MDS Alert

Published on Sun Mar 26, 2006 PDF

Billing OMRAs incorrectly could land your facility in hot water with auditors.

Doing OMRAs by the book isn't enough. You have to bill them that way, too, if you want to get paid correctly and avoid post-payment review and recoupments.

Nail down the basics: Do an Other Medicare Required Assessment or OMRA for residents in a rehab or rehab plus extensive services RUG eight to 10 days after all of their therapy stops--if the person will continue to be skilled for daily nursing care. (For details, see "Don't Let OMRA Confusion Throw You For A Loop" in the March 2006 MDS Alert.) In addition, the billing staff has to know when an OMRA assessment is replacing a regular Medicare-required assessment. That's because the RUG rate for a 30-day assessment will change on day 31, as an example. But "the OMRA changes the RUG rate as of the assessment reference date of a combined OMRA and regularly scheduled [Medicare] assessment," says Nancy Augustine, RN, MSN, a consultant with LTCQ Inc. in Lexington, MA. "Billing thus has to know the type of assessment to bill and the number of days to bill at a designated RUG" category, she emphasizes.

Remember: If the facility does an OMRA within the assessment window for a regularly scheduled MDS, the new RUG rate goes into effect as of the ARD of the combined assessment. That's true unless the ARD is on a grace day outside the payment cycle--for example, on day 32 for the 30-day assessment, says Marilyn Mines, RN, BC, director of clinical services at FR&R Healthcare Consulting in Deerfield, IL. In the latter case, the payment will change on the day it would have for the regularly scheduled assessment, which is day 31 for the 30-day assessment.

Watch Your HIPPS

The MDS staff should always code an OMRA as such on the MDS regardless of whether the assessment replaces a regularly scheduled Medicare assessment. Then the MDS team should give billing staff a heads-up that the OMRA is replacing a regularly scheduled MDS. Billing staff may be able to figure that out because the OMRA falls within the assessment window of a regular Medicare MDS--but don't count on it.

If billing doesn't realize the OMRA is replacing a regular MDS assessment, the facility could end up not billing some days for the patient's stay or it could bill an incorrect RUG category or HIPPS code, says Mines. Or if the MDS nurse codes an OMRA combined with a 30-day assessment as a regular 30-day assessment, billing staff could look at the MDS and select the wrong HIPPS code on the UB-92. And if the FI doesn't know the assessment is an OMRA (based on the HIPPS code), the facility can receive overpayments in a number of scenarios, cautions Theresa Lang, RN, BSN, PHN, RAC-C, WCC, a consultant with Specialized Medical Services in Milwaukee.

Example: The MDS team does an OMRA with an ARD on day 27 of the resident's stay, which will replace the 30-day MDS assessment. In that case, the payment should change on day 27, rather than day 31 as it would for a regular 30-day MDS assessment. "And in most cases, the OMRA will result in a lower-paying clinical RUG compared to the rehab RUG," says Lang. So if the facility bills the assessment as a regular 30-day assessment, it could receive several days of payment at an incorrect and potentially higher-paying rehab RUG level.

Software Is No Panacea

A manual communication system offers your best bet for avoiding OMRA billing snafus, in Lang's view. "Some software programs prompt the user by asking if an OMRA is replacing the 30-day assessment, but not all software does," says Lang. But facilities "usually have to do a lot of manual checks and overrides and corrections to get the bills correct for OMRA assessments that replace a regularly schedule assessment," Lang says.