MDS Alert

Published on Fri Sep 04, 2009 PDF

Keep your payment and compliance humming along.

The Other Medicare Required Assessment or OMRA provides an opportunity to ensure residents get the care they need -- and your facility gets paid for providing it. The ins and outs of doing this assessment correctly can get tricky, however.

The solution: Review the rules for doing an OMRA, and sidestep pitfalls that can trip up your compliance and quality-of-care track record.

In a nutshell: You have eight to 10 days after the patient in a rehab RUG stops receiving all therapy to set the ARD for an OMRA, if the resident will remain on Part A for skilled nursing care, says Roberta Reed, RN, MSN, a consultant with Plante & Moran Clinical Group in Cleveland, Ohio. "The first non-therapy day counts as day 1," states the RAI User's Manual.

To stay on the high road with your OMRAs, watch out for these common verboten practices.

1. Doing an OMRA for a resident who isn't in a Rehab or Rehab Plus Extensive Services  RUG. You don't do an OMRA if the resident in a nursing RUG stops receiving rehab therapy, says physical therapist Shehla Rooney, a consultant in Cookeville, Tenn. Rooney sees facilities sometimes make this error when a resident has his therapy decreased to three times a week and isn't referred for restorative nursing -- or he receives restorative that isn't captured on the MDS because it doesn't meet the RAI manual documentation requirements. Thus, the person goes into a non-rehab RUG rather than rehab low.

2. Failing to set the ARD strategically. The Medicare payment will change as of the assessment reference date for the OMRA. And usually a person will go from a higherpaying rehab RUG to a lower-paying nursing RUG. If that's the case, "setting the ARD as late as possible keeps the resident in the higher-paying rehab RUG longer," says Joy Morrow, RN, PhD, a consultant with Hansen Hunter & Co. in Beaverton, Colo.

3. Using an all-or-none approach. Rooney oftentimes finds SNFs that fear doing an OMRA when all therapy stops, so they routinely take residents off of Medicare in such cases. That approach can,however, short-change a resident who still requires ongoing skilled nursing care on a daily basis.

Another problem: A SNF team shouldn't systematically use a certain number of the eight to 10 days to decide whether to do the assessment. "It's OK to keep a person on skilled care for a few days after all therapy stops," when appropriate, says Morrow. But the team should evaluate that on a case-by-case basis, she emphasizes. "You don't want the person to end up back in the ED or hospital." But neither do you want to inappropriately use up a beneficiary's skilled days.

4. Allowing functional decline fall through the cracks. The team should identify functional decline in the OMRA period and see what's going on. If the person does go downhill after stopping therapy, did the team refer the person to restorative nursing, for example? asks Reed. Did the person end therapy too soon?

Real-world practice: If a resident at Benedictine Health Care Center at Innsbruck has any change in functional status at all during an OMRA period when nursing is her primary coverage, the rehab therapist does a therapy screen and asks for a therapy evaluation, if needed, to decide whether to put the person back on therapy.

"Ninety-five percent of the time, when someone comes off Part A therapy,he goes onto a restorative nursing program," says Melanie Phillips, an occupational therapist and director of rehab and the transitional care unit program at Benedictine. And "between the feedback we get from the restorative nursing staff about the patient and the feedback we get in the daily Medicare meeting, we do pick up on functional changes."

The team does an OMRA if the resident continues to have a nursing need for skilled coverage after therapy ends. Examples include a wound that isn't healing or a person who is newly on oxygen and unstable as a result -- or someone who has a feeding tube, reports Phillips.