MDS Alert

Published on Sat Oct 09, 2010 PDF

Your SNF could lose $$ big-time if you are unaware of this key point.

Section T is history with MDS 3.0 now in place, but your SNF can use the Medicare short-stay assessment to capture a rehab RUG for residents who don't receive five days of therapy. You have to know the rules for using this optional assessment, however, including when it makes fiscal sense to forego it.

1. Nail down the basics. The short-stay policy is designed to allow the facility to obtain a therapy RUG (either Rehabilitation or Rehab plus Extensive Services) for residents discharged from Part A on or before day eight of the Part A stay, according to CMS' Ellen Berry in a Sept. 1 webinar on RUG-IV. That includes residents who have exhausted their Part A benefits, as well as residents discharged to the hospital (planned or unplanned), or to the community, or to long-term care status at that facility or another one, said Berry. In such cases, if the resident meets certain other criteria (see the algorithm on page 127), the SNF has an option of doing a start of therapy (SOT) OMRA that you can combine with the 5-day or readmission PPS assessment.

Or you can complete the SOT OMRA as a standalone assessment after doing the 5-day or readmission assessment.

The ARD for the SOT OMRA has to be the Medicare end date (see the instructions for A2400C in Chapter 3, page A-25 of the RAI User's Manual). Physical therapy, occupational therapy or speech language pathology services must have started within the last four days of the stay, Berry noted. The resident must continue to receive at least one discipline of rehab therapy through the last day of the Part A stay (see the algorithm on page 127). For the short-stay assessment, the ARD for a SOT OMRA should not be more than three days after the start of therapy date recorded for any discipline (O0400A5, O0400B5, or O0400C5), whichever comes first, states the RAI User's Manual. "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," states the manual.

Critical: If the therapy start date is the first day of the resident's stay, the stay can't exceed four days. When the start of therapy date (which is the date of the therapy evaluation) is the first day of the resident's short-stay, the short-stay assessment-generated rehab RUG will apply to the entire stay.

What if the therapy start date occurs after day one of the resident's stay? In that case, if the SNF has done a 5-day/ readmission assessment combined with an SOT OMRA or an SOT OMRA after the 5-day assessment, the rehab RUG rate will begin on the therapy start date. 

For the short-stay assessment, RUG-IV pays on a prorated basis for therapy based on the average daily therapy minutes the resident received, Berry noted, as follows (the x stands for classification based on the ADL score):

• RLx --15-29 minutes
• RMx --30-64 minutes
• RHx -- 65-99 minutes
• RVx -- 100-143 minutes
• RUx -- 144 or > minutes

For some residents, the most appropriate payment is not always going to be a therapy RUG, Berry instructed. You have to look at the nursing RUG's CMI to see if it pays more than the therapy RUG based on an average of therapy minutes provided. To review the CMIs for the urban and rural RUG-IV groups, go to www.cms.gov/NursingHomeQualityInits/30_NHQIMDS30TechnicalInformation.asp. Click on "RUGIV Files" to open the file.

Don't lose $$: Keep in mind that "the SOT OMRA just asks you enough information to put the resident into Rehabilitation or Rehabilitation plus Extensive Services," says Ron Orth, RN, RAC-MT, BC, president of Clinical Reimbursement Solutions in Milwaukee, Wis. And "when you combine an SOT OMRA with a PPS assessment, you have the nursing RUG qualifiers as well, so the RUG grouper will case-mix index maximize." Thus, the resident won't classify into a rehab RUG if the nursing RUG pays more, he says. But that won't be the case when you do a stand-alone SOT OMRA. In that case, "the grouper will calculate a rehab RUG, if the resident qualifies -- and if the nursing RUG pays more, the SNF will lose money," Orth explains.

Remember: "SOT OMRAs must always result in a rehab RUG category or the assessment will be rejected according to CMS," Orth continues. He also reminds people doing the MDS that a 5-day PPS assessment works like it did under the RUG-III PPS system. "It will pay the rehab RUG (if the resident qualified for one of the rehab levels during the assessment period) for the entire 14-day payment period for the assessment." It's only when you do a short-stay assessment, which is coded as a start of therapy OMRA, that the rehab RUG payment goes into effect as of the therapy start date (the date of the therapy evaluation), he says. "The days prior to the therapy start date are paid at the nursing RUG."