The SNF MDS Assessment schedule has been revised and is effective for dates of service on or after October 1, 2011.
- The five-day assessment reference date must be set on any day from day one through day eight of the covered stay (the assessment window for the five-day assessment including the three-day grace period).
- The 14-day assessment reference date must be set on any day from day 13 through day 14 of the covered stay (the assessment window for the 14-day assessment, including the four-day grace period).
- The 30-day assessment reference date must be set on any day from day 27 through day 29 of the covered stay (the assessment window for the 30-day assessment including the four-day grace period).
- The 60-day assessment reference date must be set on any day from day 57 through day 59 of the covered stay (the assessment window for the 60-day assessment, including the four-day grace period).
- The 90-day assessment reference date must be set on any day from day 87 through day 89 of the covered stay (the assessment window for the 90-day assessment, including the four-day grace period).
CMS provided guidance on combining the scheduled and unscheduled PPS assessments. If the Assessment Reference Date (ARD) for an unscheduled PPS assessment is within the ARD window, including the grace period, and the ARD for the scheduled assessment would occur on a day after that of the unscheduled assessment, the assessments must be combined. When combining the scheduled and unscheduled assessments, CMS said that the Item Set for the scheduled assessment should be used. In addition, the ARD for the unscheduled assessment should be used.
Group Therapy Allocation
CMS has modified the Part A definition of group therapy. Under the revised definition, Part A group therapy is defined as therapy provided simultaneously to four patients (regardless of payer source) who are performing the same or similar activities. To qualify as group therapy facilities must plan group therapy sessions for no more or less than four patients. CMS said that if a resident misses a therapy session, the important factor in determining whether it is considered group therapy is if the facility planned for the session to have four participants. CMS noted that the group may consist of Part A and Part B residents.
In allocating the group therapy minutes, the facility would record the total therapy time for each resident on each MDS. For example, if a group of four residents participate in a group session for 60 minutes the facility would record 60 minutes of group therapy for each resident on each MDS. This group time would then be divided by four by the RUG-IV grouper to determine the allocated group therapy minutes (15 minutes in this example) that will be used to determine each patient's RUG classification.
Therapy Student Supervision
CMS noted that as of October 1, 2011 students are no longer required to be under line-of-sight supervision. However, the supervising therapists are expected to exercise judgment on the level of supervision required by a particular student. Time may be coded on the MDS when the therapist provides skilled services and direction to a student who is participating in the provision of therapy. All time that the student spends with patients should be documented.
End of Therapy (EOT) OMRA
CMS clarified that an EOT OMRA must be completed when a beneficiary who is classified in a RUG-IV Rehabilitation Plus Extensive Services or Rehabilitation group did not receive any therapy services for three or more consecutive calendar days for any reason, including if therapy is missed due to a weekend or holiday. For example, CMS said that if a patient received therapy on Friday, the facility does not offer therapy on the weekend and the patient misses therapy on the following Monday, an EOT OMRA is required. The ARD for the EOT OMRA must be set for day 1, 2, or 3 after the date of the last therapy session.
An End of Therapy with Resumption (EOT-R) may be used when the resident will resume therapy, provided the therapy will be at the same level as before the therapy was discontinued. This resumption, however, must occur no more than five days after the last day of therapy. Facilities are advised that they should bill the non-therapy RUG given on the EOT OMRA beginning the day after the patient's last therapy session. Then, beginning the day that therapy was resumed, the facility would begin billing the therapy RUG that was in place before the EOT OMRA.
CMS clarified that an EOT OMRA is not required if a resident is discharged from a Part A stay before missing three days of therapy.
If an EOT-R is used, the HIPPS code used to bill the days affected should include the AI code used on the EOT-R.
Change of Therapy (COT) OMRA
For all assessments with an ARD on or after October 1, 2011 a COT OMRA is required if the therapy received during the COT observation period does not reflect the RUG-IV classification level on the most recent PPS assessment that was used for payment. CMS is defining the COT observation period as a successive 7-day window beginning the day following the ARD of the resident's last PPS assessment used for payment. The COT OMRA is required when the therapy received during the COT observation period would cause the patient to be reclassified into a different RUG category, be it a higher or lower one. If the therapy that is performed during the COT observation period is consistent with the patient's current RUG-IV classification a COT OMRA is not required. Providers should perform an informal change of therapy evaluation to consider the intensity of the therapy provided during the COT observation period. However, providers are required to consider the total reimbursable therapy minutes, the number of therapy disciplines, the number of therapy days, and restorative nursing for those in a Rehab Low category.
The COT OMRA has retroactive payment implications as it establishes a new RUG beginning on Day 1 of the COT observation period used to set the ARD of the COT OMRA and continues until the next scheduled or unscheduled PPS assessment. CMS noted that in some cases a resident simultaneously may meet the criteria for a therapy and a non-therapy RUG that has a higher per diem rate, resulting in an index that maximized into a non-therapy RUG group. In such a case the facility is required to complete a COT evaluation for all patients receiving any amount of skilled therapy services, even those indexed into a non-therapy RUG group.
CMS also clarified that the COT OMRA is not required if Day 7 of the COT observation period also is the day of discharge. In addition, a COT OMRA is not required if the ARD of a scheduled PPS assessment is set on or before Day 7 of the COT observation period.
CMS said that in regards to co-treatment, under which two clinicians from a different discipline treat a Part A patient at the same time, both disciplines may code the full treatment session. However, the decision to co-treat should be made on a case-by-case basis and should be documented in the patient's plan of care. CMS expects co-treatment to be used in specific clinical circumstances and therefore be limited.
Leave of Absence (LOA)
- For scheduled PPS assessments, the Medicare assessment schedule is adjusted to exclude a LOA when determining the appropriate ARD for a given assessment.
- For unscheduled PPS assessments, days during which a resident experiences a LOA must be counted toward the ARD for a given unscheduled assessment, such as an EOT OMRA or a COT OMRA. CMS also noted that the ARD for an unscheduled PPS assessment may be set for an LOA day.