheduled PPS MDS may NOT be on LOA/skip day Unscheduled PPS MDS may be on LOA/skip day 27 If resident goes to ER at 10 p.m. Wednesday, day 22 of his Part A stay, and returns at 3 a.m. the next day, Wednesday is not billable to Part A. As a result, the day of his return to the SNF, Thursday, becomes day 22 of his Part A stay. Wed Thu Fri Sat Sun Mon Tue /20/15 5/21/15 5/22/15 5/23/15 5/24/15 5/25/15 5/26/15 Wed Thu Fri Sat Sun Mon Tue /27/15 5/28/15 5/29/15 5/30/15 5/31/15 6/1/15 6/2/15 Wed Thu Fri Sat Sun Mon Tue skip /20/15 5/21/15 5/22/15 5/23/15 5/24/15 5/25/15 5/26/15 Wed Thu Fri Sat Sun Mon Tue /27/15 5/28/15 5/29/15 5/30/15 5/31/15 6/1/15 6/2/15 28 Leave of Absence: Page 2-12 Leave of Absence (LOA), which does not require comple1on of either a Discharge assessment or an Entry tracking record, occurs when a resident has a: Temporary home visit of at least one night; or Therapeu1c leave of at least one night; or Hospital observa1on stay less than 24 hours and the hospital does not admit the pa1ent. For scheduled PPS s, the schedule must be adjusted to exclude the LOA because the may not be on a non-benefit period day. The schedule is not restarted upon return from LOA Wed LOA and Scheduled Leq SNF at 6:00pm on Wednesday, which is Day 27 of the resident s stay Returns to the SNF on Thursday at 9:00am LOA day may NOT be used as for a PPS scheduled assessment (page 2-75) LOA day MAY be used as for a PPS unscheduled assessment Thu Nonbillable Wilhide Consul1ng, Inc. (c) 5

6 When a SNF plans to combine a scheduled and unscheduled assessment on a given day, & that day becomes an LOA day for the resident: LOA day may s1ll be used as the of the unscheduled assessment, LOA day cannot be used as the of the scheduled assessment. May 10 May 17 May When a SNF plans to combine a scheduled and unscheduled assessment on a given day, & that day becomes an LOA day for the resident: LOA day may s1ll be used as the of the unscheduled assessment, LOA day cannot be used as the of the scheduled assessment. May 10 May 17 LOA May 18 5 day 14 day 5 day 14 day day would need to have an that falls on one of the resident s Medicare A benefit days. (prior to or aqer LOA day, depending on range) 32 Review Reminder: If LOA is not to hospital, it can be more than one night. PT PT PT PT PT Sick no PT LOA LOA to ER no PT EOT Count Back from LOA, no PT 33 Resident Discharged from Part A Skilled Services and Returns to SNF Part A Skilled Level Services (30 day tracking) Do PPS DC If resident remains in cer1fied bed, OBRA schedule con1nues. No reason to change the OBRA schedule when Part A benefits resume. (Consider Sig Change) Start Medicare schedule again with a PPS 5 day MDS Do the GG assessment in 1 st three days of SNF stay The original date of entry (Item A1600) is retained. New Medicare Start Date in A Delay in Requiring and Receiving Skilled Services Ch 6, Sec 6.7 Delay in Requiring and Receiving Skilled Services When the beneficiary requires and receives SNF level of care services within 30 days from the hospital discharge, Day 1 for the Medicare assessment schedule is the day on which SNF level of care services begins. Remember GG admission assessment on first 3 days of SNF stay. Example: Hospital discharge August 1 Discharge is Day Zero (Ch 8, Benefit Policy Manual, Sec1on ) SNF determines on August 31 that beneficiary requires skilled service for a condi1on that was treated during the qualifying hospital stay, then the SNF would start the Medicare assessment schedule with a 5-day Medicare-required assessment, with August 31 as Day 1 for scheduling purposes. OBRA Admission assessment would have already been completed by day 14 of the stay Wilhide Consul1ng, Inc. (c) 6

7 Just a few simple rules! OMRAs End Change Start Unscheduled PPS Assessments Therapy Coding Tips and Special Popula;ons (OMRAs) 2-55 When coding standalone OMRAs:, SOT, EOT Facili1es must set the for the assessment for a day within the allowable window for that assessment type, but may only do so no more than two days aqer the window has passed. Even if the resident discharges during this two day period Standalone Fri checkpoint Friday Sat 10 Sun 11 Mon Too Late! Sevng for Stand alone EOT/SOT Last therapy SOT works the same way! Tip: Open Friday before you go home. Delete Monday if not needed Wilhide Consul1ng, Inc. (c) 7

8 2.12 Medicare and OBRA Assessment Combina;ons When any OMRA is combined with a discharge assessment, the for that combina1on assessment may be set one or two days aqer the day of discharge. OMRA/ Discharge OMRAs and Interviews: Page 2-55 When coding a standalone OMRA, the interview items may be coded using the responses provided by the resident on a previous assessment only if the DATE of the interview responses from the previous assessment (as documented in item Z0400) were obtained no more than 14 days prior to the DATE of comple1on for the interview items on the unscheduled assessment (as documented in item Z0400) for which those responses will be used OMRAs and Interviews: Page 2-55 Note: In limited circumstances, it may not be prac1cable to conduct the resident interview por1ons of the MDS (Sec1ons C, D, F, J) on or prior to the for a standalone unscheduled PPS assessment. In such cases where the resident interviews (and not the staff assessment) are to be completed and the assessment is a standalone unscheduled assessment, providers may conduct the resident interview por1ons of that assessment up to two calendar days aqer the (Item A2300) Da1ng Interviews Must sign Z0400 with the date each interview was actually completed. You may sign Z0400 more than once if you do interviews and other assessment items. Chapter 3, Page Z-7: All staff who completed any part of the MDS must enter their signatures, 1tles, sec1ons or por1on(s) of sec1on(s) they completed, and the date completed. If a staff member cannot sign Z0400 on the same day that he or she completed a sec1on or por1on of a sec1on, when the staff member signs, use the date the item originally was completed OMRA Specifics: A deeper dive SOT EOT Start of Therapy (SOT) OMRA 2-47 Op1onal. Completed only to classify a resident into a Rehab RUG. If the RUG assigned is not Rehab, will not be accepted into CMS database. must be set on days 5-7 aqer the start of therapy with the excep1on of the Short Stay Assessment. The date of the earliest therapy evalua1on is counted as day 1 when determining the, regardless if treatment is provided or not on that day. May be combined with scheduled PPS assessments Wilhide Consul1ng, Inc. (c) 8

9 Start of Therapy (SOT) OMRA 2-47 SOT not necessary if rehabilita1on services start within the window (including grace days) of the 5-day assessment, since the therapy rate will be paid star1ng Day 1 of the SNF stay. may not precede the of first scheduled PPS assessment of the Medicare stay (5-day assessment). SOT illustra1on PT Eval Nursing RUG Controls payment 6 OT Eval SOT Range SOT controls payment beginning on the earliest Therapy Start Date Medicare Short Stay Assessment Medicare Short Stay Assessment: All 8 must be true Unique Grouper calcula1on for one purpose: Assigns a Rehab/Rehab+Ext RUG under very specific circumstances when a resident received Rehabilita1on Services for < 4 days in a Medicare stay that is < 8 days. 1. Must be SOT OMRA. May be combined with any OBRA assessment if all rules met day must be completed. May be combined with this SOT OMRA 3. must be NLT Day 8 of Part A Stay. 4. must be last day of Part A Stay* Medicare Short Stay Assessment: All 8 must be true 5. must be NLT 3 days aqer SOT. 6. Rehab must have started in last 4 days of Part A stay. 7. Rehab must con1nue through last day of Part A stay. At least one discipline must have: End of therapy date = the end of covered Medicare stay date, or Dash-filled end of therapy date indica1ng ongoing therapy, e.g.: Resident discharged and therapy was planned to con1nue had resident stayed in facility. Part A stopped and therapy con1nued (eg: Exhaust or pay source change) 8. RUG of this assessment must be Rehab or Rehab + Ext. Aqer Case Mix Maximizing. Medicare Short Stay Rehab Categories Average Daily Minutes: Ultra: >= 144 Very: High: Medium: Low: No Rehab category for < 15 minutes Wilhide Consul1ng, Inc. (c) 9

10 End of Therapy (EOT) OMRA: Eval To ER Z0150 non-therapy RM x Do 5d/SOT/PPSDC/OBRA DC combina1on Set for day of discharge Ensure A2400C = Ensure one discipline has dashes in therapy end date 180/4 = 45 RM x 15 min 10 min 0 min 0 min EOT Required Day of therapy = 15 min by a discipline No Rehab RUG: No EOT Always use Z0150 HIPPS for EOT OMRA, to begin paying the day aqer last therapy S M T W Th F Sa PT OT Tot Day RUB S M T W Th F Sa PT Sick 75 0 OT Tot D S M T W Th F Sa PT OT Tot No EOT CB1 You shall rise and show respect to the aged EOT rules: Page 2-49 If resident discharged from the SNF on or prior to the third consecu1ve day of missed therapy services, then no EOT is required. If a SNF chooses to complete the EOT OMRA in this situa1on, they may combine the EOT OMRA with the discharge assessment. Review: EOT purpose is to reset the RUG from therapy to non-therapy usually less money Choosing EOT is usually NOT A GOOD CHOICE, but it is allowed: no provider liability Therapy ends EOT rules: Page Discharge EOT ALLOWED BUT NOT REQUIRED Wilhide Consul1ng, Inc. (c) 10

11 EOT rules: Page 2-48 Sec1on 2.9 Therapy ends Therapy ends LCD Remains on another pay source Discharge from Part A: EOT Required Provider liability if missed EOT Required EOT affect on IF EOT on day 36 or 37, no. If EOT on day 38, required. EOT-R RUB Last tx Check If at any point, rehabilita1on therapy ends before the last day of a observa;on period and an End of Therapy OMRA is performed with an set for on or prior to Day 7 of the observa1on period, then the change of therapy evalua1on process ends un1l the next PPS assessment used for payment reflec1ng the u1liza1on of skilled therapy services Best prac1ce: Do EOT to avoid When resump1on of therapy date is no more than 5 consecu1ve calendar days aqer the last day of therapy provided, and Therapy services have resumed at the same RUG- IV classifica1on level, and With the same therapy plan of care that had been in effect prior to the EOT OMRA, an End of Therapy OMRA with Resump1on (EOT-R) may be completed Therapy ends EOT Resump1on criteria: Start back at same RUG level and same therapy plan of care Therapy ends EOT Check Check Resump1on date, not day aier, is day 1 of next count. You shall rise and show respect to the aged Wilhide Consul1ng, Inc. (c) 11

12 If unable to do EOT-R Must do new therapy evalua1ons for all disciplines prior to restar1ng If new evals are not done, then there can be no therapy minutes on subsequent MDSs May do SOT or wait un1l next scheduled assessment to recapture Rehab RUG A word about therapy evalua1ons Ini1al Evalua1on: Required for each discipline prior to star1ng a course of therapy Required for each discipline upon each reentry aqer discharge assessment Not required for LOA Required aqer a three day break in therapy if EOT-R is not permihed Date of ini1al evalua1on remains as the therapy start date un1l a new course of therapy with a new ini1al evalua1on EOT-R Billing Review : RUC EOT-R Resume When therapy resumes, the RUG in effect prior to the break in therapy controls payment You shall rise and show respect to the aged. Change of Therapy ( OMRA) begins on 2-51 Required when 1. resident was receiving a sufficient level of rehabilita1on therapy to qualify for a Rehabilita1on category and 2. intensity of therapy changes to such a degree that it would no longer reflect the RUG-IV classifica;on and payment assigned for a given SNF resident based on the most recent assessment used for Medicare payment Intensity of Therapy Earned R U V H M L X L C B A Rules 2-51 is set for Day 7 of a observa1on period. observa1on periods are successive 7-day windows with the first observa1on period beginning on the day following the set for the most recent scheduled or unscheduled PPS assessment, except for an EOT-R assessment. For example: If for 30-day assessment is set for day 30, and there are no intervening assessments, then the observa1on period ends on Day 37. If the for the pa1ent s most recent (whether the was completed or not) was Day 37, the next observa1on period would end on Day Wilhide Consul1ng, Inc. (c) 12

13 Rules 2-51: In cases where the last PPS Assessment was an EOT-R, the end of the first observa1on period is Day 7 aqer the Resump1on of Therapy date (O0450B) on the EOT- R, rather than the. The resump1on of therapy date is counted as day 1 when determining Day 7 of the observa1on period. For example: If the for an EOT-R is set for day 35 and the resump1on date is the equivalent of day 37, then the observa1on period ends on day 43. Rules 2-51 The would be completed if the pa1ent s therapy intensity, as described above, has changed to classify the resident into a higher or lower RUG category. For example: 14 RHB : RU RV RM RL Or ANY Nsg RUG if Rehab earned was NOT RH Required Rules 2-51 The would be completed if the pa1ent s therapy intensity, as described above, has changed to classify the resident into a higher or lower RUG category. For example: Rules 2-51 The would be completed if the pa1ent s therapy intensity, as described above, has changed to classify the resident into a higher or lower RUG category. For example: 14 RHB : RH with ANY last leher, or a nursing RUG while RH was earned but not assigned NOT Required You shall rise and show respect to the aged RVB checkpoint Whether was required on day 21 or not, day 22 is day 1 of the next count 28 checkpoint Rules 2-51: If Day 7 of the observa1on period falls within the window of a scheduled PPS Assessment, the SNF may choose to 1. complete the PPS Assessment alone by sevng the of the scheduled PPS assessment for an allowable day that is on or prior to Day 7 of the observa1on period. This effec1vely resets the observa1on period to the 7 days following that scheduled PPS Assessment. OR 2. combine the OMRA and scheduled assessment following the instruc1ons discussed in Sec1on Illustra1on of choices: Complete the PPS Assessment alone by sevng the of the scheduled PPS assessment for an allowable day that is on or prior to Day 7 of the observa1on period : RUB 14 RVC 15 Day 15 RVC RUC Day 13, 14 or 15 are allowed s for the stand alone 14 day assessment Wilhide Consul1ng, Inc. (c) 13

14 Illustra1on of choice: Combine with scheduled assessment: RVB Day 15 RUB Schedule a 14 day/ with on day Key Point: Payment Day RUB RVB sets payment from day 1 of lookback going forward. This some1mes causes a scheduled PPS assessment not to be used for payment But the scheduled assessment is s1ll required What to choose? Combine Replace* When RUG stays the same: Use any day in lookback for scheduled MDS and restart count the next day. 81 When checkpoint is day of discharge When a resident s discharge from the SNF is on or prior to Day 7 of the observa1on period, then no OMRA is required. If a SNF chooses to complete the OMRA in this situa1on, they may combine the OMRA with the discharge assessment. - Page 2-52 is allowed but not required if checkpoint is the day of discharge. Should do if RUG is higher Emergent discharge? Should not do if RUG is lower But, no provider liability for either choice, as long as day 7 of count is chosen for. 82 Rules 2-51: RUC controlling payment RVC check 8 The may not precede the of the first scheduled or unscheduled PPS assessment of the Medicare stay used to establish the pa1ent s ini1al RUG-IV therapy classifica1on in a Medicare Part A SNF stay. If the date listed in A2400C is on or aqer Day 7 of the observa1on period, then a OMRA would be required if all other condi1ons are met L C D L T C D C 5 DAY RUG Nursing? Rehab? Rehab RUG earned? count begins If you are going to bill day 7 and the Rehab RUG changes, not op1onal! 83 No No count begins 84 Wilhide Consul1ng, Inc. (c) 14

15 Rules: 2-52 Except as described below, a OMRA may only be completed when a resident is currently classified into a RUG-IV therapy group (regardless of whether or not the resident is classified into this group for payment), based on the resident s most recent assessment used for payment. The OMRA may be completed when a resident is not currently classified into a RUG-IV therapy group, but only if both of the following condilons are met: 1. Resident has been classified into a RUG-IV therapy group on a prior assessment during the resident s current Medicare Part A stay, and 2. No discon1nua1on of therapy services (planned or unplanned discon1nua1on of all rehabilita1on therapies for three or more consecu1ve days) occurred between Day 1 of the observa1on period for the OMRA that classified the resident into his/her current nontherapy RUG-IV group and the of the OMRA that reclassified the resident into a RUG-IV therapy group Illustra1on of rule on slide 64: S M T W Th F Sa PT OT Tot Day RUB S M T W Th F Sa PT Sick 75 0 OT Tot No Rehab RUG earned Count con1nues: May Do Rehab RUG established No therapy RUG, & no 3 day break in therapy: Do S M T W Th F Sa PT OT Tot More rules 2-52 Under these circumstances [slide 64], comple1ng the OMRA to reclassify the resident into a therapy group may be considered op1onal. Addi1onally, the OMRA which classifies a resident into a non-therapy group or the OMRA which reclassifies the resident into a therapy group may be combined with another assessment, per the rules for combining assessments discussed in Sec1ons 2.10 through 2.12 of this manual. 88 More Rules 2-53 A OMRA may be used to reclassify a resident into a RUG-IV therapy group only when the resident was classified into a RUG-IV nontherapy by a previous OMRA (which may have been combined with another assessment, per the rules for combining assessments discussed in Sec1ons 2.10 through 2.12 of this manual). 89 Illustra1on of rule on slide 67: S M T W Th F Sa PT OT Tot Day RUA Rehab RUG NOT earned on PPS 30 day on day 29, so count STOPS. NO on day 36 unless 30 day combined with Day 15 S M T W Th F Sa PT OT Tot Day 22: No due - Rehab RUG same S M T W Th F Sa PT OT Tot Day Nursing RUG earned 90 Wilhide Consul1ng, Inc. (c) 15

16 More Rules: Chapter 6, pg 6-14 If a new PPS assessment used for payment occurs with an set for on or prior to the last day of a observa1on period, then a Change of Therapy OMRA is not required for that observa1on period. Example: An SCSA is performed with an of Day 10. An evalua1on for the Change of Therapy OMRA would occur on Day 17 but the 14-Day assessment intervenes with on Day 15. A Change of Therapy OMRA is not performed with an on Day 17. Rather, the OMRA evalua1on process is restarted with the 14-day assessment with on Day 15. Day 1 of the next observa1on period is Day 16 and the new OMRA evalua1on would be done on Day 22. June Sunday Monday Tuesday Wednesday Thursday Friday Saturday SNF Day PPS 5 day SCSA 14 Day Checkpoint Page 2-56 USED FOR PAYMENT An assessment is considered to be used for payment in that it either: 1. Controls the payment for a given period or, 2. With scheduled assessments may set the basis for payment for a given period. To set the basis for payment for a given period at least one day in that period must be billed to Medicare Part A 93 7 RUC 5 day Controls vs Sevng Basis for Payment RVC 14 day RUC RUC day: RUC sets basis AND controls payment for day: RVC sets basis for : RUC controls payment for Illustra1on: PPS scheduled assessment is not used for payment so it cannot replace a Illustra1on 21 RVB Provider Liability RMB 30 D DC 21 RVB RMB 30 D DC If scheduled assessment does not set the basis for a given period, it may not be used in place of. If the is not done, it is missed: provider liability 6-14 Change 30 D to before transmidng, using 7 day encoding/edi;ng period Wilhide Consul1ng, Inc. (c) 16

17 7 Day Encoding/Edi1ng Period Page 5-8: Facili1es have up to 7 days to encode (enter into the soqware) and edit an MDS assessment aier the MDS has been completed. Changes may be made to the electronic record for any item during the encoding and edi1ng period, provided the response refers to the same observalon period. Op1ons: If scheduled PPS assessment submihed, may modify to add (5-11) May not modify to add scheduled assessment (5-11) Type of Assessment may be modified when it does not change the Item Set Code (ISC) If scheduled assessment not on (early) may modify and take default days, as opposed to provider liability Item Set Code 2-86 EARLY/LATE Non-compliance with PPS Schedule: IF is set early, day 1 for next is the day aqer the early. November 1 30 Day Non-compliance with PPS Schedule: IF is set late, with no intervening assessment, day 1 for next is the day aqer the late Day Will receive default for the two days the early was out of compliance Will receive default for the two days the late was out of compliance Wilhide Consul1ng, Inc. (c) 17

18 Non-compliance with PPS Schedule: Missed Assessment: Page 2-74 IF is set late, aqer an intervening assessment, the late does not reset the count Default 7 Day Default Will receive default for the days the late should have controlled payment, un1l 30 day kicks in on day Late Day 14-Day Day Day Check 38 Last Tx EOT DISCHARGE Required but not done Provider Liability: Day Combining Medicare Scheduled and Unscheduled Assessments 2-56 If an unscheduled PPS assessment is required in the assessment window (including grace days) of a scheduled PPS assessment that has not yet been performed, then facili1es must combine the scheduled and unscheduled assessments by sevng the of the scheduled assessment for the same day that the unscheduled assessment is required. A scheduled PPS assessment cannot occur aqer an unscheduled assessment in the assessment window the scheduled assessment must be combined with the unscheduled assessment using the appropriate for the unscheduled assessment. Sec;on 2.10 Combining Medicare Scheduled and Unscheduled Assessments In cases when a facility fails to combine a scheduled and unscheduled PPS assessment as required by the combined assessment policy, the payment is controlled by the unscheduled assessment. -Page Last Therapy EOT Not 14 Day allowed Sec;on 2.10 Combining Medicare Scheduled and Unscheduled Assessments In this case, 14 day will not be used for payment. The EOT will pay from Day 12 into the 14 day payment period un1l the next scheduled or unscheduled assessment used for payment. Reminder: Scheduled prior to EOT is allowed, but, the EOT will pay day 12 15, and the non-therapy RUG from the 14 day (Z0150) will pay beginning on day 16. Page Last Therapy Day EOT Last Therapy EOT 14 Day Best Prac1ce: If you can combine an EOT or SOT with scheduled, that is the thing to do. is different: May do scheduled without before or on checkpoint Wilhide Consul1ng, Inc. (c) 18

19 Note: A missed is provider liability Even if the RUG would have gone up A missed PPS assessment is provider liability It is always beher to do it late for default rate Significant Change 2-54 SCSA or SCPA will also act as an unscheduled PPS assessment. Will set payment on If combined with scheduled PPS MDS, will set payment on unless set on a grace day If set on grace day will set payment on day 1 of the billing cycle for the scheduled assessment What about other insurance? What about other insurance? Assessments that are completed for purposes other than OBRA and SNF PPS reasons are not to be submihed, e.g., private insurance, including but not limited to Medicare Advantage Plans. - Page 5-1 RAI Manual OBRA schedule must be followed for anyone in a Medicare or Medicaid cer1fied bed. Resident pay source is not relevant Cer1fica1on of the bed is all that is relevant. Chapter 2, page Choices: Do two: Admission and PPS 5 day Soqware dependent Do one: Admission and send RUG from that assessment to the insurance company Discussion? What if I do just the Admission, then need a 5 day for Original Medicare later? Choices: Modify Admission, add 5 day & Medicare dates in A2400 You may modify the reason for assessment when the ISC does not change. Page 5-11 Use the Admission assessment to bill the days, without the PPS 5 day or A2400 dates -page 6-56 Discussion? Wilhide Consul1ng, Inc. (c) 19

20 Page 6-55: SNF may bill the default code when a Medicare-required assessment does not exist in the QIES ASAP system when: 1. The stay is less than 8 days within a spell of illness, 2. The SNF is no1fied on an un1mely basis of or is unaware of a Medicare Secondary Payer denial, 3. The SNF is no1fied on an un1mely basis of a beneficiary s enrollment in Medicare Part A, 4. The SNF is no1fied on an un1mely basis of the revoca1on of a payment ban, 5. The beneficiary requests a demand bill, or 6. The SNF is no1fied on an un1mely basis or is unaware of a beneficiary s disenrollment from a Medicare Advantage plan. Page 6-55: In situa;ons 2-6, you may use Admission assessment to bill for all days of covered care associated with Medicare-required 5-& 14-day assessments, even if the beneficiary is no longer receiving therapy services that were iden1fied under the most recent clinical assessment. If you don t need to use it for all 30 days, because you have the other PPS assessments, it can be used for the days paid by the PPS 5 day MDS. The of the OBRA Admission assessment may be before or during the Medicare stay and does not have to fall within the window of the 5- day or 14-day assessment For covered days associated with 30, 60, or 90-day MDSs, the SNF must have a valid OBRA MDS in QIES ASAP system that falls within the window of the PPS assessment in order to receive full payment at the RUG category in which the resident grouped. If of the valid OBRA assessment falls outside the window of the PPS assessment, the SNF must bill the default code. Note: Stand alone OBRA or PPS Discharge Assessments do not produce a RUG and could not be used for payment. Scenarios: BO reports private insurance is paying, and they need levels. Later they say the insurance would not pay. THIS IS SITUATION #2. Choices: Use transmihed Admission assessment The RUG from that one will pay up to 30 days Think that through Follow PPS schedule but don t submit, in case you need them. May have more accurate RUGs to bill May or may not be a good thing Scenarios: BO says Medicare HMO is paying and they don t need RUGs. Later they say it should have been Original Medicare and they need RUGs. THIS IS SITUATION #6. Same op1ons OR: BO says Medicare HMO is paying and they don t need RUGs, but later they say the Medicare HMO needs RUGs: If they say they follow Medicare guidelines, the rules in Chapter 6 apply. 119 What if it s not any of those excep1ons & I just don t have the PPS MDS that I need? (6-55) When the SNF failed to set the 1mely and resident was already discharged from Part A when this was discovered: If a valid OBRA assessment exists in the QIES ASAP system with an that is on an allowable day for the PPS MDS, the SNF may bill the RUG category in which the resident classified. (Stand alone discharge assessment does not count) So, you can use the Admission assessment, without the PPS 5 day combined, to bill for the days a PPS 5 day is responsible for. Or a Sig Change, or an Annual, or a Quarterly, or a Sig CorrecJon 120 Wilhide Consul1ng, Inc. (c) 20

21 HIPPS Code Refresher HIPPS Codes RUG RUC HIPPS Code will be calculated by Grouper. RUC10 AI The facility is required to set the on the MDS Item Set or in the facility soqware within the appropriate ;meframe of the assessment type being completed. -p 2-8 Having an on a schedule is not sufficient. Compliance: Setting a PPS PPS 5 Day MDS judywilhide.com Page 6-55 If the SNF fails to set the within the defined window for a Medicare-required assessment, including the grace days, and the resident is s1ll on Part A, the SNF must complete a late assessment. The can be no earlier than the day the error was iden1fied. Late PPS assessments Page 6-54 If the is set for prior to the end of the period during which the late assessment a) would have controlled the payment, and b) no intervening assessments have occurred, the SNF will bill the default rate for the number of days the assessment is out of compliance, to include the date of the late assessment Wilhide Consul1ng, Inc. (c) 21

22 Late set outside payment period, and/or aqer intervening assessment: Page 6-54 PPS 14 Day : Illustra1on: Late, aqer payment cycle, aqer intervening assessment If of late assessment is set aqer the end of the period during which the late assessment would have controlled payment, or in cases where an intervening assessment has occurred and the resident is s1ll on Part A, the provider must s1ll complete the assessment. The can be no earlier than the day the error was iden1fied. The SNF must bill all covered days during which the late assessment would have controlled payment had the been set 1mely at the default rate regardless of the HIPPS code calculated from the late assessment. 5-Day 14-Day 1 9/28/ /12/ /29/ /13/ /30/ /14/ /1/ /15/ /2/ /16/ /3/ /17/ /4/ /18/ /5/ /19/ /6/ /20/ /7/ /21/ /8/ /22/ /9/ /23/ /10/ /24/ /11/ /25/ /26/ /27/ Day DAY 32 10/29/ /30/ /31/ DAY 36 11/2/ /3/ /4/ /5/ /6/ /7/ /8/ /9/ /10/ /11/ /12/2009 Not used for payment Checkpoint Sevng PPS s A SNF may not use a date outside the SNF Part A Medicare Benefit (i.e., 100 days) as the for a scheduled* PPS assessment. For example, the resident returns to the SNF on December 11 following a hospital stay, requires and receives SNF skilled services, and has 3 days leq in the SNF benefit period. SNF must set the for the PPS assessment on December 11, 12, or 13 to bill for the RUG category associated with the assessment. Default for days Early Late out of compliance *May use LOA day as for unscheduled PPS Assessments Pg Tips: Provider No Liability* Have a back-up to open PPS Assessments. Communicate daily with Rehab. Review PPS scheduler spreadsheets (or other method of tracking) very frequently, if not daily Wilhide Consul1ng, Inc. (c) 22

23 Scenario: Resident admihed Friday aqernoon and dies Sunday night prior to midnight. MDSC comes in on Monday. No PPS 5 day was set and now the resident is not on a Part A stay. Next Steps? You may not set an now. There was not one set and the resident is not on Part A now. Since the stay is less than 8 days, you may bill default rate for the two days. Consider paper MDS in admission chart for resident with set on paper form. Keep that form in the chart and use it to open a PPS 5 day when MDSC comes in on Monday. Page A-30 and When the resident dies or is discharged prior to the end of the look-back period for a required assessment, the must be adjusted to equal the discharge date. A-30 If the SNF fails to set the of a scheduled PPS assessment prior to the end of the last day of the window, including grace days, and the resident is no longer a SNF Part A resident, and as a result a Medicare-required assessment does not exist in the QIES ASAP for the payment period, the provider may not usually bill for days when an assessment does not exist in the QIES ASAP... If the resident was already discharged from Medicare Part A when this is discovered, an assessment may not be performed QUESTIONS? 135 Wilhide Consul1ng, Inc. (c) 23

24 Rehab RUG controllling payment? No Prepared by Judy Wilhide Brandt 2/1/15 Page 1 Rehab RUG earned? No 3 day break in therapy? Do EOT Day 7 of count? In window of scheduled PPS? Higher Combine Scheduled with on checkpoint. + 7 is next checkpoint Rehab RUG earned? Lower Do not do. Set scheduled on or before checkpoint. + 7 is next checkpoint CAUTON: Scheduled may only reset count if USED FOR PAYMENT** Same? Rehab RUG different than controlling Rehab RUG? Do. + 7 is next checkpoint Do not do. Set scheduled on any day in window. + 7 is next checkpoint No No Algorithm GO TO EOT ALGORITHM If no 3 day break in therapy in 7 day lookback, there are 2 choices: Do scheduled PPS assessment & count stops. OR, combine scheduled with to allow count to con nue. Use of these algorithms assumes thorough understanding of instruc ons in Ch 2 & 5 of current RAI manual. COPYRIGHT: WILHIDE CONSULTING, INC. Jan User assumes all liability for correct interpreta on of RAI manual rules. * count starts the day a er an in which a Rehab RUG is earned, even if it is not assigned due to CMI. If this is the case, the is required only if it changes the overall payment category. **If scheduled assessment will not set basis for payment for any days, must do on checkppoint. Ex: 30 day done on day 27, which is checkpoint. DC on day 29. May not use 30 day to reset count b/c it does not control payment un l day 31 is billed.

25 Prepared by Judy Wilhide Brandt 2/1/15 Page 1 Rehab RUG controllling payment? EOT Algorithm 3 day break in therapy? Will therapy resume on day 4 or 5 a er last therapy day at the same RUG level and same plan of care per discipline? No Will therapy start back at all? No Do EOT on day 1,2 or 3 a er last therapy day. Do EOT- R on day 1,2 or 3 a er last therapy day. Resump on date is day 1 of next lookback. All rehab discipines MUST do new ini al evalua ons prior to ANY further treatment. No more counts. Con nue PPS schedule. Choice: May do either Go to SOT algorithm Do SOT Wait un l net scheduled PPS assessment to capture Rehab RUG.

26 Prepared by Judy Wilhide Brandt 2/1/15 Page 1 Non- Rehab RUG* controllling payment? SOT Algorithm SNF Stay < 8 days? * Medicare Short Stay Regimen of therapy begun? Set SOT on day 5, 6 or 7, with earliest ini al eval date** as day 1. THerapy start in last 4 days?* Is RTM average > 15 min?** *Day of discharge counts as a day for each step of the Short Stay Algorithm **Add reimbursable therapy minutes (RTM), then divide by # of days of therapy. Day of eval counts as day 1 even if no RTM given. Day of discharge counts l *Two possibli es: Therapy is just star ng, or star ng back a er a 3 day break & not eligible for EOT- R Make sure: 1. Reason for assessment: 5 day/sot/discharge 2. Day of discharge must be =, Discharge date & Medicare end date 3. Therapy end date must = "- " (dash) **If more than one discipline, use earliest ini al eval date as day 1 for SOT count. S ll not working? 1. Re=check accuracy of all the above, if accurate: 2. Does nursing RUG on this assessment pay more than Rehab RUG earned on this assessment? 3. If so, take SOT off and send up as 5 D/DC only.