MDS Alert

Published on Tue Jan 04, 2011 PDF

Obtain the fairest reimbursement and sidestep unnecessary assessments.

In a nutshell: "CMS expects that facilities will use this optional assessment in cases where the rehab level will pay more than the resident's RUG prior to the initiation of therapy," says Jennifer Pettis, RN, WCC, RAC-MT, a consultant with Harmony Healthcare International in Topsfield, Mass.

You may complete the SOT OMRA at any time during the resident's stay, said CMS' Ellen Berry in a November 2010 CMS-sponsored provider call on RUG-IV and MDS 3.0. When you do an SOT OMRA, the rehab payment rate begins on the earliest start of therapy date, which is the date of the first therapy evaluation, Berry noted.

When doing an SOT OMRA (other than for a short-stay assessment), the assessment reference date (ARD) for the SOT OMRA must be day five, six, or seven, with day one being the earliest therapy start date (therapy evaluation date), Berry reminded providers in a September 2010 provider call.

Different rules: For a short-stay assessment, the ARD for the SOT OMRA can't be more than three days after the start of therapy date (for more information, see MDS Alert, Vol. 8, No. 12, and Chapter 6, Section 6.4 of the RAI User's Manual).

Check the RUG: The RAI User's Manual notes that if the SOT OMRA doesn't produce a Rehabilitation or Rehabilitation Plus Extensive Services RUG, the assessment won't be accepted, cautions Elisa Bovee, MS OTR/L, with Harmony Healthcare International in Topsfield, Mass. And the facility can't use it for billing, the manual notes.

Remember: You don't complete an SOT OMRA to increase or decrease a therapy RUG once a person is assigned to one, Berry advised.

You must be aware of the RUG case-mix indices (CMIs) in order to determine whether to do the SOT OMRA, Berry said in the November provider call (see the CMIs on page 9).

Even though the SNF is providing therapy, sometimes it won't be a good idea to do an SOT OMRA -- especially for some of the medium rehab RUGs, advises Sherri Robbins, RN, supervising consultant for BKD LLP in Springfield, Mo.

Stay in step with the ADL score: When deciding whether to do an SOT OMRA for a patient in a nontherapy RUG, pay attention to the resident's ADL score, Berry stressed in the November provider call.

Pauline Franko, PT, MCSP, agrees, noting that a resident's ADL score may improve from an 11 to a 10, as an example. And that one-point change in ADL score will automatically change his rehab RUG score from a C to a B, cautions Franko, owner of Encompass Consulting & Education LLC in Tamarac, Fla. (see the rehab RUG CMIs, page 9).

"You don't always combine the SOT OMRA with another assessment," advises Glenda Mack, MSPT, CWS, CLT, a consultant in Louisville, Ky. "It can be a stand-alone assessment if the ARD [for the SOT OMRA] is not an available ARD for any other standard PPS (5, 14, 30, 60, or 90-day) assessment."

Key: "Providers need to keep in mind that the SOT OMRA just asks you enough information to put the resident into Rehabilitation or Rehabilitation Plus Extensive Services," counsels Ron Orth, RN, RAC-MT, CPC, president of Clinical Reimbursement Solutions in Milwaukee, Wis. And "when you combine a start of therapy OMRA with a PPS assessment, you have the nursing RUG qualifiers as well. So the RUG grouper will case-mix index maximize and not put the resident in rehab if the nursing RUG pays more.

But that's not the case when you do a stand-alone start of therapy OMRA. It will calculate a rehab RUG, if the resident qualifies. And if the nursing RUG pays more, the SNF will lose money," he cautions.

"That's why SNFs have to look to see whether they should do a stand-alone SOT OMRA," says Orth. "And it's the reason CMS states that SOT OMRAs are optional." You have to review each case separately, he adds.

Beware: "CMS strongly recommends that you do not combine [the SOT OMRA] with the 5-day assessment with the exception being for the short stay assessment," Berry said in the November provider call. "When you combine the 5-day with the start of therapy OMRA, you must bill the non-therapy HIPPS for the days prior to the earliest start of therapy date."