5/11/2017. Carol Maher, RN-BC, RAC-CT, RAC-MT, CPC. It s official!

Transcription

1 Carol Maher, RN-BC, RAC-CT, RAC-MT, CPC It s official! 2 1

2 Capturing the services and resident characteristics provided to Medicare A residents in specific timeframes. Determining the Medicare payment through the RUG score obtained from accurate and timely MDS completion. Meet regulatory requirements. Prevent missed (provider liability) or reduced payment (default payment). 3 (5, 14, 30, 60, or 90-day PPS MDSs) 2

3 Each of the Medicare-required scheduled assessments has defined days within which the Assessment Reference Date (ARD) must be set. The facility is required to set the ARD on the MDS form itself or in the facility software within the appropriate timeframe of the assessment type being completed. For example, the ARD for the Medicare-required 5-day scheduled assessment must be set on days 1 through 8. Timeliness of the PPS assessment is defined by selecting an ARD within the prescribed ARD window. 5 Assessment Type Assessment Window Grace s # of s Paid Medicare Payment s 5-day MDS day MDS day MDS day MDS day MDS

4 Scheduling tool in your MDS software system. 100-day tool/calendar spreadsheets for each Medicare resident. Medicare binder of active Medicare A residents: 100-day tool for each Medicare A resident; RUG guide; Facility payment per RUG score; Medicare Benefit Policy Manual, Chapter 8. Census reports. Therapy software

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6 Do NOT restart the PPS schedule. Do NOT complete a Discharge Assessment. Adjust the PPS schedule. The day before midnight out of the facility is not a Medicare covered day. Skip that day in the PPS schedule. Reprint your 100-day tool to skip the day the resident had been out of the facility over midnight. Midnight rule applies whenever the resident is not in the SNF at midnight (LOAs). 11 Scheduled PPS Assessments The Medicare assessment schedule is adjusted to exclude the LOA when determining the appropriate ARD for a given assessment. Example: A resident leaves SNF X at 6:00pm on Wednesday ( 27) and returns to the SNF on Thursday at 9:00am. Wednesday becomes a nonbillable day and Thursday becomes 27 of the resident s stay. 12 6

7 Do not complete an OBRA or Part A PPS Discharge MDS. The day the resident was not in the facility at midnight is skipped in the PPS schedule. Reprint the 100-day tool to remove the non-billable day, so that you can see the new/correct assessment windows. The skipped day must be included in the count of days affecting unscheduled assessments (s and EOTs) information will be provided later in this webinar. The Medicare Certifications/Re-Certifications are not affected by the skipped day. 13 If admitted to the hospital as an in-patient (not admitted to observation ), even if less than 24 hours and not over midnight, restart the PPS schedule. New therapy evals required (orders, clarification orders, and plans of care) if therapy will be provided. New Certs/Re-certs started. Restart the PPS Schedule at day

8 Complete an OBRA Discharge with return anticipated (can be combined with Part A PPS Discharge MDS). The PPS schedule begins again at day 1 on the day of readmission if Medicare coverage is reasonable and necessary and there are Medicare A days available. A new 5-day MDS would be required, followed by 14-day, 30-day, etc., as needed. New therapy orders and initial evaluations must be completed after the readmission if therapy will be provided. No therapy days/minutes can be coded without new initial evaluations following a re-admission. (Page O-19 of Chapter 3 of the RAI User s Manual) Medicare Certification and Re-Certification process begins again. Resume the OBRA assessment schedule where it left off. 15 Complete OBRA (return anticipated) and Part A PPS Discharge Assessments. Resume OBRA schedule where it left off. Begin PPS cycle again upon returns with a Medicare 5-day MDS (A0310B = 1). New therapy initial evaluations and orders are required if therapy will be provided/necessary. Medicare Certifications/Re-Certifications begin again upon re-admission. 16 8

9 Your resident has been covered by Medicare for 26 days. At 2 AM on day 26 he is discharged to the acute-care hospital and admitted. He returns two days later and requires continuing Medicare coverage. Which PPS assessment would be completed next? A. Admission/5-day MDS B. 30-day PPS MDS C. 5-day PPS MDS D. No PPS MDS should be completed since he was only in the hospital two days. 17 Your resident s granddaughter got married on day 26 of her Medicare stay. The resident s son hired private duty nurses to accompany the resident to the wedding so that she would not miss this important occasion. Your team trained the caregivers. The wedding was out of town. The resident did not return until two days later. She required skilled care upon return. Admitted 1/1/17. Left the facility on 1/26/17 and returned on 1/28/17. Which PPS MDS should be completed next after her return from the wedding? A. Admission/5-day B. 30-day PPS MDS C. 5-day D. Resident can t have Medicare coverage since gone more than four hours. 18 9

10 If resident dies on day of admission, or discharges to the community on same day as admission, complete the 5-day PPS assessment for RUG payment for day of admission. Medicare does not usually pay for the day of discharge except in this situation where the admission and discharge occur on the same day and the discharge is to a non-medicare provider. If resident discharges to the hospital or other Medicare provider (SNF, LTCH, IRF), no PPS assessment needs to be completed, because no RUG payment will be realized. 19 An 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 th following a hospital stay, requires and receives SNF skilled services (and meets all other required coverage criteria), and has three 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

11 Resident was admitted on Monday for a planned short stay. Generic notice given on Wednesday reporting Friday as the LCD (day 5 LCD); resident discharged on Saturday. In this case, Friday s date would be entered in A2400C. Because the resident discharged the day after the LCD and within the window for the 5 day MDS, the 5 day can be combined with the discharge MDS. In the above scenario, had the resident remained in the facility, the ARD for the 5 day PPS MDS would need to have been no later than Friday s date (Medicare end date 2400C)

12 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. If the ARD on the late assessment is set for prior to the end of the period during which the late assessment would have controlled the payment, had the ARD been set timely, and/or no intervening assessments have occurred, the SNF will bill the default rate for the number of days that the assessment is out of compliance. This is equal to the number of days between the day following the last day of the available ARD window (including grace days when appropriate) and the late ARD (including the late ARD). The SNF would then bill the Health Insurance Prospective Payment System (HIPPS) code established by the late assessment for the remaining period of time that the assessment would have controlled payment. 23 The allowable window for setting the ARD for the 14-day PPS MDS is days (including grace days). The MDS Coordinator realized that she had forgotten to set the ARD for the 14-day PPS MDS on day 23 of the resident s Medicare A stay. Since the PPS window was closed, she cannot set the ARD any earlier than the day she recognized the error (day 23). The 14-day PPS MDS was opened in the MDS software with the ARD of day 23. The facility will be charged five days of default rate (days out of compliance begin accumulating on day 19). The ARD was five days out of compliance. (s 19-23). After the late PPS MDS has been completed and transmitted, the RUG from the late assessment would be billed beginning the day after the five default days paid

13 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 an 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. There is a short list of exceptions to this rule found in Chapter 6 of the RAI User s Manual, pages 6-55 and SOTs, s, EOTs, and EOT-Rs 13

14 27 Must be done to place a resident into a Rehab RUG if Rehab RUG not obtained by MDS, it will be rejected when transmitted. Completed only if previous MDS not in Rehab RUG. ARD (Item A2300) must be set on days 5-7 after the start of therapy (Item O0400A5, or O0400B5, or O0400C5, whichever is the earliest date) with the exception of the Short Stay Assessment (see Chapter 6, Section 6.4). The date of the earliest therapy evaluation is counted as day 1 when determining the ARD for the Start of Therapy OMRA, regardless if treatment is provided or not on that day. Establishes a RUG-IV classification and Medicare payment (see Chapter 6, Section 6.4 for policies on determining RUG-IV payment), which begins on the day of the earliest therapy initial evaluation

15 Start of Therapy (SOT) OMRAs are voluntary. SOTs do not include clinical RUG items when completed as a standalone assessment. Many nursing RUGs pay higher than the lower (Rehab Medium or Rehab High) Rehab RUGs. Occasionally, a SOT is completed which causes unnecessary lower payment. Remember, it is a voluntary MDS. Only complete a SOT when it will benefit the SNF s reimbursement. Do not combine the SOT with the 5-day PPS MDS unless completing a short stay Adm ARD PT Eval + 50 min PT 50 min PT 50 min PT 50 min PT 50 min OT Eval + 50 min OT 50 min OT 50 min OT 50 min OT 50 min 30 15

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17 100% Individual Minutes, plus 50% of Concurrent Minutes, plus 25% of Group Therapy Minutes (not to exceed 25% cap). Reimbursable Therapy Minutes 33 Minimum of 720 Reimbursable Therapy Minutes provided in 7-day look-back window, PLUS One therapy discipline provided at least five days (day = 15 or more minutes of therapy provided), PLUS Second therapy discipline provided at least three days

18 At least 500 Reimbursable Therapy Minutes provided in 7-day look-back window, PLUS At least one therapy discipline provided treatment at least five days in look-back window. 35 At least 325 Reimbursable Therapy Minutes provided during 7-day look-back window, PLUS At least one therapy discipline treated for five days in the look-back window

19 At least 150 Reimbursable Therapy Minutes provided during the 7-day look-back window, PLUS Any combination of therapy disciplines (P.T., O.T., S.L.P.) provided therapy for at least five distinct calendar days in the 7-day window. 37 At least 45 minutes of therapy provided, PLUS Any combination of therapy disciplines provided therapy at least three distinct calendar days in the look-back window, PLUS Two Restorative Nursing Programs provided at least six days each during the look-back window

20 Required when intensity of therapy increases or decreases from RUG of most recent PPS assessment. Required even for assessments with Nursing RUG if receiving enough therapy to qualify for a Rehab RUG. Changes in ADLs or other nursing services do not require s. 39 Increase or decrease in number of reimbursable therapy minutes () that is enough to change the paying RUG. (Change in RUG means changing from Rehab Very High to Rehab High or Rehab Ultra High, for example. Consider whether the second character of the Rehab RUG would change). Increase or decrease in the number of therapy days that is enough to change the paying RUG. (RU, RV, and RH require that at least one therapy discipline had provided five distinct calendar days of therapy during the 7-day look-back). Increase or decrease in therapy disciplines that is enough to change the paying RUG. (Rehab Ultra High requires two therapy disciplines have provided therapy during the 7-day look-back. One discipline must have provided at least five calendar days of therapy. The second discipline must have provided at least three calendar days of therapy during the look-back.) Change in Restorative Nursing in Rehab Low that would change the paying RUG

21 The 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. First requirement: An MDS was completed where the resident qualified for a Rehab RUG. Next step: The day after the ARD of the MDS where the resident qualified for a Rehab RUG is day one for the first rolling window. 41 Observation Period: Rolling 7-day window beginning: On the day following ARD of most recent assessment, or On the day therapy resumes with EOT-R OMRA. Ending every 7 calendar days thereafter, or On the ARD of next scheduled assessment

22 ARD 14 OBS 1 15 OBS 2 16 OBS 3 17 OBS 4 18 OBS 5 19 OBS 6 20 OBS 7 ARD Check Date 27 OBS 7 ARD Check Date 21 OBS 1 22 OBS 2 23 OBS 3 24 OBS 4 25 OBS 5 26 OBS 6 The rolling windows will only change when a new ARD is set, therapy ends (EOT ARD set), or Medicare coverage ends Last of Therapy 42 OBS 3 36 EOT ARD 1 43 OBS 4 37 EOT ARD 2 44 OBS 5 38 EOT ARD 3 45 OBS OBS 7 40 OBS 1 Therapy Resumes OBS 2 48 Check Date The only time that the window is not based upon an ARD is when an EOT-R has been completed. In this case, the calendar begins on the date therapy resumed

23 Unscheduled ARD Flexibility Period Facilities are permitted to set the ARD of an unscheduled PPS assessment for a day within the allowable ARD window for that assessment no more than 2 days after the window has passed. Flexibility period is 1-2 days! Firm limit! 45 7 of period is Wednesday April 18 th. Facility may set the ARD onto the MDS form for Wednesday 18 th on either April 18 th, 19 th, or 20 th. (These are not grace days, do not set the ARD for a date in the flexibility window.) After April 20 th, the flexibility period would have passed. If the facility discovers on April 23 rd that the ARD had not been set onto the MDS, the ARD for the could be no earlier than April 23 rd (date the error was identified)

24 Unscheduled PPS Assessments s during which a resident experiences an LOA must be counted toward the ARD for a given unscheduled assessment. OMRA Example: If the ARD for a resident s 30- day assessment were set for November 7 th and the resident went to the emergency room at 11:00pm on November 9 th, returning at 2:00pm on November 10 th, day 7 of the observation period would remain November 14 th. 47 Leave of Absence (LOA) Policy Clarification Question: Can the ARD set of an unscheduled PPS assessment be set for an LOA day? Answer: Yes; it is possible that the ARD for a given unscheduled PPS assessment may be set for an LOA day

25 Leave of Absence (LOA) Policy Clarification Question: Can the ARD set of a scheduled PPS assessment be set for an LOA day? Answer: No; the ARD for a given scheduled PPS assessment may NOT be set for an LOA day. 49 Admit date 1/1/17. checkpoint 1/28/17. Resident out over midnight on 1/28/17. Therapy has increased from the previously paying RUG. Can you combine the with the 30-day with the ARD of 1/28/17? A. Yes B. No 50 25

26 RUG and Rate changes day one of 7-day observation period, and can carry forward to the next 7-day. RU RVB 51 The RUG rate from the begins payment day one of the 7-day observation window. Example: ARD of 14-day = day 14 resulting in the RUB RUG. observation window day days checkpoint revealed that the resident received only 700 minutes of therapy in the 7-day look-back. The resulting RUG on the ARD ( 21) was RVB. RVB began payment day 15. The RUB from the 14-day will not pay any days, but was a required assessment

27 MDS Coordinators pilot their teams! 53 If day 7 of the observation period falls within the ARD window of a scheduled PPS assessment, the SNF may choose to complete the scheduled 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 observation period. This effectively resets the observation period to the 7 days following that scheduled PPS assessment ARD. Alternatively, the SNF may choose to combine the OMRA and scheduled assessment following the instructions discussed in Section

28 OMRA: If day 7 of the observation period falls within the ARD window of a scheduled PPS assessment, the SNF may choose to complete the PPS assessment alone, resetting the observation period to the 7 days following that scheduled PPS assessment ARD ARD Due May complete 30- alone (resetting the window) 30- Window 55 Scheduled Assessment ARDs (5,14, 30, 60, or 90-day PPS MDSs) cannot follow an EOT,, or SOT ARD in the scheduled window. Example: If ARD set for day 14, you cannot set 14-day ARD for days ARD 14- Window Does not impact 14- day ARD 56 28

29 When the ARD of the Scheduled Assessment is on or before day 7 of the checkpoint and therapy has changed. 57 If therapy has decreased to a lower paying RUG, substitute the scheduled assessment for the by setting the ARD of the scheduled assessment for a date on or before day 7 of the checkpoint. Also open that ARD in the software in case it is required! (More about this later). Lower payment postponed until later! 58 29

30 If therapy has INCREASED to a higher paying RUG, combine the with the scheduled assessment in order to obtain the higher paying RUG retroactively to day 1 of the observation period. (Must use day 7 of window as ARD!) Higher Therapy RUG = More Money sooner! 59 In Philadelphia County, RUB pays $657.84/day while RVB pays $ per day. (A difference of $169.13/day.) If the resident s payer has changed to RUB from RVB when day 27 is both the checkpoint and a day in the scheduled 30-day window, combining the with the 30-day would allow the facility to be paid at the RUB RUG on day 21 instead of day 31 (start date for 30-day PPS MDS). This combined assessment would result in an additional $1,691.30! 60 30

31 61 If a new PPS assessment used for payment occurs with an ARD set for on or prior to the last day of a observation period, then a Change of Therapy OMRA is not required for that observation period. If an assessment has an ARD set for on or prior to day 7 of the observation period, but this assessment is not used for payment, then completing this assessment does not impact the ARD calendar

32 Assessmen t Type Window Grace days # of days paid s paid 5-day day day day day Remember, the SNF does not receive payment for the date of discharge. Used for payment means that the MDS was required for Medicare payment or required to set the basis for the payment block. Use your 100-day tools to recognize when assessments are used for payment. 63 Explanation: If the resident discharges before the scheduled assessment is used for payment and the required was not coded prior to submission of the MDS, then the facility cannot receive payment from day 1 of the window through discharge. SUN MON TUES WED THU FRI SAT Check Date none needed

33 Explanation: If the resident discharges before the scheduled assessment is used for payment and the required was not coded prior to submission of the MDS, then the facility cannot receive payment from day 1 of the window through discharge. SUN MON TUES WED THU FRI SAT Check Date none needed Check 65 Explanation: If the resident discharges before the scheduled assessment is used for payment and the required was not coded prior to submission of the MDS, then the facility cannot receive payment from day 1 of the window through discharge. SUN MON TUES WED THU FRI SAT Check Date none needed Check 30- ARD Window 66 33

34 Explanation: If the resident discharges before the scheduled assessment is used for payment and the required was not coded prior to submission of the MDS, then the facility cannot receive payment from day 1 of the window through discharge. SUN MON TUES WED THU FRI SAT 20 Check Date none needed Check 30- ARD Window Needed RUG will Drop 67 In this example, if the standalone 30-day was completed without combining the 30-day with the, the would be considered missed, because the resident discharged before the 30-day was used for payment. (Even if completed, transmitted and accepted) SUN MON TUES WED THU FRI SAT Needed RUG will Drop Check Date none needed 27 7 Check 1 28 Stand-Alone 30- Done Resident Discharge 30- ARD Window Payment Window (s 31 60) 5 6 Provider liability would begin on day 21! 68 34

35 Explanation: If the resident discharges before the scheduled assessment is used for payment and the required was not coded prior to submission of the MDS, then the facility cannot receive payment from day 1 of the window through discharge. SUN MON TUES WED THU FRI SAT Needed RUG will Drop Check Date none needed Check Stand-Alone 30- Done Resident Discharge 30- ARD Window Provider Liability 4 Provider Liability 30- Payment Window (s 31 60) Open s in addition to scheduled assessments when in scheduled window. Do not transmit PPS assessment until resident has remained in the facility into the second day of payment window. Delete (strike through) unnecessary s. Wait to transmit assessments until resident is safely into the payment window

36 PT OFF PT OFF PT 100 PT 100 PT 100 PT 1OO PT 100 OT OFF OT OFF OT 60 OT 60 OT 60 OT 60 OT 60 7-DAY TOTAL MINUTES 800 TOTAL MINUTES REQUIRED??? What is the best strategy? 71 8 ARD for 5-day. Resident received three days of therapy for 120 minutes. There were no Restorative Nursing programs being provided. RUG HE2. 15 ARD for 14-day. Resident receives five days of P.T., five days of O.T., with total minutes of 725, so qualifies for the Rehab Ultra High RUG. Can 14-day be combined with a? 72 36

37 73 If Medicare coverage does not end within three days of the therapy end date, an EOT is required. It is the EOT ARD that affects the calendar NOT the actual last day of therapy

38 Last day of observation is on May 4 th. Therapy s late treatment day was May 2 nd. If the ARD for EOT OMRA is set for May 3 rd or May 4 th, the SNF would not be required to complete the OMRA. If the ARD for the EOT OMRA were set for May 5 th, regardless of when therapy ended, then a OMRA would be required with an ARD of May 4 th. 75 In cases where a resident is discharged from the SNF on or prior to day 7 of the observation period, then no OMRA is required. More precisely, in cases where the date coded for Item A2000 is on or prior to day 7 of the observation period, then no OMRA is required. If an SNF chooses to complete the OMRA in this situation, they may combine the OMRA with the discharge assessment

39 In cases where the last day of the Medicare Part A benefit (the date used to code A2400C on the MDS) is prior to day 7 of the observation period, then no OMRA is required. If the date listed in A2400C is on or after day 7 of the observation period, then a OMRA would be required if all other conditions are met. 77 Finally, in cases where the date used to code A2400C is equal to the date used to code A2000 that is, cases where the discharge from Medicare Part A is the same day as the discharge from the facility and this date is on or prior to day 7 of the observation period, then no OMRA is required. Facilities may choose to combine the OMRA with the Discharge assessment under the rules outlined for such combination in this chapter

40 Flexibility period exists even if resident discharges. Facility can set the ARD for OMRAs during the flexibility period even if the resident has been discharged as long as no more than two days have passed since day 7 of the checkpoint of the period is day 100 of the resident s benefit period. Therapy will be given on day 100, and then benefits exhaust. Therapy decreased from the previously paying RUG. Must a be completed? 80 40

41 Example of a late unscheduled assessment would be if a OMRA was completed with an ARD of day 39, while day 7 of the observation period was day 37. In this case, the OMRA would be considered two days late and the facility would bill the default rate for two days, and then bill the HIPPS code from the late OMRA until the next scheduled or unscheduled assessment controls payment, in this case, for at least five days. NOTE: In such cases where a late assessment is completed and no intervening assessments occur, the late assessment is used to establish the calendar Admit Date 8 5-day PPS ARD day PPS ARD Required but not opened ( 7) opened Next Checkpoint

42 In the case of an unscheduled PPS 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 the late unscheduled assessment policy, the provider-liable period only lasts until the point when an intervening assessment controls the payment. 83 The 30-day ARD was set for day 27 = RVB. 34, therapy decreased to RHB. No was opened. Resident discharged on day 35. Facility realized that the was missed during their Triple Check meeting conducted on day 38. What is the payment implication? 84 42

43 A. One day of default. B. One day of provider liability. C. Seven days of default rate. D. Seven days of provider liability. E. Combine the with the Discharge MDS. 85 End of Therapy ARD set. Medicare coverage ends. Resident did not receive enough therapy in the 7- day assessment window to qualify for a Rehab RUG, and has three consecutive days of missed therapy after day 1 of the observation window of the that placed the resident into a non-therapy RUG

44 87 A Medicare-required 14-day assessment with an ARD of day 32 would be paid at the default rate for days 15 through 30. A late assessment cannot be used to replace a different Medicare-required assessment. In the example above, the SNF would also need to complete the 30-day Medicare-required assessment within days 27-33, which includes grace days. The 30-day assessment would cover days 31 through 60 as long as the beneficiary has SNF days remaining and is eligible for SNF Part A services. In this example, the late 14-day assessment would not be considered an assessment used for payment and would not impact the calendar, as only an assessment used for payment can affect the calendar

45 1 Admit Date 8 5-day PPS ARD day ARD day ARD 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 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) occurred between 1 of the observation period for the OMRA that classified the resident into his/her current non-therapy RUG-IV group, and the ARD of the OMRA that reclassified the resident into a RUG-IV therapy group

46 For example: Mr. T. classified into the RUG group RUA on his 30-day assessment with an ARD set for day 30 of his stay. On day 37, the facility checked the amount of therapy provided to Mr. T. and found that while he did receive the requisite number of therapy minutes to qualify for this RUG category, he only received therapy on four distinct calendar days, which would make it impossible for him to qualify for an Ultra-High Rehabilitation RUG group. Moreover, due to lack of five distinct calendar days of therapy and a lack of restorative nursing services, Mr. T. did not qualify for a therapy RUG group. Mr. T. s rehabilitation regimen has continued throughout this time period. The facility may complete a OMRA with an ARD of day 44 to reclassify Mr. T. back into RUA PT off PT off PT 100 PT 0 PT 100 PT 100 PT 100 OT off OT off OT 60 OT 0 OT 60 OT 60 OT 60 SLP off SLP off SLP 60 SLP 12 SLP 60 SLP 60 SLP PT off PT off PT 100 PT 100 PT 100 PT 100 PT 100 OT off SLP off OT off SLP off OT 60 SLP 60 OT 60 SLP 60 OT 60 SLP 60 OT 60 SLP 60 OT 60 SLP

47 28 30-day ARD Rehab RUG No No 34 No 35 required NSG RUG No 40 No 41 No 42 NSG RUG No NOT Allowed = Rehab RUG but no allowed 93 No discontinuation of therapy services (planned or unplanned) occurred between 1 of the observation period for the OMRA that classified the resident into his/her current non-therapy RUG-IV group and the ARD of the OMRA that reclassified the resident into a RUG-IV therapy group

48 If the assessment that placed the resident into the non-therapy RUG was not a or /Scheduled PPS combination (ex., 30- day/), the resident cannot be placed back into the Rehab RUG until the next scheduled assessment where they qualify for a Rehab RUG. 5-day (day 8) = RUB. 14-day (day 15) = CC1 (Nursing RUG) because resident only received four calendar days of. 22 resident receiving Ultra High therapy. No can be completed!!! 95 If the assessment that placed the resident into the non-therapy RUG was not a or /Scheduled PPS combination (ex., 30- day/), the resident cannot be placed back into the Rehab RUG until the next scheduled assessment where they qualify for a Rehab RUG. 5-day (day 8) = RUB. 14-day (day 15) = CC1 (Nursing RUG) because resident only received four calendar days of. 22 resident receiving Ultra High therapy. No can be completed!!! 96 48

49 Mistaken minutes on the MDS; Missed days not made up immediately; Scheduled assessment done instead of, but resident discharges prior to payment period for scheduled assessment; Less than 5 calendar days of therapy provided during the 7-day look-back window; Refusals; Staffing issues; Holidays. 97 Some Fiscal Intermediaries/MACs have recommended documentation of the informal observation windows. This is not REQUIRED, but RECOMMENDED. Documentation may include: Therapy days and minutes for each therapy discipline. RUG expected. Signatures/initials of staff members completing the observations. This documentation may be helpful with ARDs and reviewing checkpoints

50 Date 8/1 5-d 8/7 14-d 8/14 8/20 30-d 8/27 PT s PT Minutes OT s OT Minutes SLP s SLP Minutes needed? Y/N N/A No Yes No Initials MDS and Rehab Manager CAM LLL CAM LLL CAM LLL CAM LLL PT 75 PT 90 PT 75 PT 60 PT PT 60 PT 75 OT 75 OT 60 OT 75 OT 75 OT OT 60 OT 30 7 day total ARD 5- day

51 PT 75 PT 90 PT 75 PT 60 PT PT 75 PT 90 OT 75 OT 60 OT 75 OT 60 OT OT 75 OT 75 7 day total ARD 5- day PT 0 PT 0 PT 120 PT 120 PT 120 PT 120 PT 120 OT 0 OT 0 OT 60 OT 0 OT REFUSED OT 0 OT 60 7-day lookback 720 TOTAL MINUTES required???

52 PT off PT off PT 100 PT REF PT 100 PT 100 PT 100 OT off OT off OT 60 OT Off OT 60 OT Off OT 60 SLP off SLP off SLP 60 SLP 60 SLP OFF SLP 60 SLP 60 7-day lookback 760 TOTAL MINUTES PT OFF PT OFF PT 100 PT 100 PT 100 PT 1OO PT 100 OT OFF OT OFF OT 60 OT 60 OT 60 OT 60 OT 60 7-DAY TOTAL MINUTES 800 TOTAL MINUTES REQUIRED??? What is the best strategy?

53 End of Therapy ARD set. Medicare Coverage ends. Resident did not receive enough therapy in the 7- day assessment window to qualify for a Rehab RUG and has three consecutive days of missed therapy after day one of the observation window of the that placed the resident into a non-therapy RUG. 105 Of of a Rehab RUG when nursing skilled coverage continues

54 Required when: 1. Rehab RUG is payer 2. Continues to need Part A SNF-level services after the planned or unplanned discontinuation of all rehabilitation therapies for three or more consecutive days. 3. IMPORTANT NOTE: The resident must require and receive a daily skilled nursing service or Medicare A coverage must end with the end of therapy! 107 Assessment Reference Date must be set on day 1, 2, or 3 after all therapies have ended. Last day therapy was provided is day 0. (Not the date the physician wrote the order to discontinue therapy) Establishes a new non-therapy RUG and Medicare payment rate which begins the day after the last therapy treatment

55 - If the resident received therapy Friday, was not scheduled for therapy on Saturday or Sunday and refused therapy for Monday, one would be Saturday. For purposes of determining when an EOT OMRA must be completed, a treatment day is defined exactly the same way as in Chapter 3, Section O, 15 minutes of therapy a day. If a resident receives less than 15 minutes of therapy in a day, it is not coded on the MDS and it cannot be considered a day of therapy P.T. 30 O.T. 30 P.T. 15 O.T. 45 No Therapy P.T. 12 O.T. 0 Refused Therapy P.T. 30 O.T. 30 P.T. 30 O.T. 30 Is an EOT required? Which dates should be considered for the ARD of the EOT?

56 Misses three days of therapy. Therapy begins again within five consecutive calendar days. Therapy is same RUG level as prior to missed days. No new therapy evals required. Enter resumption dates in O0450A and B. observation window begins on day therapy resumed. Uses the EOT item set. 111 Section O0450 Billing - Rehab RUG level payment resumes on the date stated in O0450b

57 First, the resident must resume therapy at the same RUG-IV therapy level as was in effect prior to the break in therapy. So, if the resident was last billed at Very-High rehabilitation, then the resident must resume at Very-High rehabilitation. Second, the resident s previous therapy plan must still be in effect. For example, if the resident qualified for Very-High rehabilitation on the basis of receiving Physical and Occupational therapies, then these disciplines must resume at the same intensity as prior to the break in therapy. If, for a given resident, one or both of these two conditions are not met, then an EOT-R may not be completed for that resident. 113 ARD = 30, RUG = RUB. Therapy provided days No therapy provided days 36, 37, 38, 39. Therapy restarts at same level on day

58 ARD RUB ARD RUB ARD obs ARD 1 EOT ARD 2 EOT ARD 3 EOT Res ump tion

59 s paid at RUB (Z0100A) from 30- day MDS. s paid at nursing RUG from Z0150A of EOT-R MDS. Beginning day 40, payment will resume at RUB (Z0100A RUG from 30-day MDS) level since therapy resumed within five days and at same level as the 30-day MDS ARD RUB ARD ARD 1 EOT ARD 2 EOT ARD 3 EOT Res ump tion RUB RUB 30 RUG 30 RUB 30 RUB 30 RUB 30 NSG NSG NSG NSG RUB 0A RUB 0A

60 30-day PPS MDS ARD is day 30, RUG (Z0100A) is RUB. Therapy provided days No therapy days 36, 37, 38, 39 resident ill. Therapy resumes on day 40 but at RM level since resident not feeling well ARD of 30d RUB

61 Total on day 37 (days 31-37) NOT consistent with 30-day RUG, OMRA not required if ARD set on day 36 or 37 since all therapy ended prior to end of observation window. EOT OMRA ARD day 36, 37, 38. Therapy resumes day 40 but at RM level. New observation begins on day ARD RUB ARD ARD 1 EOT ARD 2 EOT ARD 3 EOT New ther apy eval

62 30-day RUG continues to pay through day 35. EOT OMRA Z0150A Nursing RUG pays for days Beginning day 40, Nursing RUG continues from EOT until SOT is completed. New therapy initial evals and care plan would be required to restart therapy ARD RUB ARD ARD 1 EOT ARD 2 EOT ARD 3 EOT New ther apy eval RUB RUB 30 RUB 30 RUB 30 RUB 30 RUB 30 NSG NSG NSG NSG NSG Or SOT NSG Or SOT

63 ARD always set for day 1, 2, or 3 after last therapy treatment day. No new evals needed if therapy resumes within five calendar days at EXACTLY same RUG level. If therapy does not start within five calendar days or resumes at a different RUG level, do new therapy evals. Do SOT to start rehab RUG payment

64 All eight of the following requirements MUST be met: 1. Assessment must be a SOT OMRA (A310C = 1). o Can be combined with a discharge assessment when the end of Part A stay is the result of discharge from the facility, but should not be combined with a discharge if the resident dies in the facility or is transferred to another payer source within the facility A PPS 5-day MDS has been completed. (Can be combined with SOT OMRA). 3. The ARD (A2300) must be on or before the 8 th day of the Part A Medicare Covered Stay. 4. The ARD (A2300) of the SOT OMRA must be the last covered day of Medicare Part A. The end of the Medicare stay date is the date Part A ended. (A2300 must equal A2400C)

65 5. The ARD (Item A2300) of the Start of Therapy OMRA may not be more than three days after the start of therapy date (Items O0400A5, O0400B5, or O0400C5, whichever is earliest), not including the start of therapy date. o This is an exception to the rules for selecting the ARD for a SOT OMRA, as it is not possible for the ARD for the Short Stay Assessment to be 5-7 days after the start of therapy since therapy must have been able to be provided only 1-4 days. 6. Rehab therapy (S.L.P., O.T., or P.T.) started during the last four days of the Medicare Part A covered stay (including weekends). o The end of Medicare stay date (Item A2400C) minus the earliest start date for the three therapy disciplines (Items O0400A5, O0400B5, or O0400C5) must be three days or less At least one therapy discipline continued through the last day of the Medicare Part A stay. At least one of the therapy disciplines must have a dash-filled end of therapy date (Items O0400A6, O0400B6, or O0400C6) indicating ongoing therapy or an end of therapy date equal to the end of covered Medicare stay date (Item A2400C). Therapy is considered to be ongoing when: o The resident was discharged and therapy was planned to continue had the resident remained in the facility, or o The resident s SNF benefit exhausted and therapy continued to be provided, or o The resident s payer source changed and therapy continued to be provided

66 8. The RUG group assigned to the Start of Therapy OMRA must be Rehabilitation Plus Extensive Services or a Rehabilitation group (Z0100A). If the RUG group assigned is not a rehab or rehab plus extensive RUG, the assessment will be rejected. If all eight requirements are met, set the Medicare Short Stay Indicator by checking Item Z0100C. Calculate average therapy minutes by dividing the total therapy minutes by the number of days from the start of therapy through the ARD. 131 Therapy started October 1 st,no therapy was provided on October 2 nd or 3 rd. ARD is October 3 rd. The average minutes are calculated by dividing by three days

67 If therapy average minutes provided were: 144 minutes or more = Rehab Ultra High minutes = Rehab Very High minutes = Rehab High minutes = Rehab Medium minutes = Rehab Low If Nursing extensive services also provided, can be placed into X or L on short stay

68 When Medicare A coverage ends for any reason, unless the resident dies while on Medicare. Required when remaining in the SNF after Medicare coverage ends (benefits exhaust or skilled services ended). Required when the resident discharges unexpectedly to the hospital or other provider. Required when the resident discharges to the community. 135 A0310H. Is this a SNF PPS Part A Discharge (End of Stay) Assessment?

69 A standalone Part A PPS Discharge assessment (NPE Item Set) is required when the resident s Medicare Part A stay ends (as documented in A2400C, End Date of Most Recent Medicare Stay) but the resident remains in the facility. The ARD (Item A2300) for the Part A PPS Discharge assessment is always equal to the end date of most recent Medicare stay (A2400C). A2300 = A2400C TheARD may be coded on the assessment any time during the assessment completion period (i.e., End Date of Most Recent Medicare Stay [A2400C] + 14 calendar days). 137 If a resident receiving services under SNF Part A PPS has a Discharge Date (A2000) that occurs on the day of or one day after the End Date of Most Recent Medicare Stay (A2400C), then both an OBRA Discharge assessment and a Part A PPS Discharge assessment are required, but these two assessments can be combined. When the OBRA and Part A PPS Discharge assessments are combined, the ARD (A2300) must be the same as the Discharge Date (A2000). A2300 (ARD) = A2000 (Physical discharge date). While the Part A PPS Discharge is required, Section GG would not be required when the discharge was unplanned or the SNF stay was less than three days

70 Print new 100-day tools for each active Medicare A resident. 2. Keep a Medicare binder of all active Medicare A residents in alphabetical order and all residents who have discharged that month from Medicare (back of binder). Keep the discharged tools until after Medicare Triple Check. 3. Create a Change of Therapy OMRA Observation Tool for each resident receiving therapy

71 Be prepared to set ARDs with MDS Coordinator for each scheduled Assessment window. Review each resident at seven days from ARD to determine if in same therapy RUG if days, minutes, or disciplines different, required. Review each resident with rolling 7-day window. Notify MDS Coordinator immediately of missed therapy, addition or removal of discipline, change in ARD

72 Must be held where entire team can view the therapy software. MDS Coordinator must bring additional tools for managing PPS schedules (100-day tools, calendars, schedules, etc.). Best practice MDS assessments also should also be visible during PPS meeting. Bring laptop with MDS software loaded so that MDS assessments can be reviewed/added. Review all residents in assessment window. Review alphabetically so no resident is missed. MDS Coordinator bring binder of 100-day tools of Medicare A residents. Set ARDs review every resident on 7-day rolling assessment windows. (Clearly state date of ARDs). 143 Review each resident to determine when resident has reached the payment window so transmission can be safely done. Report any resident refusals. Rehab Manager gives the MDS Coordinator a copy of the PPS minutes/days the day after the ARD. Discuss when therapy disciplines begin or end services. Discuss possible discharge dates/plans. Complete Observation tools. Review the Section GG evaluations/assessments and collaborate to determine the correct coding for Section GG and set a Discharge goal within three days of admission and the residents status for the items during the last three days of the Medicare A stay

73 Discuss resident progress on nursing unit, as well as in therapy. Compare therapy minutes to minutes on MDS. Ensure that therapy evaluations and physician orders are signed. Check Medicare Certifications/Re-certification forms for completion/signatures/dates and prepare certs for the following week. Discuss who needs a Medicare Beneficiary Notice. Discuss discharge plans/changes of discharge plans. Review P.L.O.F. Read nurses notes and therapy notes write weekly Medicare note if daily notes not sufficient. 145 Review UB-04s. Check 3-day qualifying stay dates with hospital records (not your facility s face sheet). Check resident name, SSN, birthdate, MCR # against CWF (not your facility s face sheet or EHR). Check to ensure that the physicians orders were signed by the author of the orders. Double check therapy days and minutes on MDS with therapy logs. Use the Medicare 100-day tools to review the number of days that each MDS entered on the UB-04 should pay

74 Check Final Validation report to ensure MDSs have been accepted prior to billing/check for error messages related to resident identifiers/rugs. Check therapy start and end dates on MDS with therapy logs. Double check when OMRAs (s, EOTs, EOT-Rs, or SOTs) begin and end therapy RUG payment. Determine if a or EOT has been missed or late. Check Medicare Certifications/Re-Certifications. 147 cmaher@hhc-cpa.com