Housekeeping. Harmony Healthcare International, Inc. The Devils in The Details: RUG Intimacy. Objectives. Copyright 2012 All Rights Reserved

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1 The Devils in The Details: RUG Intimacy Harmony University The Provider Unit of (HHI) Presented by: Caroline Mullin, OTR/L Corporate Consultant/Denial Manager Housekeeping Sign In and Sign Out Contact Hours Certificate A Little About Me Handouts Contact Information for Questions 2 Objectives The learner will be able to determine Medicare Coverage Criteria/Skilled Care Learner will be able to identify the categories classifications Learner will be able to identify criteria for the RUG class The learner will be able to identify RUG leveling in relation to the MDS 3 1

2 Reimbursement History The Balanced Budget Act of 1997 included the implementation of a Medicare Prospective Payment System (PPS) for skilled nursing facilities (SNFs) The PPS system replaced the retrospective cost-based system for SNFs under Part A of the Medicare program (Federal Register Vol. 63, No. 91, May 12, 1998, Final Rule) 4 Reimbursement History In 2005, the Centers for Medicare & Medicaid Services (CMS) initiated a national nursing home staff time measurement (STM) study, referred to as the Staff Time and Resource Intensity Verification (STRIVE) Project 5 Reimbursement History The STRIVE project represents the first nationwide time study for nursing homes in the United States to be conducted since 1997, and the data collected has been used to update payment systems for Medicare SNFs and Medicaid nursing facilities (NFs) Based on this analysis, CMS developed the classification system that incorporates the MDS 3.0 items 6 2

3 The Minimum Data Set (MDS) MDS assessment data is used to calculate the classification necessary for payment The MDS contains extensive information on the resident s nursing and therapy needs, ADL impairments, cognitive status, behavioral problems, and medical diagnoses 7 The Minimum Data Set (MDS) This information is used to define RUG- IV groups that form a hierarchy from the greatest to the least resources used Residents with more specialized nursing requirements, licensed therapies, greater ADL dependency, or other conditions will be assigned to higher groups in the hierarchy 8 Classification System 8 levels of hierarchy 66 groups An index-maximizing system 9 3

4 ADL Discussion ADL Discussion 10 ADL Self performance Staff assistance Only code facility staff assistance Only code for activities that occur while a resident of the facility 11 ADL Column 1: ADL Self Performance Code 0, independent: if resident completed activity with no help or oversight every time during the 7-day look-back period Code 1, supervision: if oversight, encouragement, or cueing was provided three or more times during the last 7 days Code 2, limited assistance: if resident was highly involved in activity and received physical help in guided maneuvering of limb(s) or other nonweight-bearing assistance on three or more times during the last 7 days 12 4

5 ADL Code 3, extensive assistance: if resident performed part of the activity over the last 7 days, help of the following type(s) was provided three or more times: Weight-bearing support provided three or more times Full staff performance of activity during part but not all of the last 7 days Code 4, total dependence: if there was full staff performance of an activity with no participation by resident for any aspect of the ADL activity. The resident must be unwilling or unable to perform any part of the activity over the entire 7-day lookback period. 13 ADL Code 7, activity occurred only once or twice: if the activity occurred but not three times or more Code 8, activity did not occur: if the activity did not occur or family and/or non- facility staff provided care 100% of the time for that activity over the entire 7-day period 14 ADL Column 2: ADL Support Code 0, no setup or physical help from staff: if resident completed activity with no help or oversight Code 1, setup help only: if resident is provided with materials or devices necessary to perform the ADL independently. This can include giving or holding out an item that the resident takes from the caregiver. Code 2, one person physical assist: if the resident was assisted by one staff person 15 5

6 ADL Code 3, two+ person physical assist: if the resident was assisted by two or more staff persons Code 8, ADL activity itself did not occur during the entire period: if the activity did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire 7- day period 16 ADL Step 1 To calculate the ADL score use the following chart for bed mobility (G0110A), transfer (G0110B), and toilet use (G0110I) Self-Performance Column 1 Support Column 2 ADL Score -,0,1,7 or 8 Any number 0 2 Any number 1 3 -, , or ADL Step 2 To calculate the ADL score for eating (G0110H), use the following chart Self-Performance Column 1 Support Column 2 ADL Score -,0, 1, 2, 7 or 8 -,0, 1, 8 0 1, 2,

7 Details Rehabilitation 19 Rehab Plus Extensive Extensive Services used for Rehab Plus Extensive: Tracheostomy care Ventilator/respirator Isolation for active infectious disease while a resident 20 Rehab Plus Extensive Ultra High Rehabilitation Plus Extensive Services Rehabilitation treatment 720 minutes/week minimum At least 1 rehabilitation discipline 5 days/week A second rehabilitation discipline 3 days/week Tracheostomy care, ventilator/respirator, or isolation for active infectious disease while a resident RUX (11-16) RUL (2-10) 21 7

8 Rehab Plus Extensive Very High Rehabilitation Plus Extensive Services Rehabilitation treatment 500 minutes/week minimum Tracheostomy care, ventilator/respirator, or isolation for active infectious disease while a resident RVX (11-16) RVL (2-10) 22 Rehab Plus Extensive High Rehabilitation Plus Extensive Services Rehabilitation treatment 325 minutes/week minimum At least 1 rehabilitation discipline 5 days/week Tracheostomy care, ventilator/respirator, or isolation for active infectious disease while a resident RHX (11-16) RHL (2-10) 23 Rehab Plus Extensive Medium Rehabilitation Plus Extensive Services Rehabilitation treatment 150 minutes/week minimum 5 days any combination of 3 rehabilitation disciplines Tracheostomy care, ventilator/respirator, or isolation for active infectious disease while a resident RMX (11-16) RML (2-10) 24 8

9 Rehab Plus Extensive Low Rehabilitation Plus Extensive Services Rehabilitation treatment 45 minutes/week minimum 3 days any combination of 3 rehabilitation disciplines Restorative nursing 6 days/week, 2 services Tracheostomy care, ventilator/respirator, or isolation for active infectious disease while a resident RLX (2-16) 25 Rehabilitation Ultra High Rehabilitation Rehabilitation treatment 720 minutes/week minimum At least 1 rehabilitation discipline 5 days/week A second rehabilitation discipline 3 days week RUC (11-16) RUB (6-10) RUA (0-5) 26 Rehabilitation Very High Rehabilitation Rehabilitation treatment 500 minutes/week minimum At least 1 rehabilitation discipline 5 days/week RVC (11-16) RVB (6-10) RVA (0-5) 27 9

10 Rehabilitation High Rehabilitation Rehabilitation treatment 325 minutes/week minimum At least 1 rehabilitation discipline 5 days/week RHC (11-16) RHB (6-10) RHA (0-5) 28 Rehabilitation Medium Rehabilitation Rehabilitation treatment 150 minutes/week minimum 5 days any combination of 3 rehabilitation disciplines RMC (11-16) RMB (6-10) RMA (0-5) 29 Rehabilitation Low Rehabilitation Rehabilitation treatment 45 minutes/week minimum 3 days any combination of 3 rehabilitation disciplines Restorative Nursing 6 days/week, 2 services RLB (11-16) RLA (0-10) 30 10

11 The RU Patient 720 minutes 5x/week = 72 minutes per discipline/day 720 minutes 6x/week = 60 minutes per discipline/day 720 minutes 7x/week = 52 minutes per discipline/day Assuming two disciplines 31 RU vs. RV? Many patients who can tolerate 50 minutes of therapy by two disciplines a day are able to tolerate 72 minutes of therapy by each discipline Patients who appear more medically complex may require longer time to complete activities 32 RU vs. RV? Patients who appear more independent can benefit from higher level functional skills Activity tolerance Balance skills Car transfers Laundry Cooking Core Strength Reach Bend Push Pull Stoop 33 11

12 RU Treatment Session Initiation of session: minutes: Orientation, follow-up from last treatment, interview regarding complaints of pain or new onset of issues Physical challenges: minutes: Therapeutic exercise, functional task completion, thermal modalities Mental challenges: minutes: Table top activities, problem solving tasks, safety awareness training Conclusion of session: 10 minutes: Discuss discharge planning and plan for next session 34 The RM Patient Highly involved, medically complex patient at start of care Winding down therapy services at the end of the plan of care 35 Therapy Services Individual services are provided by one therapist or assistant to one resident at a time Concurrent therapy is defined as the treatment of 2 residents at the same time, when the residents are not performing the same or similar activities, regardless of payer source, both of whom must be in line-of-sight of the treating therapist or assistant for Medicare Part A Group therapy is defined for Medicare Part A as the treatment of 4 residents, regardless of payer source, who are performing the same or similar activities, and are supervised by a therapist or an assistant who is not supervising any other individuals 36 12

13 Therapy Calculations Add the individual minutes, one-half of the concurrent minutes and onequarter of the group minutes and record as Total Minutes All individual ½ concurrent + ¼ group Total Minutes 37 Therapy Calculations If allocated group minutes (one-quarter) divided by Total Minutes is greater than 0.25, proceed to the next step ¼ Group Minutes /Total Minutes = >.25? If yes, proceed If no, use total minutes to determine RUG 38 Therapy Calculations Add individual minutes and one-half of concurrent minutes, multiply this sum by 4.0 and then divide by 3.0, and record as Adjusted Minutes All Individual + ½ Concurrent SUM then (SUM X 4)

14 Therapy Calculations Decimal Points in Calculations: Are retained in all steps EXCEPT when determining Total Therapy Minutes (sum of PT, OT, and SLP) When calculating Total Therapy Minutes record only the whole number with all values after the decimal dropped 40 Therapy Calculations Practice Calculate the Total Minutes: OT: Individual: 100 Concurrent: 100 Group: Therapy Calculations Practice Calculate the Total Minutes: PT: Individual: 300 Concurrent: 200 Group:

15 Therapy Calculations Practice Calculate the Total Minutes: SLP: Individual: 30 Concurrent: 0 Group: Therapy Calculations Practice Total PT Minutes* Total OT Minutes* + Total SLP Minutes* Total Therapy Minutes** *Retain digits after the decimal **Drop digits after the decimal 44 Therapy Students Therapy Student Supervision Each SNF would determine for itself the appropriate manner of supervision of therapy students consistent with applicable State laws, local laws, and practice standards This policy change would not change the manner in which therapy minutes are currently recorded on the MDS or cause the student s time to become separately reimbursable 45 15

16 Therapy Students Therapy Student Supervision Consistent with the existing policy, as set forth in the RAI User s Manual, Chapter 3, Section O, as the therapy student is under the direction of the supervising therapist (even if no longer required to be under line-of-sight supervision), the time the student spends with a patient will continue to be billed as if it were the supervising therapist alone providing the therapy 46 Therapy Students Therapy Student Supervision In other words, the therapy student, for the purpose of billing, is treated as simply an extension of the supervising therapist rather than being counted as an additional practitioner HHI recommends student programs to facilitate growth with the department Can increase revenue particularly when paired with the DOR 47 Co-Treatment Multidisciplinary treatment sessions are reimbursable by both disciplines for the total amount of treatment minutes PT and OT treat a patient simultaneously for 60 treatment minutes, each clinician is able to bill the total amount of treatment time 48 16

17 Nursing Classifications 49 Special Care Special Care High: HE2 & HE1 (15-16) HD2 & HD1 (11-14) HC2 & HC1 (6-10) HB2 & HB1 (2-5) Special Care Low: LE2 & LE1 (15-16) LD2 & LD1 (11-14) LC2 & LC1 (6-10) LB2 & LB1 (2-5) With an ADL score of 0 or 1, resident falls to Clinically Complex RUG 50 Special Care High Comatose (must be ADL dependent or ADL did not occur) Septicemia Diabetes with both daily insulin injections and insulin order changes (2 out of 7 days) Quadriplegia and ADL >5 COPD and SOB when lying flat 51 17

18 Special Care High Fever and one of the following: Pneumonia Vomiting Weight loss Feeding tube (with calorie/cc requirements met) IV Fluids Respiratory therapy (7 days) 52 Special Care Low Cerebral Palsy with ADL score of >5 Multiple Sclerosis with ADL score of >5 Parkinson s Disease with ADL score of >5 Respiratory failure and oxygen while a resident Tube feeding with intake requirement met Two or more stage 2 pressure ulcers or one stage 3, 4 or unstageable due to eschar/slough with 2 or more treatments (certain treatments apply) 53 Special Care Low Two or more venous/arterial ulcers or one stage 2 pressure ulcer and one venous/arterial ulcer with two or more treatments (certain treatments apply) Foot infection, diabetic foot ulcer or other open lesion of foot with dressings Radiation treatment while a resident Dialysis treatment while a resident 54 18

19 Clinically Complex CE2 & CE1 (15-16) CD2 & CD1 (11-14) CC2 & CC1 (6-10) CB2 & CB1 (2-5) CA2 & CA1 (0-1) Includes Extensive Services and Special Care patients with an ADL score of 0 or 1 55 Clinically Complex Pneumonia Hemiplegia/hemiparesis with an ADL score of >5 Surgical wounds or open lesions with certain skin treatments Burns (continued next slide) 56 Clinically Complex Chemotherapy while a resident Oxygen while a resident IV medications while a resident Transfusion while a resident 57 19

20 : Oxygen Regarding the suggestion for defined oxygen therapy regimens for classification in the Clinically Complex category, they note that the patient must require skilled services, and under the regulations at 42 CFR (b)(8), services that qualify as skilled nursing services include the initial phases of a regimen involving the administration of medical gases. Because the initial phases of an oxygen therapy regimen qualify as SNF services, they are not going to require a minimum number of days or amount of time for classification, and will maintain the MDS 2.0 coding instructions for oxygen therapy for use in the model. 58 Restorative Nursing End Split for Behavioral Symptoms and Cognitive Performance and Reduced Physical Functioning categories 59 Restorative Nursing Count the number of the following restorative services provided for 15 or more minutes a day for 6 or more of the last 7 days: H0200C, H0500** Urinary toileting program and/or bowel toileting program O0500A,B** Passive and/or active ROM O0500C Splint or brace assistance O0500D,F** Bed mobility and/or walking training 60 20

21 Restorative Nursing Restorative O0500E Transfer training O0500G Dressing and/or grooming training O0500H Eating and/or swallowing training O0500I Amputation/prostheses care O0500J Communication training 61 Behavioral Symptoms and Cognitive Performance Behavior and/or cognitive combined Restorative nursing end split-provided for 15 or more minutes a day for 6 or more of the last 7 days ADL Score 5 or less BB1 & BB2 (2-5) BA1 & BA2 (0-1) 62 Behavioral Symptoms and Cognitive Performance Behavioral /Cognitive If the ADL score is less than or equal to 5, Reduced Physical Functioning category will apply Resident s BIMS Summary Score is less than or equal to 9, he or she is cognitively impaired and classifies 63 21

22 Behavioral Symptoms and Cognitive Performance Behavioral /Cognitive If BIMS is not completed the resident is cognitively impaired by staff assessment if one of the three following conditions exists: 1) B0100 Coma (B0100 = 1) and completely ADL dependent 2) C1000 Severely impaired cognitive skills (C1000 = 3) 64 Behavioral Symptoms and Cognitive Performance Behavioral /Cognitive 3) Two or more of the following impairment indicators are present: B0700 > 0 Problem being understood C0700 = 1 Short-term memory problem C1000 > 0 Cognitive skills problem and One or more of the following severe impairment indicators are present: B0700 >= 2 Severe problem being understood C1000 >= 2 Severe cognitive skills problem 65 Behavioral Symptoms and Cognitive Performance Behavioral /Cognitive Behavior: Determine whether the resident presents with one of the following behavioral symptoms: E0100A Hallucinations E0100B Delusions E0200A Physical behavioral symptoms directed toward others (2 or 3) E0200B Verbal behavioral symptoms directed toward others (2 or 3) 66 22

23 Behavioral Symptoms and Cognitive Performance Behavioral /Cognitive E0200C Other behavioral symptoms not directed toward others (2 or 3) E0800 Rejection of care (2 or 3) E0900 Wandering (2 or 3) 67 Reduced Physical Function Category applies if no other category requirements are met Restorative nursing end-split PE1 & PE2 (15-16) PD1 & PD2 (11-14) PC1 & PC2 (6-10) PB1& PB2 (2-5) PA1 & PA2 (0-1) 68 The Importance of Accurate Interviews CMS stressed the importance of the interviews and the need to make every attempt to complete them State survey agencies have verified that, in some cases, interviews are not completed when the resident could participate Failure to complete the interviews places the facility at risk for citation during survey 69 23

24 The Importance of Accurate Interviews Resident interviews are an important aspect of the entire care planning process All residents capable of any communication should be asked to provide information regarding what they consider to be the most important facets of their lives 70 Section D: Mood The signs/symptoms of mood distress are identifiable and treatable Assessment/Coding in this Section does not assign a diagnosis of depression or other mood disorder Facility staff should incorporate these indicators when developing individualized care plans 71 Section D0100: Mood Review Makes Self Understood item (B0700) to determine if the resident is understood at least sometimes (B0700 = 0, 1, or 2) Review Language item (A1100) to determine if the resident needs or wants an interpreter to communicate with doctors or health care staff (A1100 = 1) If the resident needs or wants an interpreter, complete the interview with an interpreter 72 24

25 D0200: Mood Interview (PHQ-9 ) Look-back period = 14 days Looks back prior to admission. Conduct the interview the day before or day of the ARD. Suggested language per the RAI: Over the last 2 weeks, have you been bothered by any of the following problems? 73 D0200: Mood Interview (PHQ-9 ) Then, for each question in Resident Mood Interview (D0200), read the item as it is written Do not provide definitions because the meaning must be based on the resident s interpretation. For example, the resident defines for himself what tired means; the item should be scored based on the resident s interpretation. Each question must be asked in sequence to assess presence (column 1) and frequency (column 2) before proceeding to the next question Enter code 9 for any response that is unrelated, incomprehensible, or incoherent, or if the resident s response is not informative with respect to the item being rated 74 D0200: Mood Interview (PHQ-9 ) Record the resident s responses as they are stated, regardless of whether the resident or the assessor attributes the symptom to something other than mood Further evaluation of the clinical relevance of reported symptoms should be explored by the responsible clinician 75 25

26 D0200: Mood Interview (PHQ-9 ) Coding Tips and Special Populations: If the resident uses his own words to describe a symptom, this should be briefly explored. If it is determined that the resident is reporting the intended symptom but using his own words, ask them to tell you how often they were bothered by that symptom. Select only one frequency response per item If the resident has difficulty selecting between two frequency responses, code for the higher frequency 76 D0200: Mood Interview (PHQ-9 ) Coding Tips and Special Populations Some items (e.g., item F) contain more than one phrase. If a resident gives different frequencies for the different parts of a single item, select the highest frequency as the score for that item. Residents may respond to questions: Verbally By pointing to their answers on the cue card, OR By writing out their answers 77 D0200: Mood Interview (PHQ-9 ) Interviewing Tips and Techniques: Repeat a question if you think that it has been misunderstood or misinterpreted If the resident goes off topic, the assessor should gently guide the conversation back on topic If the resident has difficulty selecting a frequency response, start by offering a single frequency response and follow with a sequence of more specific questions. This is known as unfolding 78 26

27 D0200: Mood Interview (PHQ-9 ) Interviewing Tips and Techniques Noncommittal responses such as not really should be explored. Probe by asking neutral or nondirective questions such as: What do you mean? Tell me what you have in mind. Tell me more about that. Please be more specific. Give me an example. Sometimes respondents give a long answer to interview items. Summarize their longer answer and then ask them which response option best applies This is known as echoing 79 D0200: Mood Interview (PHQ-9 ) Interviewing Tips and Techniques If the resident has difficulty with longer items, separate the item into shorter parts, and provide a chance to respond after each part This is known as disentangling, this method is helpful with resident who have moderate cognitive impairment but can respond to simple, direct questions 80 Resident Interviews Resident interviews are about enabling the resident to participate in the creation of their care plan and honoring their personal preferences Confused residents should not be screened out of the interview process Section D has critical care planning and reimbursement implications 81 27

28 Section Z All staff who completed any part of the MDS must enter their signatures, titles, sections or portion(s) of section(s) they completed, and the date completed If a staff member cannot sign Z0400 on the same day that he or she completed a section or portion of a section, when the staff member signs, use the date the item originally was completed 82 MDS PPS Scheduled vs. Unscheduled Assessments 83 Medicare Part A Skilled Care Criteria Unscheduled Assessments EOT COT SOT 84 28

29 Final Rule The criteria set forth for skilled nursing facility level of care must be met in order for a beneficiary to meet the requirements for a SNF Part A stay. These requirements are: 85 Skilled Care Criteria The patient requires skilled nursing services or skilled rehabilitation services, that is, services that must be performed by or under the supervision of professional or technical personnel; Are ordered by a physician; and The services are rendered for a condition for which the patient received inpatient hospital services or for a condition that arose while receiving care in a SNF for a condition for which he received inpatient hospital services 86 Skilled Care Criteria The patient requires these skilled services on a daily basis; As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF; AND 87 29

30 Skilled Care Criteria The services must be reasonable and necessary for the treatment of a patient s illness or injury, that is, be consistent with the nature and severity of the individual s illness or injury, the individual s particular medical needs, and accepted standards of medical practice. The services must also be reasonable in terms of duration and quantity. 88 Unscheduled Assessments Start of Therapy End of Therapy End of Therapy with Resumption Change of Therapy Short Stay 89 Need to Know Your Nursing RUGs! An unscheduled assessment can strike at any time! Nursing anchors skilled care, be aware of what lies under your Rehab RUG Index Maximization 90 30

31 Start of Therapy (SOT) Optional assessment Completed only to classify a resident into a Rehabilitation Plus Extensive Services or Rehabilitation group (CMS will not accept a Nursing RUG) only if the resident is not already classified in a Rehab RUG ARD must be set on days 5-7 after the start of therapy Medicare payment rate begins on the day therapy started Must be completed within 14 days after the ARD 91 End of Therapy (EOT) Required when the resident was classified in a Rehabilitation Plus Extensive Services or Rehabilitation group and continues to need Part A SNF-level services after the planned or unplanned discontinuation of all rehabilitation therapies for three or more consecutive days ARD must be set on day 1, 2, or 3 after all rehabilitation therapies have been discontinued or when there are three more consecutive days without any therapy services 92 End of Therapy (EOT) Must be completed within 14 days after the ARD Establishes a new non-therapy RUG classification and Medicare payment rate which begins the day after the last day of therapy treatment 93 31

32 End of Therapy Resumption (EOT-R) In cases where therapy resumes after an EOT OMRA is performed and more than 5 consecutive calendar days have passed since the last day of therapy provided, or therapy services will not resume at the same therapy classification level that had been in effect prior to the EOT OMRA, an SOT OMRA is required to classify the resident back into a therapy group and a new therapy evaluation is required as well 94 End of Therapy Resumption (EOT-R) In cases where therapy resumes after the EOT OMRA is performed and the resumption of therapy date is no more than 5 consecutive calendar days after the last day of therapy provided, and the therapy services have resumed at the same classification level that had been in effect prior to the EOT OMRA, an End of Therapy OMRA with Resumption (EOT-R) may be completed 95 Change of Therapy (COT) Required when the resident was receiving any amount of skilled therapy services and when the intensity of therapy (as indicated by the total reimbursable therapy minutes (RTM) delivered, and other therapy qualifiers such as number of therapy days and disciplines providing therapy) changes to such a degree that it would no longer reflect the classification and payment assigned for a given SNF resident based on the most recent assessment used for Medicare payment 96 32

33 Change of Therapy (COT) ARD is set for Day 7 of a COT observation period. The COT observation periods are successive 7- day windows with the first observation period beginning on the day following the ARD set for the most recent scheduled or unscheduled PPS assessment (except for an EOT-R assessment) 97 Change of Therapy (COT) If Day 7 of the COT observation period falls within the ARD window of a scheduled PPS Assessment, the SNF may choose to complete the PPS Assessment only by setting the ARD of the scheduled PPS assessment for an allowable day that is prior to Day 7 of the COT observation period. This effectively resets the COT observation period to the 7 days following that scheduled PPS Assessment ARD. 98 Change of Therapy (COT) In cases where the last PPS Assessment was an EOT-R, the end of the first COT observation period is Day 7 after the Resumption of Therapy date (O0450B) on the EOT- R, rather than the ARD The resumption of therapy date is counted as day 1 when determining Day 7 of the COT observation period 99 33

34 Change of Therapy (COT) Must be completed within 14 days after the ARD Establishes a new category. Payment begins on Day 1 of that COT observation period and continues for the remainder of the current payment period, unless the payment is modified by a subsequent COT OMRA or other PPS assessment 100 Medicare Short-Stay Assessment If the 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 Rehabilitation Plus Extensive Services or Rehabilitation category when a resident was not able to receive 5 days of therapy 101 Medicare Short-Stay Assessment 1. The assessment must be a Start of Therapy OMRA A0310C = 1 or 3 2. A PPS 5-day or re-admission return assessment must be complete (may be combined) 3. The ARD (A2300) must be on or before the 8th day of the Part A Medicare covered stay The ARD minus the start of Medicare stay date (A2400B) must be 7 days or less

35 Medicare Short-Stay Assessment 4. The ARD (A2300) of the Start of Therapy OMRA must be the last covered Medicare Part A day. The Start of Therapy OMRA ARD must equal the end of Medicare stay date (A2400C). The end of the Medicare stay date is the date Part A ended. **See instructions for A2400C in Chapter 3 for more detail 103 Medicare Short-Stay Assessment 5. The ARD (A2300) of the Start of Therapy OMRA may not be more than 3 days after the start of therapy date 6. Rehabilitation therapy (Speech-Language Pathology services, Occupational Therapy, or Physical Therapy) started during the last 4 days of the Medicare Part A covered stay (including weekends) 104 Medicare Short-Stay Assessment 7. At least one therapy discipline continued through the last day of the Medicare Part A covered stay 8. The RUG group assigned to the Start of Therapy OMRA must be Rehabilitation Plus Extensive Services or a Rehabilitation group (Z0100A)

36 Medicare Short-Stay Assessment If all eight of these conditions are met, then the assignment of the rehabilitation therapy classification is calculated based on average daily minutes actually provided, and the resulting group is recorded in MDS item Z0100A (Medicare Part A HIPPS Code) Payment begins the date of the first therapy evaluation through date of discharge Use the Short-Stay Algorithm in the RAI Manual (Chapter 6) 106 Rehab Categories Short-Stay Assessment average daily therapy minutes = RL_ average daily therapy minutes = RM_ average daily therapy minutes = RH_ average daily therapy minutes = RV_ =/> 144 average daily therapy minutes = RU_ 107 Combining Assessments There may be instances when more than one Medicare-required assessment is due in the same time period It is possible that a Medicare-required Scheduled Assessment and a Medicare Unscheduled Assessment may be combined or that two Medicare Unscheduled assessments may be combined When combining assessments, the more stringent requirements must be met

37 Strategies for Success ARD Management ADL Coding/Capturing New MDS Coding guidelines Rehab Case Management Mode of therapy Groups Intensity/days of service New OMRA assessments Hospital Data while a resident 109 Questions/Answers Harmony Healthcare International 1 (800) Cmullin@Harmony-Healthcare.com 110 Harmony Healthcare International Have you Considered a Customized Complimentary HARMONY(HHI) MEDICARE PROGRAM EVALUATION or CASE MIX ANALYSIS for your Facility? Perhaps your facility has potential for additional revenue Benchmark your facility against key indicators and national norms us at for more information RUGS@harmony-healthcare.com Analysis is cost & obligation free