The Prospective Payment System

Transcription

1 Judy Wilhide Brandt, RN, BA, RAC-MT, QCP, CPC, DNS-CT The Prospective Payment System January 2018 NC & VA Source: 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 Combinations 2.13: Factors Impacting the SNF Medicare Assessment Schedule 2.14: Expected Order of MDS Records 2.15: Determining Item Set for MDS Records 2 Wilhide Consulting, Inc. (c) 1

2 Source: Chapter 6: 6.1: SNF PPS Background 6.2: Using the MDS in the Medicare Prospective Payment System 6.3: RUG-IV Overview 6.4: Relationship between the assessment and the claim 6.5: SNF PPS Eligibility Criteria 6.6: RUG-IV 66-Group Model Calculation Worksheet for SNFs 6.7: SNF PPS Policies 6.8: Non-compliance with the SNF PPS Assessment Schedule 3 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. Page 5-1 judywilhide.com 4 Wilhide Consulting, Inc. (c) 2

3 Two Basic Types of PPS Assessments: Scheduled Unscheduled Prescribed range of days from which to select. Penalties for improper selection. Prescribed scenarios that facility must correctly identify in which the assessment is required. Penalties for improper selection. 5 HIPPS & MDS 3.0 HIPPS Code will be calculated by Grouper. HIPPS = Health Insurance Prospective Payment System 6 Wilhide Consulting, Inc. (c) 3

4 Completion/Submission of PPS-only assessments Must be completed (Z0500b) no later than ARD (A2300) + 14 days Must be submitted no later than completion (Z0500b) + 14 days A SNF PPS Claim may not be submitted for payment unless the PPS MDS has been accepted into the national repository (QIES ASAP system). If a SNF PPS MDS is submitted and/or completed late, there is no financial penalty in the RUG payment for late completion or transmission. Once the PPS MDS is accepted into QIES ASAP, the SNF may bill the RUG score from that assessment. 7 Other uses of scheduled PPS assessments Quality Measures OBRA & Scheduled PPS assessments used for calculating Short and Long Term measures Public Reporting Five Star Survey MDS Indicators SNF QRP Scheduled PPS Assessments & SNF PPS Discharge used to calculate MDS based SNF-QRP measures Initial assessment will be used to calculate risk adjustments and exclusions for SNF-QRP 8 Wilhide Consulting, Inc. (c) 4

5 Scheduled PPS Assessments 2-43 Type ARD/Grace Day Window Payment Days 5 day Day Day Day Day Day 1 First Medicare day 9 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 6/18/14 10 Wilhide Consulting, Inc. (c) 5

6 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 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. Never earlier than A1600 entry date Never dashes on ANY discharge Wilhide Consulting, Inc. (c) 6

7 Part A PPS Discharge (NPE) Purpose: To calculate SNF Quality Reporting Program (SNF QRP) Quality Measures for Original Part A stays only 1. Falls with Major Injury 2. New/worsened Pressure Ulcer 3. Residents with admission and discharge functional status assessment and care plan that addresses function What is a PPS Discharge? (NPE) J1800 & J1900: Falls since entry or last OBRA/PPS MDS GG DC Functional Status M0210, M0300, M0800 Current & Worsened Pressure Ulcers Wilhide Consulting, Inc. (c) 7

8 Part A stay ends & resident stays in SNF When is PPS DC Required? May (MUST) be combined with OBRA DC when Part A stay ends and resident physically discharges from SNF on or one day after last Part A day (A2400C) NOT required when Part A stay ends in death PPSDC/OBRA Discharge (ND) RA or RNA & planned Any except 03 GG Discharge Fxl Abilities Falls Pressure Ulcers At least 3 days Cognitive Patterns, Mood, Behaviors, Fxl Status, Bowel/Bladder, Diagnoses, Pain, Other Health Conditions, Swallowing/Nutrition, PU dimensions, Meds, Special Tx, Restraints, Discharge Plan Wilhide Consulting, Inc. (c) 8

9 Unplanned OR To acute hospital OR Part A stay < 3 days PPS DC/OBRA Discharge (ND) No Discharge GG Falls Pressure Ulcers Cognitive Patterns, Mood, Behaviors, Fxl Status, Bowel/Bladder, Diagnoses, Pain, Other Health Conditions, Swallowing/Nutrition, PU dimensions, Meds, Special Tx, Restraints, Discharge Plan First forced combination in MDS history 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 Abilities Section 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 when Part A ends and resident stays in SNF! Wilhide Consulting, Inc. (c) 9

10 Factors Impacting the SNF PPS Schedule Section 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. (Section 2.12) When the resident dies or is discharged prior to the end of the lookback period for a required assessment, the ARD must be adjusted to equal the discharge date. (Page A-31) 20 Wilhide Consulting, Inc. (c) 10

11 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 certified bed Transfers to another payer source = remains in the certified bed but no longer billing Part A for the 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. 21 Missed Assessment If the SNF fails to set the ARD of a scheduled PPS assessment prior to the end of the last day of the ARD 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. When an assessment does not exist in the QIES ASAP, there is not an assessment based RUG the provider may bill. In order to bill for Medicare SNF Part A services, the provider must submit a valid assessment that is accepted into the QIES ASAP. The provider must bill the RUG category that is verified by the system. If the resident was already discharged from Medicare Part A when this is discovered, an assessment may not be performed Wilhide Consulting, Inc. (c) 11

12 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 Rehabilitation Plus Extensive Services or Rehabilitation category when a resident received rehabilitation therapy and was not able to have received 5 days of therapy due to discharge from Medicare Part A. See Chapter 6, Section 6.4 for greater detail. 23 Resident is Admitted to an Acute Care Facility and Returns If a Medicare Part A resident is admitted 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. DCRNA + PPS DC May also need to combine a PPS assessment Reentry tracking form Consider Significant Change Restart PPS schedule with PPS 5 day Continue OBRA schedule where it left off if no SCSA 24 Wilhide Consulting, Inc. (c) 12

13 Resident Is Sent to Acute Care Facility, Not in SNF over Midnight, and Is Not Admitted to Acute Care Facility If a resident is out of the facility over a midnight, less than 24 hours, and is not admitted 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 calculating 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 25 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 26 Wilhide Consulting, Inc. (c) 13

14 Leave of Absence: Page 2-13 Leave of Absence (LOA), which does not require completion 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 Therapeutic leave of at least one night; or Hospital observation stay less than 24 hours and the hospital does not admit the patient. 27 LOA and Scheduled ARD For scheduled PPS ARDs, the schedule must be adjusted to exclude the LOA because the ARD may not be on a non-benefit period day. The schedule is not restarted upon return from LOA Wed Thu Nonbillable Left 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 ARD for a PPS scheduled assessment (page 2-81) LOA day MAY be used as ARD for a PPS unscheduled assessment 28 Wilhide Consulting, Inc. (c) 14

15 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 still be used as the ARD of the unscheduled assessment, LOA day cannot be used as the ARD of the scheduled assessment. May 10 5 day ARD May 17 COT 14 day May When a SNF plans to combine a scheduled and 2-81 unscheduled assessment on a given day, & that day becomes an LOA day for the resident: LOA day may still be used as the ARD of the unscheduled assessment, LOA day cannot be used as the ARD of the scheduled assessment. May 10 May 17 LOA May 18 5 day ARD COT 14 day 14-day would need to have an ARD that falls on one of the resident s Medicare A benefit days. (prior to or after LOA day, depending on ARD range) 30 Wilhide Consulting, Inc. (c) 15

16 Review Reminder: If LOA is not to hospital, it can be more than one night. ARD COT ARD LOA ARD PT PT PT PT PT Sick no PT COT ARD LOA to ER no PT EOT Count Back from LOA, no PT 31 Resident Discharged from Part A Skilled Services and Returns to SNF Part A Skilled Level Services (30 day tracking) Do PPS DC on last covered day (LCD) If resident remains in certified bed, OBRA schedule continues. 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 Wilhide Consulting, Inc. (c) 16

17 Delay in Requiring and Receiving Skilled Services Ch 6, Sec 6.7 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, Section ) SNF determines on August 31 that beneficiary requires skilled service for a condition 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. 33 Just a few simple rules! Unscheduled PPS Assessments 34 Wilhide Consulting, Inc. (c) 17

18 Other Medicare Required Assessments (OMRA) End Change Start Therapy 35 Coding Tips and Special Populations (OMRAs) 2-60 When coding standalone OMRAs: Must set ARD for a day within the allowable ARD window, but may only do so no more than two days after the window has passed. Even if the resident discharges during this two day period 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 completion for the interview items on the unscheduled assessment (as documented in item Z0400) for which those responses will be used. Providers may conduct resident interview portions of that assessment up to two calendar days after the ARD 36 Wilhide Consulting, Inc. (c) 18

19 Standalone COT ARD 1 ARD COT 37 COT checkpoint Friday 1 ARD Fri 9 Sat 10 Sun 11 Mon COT Too Late! Tip: Open Friday before you go home. Delete Monday if not needed. 38 Wilhide Consulting, Inc. (c) 19

20 Setting ARD for Stand alone EOT/SOT 1 2 Last therapy SOT works the same way! Medicare and OBRA Assessment Combinations When any OMRA is combined with a discharge assessment, the ARD for that combination assessment may be set one or two days after the day of discharge. OMRA/ Discharge 40 Wilhide Consulting, Inc. (c) 20

21 OMRA Specifics: A deeper dive SOT EOT COT 41 Start of Therapy (SOT) OMRA 2-51 Optional. Completed only to classify a resident into a Rehab RUG. If the RUG assigned is not Rehab, will not be accepted into CMS database. ARD must be set on days 5-7 after the start of therapy with the exception of the Short Stay Assessment. The date of the earliest therapy evaluation is counted as day 1 when determining the ARD, regardless if treatment is provided or not on that day. May be combined with scheduled PPS assessments. SOT not necessary if rehabilitation services start within the ARD window (including grace days) of the 5-day assessment, since the therapy rate will be paid starting Day 1 of the SNF stay. ARD may not precede the ARD of first scheduled PPS assessment of the Medicare stay (5-day assessment). 42 Wilhide Consulting, Inc. (c) 21

22 SOT illustration PT Eval Nursing RUG Controls payment 6 OT Eval SOT Range SOT controls payment beginning on the earliest Therapy Start Date 43 Medicare Short Stay Assessment To be considered a Medicare Short Stay assessment and use the special RUG-IV short stay rehabilitation therapy classification: Assessment must be a Start of Therapy OMRA Resident must have been discharged from Part A on or before day 8 of the Part A stay Resident must have completed only 1 to 4 days of therapy With therapy having started during the last 4 days of the Part A stay Wilhide Consulting, Inc. (c) 22

23 Medicare Short Stay Assessment: All 8 must be true 1. Must be SOT OMRA. End of therapy date = the end 2. PPS 5 day must be completed. of covered Medicare stay date, 3. ARD must be NLT Day 8 of Part A or Stay. Dash-filled end of therapy date indicating ongoing therapy 4. ARD must be last day of Part A Stay. 8. RUG of this assessment must be Rehab or Rehab + Ext. 5. ARD must be NLT 3 days after SOT. 6. Rehab must have started in last 4 days of Part A stay. 7. Rehab must continue through last day of Part A stay. At least one discipline must have: 45 Medicare Short Stay Rehab Categories Average Daily Minutes: Ultra: >= 144 Very: High: Medium: Low: No Rehab category for < 15 minutes 46 Wilhide Consulting, Inc. (c) 23

24 Eval To ER Z0150 non-therapy RM x Do 5d/SOT/PPSDC/OBRA DC combination Set ARD for day of discharge Ensure A2400C = ARD Ensure one discipline has dashes in therapy end date 180/4 = 45 RM x 47 End of Therapy (EOT) OMRA: min 10 min 0 min 0 min EOT Required Day of therapy = 15 min by a discipline 48 Wilhide Consulting, Inc. (c) 24

25 Always use Z0150 HIPPS for EOT OMRA, to begin paying the day after last therapy 49 No Rehab RUG: No EOT 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. 50 Wilhide Consulting, Inc. (c) 25

26 EOT rules: Page 2-53 If resident discharged from the SNF on or prior to the third consecutive day of missed therapy services, then no EOT is required. If a SNF chooses to complete the EOT OMRA in this situation, they may combine the EOT OMRA with the discharge assessment. Review: EOT purpose is to reset the RUG from therapy to nontherapy usually less money Choosing EOT is usually NOT A GOOD CHOICE, but it is allowed: no provider liability 51 EOT rules: Page 2-53 Therapy ends Discharge EOT ALLOWED BUT NOT REQUIRED 52 Wilhide Consulting, Inc. (c) 26

27 EOT rules: Page 2-53 Therapy ends Discharge from Part A: EOT Required Provider liability if missed 53 Section 2.9 Therapy ends LCD Remains on another pay source EOT Required 54 Wilhide Consulting, Inc. (c) 27

28 EOT affect on COT IF EOT on day 36 or 37, no COT. If EOT on day 38, COT required. ARD RUB Last tx COT Check 38 If at any point, rehabilitation therapy ends before the last day of a COT observation period and an End of Therapy OMRA is performed with an ARD set for on or prior to Day 7 of the COT observation period, then the change of therapy evaluation process ends until the next PPS assessment used for payment reflecting the utilization of skilled therapy services Best practice: Do EOT to avoid COT 55 EOT-R When resumption of therapy date is no more than 5 consecutive calendar days after the last day of therapy provided, and Therapy services have resumed at the same RUG-IV classification 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 Resumption (EOT-R) may be completed Wilhide Consulting, Inc. (c) 28

29 Therapy ends EOT ARD Resumption criteria: Start back at same RUG level and same therapy plan of care 57 Therapy ends EOT ARD COT Check COT Check Resumption date, not day after ARD, is day 1 of next COT count Wilhide Consulting, Inc. (c) 29

30 If unable to do EOT-R Must do new therapy evaluations for all disciplines prior to restarting If new evals are not done, then there can be no therapy minutes on subsequent MDSs May do SOT or wait until next scheduled assessment to recapture Rehab RUG 59 A word about therapy evaluations Initial Evaluation: Required for each discipline prior to starting a course of therapy Required for each discipline upon each reentry after discharge assessment Not required for LOA Required after a three day break in therapy if EOT-R is not permitted Date of initial evaluation remains as the therapy start date until a new course of therapy with a new initial evaluation. 60 Wilhide Consulting, Inc. (c) 30

31 EOT-R Billing Review ARD: RUC EOT-R ARD Resume You shall rise and show respect to the aged. When therapy resumes, the RUG in effect prior to the break in therapy controls payment 61 Change of Therapy (COT OMRA) begins on 2-55 Required when 1. resident was receiving a sufficient level of rehabilitation therapy to qualify for a Rehabilitation category and 2. intensity of therapy changes to such a degree that it would no longer reflect the RUG-IV classification and payment assigned for a given SNF resident based on the most recent assessment used for Medicare payment 62 Wilhide Consulting, Inc. (c) 31

32 Intensity of Therapy Earned R U V H M L X L C B A 63 COT Rules 2-55 ARD is set for Day 7 of a COT observation period. 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. For example: If ARD for 30-day assessment is set for day 30, and there are no intervening assessments, then the COT observation period ends on Day 37. If the ARD for the patient s most recent COT (whether the COT was completed or not) was Day 37, the next COT observation period would end on Day Wilhide Consulting, Inc. (c) 32

33 COT Rules: 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. For example: If the ARD for an EOT-R is set for day 35 and the resumption date is the equivalent of day 37, then the COT observation period ends on day The COT would be completed if the patient s therapy intensity, as described above, has changed to classify the resident into a higher or lower RUG category. For example: RHB 21: RU RV RM RL Or ANY Nsg RUG if Rehab earned was NOT RH COT Required 66 Wilhide Consulting, Inc. (c) 33

34 COT Rules The COT would be completed if the patient 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 letter, or a nursing RUG while RH was earned but not assigned COT NOT Required You shall rise and show respect to the aged. 67 COT Rules The COT would be completed if the patient s therapy intensity, as described above, has changed to classify the resident into a higher or lower RUG category. For example: 14 RVB 21 COT checkpoint 28 COT checkpoint Whether COT was required on day 21 or not, day 22 is day 1 of the next COT count 68 Wilhide Consulting, Inc. (c) 34

35 COT Rules: If Day 7 of the COT observation period falls within the ARD window of a scheduled PPS Assessment, the SNF may choose to 1. complete the PPS Assessment alone by setting the ARD of the scheduled PPS assessment for an allowable day that is on or 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. OR 2. combine the COT OMRA and scheduled assessment following the instructions discussed in Section Illustration of choices: Complete the PPS Assessment alone by setting the ARD of the scheduled PPS assessment for an allowable day that is on or prior to Day 7 of the COT observation period : RUB 14 RVC 15 Day 15 RVC RUC Day 13, 14 or 15 are allowed ARDs for the stand alone 14 day assessment 70 Wilhide Consulting, Inc. (c) 35

36 Illustration of choice: Combine COT with scheduled assessment: 7 8 RVB Day 15 RUB Schedule a 14 day/cot with ARD on day Key Point: Payment Day RUB COT RVB COT sets payment from day 1 of COT lookback going forward. This sometimes causes a scheduled PPS assessment not to be used for payment But the scheduled assessment is still required. 72 Wilhide Consulting, Inc. (c) 36

37 What to choose? Combine Replace* When RUG stays the same: Use any day in lookback for scheduled MDS and restart COT count the next day. 73 When COT checkpoint is day of discharge When a resident s discharge from the SNF is on or prior to Day 7 of the COT observation period, then no COT OMRA is required. If a SNF chooses to complete the COT OMRA in this situation, they may combine the COT OMRA with the discharge assessment. - Page 2-52 COT is allowed but not required if checkpoint is the day of discharge. Should do COT if RUG is higher Emergent discharge? Should not do COT if RUG is lower But, no provider liability for either choice, as long as day 7 of COT count is chosen for COT ARD. 74 Wilhide Consulting, Inc. (c) 37

38 RUC controlling payment RVC COT check 8 If the date listed in A2400C is on or after Day 7 of the COT observation period, then a COT OMRA would be required if all other conditions are met L C D L T C D C If you are going to bill day 7 and the Rehab RUG changes, COT not optional! 75 COT Rules: The COT ARD may not precede the ARD of the first scheduled or unscheduled PPS assessment of the Medicare stay used to establish the patient s initial RUG-IV therapy classification in a Medicare Part A SNF stay. 5 DAY RUG Nursing? Rehab? Rehab RUG earned? Yes COT count begins No No COT count begins 76 Wilhide Consulting, Inc. (c) 38

39 COT Rules: Except as described below, a COT 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 COT OMRA may be completed when a resident is not currently classified into a RUG-IV therapy group, but only if both of the following conditions 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 discontinuation of therapy services (planned or unplanned discontinuation of all rehabilitation therapies for three or more consecutive days) occurred between Day 1 of the COT observation period for the COT OMRA that classified the resident into his/her current non-therapy RUG-IV group and the ARD of the COT OMRA that reclassified the resident into a RUG-IV therapy group. Under these circumstances, completing the COT OMRA to reclassify the resident into a therapy group may be considered optional. 77 Illustration of rule on slide 64: S M T W Th F Sa PT OT Tot Day ARD RUB Rehab RUG established S M T W Th F Sa PT Sick 75 0 OT Tot No Rehab RUG earned COT No therapy RUG, & no 3 day break in therapy: Do COT COT Count continues: May Do COT S M T W Th F Sa PT OT Tot 750 COT 78 Wilhide Consulting, Inc. (c) 39

40 Illustration of COT rules: S M T W Th F Sa PT OT Tot Day ARD RUA ARD Day 15 S M T W Th F Sa PT OT Tot COT Day 22: No COT due - Rehab RUG same Rehab RUG NOT earned on PPS 30 day on day 29, so COT count STOPS. NO COT on day 36 unless 30 day combined with COT S M T W Th F Sa PT OT Tot Day Nursing RUG earned 79 More Rules: Chapter 6, pg 6-14 If a new PPS assessment used for payment occurs with an ARD set for on or prior to the last day of a COT observation period, then a Change of Therapy OMRA is not required for that observation period. Example: An SCSA is performed with an ARD of Day 10. An evaluation for the Change of Therapy OMRA would occur on Day 17 but the 14-Day assessment intervenes with ARD on Day 15. A Change of Therapy OMRA is not performed with an ARD on Day 17. Rather, the COT OMRA evaluation process is restarted with the 14-day assessment with ARD on Day 15. Day 1 of the next COT observation period is Day 16 and the new COT OMRA evaluation would be done on Day Wilhide Consulting, Inc. (c) 40

41 June Sunday Monday Tuesday Wednesday Thursday Friday Saturday SNF Day PPS 5 day SCSA 14 Day COT 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 82 Wilhide Consulting, Inc. (c) 41

42 Controls vs Setting Basis for Payment 7 RUC 5 day RVC 14 day RUC COT RUC 5 day: RUC sets basis AND controls payment for day: RVC sets basis for COT: RUC controls payment for Illustration: PPS scheduled assessment is not used for payment so it cannot replace a COT 21 COT RVB Provider Liability RMB 30 D DC If scheduled assessment does not set the basis for a given period, it may not be used in place of COT. If the COT is not done, it is missed: provider liability Wilhide Consulting, Inc. (c) 42

43 COT Illustration 21 COT RVB RMB 30 D DC Change 30 D to COT before transmitting, using 7 day encoding/editing period 85 7 Day Encoding/Editing Period Page 5-8: Facilities have up to 7 days to encode (enter into the software) and edit an MDS assessment after the MDS has been completed. Changes may be made to the electronic record for any item during the encoding and editing period, provided the response refers to the same observation period. 86 Wilhide Consulting, Inc. (c) 43

44 Options: If scheduled PPS assessment submitted, may modify to add COT (5-11) May not modify COT 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 COT ARD (early) may modify and take default days, as opposed to provider liability. 87 Item Set Code Wilhide Consulting, Inc. (c) 44

45 Early/Late COT 89 Non-compliance with PPS Schedule: COT IF COT ARD is set early, day 1 for next COT is the day after the early COT ARD. November 1 30 Day ARD COT COT Will receive default for the two days the early COT was out of compliance Wilhide Consulting, Inc. (c) 45

46 Non-compliance with PPS Schedule: COT IF COT ARD is set late, with no intervening assessment, day 1 for next COT is the day after the late COT ARD Day ARD COT Will receive default for the two days the late COT was out of compliance Non-compliance with PPS Schedule: COT IF COT ARD is set late, after an intervening assessment, the late COT does not reset the COT count Day Default Default Will receive default for the days the late COT should have controlled payment, until 30 day kicks in on day Late COT 92 Wilhide Consulting, Inc. (c) 46

47 Missed Assessment: Page Day 14-Day Day ARD 30-Day COT Check 38 Last Tx EOT ARD 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 facilities must combine the scheduled and unscheduled assessments by setting the ARD of the scheduled assessment for the same day that the unscheduled assessment is required. A scheduled PPS assessment cannot occur after an unscheduled assessment in the assessment window the scheduled assessment must be combined with the unscheduled assessment using the appropriate ARD for the unscheduled assessment. 94 Wilhide Consulting, Inc. (c) 47

48 Section 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 ARD allowed ARD Section 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 until the next scheduled or unscheduled assessment used for payment Last Therapy EOT ARD 14 Day ARD Wilhide Consulting, Inc. (c) 48

49 Reminder: Scheduled assessment prior to EOT ARD 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 ARD EOT ARD Best Practice: If you can combine an EOT or SOT with scheduled, that is the thing to do. COT is different: May do scheduled without COT before or on COT checkpoint. 97 Note: A missed COT is provider liability Even if the RUG would have gone up A missed PPS assessment is provider liability It is always better to do it late for default rate 98 Wilhide Consulting, Inc. (c) 49

50 Significant Change or Significant Correction to Prior Comprehensive: Effect on PPS payment 2-59 SCSA or SCPCA will also act as an unscheduled PPS assessment. Will set payment on ARD If combined with scheduled PPS MDS, will set payment on ARD 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. 99 What about other insurance? Assessments that are completed for purposes other than OBRA and SNF PPS reasons are not to be submitted, 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 certified bed. Resident pay source is not relevant Certification of the bed is all that is relevant. Chapter 2, page Wilhide Consulting, Inc. (c) 50

51 What about other insurance? Cannot combine OBRA with PPS if pay source is not Original Medicare A 101 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 notified on an untimely basis of or is unaware of a Medicare Secondary Payer denial, 3. The SNF is notified on an untimely basis of a beneficiary s enrollment in Medicare Part A, 4. The SNF is notified on an untimely basis of the revocation of a payment ban, 5. The beneficiary requests a demand bill, or 6. The SNF is notified on an untimely basis or is unaware of a beneficiary s disenrollment from a Medicare Advantage plan. 102 Wilhide Consulting, Inc. (c) 51

52 Page 6-55: In situations 2-6, you may use Admission assessment to bill for all days of covered care associated with Medicarerequired 5-& 14-day assessments, even if the beneficiary is no longer receiving therapy services that were identified 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 ARD of the OBRA Admission assessment may be before or during the Medicare stay and does not have to fall within the ARD window of the 5-day or 14-day assessment. 103 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 ARD window of the PPS assessment in order to receive full payment at the RUG category in which the resident grouped. If ARD of the valid OBRA assessment falls outside the ARD 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. 104 Wilhide Consulting, Inc. (c) 52

53 More rules (6-56) Under all situations other than exceptions 1-5, the following apply when the SNF failed to set the ARD prior to the end of the last day of the ARD window, including grace days, or later and the resident was already discharged from Medicare Part A when this was discovered: 1. If a valid OBRA assessment (except a stand-alone discharge assessment) exists in the QIES ASAP system with an ARD that is within the ARD window of the PPS assessment, the SNF may bill the RUG category in which the resident classified. In the case of an unscheduled assessment, if the SNF fails to set the ARD for an unscheduled PPS assessment within the defined ARD window for that assessment, and the resident has been discharged from Part A, the assessment is missed and cannot be completed. All days that would have been paid by the missed assessment (had it been completed timely) are considered provider-liable. However, as with late unscheduled assessment policy, the provider-liable period only lasts until the point when an intervening assessment controls the payment. 105 HIPPS Code Refresher RUG RUC RUC10 AI Wilhide Consulting, Inc. (c) 53

54 HIPPS Codes HIPPS Code will be calculated by Grouper. 107 Compliance: Setting a PPS ARD judywilhide.com 108 Wilhide Consulting, Inc. (c) 54

55 The facility is required to set the ARD on the MDS Item Set or in the facility software within the appropriate timeframe of the assessment type being completed. -p 2-9 Having an ARD on a schedule is not sufficient PPS 5 Day MDS If the SNF fails to set the ARD within the defined ARD window for a Medicare-required assessment, including the grace days, and the resident is still on Part A, the SNF must complete a late assessment. The ARD can be no earlier than the day the error was identified Late PPS assessments Page 6-54 If the ARD 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 ARD date of the late assessment. 110 Wilhide Consulting, Inc. (c) 55

56 Late ARD set outside payment period, and/or after intervening assessment: Page 6-54 If ARD of late assessment is set after 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 still on Part A, the provider must still complete the assessment. The ARD can be no earlier than the day the error was identified. The SNF must bill all covered days during which the late assessment would have controlled payment had the ARD been set timely at the default rate regardless of the HIPPS code calculated from the late assessment. 111 PPS 14 Day ARD: Illustration: Late, after payment cycle, after intervening 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 ARD 32 10/29/ /30/ /31/ DAY ARD 36 11/2/ /3/ /4/ /5/ /6/ /7/ /8/ /9/ /10/ /11/ /12/2009 Not used for payment COT Checkpoint 112 Wilhide Consulting, Inc. (c) 56

57 ARD Outside the Medicare Part A SNF Benefit A SNF may not use a date outside the SNF Part A Medicare Benefit (i.e., 100 days) as the ARD for a scheduled PPS assessment, unless that scheduled PPS assessment is combined with an OBRA Discharge Assessment (see Section 2.12). For example, the resident returns to the SNF on December 11 following a hospital stay, and has 3 days left in his/her SNF benefit period. The SNF must set the ARD for the PPS assessment on December 11, 12, or 13 to bill for the RUG category associated with the assessment. A SNF may use a date outside the SNF Part A Medicare Benefit as the ARD for an unscheduled PPS assessment, but only in the case where the ARD for the unscheduled assessment falls on a day that is not counted among the beneficiary s 100 days due to a leave of absence (LOA), as defined in Chapter 2, sections 2.5 and 2.13, and the resident returns to the facility from the LOA on Medicare Part A. Pg Default for days Early Late out of ARD compliance ARD 114 Wilhide Consulting, Inc. (c) 57

58 Provider No Liability* ARD 115 Scenario: Resident admitted Friday afternoon and dies Sunday night prior to midnight. MDSC comes in on Monday. No PPS 5 day ARD was set and now the resident is not on a Part A stay. Next Steps? You may not set an ARD 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 ARD 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-31 and Wilhide Consulting, Inc. (c) 58

59 When the resident dies or is discharged prior to the end of the look-back period for a required assessment, the ARD must be adjusted to equal the discharge date. A-31 If the SNF fails to set the ARD of a scheduled PPS assessment prior to the end of the last day of the ARD 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/Discussion Wilhide Consulting, Inc. (c) 59

60 Rehab RUG controllling payment? Yes No Prepared by Judy Wilhide Brandt 2/1/15 Page 1 Rehab RUG earned? No 3 day break in therapy? Yes Do EOT Day 7 of COT count? In window of scheduled PPS? Higher Combine Scheduled with COT on COT checkpoint. ARD + 7 is next COT checkpoint Yes Yes Rehab RUG earned? Yes Lower Do not do COT. Set scheduled ARD on or before COT checkpoint. ARD + 7 is next COT checkpoint CAUTON: Scheduled may only reset COT count if USED FOR PAYMENT** Same? Yes Rehab RUG different than controlling Rehab RUG? Yes Do COT. ARD + 7 is next COT checkpoint Do not do COT. Set scheduled ARD on any day in window. ARD + 7 is next COT checkpoint No No COT Algorithm GO TO EOT ALGORITHM If no 3 day break in therapy in 7 day lookback, there are 2 choices: Do scheduled PPS assessment & COT count stops. OR, combine scheduled with COT to allow COT 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. *COT count starts the day a er an ARD in which a Rehab RUG is earned, even if it is not assigned due to CMI. If this is the case, the COT is required only if it changes the overall payment category. **If scheduled assessment will not set basis for payment for any days, must do COT on COT checkppoint. Ex: 30 day done on day 27, which is COT checkpoint. DC on day 29. May not use 30 day to reset COT count b/c it does not control payment un l day 31 is billed.

61 Prepared by Judy Wilhide Brandt 2/1/15 Page 1 Rehab RUG controllling payment? EOT Algorithm Yes 3 day break in therapy? Yes 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. Yes Yes Do EOT- R on day 1,2 or 3 a er last therapy day. Resump on date is day 1 of next COT lookback. All rehab discipines MUST do new ini al evalua ons prior to ANY further treatment. No more COT 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.

62 Prepared by Judy Wilhide Brandt 2/1/15 Page 1 Non- Rehab RUG* controllling payment? SOT Algorithm SNF Stay < 8 days? * Medicare Short Stay Yes Regimen of therapy begun? Yes Set SOT ARD on day 5, 6 or 7, with earliest ini al eval date** as day 1. Yes THerapy start in last 4 days?* Yes Is RTM average > 15 min?** Yes *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 = ARD, 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.