The Prospective Payment System - Virginia Health Care ... · 2/9/18 Wilhide Consulting, Inc. (c) 3 Two Basic Types of PPS Assessments: Scheduled •Prescribed range of days from which

2/9/18

Wilhide Consulting, Inc. (c) 1

The Prospective Payment System

Judy Wilhide Brandt, RN, BA, RAC-MT, QCP, CPC, [email protected]

January 2018NC & VA

Source:

2

•Current RAI Manual, Chapter 2 & 6 (‘resources’ www.judywilhide.com)

•Chapter 2: •2.8: The SNF PPS Assessment Schedule•2.9: MDS Medicare Assessments for SNFs•2.10: Combining Medicare Scheduled and Unscheduled Assessments•2.11: Combining Medicare Assessments and OBRA Assessments •2.12: Medicare and OBRA Assessment Combinations•2.13: Factors Impacting the SNF Medicare Assessment Schedule•2.14: Expected Order of MDS Records•2.15: Determining Item Set for MDS Records

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Source:

•Chapter 6: •6.1: SNF PPS Background•6.2: Using the MDS in the Medicare Prospective Payment System•6.3: RUG-IV Overview•6.4: Relationship between the assessment and the claim•6.5: SNF PPS Eligibility Criteria•6.6: RUG-IV 66-Group Model Calculation Worksheet for SNFs •6.7: SNF PPS Policies•6.8: Non-compliance with the SNF PPS Assessment Schedule

3

What is SNF PPS?

judywilhide.com 4

Original Medicare A

• Not:• Medicare Health Plan• Medicare Advantage• State Dual-Eligible HMO• Private insurance• Tricare

We transmit PPS assessments on Original Medicare A only.

Page 5-1

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Two Basic Types of PPS Assessments:

Scheduled• Prescribed range of days from which to

select.• Penalties for improper selection.

Unscheduled• Prescribed scenarios that facility must

correctly identify in which the assessment is required.

• Penalties for improper selection.

5

HHIIPPPPSS && MMDDSS 33..00

6

HIPPS = Health Insurance Prospective Payment System

HIPPS Code will be calculated by Grouper.

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Completion/Submission of PPS-only assessments

•Must be completed (Z0500b) no later than ARD (A2300) + 14 days•Must be submitted no later than completion (Z0500b) + 14 days

7

• A SNF PPS Claim may not be submitted for payment unless the PPS MDS has been accepted into the national repository (QIES ASAP system).

• If a SNF PPS MDS is submitted and/or completed late, there is no financial penalty in the RUG payment for late completion or transmission.

• Once the PPS MDS is accepted into QIES ASAP, the SNF may bill the RUG score from that assessment.

Other uses of scheduled PPS assessments

Quality Measures•OBRA & Scheduled PPS assessments used for calculating Short and Long Term measures•Public Reporting•Five Star

•Survey “MDS Indicators”

SNF QRP•Scheduled PPS Assessments & SNF PPS Discharge used to calculate MDS based SNF-QRP measures•Initial assessment will be used to calculate risk adjustments and exclusions for SNF-QRP

8

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Scheduled PPS Assessments

Type ARD/Grace DayWindow

Payment Days

5 day 1-8 1-14

14 Day 13-18 15-30

30 Day 27-33 31-60

60 Day 57-63 61-90

90 Day 87-93 91-100

9

Day 1 – First Medicare day

2-43

Thu Fri Sat Sun Mon Tue Wed1 2 3 4 5 6 7

5/1/14 5/2/14 5/3/14 5/4/14 5/5/14 5/6/14 5/7/14Thu Fri Sat Sun Mon Tue Wed8 9 10 11 12 13 14






6/12/14 6/13/14 6/14/14 6/15/14 6/16/14 6/17/14 6/18/1410

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Thu Fri Sat Sun Mon Tue Wed50 51 52 53 54 55 56







7/31/14 8/1/14 8/2/14 8/3/14 8/4/14 8/5/14 8/6/14Thu Fri99 100

8/7/14 8/8/1411

•A2400C (Medicare end) is whichever occurs first: •Date SNF benefit exhausts or •Date of last day covered as recorded on NOMNC or•Date payer source changes from Medicare A to another payer (regardless if the resident was moved to another bed or not) or •Date resident was discharged from the facility.

NNeevveerr eeaarrlliieerr tthhaann AA11660000 eennttrryy ddaattee

NNeevveerr ddaasshheess oonn AANNYY ddiisscchhaarrggee

AA22440000 ddooeess nnoott iinncclluuddee ssttaayyss

bbiillllaabbllee ttoo MMeeddiiccaarree AAddvvaannttaaggee

HHMMOO ppllaannss..

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Part A PPS Discharge (NPE)

Purpose: To calculate SNF Quality Reporting Program (SNF QRP) Quality Measures for Original Part A stays only

1. Falls with Major Injury2. New/worsened Pressure Ulcer3. Residents with admission and discharge functional status

assessment and care plan that addresses function

What is a PPS Discharge? (NPE)

GG DC Functional Status

J1800 & J1900: Falls since entry or last OBRA/PPS MDS

M0210, M0300, M0800 Current & Worsened

Pressure Ulcers

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When is PPS DC Required?

“May” (MUST) be combined with OBRA DC when Part A stay ends and resident physically discharges from SNF on or one day after last Part A day (A2400C)

NOT required when Part A stay ends in death

Part A stay ends & resident stays in SNF

PPSDC/OBRA Discharge (ND)

GG Discharge Fxl Abilities

Falls Pressure Ulcers

Cognitive Patterns, Mood, Behaviors, Fxl Status, Bowel/Bladder, Diagnoses, Pain, Other Health Conditions, Swallowing/Nutrition, PU dimensions, Meds, Special Tx, Restraints, Discharge Plan

Any except 03

At least 3 days

RA or RNA & planned

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PPS DC/OBRA Discharge (ND)

Falls Pressure Ulcers

Cognitive Patterns, Mood, Behaviors, Fxl Status, Bowel/Bladder, Diagnoses, Pain, Other Health Conditions, Swallowing/Nutrition, PU dimensions, Meds, Special Tx, Restraints, Discharge Plan

Unplanned ORTo acute hospital ORPart A stay < 3 days

No Discharge GG

First forced combination in MDS history

OBRA Discharge and PPS Discharge must be combined when both are due.• A2400C = A2000 Discharge Date• A2400C one day prior to A2000 Discharge Date

• PPS DC doesn’t always have Discharge FxlAbilities Section GG

• PPS DC always has items to calculate QRP Falls w/major injury and QRP new/worsened pressure ulcers

Reminder: You just have to remember to do the stand-alone PPS Discharge when Part A ends and resident stays in SNF!

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19

Section 2.13

Factors Impacting the SNF PPS Schedule

20

Resident Expires Before or On the Eighth Day of SNF Stay•If beneficiary dies before or on 8th day of SNF stay, should prepare & submit a PPS MDS as completely as possible. •If PPS MDS not completed, provider must bill the default rate for any Medicare days. •Medicare Short Stay Policy may also apply. Must also complete a Death in Facility Tracking. (Section 2.12)

When the resident dies or is discharged prior to the end of the look-back period for a required assessment, the ARD must be adjusted to equal the discharge date. (Page A-31)

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21

• If beneficiary is discharged from the SNF or transferred to another payer source before or on the eighth day of the covered SNF stay, the provider should prepare a Medicare-required assessment as completely as possible and submit the assessment as required.• “Discharged from the SNF” = leaves the certified bed• “Transfers to another payer source” = remains in the certified bed but no longer billing

Part A for the stay.

•If there is not a PPS MDS in the QIES ASAP system, the provider must bill the default rate for any Medicare days. •If Part A stay ends & beneficiary remains in the facility, a Part A PPS Discharge assessment is required. •When physically discharged, must also complete an OBRA Discharge assessment which may be combined with a PPS assessment if all requirements for both are met.

Resident Discharged Before or On the Eighth Day of SNF Stay

22

Missed AssessmentIf the SNF fails to set the ARD of a scheduled PPS assessment prior to the end of the last day of the ARD window, including grace days, and the resident is no longer a SNF Part A resident, and as a result a Medicare-required assessment does not exist in the QIES ASAP for the payment period, the provider may not usually bill for days when an assessment does not exist in the QIES ASAP. When an assessment does not exist in the QIES ASAP, there is not an assessment based RUG the provider may bill. In order to bill for Medicare SNF Part A services, the provider must submit a valid assessment that is accepted into the QIES ASAP. The provider must bill the RUG category that is verified by the system. If the resident was already discharged from Medicare Part A when this is discovered, an assessment may not be performed. 6-55

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Short Stay•If beneficiary dies, is discharged from the SNF, or discharged from Part A level of care on or before the eighth day of covered SNF stay, the resident may be a candidate for the short stay policy. •The short stay policy allows the assignment into a Rehabilitation Plus Extensive Services or Rehabilitation category when a resident received rehabilitation therapy and was not able to have received 5 days of therapy due to discharge from Medicare Part A. See Chapter 6, Section 6.4 for greater detail.

23

Resident is Admitted to an Acute Care Facility and Returns•If a Medicare Part A resident is admitted to an acute care facility and later returns to the SNF (even if the acute stay facility is less than 24 hours and/or not over midnight) to resume Part A coverage, the Medicare assessment schedule is restarted with a PPS 5 day assessment.

24

Restart PPS schedule with PPS 5 dayContinue OBRA schedule where it left off if

no SCSA

Reentry tracking form

Consider Significant Change

DCRNA + PPS DCMay also need to combine a PPS

assessment

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25

•If a resident is out of the facility•over a midnight, • less than 24 hours, and • is not admitted to an acute care facility, the Medicare assessment schedule is not restarted.

•The day the resident was absent at midnight is not a covered Part A day. This the “midnight rule.” •The Medicare assessment schedule must then be adjusted to skip the day in calculating when the next Medicare assessment is due. •Scheduled PPS MDS may NOT be on LOA/skip day•Unscheduled PPS MDS may be on LOA/skip day

Resident Is Sent to Acute Care Facility, Not in SNF over Midnight, and Is Not Admitted to Acute Care Facility

If resident goes to ER at 10 p.m. Wednesday, day 22 of his Part A stay, and returns at 3 a.m. the next day, Wednesday is not billable to Part A. As a result, the day of his return to the SNF, Thursday, becomes day 22 of his Part A stay.

Wed Thu Fri Sat Sun Mon Tue22 23 24 25 26 27 28

5/20/15 5/21/15 5/22/15 5/23/15 5/24/15 5/25/15 5/26/15Wed Thu Fri Sat Sun Mon Tue29 30 31 32 33 34 35

5/27/15 5/28/15 5/29/15 5/30/15 5/31/15 6/1/15 6/2/15

Wed Thu Fri Sat Sun Mon Tueskip 22 23 24 25 26 27

5/20/15 5/21/15 5/22/15 5/23/15 5/24/15 5/25/15 5/26/15Wed Thu Fri Sat Sun Mon Tue28 29 30 31 32 33 34

5/27/15 5/28/15 5/29/15 5/30/15 5/31/15 6/1/15 6/2/1526

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Leave of Absence: Page 2-13

•Leave of Absence (LOA), which does not require completion of either a Discharge assessment or an Entry tracking record, occurs when a resident has a: •Temporary home visit of at least one night; or •Therapeutic leave of at least one night; or •Hospital observation stay less than 24 hours and the hospital does not admit the patient.

27

• For scheduled PPS ARDs, the schedule must be adjusted to exclude the LOA because the ARD may not be on a non-benefit period day. • The schedule is not restarted upon return from LOA

28

• Left SNF at 6:00pm on Wednesday, which is Day 27 of the resident’s stay • Returns to the SNF on Thursday at 9:00am• LOA day may NOT be used as ARD for a PPS scheduled assessment (page 2-81)• LOA day MAY be used as ARD for a PPS unscheduled assessment

Wed Thu

27 27Non-

billable

LOA and Scheduled ARD

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When a SNF plans to combine a scheduled and unscheduled assessment on a given day, & that day becomes an LOA day for the resident:• LOA day may still be used as the ARD of the

unscheduled assessment, • LOA day cannot be used as the ARD of the scheduled

assessment.

2-81

May 10

5 day ARD

May 17

May 18

COT 14 day

29

When a SNF plans to combine a scheduled and unscheduled assessment on a given day, & that day becomes an LOA day for the resident:• LOA day may still be used as the ARD of the

unscheduled assessment, • LOA day cannot be used as the ARD of the scheduled

assessment.

2-81

May 10

5 day ARD

May 17

May 18

LOA

COT 14 day

14-day would need to have an ARD that falls on one of the resident’s Medicare A benefit days. (prior to or after LOA day, depending on ARD range)

30

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Review

31

ARD COT ARD

LOA

ARD

PT PT PT PT PT

Sick no PT

COT ARDLOAto ER no PT

Back from LOA, no PT

EOT Count

Reminder: If LOA is not to hospital, it can be more than one night.

32

•Do PPS DC on last covered day (LCD)•If resident remains in certified bed, OBRA schedule continues. •No reason to change the OBRA schedule when Part A benefits resume. (Consider Sig Change)

•Start Medicare schedule again with a PPS 5 day MDS•Do the GG assessment in 1st three days of SNF stay•The original date of entry (Item A1600) is retained. •New Medicare Start Date in A2400

Resident Discharged from Part A Skilled Services and Returns to SNF Part A Skilled Level Services (30 day tracking)

2/9/18


•When the beneficiary requires and receives SNF level of care services within 30 days from the hospital discharge, Day 1 for the Medicare assessment schedule is the day on which SNF level of care services begins.•Remember GG admission assessment on first 3 days of SNF stay.•Example: •Hospital discharge August 1 •Discharge is Day Zero (Ch 8, Benefit Policy Manual, Section 20.2.1)

•SNF determines on August 31 that beneficiary requires skilled service for a condition that was treated during the qualifying hospital stay, then the SNF would start the Medicare assessment schedule with a 5-day Medicare-required assessment, with August 31 as Day 1 for scheduling purposes.•OBRA Admission assessment would have already been completed by day 14 of the

stay.33

Delay in Requiring and Receiving Skilled Services Ch 6, Sec 6.7

Unscheduled PPS Assessments

34

Just a few simple rules!

2/9/18


Other Medicare Required Assessments (OMRA)

35

Therapy

Change

End

Start

CCooddiinngg TTiippss aanndd SSppeecciiaall PPooppuullaattiioonnss ((OOMMRRAAss)) 22--6600

When coding standalone OMRAs:•Must set ARD for a day within the allowable ARD window, but may only do so no more than two days after the window has passed.•Even if the resident discharges during this two day period•Interview items may be coded using the responses provided by the resident on a previous assessment only if the DATE of the interview responses from the previous assessment (as documented in item Z0400) were obtained no more than 14 days prior to the DATE of completion for the interview items on the unscheduled assessment (as documented in item Z0400) for which those responses will be used.•Providers may conduct resident interview portions of that assessment up to two calendar days after the ARD

36

2/9/18


Standalone COT ARD

37

1ARD

2 3 4 5 6 7

8

COT

9 10 11 12 13 14

1 2 3 4 5 6

7

COT checkpoint Friday

38

1ARD

2 3 4 5 6 7

8Fri

COT

9Sat

10Sun

11Mon

12 13 14

Too Late!

Tip: Open Friday before you go home. Delete Monday if not needed.

2/9/18


Setting ARD for Stand alone EOT/SOT

39

1 2Last therapy

3 4 5 6 7

8 9 10 11 12 13 14

1 2 3

SOT works the same way!

22..1122 MMeeddiiccaarree aanndd OOBBRRAA AAsssseessssmmeenntt CCoommbbiinnaattiioonnss

• When any OMRA is combined with a discharge assessment, the ARD for that combination assessment may be set one or two days after the day of discharge.

40

OMRA/

Discharge

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OMRA Specifics: A deeper dive

41

SOT

EOT

COT

Start of Therapy (SOT) OMRA 2-51

•Optional.•Completed only to classify a resident into a Rehab RUG. If the RUG assigned is not Rehab, will not be accepted into CMS database.•ARD must be set on days 5-7 after the start of therapy with the exception of the Short Stay Assessment. •The date of the earliest therapy evaluation is counted as day 1 when determining the ARD, regardless if treatment is provided or not on that day.•May be combined with scheduled PPS assessments.•SOT not necessary if rehabilitation services start within the ARD window (including grace days) of the 5-day assessment, since the therapy rate will be paid starting Day 1 of the SNF stay.•ARD may not precede the ARD of first scheduled PPS assessment of the Medicare stay (5-day assessment).

42

2/9/18


SOT illustration

1 2 3 4 5 PT Eval

6 OT Eval

7

8 9 10 11 12 13 14

43

SOT Range

SOT controls payment beginning on the earliest Therapy Start Date

Nursing RUG Controls payment

Medicare Short Stay Assessment

To be considered a Medicare Short Stay assessment and use the special RUG-IV short stay rehabilitation therapy classification:•Assessment must be a Start of Therapy OMRA•Resident must have been discharged from Part A on or before day 8 of the Part A stay •Resident must have completed only 1 to 4 days of therapy •With therapy having started during the last 4 days of the Part A stay

44

6-18

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Medicare Short Stay Assessment: All 8 must be true

1. Must be SOT OMRA.2. PPS 5 day must be completed.3. ARD must be NLT Day 8 of Part A

Stay.4. ARD must be last day of Part A

Stay.5. ARD must be NLT 3 days after

SOT.6. Rehab must have started in last

4 days of Part A stay.7. Rehab must continue through

last day of Part A stay.•At least one discipline must have:

•End of therapy date = the end of covered Medicare stay date, or•Dash-filled end of therapy date indicating ongoing therapy

8. RUG of this assessment must be Rehab or Rehab + Ext.

45

Medicare Short Stay Rehab Categories

Average Daily Minutes:•Ultra: >= 144•Very: 100-143 •High: 65-99 •Medium: 30-64 •Low: 15 – 29 •No Rehab category for < 15 minutes

46

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47

1 2 3 4 5

Eval +60

6

60

7

60

8

To ER

• Do 5d/SOT/PPSDC/OBRA DC combination

• Set ARD for day of discharge

• Ensure A2400C = ARD

• Ensure one discipline has dashes in therapy end

date

• 180/4 = 45 RMx

RMxZ0150 non-therapy

End of Therapy (EOT) OMRA: 2-52

48

15 min 10 min 0 min 0 min

EOT Required

Day of therapy = 15 min by a discipline

2/9/18


Always use Z0150 HIPPS for EOT OMRA, to begin paying the day after last therapy

49

“You shall rise and show respect to the aged.

50

S M T W Th F SaPT 0 75 75 75 75 75 0OT 0 75 75 75 75 75 0Tot 750

5 Day RUB

S M T W Th F SaPT 0 75 75 75 Sick 75 0OT 0 75 75 75 75 0Tot 600 0

14D CB1

S M T W Th F SaPT 0 75 75 0 0 0 0OT 0 75 75 0 0 0 0Tot No EOT

No Rehab RUG: No EOT

2/9/18


EOT rules: Page 2-53

•If resident discharged from the SNF on or prior to the third consecutive day of missed therapy services, then no EOT is required.• If a SNF chooses to complete the EOT OMRA in this situation, they may combine the EOT OMRA with the discharge assessment. •Review: EOT purpose is to reset the RUG from therapy to non-therapy – usually less money•Choosing EOT is usually NOT A GOOD CHOICE, but it is allowed: no provider liability

51


Therapy ends

52

Discharge

1 2 3

EOT ALLOWED BUT NOT REQUIRED

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Therapy ends

53

Discharge from Part A:EOT Required

Provider liability if missed

Section 2.9

Therapy ends

54

1 2 3

LCD Remains on another pay

source

EOT Required

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55

EOT affect on COT

ARD RUB

31 32 33 34 35Last tx

36 37COTCheck

38

If at any point, rehabilitation therapy ends before the last day of a COT observation period and an End of Therapy OMRA is performed with an ARD set for on or prior to Day 7 of the COT observation period, then the change of therapy evaluation process ends until the next PPS assessment used for payment reflecting the utilization of skilled therapy services. -6-13

Best practice: Do EOT to avoid COT

IF EOT on day 36 or 37, no COT. If EOT on day 38, COT required.

EOT-R

•When resumption of therapy date is no more than 5 consecutive calendar days after the last day of therapy provided, and •Therapy services have resumed at the same RUG-IV classification level, and •With the same therapy plan of care that had been in effect prior to the EOT OMRA, an End of Therapy OMRA with Resumption (EOT-R) may be completed.

56

2-54

2/9/18


Therapy ends

EOT ARD

• Resumption criteria: • Start back at same RUG level and same therapy plan of

care

57

Therapy ends

EOT ARD

• Resumption date, not day after ARD, is day 1 of next COT count.

COT CheckCOT

Check

58

2-55

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If unable to do EOT-R

59

•Must do new therapy evaluations for all disciplines prior to restarting•If new evals are not done, then there can be no therapy minutes on subsequent MDSs

•May do SOT or wait until next scheduled assessment to recapture Rehab RUG

A word about therapy evaluations

•Initial Evaluation: •Required for each discipline prior to starting a course of therapy•Required for each discipline upon each reentry after discharge assessment•Not required for LOA•Required after a three day break in therapy if EOT-R is not permitted•Date of initial evaluation remains as the ‘therapy start date’ until a new course of therapy with a new initial evaluation.

60

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61

EOT-R Billing Review

31 32 33 34 35 36 37ARD: RUC38 39 40 41 42 43 44

EOT-R ARD

45 46 47 48 49 50 51Resume

52 53 54 55 56 57 58

59 60

When therapy resumes, the RUG in effect prior to the break in therapy controls payment

Change of Therapy (COT OMRA) begins on 2-55

•Required when 1. resident was receiving a sufficient level of

rehabilitation therapy to qualify for a Rehabilitation category and

2. intensity of therapy changes to such a degree that it would no longer reflect the RUG-IV classification and payment assigned for a given SNF resident based on the most recent assessment used for Medicare payment

62

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63

Intensity of Therapy Earned

R

LMHVU

ABCLX

COT Rules 2-55

•ARD is set for Day 7 of a COT observation period. •COT observation periods are successive 7-day windows with the first observation period beginning on the day following the ARD set for the most recent scheduled or unscheduled PPS assessment, except for an EOT-R assessment. For example:•If ARD for 30-day assessment is set for day 30, and there are no intervening assessments, then the COT observation period ends on Day 37.• If the ARD for the patient’s most recent COT (whether the COT was completed or not) was Day 37, the next COT observation period would end on Day 44.

64

2/9/18


COT Rules:

•In cases where the last PPS Assessment was an EOT-R, the end of the first COT observation period is Day 7 after the Resumption of Therapy date (O0450B) on the EOT- R, rather than the ARD. The resumption of therapy date is counted as day 1 when determining Day 7 of the COT observation period. For example:•If the ARD for an EOT-R is set for day 35 and the resumption date is the equivalent of day 37, then the COT observation period ends on day 43.

65

66

The COT would be completed if the patient’s therapy intensity, as described above, has changed to classify the resident into a higher or lower RUG category. For example:

14

RHB

15 16 17 18 19 20

COT Required

21:RURVRMRL

Or ANY Nsg RUG if Rehab earned was NOT RH

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67

COT Rules


14

RHB

15 16 17 18 19 20

COT NOT Required

21:RH with ANY last

letter, or a nursing RUG while RH was

earned but not assigned

68

COT Rules


14

RVB

15 16 17 18 19 20

21COT checkpoint

22 23 24 25 26 27

28COT checkpoint

Whether COT was required on day 21 or not, day 22 is day 1 of the next COT count

2/9/18


COT Rules:

•If Day 7 of the COT observation period falls within the ARD window of a scheduled PPS Assessment, the SNF may choose to

1. complete the PPS Assessment alone by setting the ARD of the scheduled PPS assessment for an allowable day that is on or prior to Day 7 of the COT observation period. This effectively resets the COT observation period to the 7 days following that scheduled PPS Assessment ARD. OR

2. combine the COT OMRA and scheduled assessment following the instructions discussed in Section 2.10.

69

70

Illustration of choices: Complete the PPS Assessment

alone by setting the ARD of the scheduled PPS

assessment for an allowable day that is on or prior to Day 7 of the COT observation period : 2-56

7 8

RUB

9 10 11 12 13

RUC

14

RVC

15

Day 15

RVC

16 17 18 19 20

Day 13, 14 or 15 are allowed ARDs for the stand alone 14 day assessment

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71

Illustration of choice: Combine COT with scheduled assessment:

7 8RVB

9 10 11 12 13

14 15Day 15RUB

16 17 18 19 20

Schedule a 14 day/COT with ARD on day 15

•COT sets payment from day 1 of COT lookback going forward.•This sometimes causes a scheduled PPS assessment not to be used for payment•But the scheduled assessment is still required.

72

23 24 25 26 27 28 2930 DayRUB

30 31 32 33 34 35 36COT RVB

Key Point: Payment

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What to choose?

73

When RUG stays the same: Use any day in lookback for scheduled MDS and restart COT count the next day.

Combine Re

plac

e*

When COT checkpoint is day of discharge

74

•When a resident’s discharge from the SNF is on or prior to Day 7 of the COT observation period, then no COT OMRA is required. •If a SNF chooses to complete the COT OMRA in this situation, they may combine the COT OMRA with the discharge assessment. - Page 2-52

• COT is allowed but not required if checkpoint is the day of discharge.• Should do COT if RUG is higher

• Emergent discharge?• Should not do COT if RUG is lower

• But, no provider liability for either choice, as long as day 7 of COT count is chosen for COT ARD.

2/9/18


1 2 3 4 5 6 7

COT

check

8

RUC controlling payment RVC

L

C

D

L

T

C

D

C

If you are going to bill day 7 and the Rehab RUG changes, COT not

optional!

75

If the date listed in A2400C is on or after Day 7

of the COT observation period, then a COT

OMRA would be required if all other

conditions are met. 2-52

COT Rules:

The COT ARD may not precede the ARD of the first scheduled or unscheduled PPS assessment of the Medicare stay used to establish the patient’s initial RUG-IV therapy classification in a Medicare Part A SNF stay.

76

5 DAY RUG Rehab?

Nursing? Rehab RUG earned?

COT count begins

No COT count begins

No

Yes

2/9/18


COT Rules:

•Except as described below, a COT OMRA may only be completed when a resident is currently classified into a RUG-IV therapy group (regardless of whether or not the resident is classified into this group for payment), based on the resident’s most recent assessment used for payment.•The COT OMRA may be completed when a resident is not currently classified into a RUG-IV therapy group, but only if both of the following conditions are met:

1. Resident has been classified into a RUG-IV therapy group on a prior assessment during the resident’s current Medicare Part A stay, and

2. No discontinuation of therapy services (planned or unplanned discontinuation of all rehabilitation therapies for three or more consecutive days) occurred between Day 1 of the COT observation period for the COT OMRA that classified the resident into his/her current non-therapy RUG-IV group and the ARD of the COT OMRA that reclassified the resident into a RUG-IV therapy group.

Under these circumstances, completing the COT OMRA to reclassify the resident into a therapy group may be considered optional.

77

Illustration of rule on slide 64:

78


30 Day ARD RUB

S M T W Th F SaPT 0 75 75 75 Sick 75 0OT 0 75 75 75 75 0Tot 600 0

COT✓


COT✓

No therapy RUG, & no 3 day break in therapy: Do COT

COT Count continues: May Do COT

Rehab RUG established

No Rehab RUG earned

2/9/18


S M T W Th F SaPT 0 75 75 0 75 75 0OT 0 75 75 0 75 75 0Tot Day 29 600

Nursing RUG earned

Illustration of COT rules:

79


14 Day ARD RUA

S M T W Th F SaPT 0 75 75 75 75 75 0OT 0 75 75 75 75 75 0Tot 720 0

COT✓

Day 22: No COT due - Rehab RUG

same

Rehab RUG NOT earned on PPS 30 day

on day 29, so COT count STOPS. NO COT

on day 36 unless 30 day combined with

COT

ARD Day 15

More Rules: Chapter 6, pg 6-14

•If a new PPS assessment used for payment occurs with an ARD set for on or prior to the last day of a COT observation period, then a Change of Therapy OMRA is not required for that observation period. Example: •An SCSA is performed with an ARD of Day 10. An evaluation for the Change of Therapy OMRA would occur on Day 17 but the 14-Day assessment intervenes with ARD on Day 15. A Change of Therapy OMRA is not performed with an ARD on Day 17. Rather, the COT OMRA evaluation process is restarted with the 14-day assessment with ARD on Day 15. Day 1 of the next COT observation period is Day 16 and the new COT OMRA evaluation would be done on Day 22.

80

2/9/18


JuneSunday Monday Tuesday Wednesday Thursday Friday Saturday

1 2

3 4 5 6 7 8 9

SNF Day 1

10 11 12 13 14 15 16

PPS 5 day SCSA 14 Day

17 18 19 20 21 22 23

COT Checkpoint

24 25 26 27 28 29 30

Page 2-56 USED FOR PAYMENT

An assessment is considered to be “used for payment” in that it either:1. Controls the payment for a given period or, 2. With scheduled assessments may set the basis for

payment for a given period.

82

To ‘set the basis for payment for a given period” at least one day in that period must be billed to Medicare Part A

2/9/18


Controls vs Setting Basis for Payment

83

7RUC5 day

8 9 10 11 12 13 14 RVC14 day

15 16

17 18 19 20 21RUCCOT

22 23 24 25 26

27 28

RUC

29 30

• 5 day: RUC sets basis AND controls payment for 1-14• 14 day: RVC sets basis for 15 – 30• COT: RUC controls payment for 15 – 30

21COTRVB

22 23 24 25 26 27 28 29 30

31 32 33 34 35 36 37 38 39 40

RMB 30 D

If scheduled assessment does not set the basis for a given period, it may not be used in place of COT. If the COT is not done, it is missed: provider liability

Illustration: PPS scheduled assessment is not ‘used for payment’ so it cannot replace a COT

Provider Liability DC

84

6-14

2/9/18


21COTRVB

22 23 24 25 26 27 28 29 30

31 32 33 34 35 36 37 38 39 40

RMB 30 D

Change 30 D to COT before transmitting, using 7 day encoding/editing period

COT Illustration

DC

85

7 Day Encoding/Editing Period

•Page 5-8: Facilities have up to 7 days to encode (enter into the software) and edit an MDS assessment after the MDS has been completed. •Changes may be made to the electronic record for any item during the encoding and editing period, provided the response refers to the same observation period.

86

2/9/18


Options:

•If scheduled PPS assessment submitted, may modify to

add COT (5-11)

•May not modify COT to add scheduled assessment (5-

11)

•Type of Assessment may be modified when it does not

change the Item Set Code (ISC)

•If scheduled assessment not on COT ARD (early) may

modify and take default days, as opposed to provider

liability.

87

Item Set Code 2-87

88

2/9/18


Early/Late COT

89

Non-compliance with PPS Schedule: COT

• IF COT ARD is set early, day 1 for next COT is the day after the early COT ARD.

90

130 Day ARD

2 3 4 5 6COT

7 8 9 10

11 12 13COT

1 2 3 4 5 1 2 3 4

5 6 7

Will receive default for “the two days the early COT was out of compliance” -6-53

November

2/9/18



• IF COT ARD is set late, with no intervening assessment, day 1 for next COT is the day after the late COT ARD.

91

730 Day ARD

8 9 10 11 12 13 14 15 16COT

17 18 19 20 21 22 23

1 2 3 4 5 6 7 8 9

1 2 3

Will receive default for “the two days the late COT was out of compliance” -6-54

4 5 6 7


• IF COT ARD is set late, after an intervening assessment, the late COT does not reset the COT count.

92

18 19 20 21 22 23 24 25 26 2730 Day

28 29 30 31 32 33 34 35 36 37

1 2 3 4 5 6 7

1 2 3

Will receive default for the days the late COT should have controlled payment, until 30 day

kicks in on day 31.

4 5 6 7 1 2 3

Late COT

Default

Default

6-54

2/9/18


Missed Assessment: Page 2-74

93

5-Day 14-Day1 152 163 174 185 196 207 218 229 2310 2411 2512 2613 2714 28

293030 Day ARD

30-Day31323334353637COT Check38Last Tx

3940EOT ARD

414243DISCHARGE444546

Provider Liability:

Day 31 - 38

Required but not done

2.10 Combining Medicare Scheduled and UnscheduledAssessments 2-56

•If an unscheduled PPS assessment is required in the assessment window (including grace days) of a scheduled PPS assessment that has not yet been performed, then facilities must combine the scheduled and unscheduled assessments by setting the ARD of the scheduled assessment for the same day that the unscheduled assessment is required.•A scheduled PPS assessment cannot occur after an unscheduled assessment in the assessment window—the scheduled assessment must be combined with the unscheduled assessment using the appropriate ARD for the unscheduled assessment.

94

2/9/18


SSeeccttiioonn 22..1100 CCoommbbiinniinngg MMeeddiiccaarree SScchheedduulleedd aanndd UUnnsscchheedduulleedd AAsssseessssmmeennttss

• In cases when a facility fails to combine a scheduled and unscheduled PPS assessment as required by the combined assessment policy, the payment is controlled by the unscheduled assessment. -Page 2-61

95

7 8 9 10 11Last Therapy

12 13 14 15 16

17 18

EOT ARD

14 Day ARD

Not allowed

SSeeccttiioonn 22..1100 CCoommbbiinniinngg MMeeddiiccaarree SScchheedduulleedd aanndd UUnnsscchheedduulleedd AAsssseessssmmeennttss

•In this case, 14 day will not be used for payment. The EOT will pay from Day 12 into the 14 day payment period until the next scheduled or unscheduled assessment used for payment.

96


12 13 14 15 16

17 18

EOT ARD

14 Day ARD

2/9/18


•Reminder: Scheduled assessment prior to EOT ARD is allowed, but, the EOT will pay day 12 – 15, and the non-therapy RUG from the 14 day (Z0150) will pay beginning on day 16. –Page 6-11

97


12 13 14 15 16

17 18

EOT ARD

14 Day ARD

• Best Practice: If you can combine an EOT or SOT with scheduled, that is the thing to do.• COT is different: May do scheduled without COT before

or on COT checkpoint.

Note:

•A missed COT is provider liability•Even if the RUG would have gone up•A missed PPS assessment is provider liability•It is always better to do it late for default rate

98

2/9/18


Significant Change or Significant Correction to Prior Comprehensive: Effect on PPS payment 2-59

• SCSA or SCPCA will also act as an unscheduled PPS assessment.•Will set payment on ARD•If combined with scheduled PPS MDS, will set payment on ARD unless set on a grace day•If set on grace day will set payment on day 1 of the billing cycle for the scheduled assessment.

99

What about other insurance?

• Assessments that are completed for purposes other than OBRA and SNF PPS reasons are not to be submitted, e.g., private insurance, including but not limited to Medicare Advantage Plans. -Page 5-1 RAI Manual•OBRA schedule must be followed for anyone in a Medicare or Medicaid certified bed.•Resident pay source is not relevant•Certification of the bed is all that is relevant.•Chapter 2, page 2-2

100

2/9/18


What about other insurance?

101

Cannot combine OBRA with PPS if pay source is not Original Medicare A

Page 6-55:

SNF may bill the default code when a Medicare-required assessment does not exist in the QIES ASAP system when:1. The stay is less than 8 days within a spell of illness,2. The SNF is notified on an untimely basis of or is unaware of a

Medicare Secondary Payer denial,3. The SNF is notified on an untimely basis of a beneficiary’s

enrollment in Medicare Part A,4. The SNF is notified on an untimely basis of the revocation of a

payment ban,5. The beneficiary requests a demand bill, or6. The SNF is notified on an untimely basis or is unaware of a

beneficiary’s disenrollment from a Medicare Advantage plan.

102

2/9/18


103

Page 6-55:

•In situations 2-6, you may use Admission assessment to bill for all days of covered care associated with Medicare-required 5-& 14-day assessments, even if the beneficiary is no longer receiving therapy services that were identified under the most recent clinical assessment. •If you don’t need to use it for all 30 days, because you have the other PPS assessments, it can be used for the days paid by the PPS 5 day MDS.

•The ARD of the OBRA Admission assessment may be before or during the Medicare stay and does not have to fall within the ARD window of the 5-day or 14-day assessment.

• For covered days associated with 30, 60, or 90-day MDSs, the SNF must have a valid OBRA MDS in QIES ASAP system that falls within the ARD window of the PPS assessment in order to receive full payment at the RUG category in which the resident grouped. • If ARD of the valid OBRA assessment falls outside the

ARD window of the PPS assessment, the SNF must bill the default code.

Note: Stand alone OBRA or PPS Discharge Assessments do not produce a RUG and could not be used for payment.

104

2/9/18


More rules (6-56)

•Under all situations other than exceptions 1-5, the following apply when the

SNF failed to set the ARD prior to the end of the last day of the ARD window,

including grace days, or later and the resident was already discharged from

Medicare Part A when this was discovered:

• 1. If a valid OBRA assessment (except a stand-alone discharge assessment) exists in the

QIES ASAP system with an ARD that is within the ARD window of the PPS assessment, the

SNF may bill the RUG category in which the resident classified.

•In the case of an unscheduled assessment, if the SNF fails to set the ARD for

an unscheduled PPS assessment within the defined ARD window for that

assessment, and the resident has been discharged from Part A, the

assessment is missed and cannot be completed.

•All days that would have been paid by the missed assessment (had it been completed

timely) are considered provider-liable.

•However, as with late unscheduled assessment policy, the provider-liable period only lasts

until the point when an intervening assessment controls the payment.

105

HIPPS Code Refresher

106

RUC

10

RUC10

RUG

AI

2/9/18


HIPPS Codes

107

HIPPS Code will be calculated by Grouper.

judywilhide.com 108

CCoommpplliiaannccee:: SSeettttiinngg aa PPPPSS AARRDD

2/9/18


•The facility is required to set the ARD on the MDS Item Set or in the facility software within the appropriate timeframe of the assessment type being completed. -p 2-9•Having an ARD on a schedule is not sufficient.

109

1 2 3 4 5 6 7

8 9 10 11 12 13 14PPS 5 Day MDS

If the SNF fails to set the ARD within the defined ARD window for a Medicare-required assessment, including the grace days, and the resident is still on Part A, the SNF must complete a late assessment. The ARD can be no earlier than the day the error was identified. 6-55

Late PPS assessments –Page 6-54

If the ARD is set for prior to the end of the period during which the late assessment

a) would have controlled the payment, andb) no intervening assessments have occurred,

the SNF will bill the default rate for the number of days the assessment is out of compliance, to include the ARD date of the late assessment.

110

2/9/18


Late ARD set outside payment period, and/or after intervening assessment: Page 6-54

•If ARD of late assessment is set after the end of the period during which the late assessment would have controlled payment, or in cases where an intervening assessment has occurred and the resident is still on Part A, the provider must still complete the assessment. The ARD can be no earlier than the day the error was identified. •The SNF must bill all covered days during which the late assessment would have controlled payment had the ARD been set timely at the default rate regardless of the HIPPS code calculated from the late assessment.

111

PPS 14 Day ARD:Illustration: Late, after payment cycle, after intervening assessment

112

5-Day 14-Day1 9/28/2009 15 10/12/20092 9/29/2009 16 10/13/20093 9/30/2009 17 10/14/20094 10/1/2009 18 10/15/20095 10/2/2009 19 10/16/20096 10/3/2009 20 10/17/20097 10/4/2009 21 10/18/20098 10/5/2009 22 10/19/20099 10/6/2009 23 10/20/200910 10/7/2009 24 10/21/200911 10/8/2009 25 10/22/200912 10/9/2009 26 10/23/200913 10/10/2009 27 10/24/200914 10/11/2009 28 10/25/2009

29 10/26/200930 10/27/2009

30-Day31 30 DAY ARD32 10/29/200933 10/30/200934 10/31/200935 14 DAY ARD36 11/2/200937 11/3/200938 11/4/200939 11/5/200940 11/6/200941 11/7/200942 11/8/200943 11/9/200944 11/10/200945 11/11/200946 11/12/2009

Not used for payment

COT Checkpoint

2/9/18


AARRDD OOuuttssiiddee tthhee MMeeddiiccaarree PPaarrtt AA SSNNFF BBeenneeffiitt

•A SNF may not use a date outside the SNF Part A Medicare Benefit (i.e., 100 days) as the ARD for a scheduled PPS assessment, unless that scheduled PPS assessment is combined with an OBRA Discharge Assessment (see Section 2.12). •For example, the resident returns to the SNF on December 11 following a hospital stay, and has 3 days left in his/her SNF benefit period. The SNF must set the ARD for the PPS assessment on December 11, 12, or 13 to bill for the RUG category associated with the assessment.•A SNF may use a date outside the SNF Part A Medicare Benefit as the ARD for an unscheduled PPS assessment, but only in the case where the ARD for the unscheduled assessment falls on a day that is not counted among the beneficiary’s 100 days due to a leave of absence (LOA), as defined in Chapter 2, sections 2.5 and 2.13, and the resident returns to the facility from the LOA on Medicare Part A.

113Pg 6-56

Default for days out of

complianceEarly ARD

LateARD

114

2/9/18


Provider Liability*

NoARD

115

116

Scenario:•Resident admitted Friday afternoon and dies Sunday night prior to midnight. MDSC comes in on Monday. No PPS 5 day ARD was set and now the resident is not on a Part A stay. Next Steps?

You may not set an ARD now. There was not one set and the resident is not on Part A now. Since the stay is less than 8 days, you may bill default rate for the two days. Consider paper MDS in admission chart for resident with ARD set on paper form. Keep that form in the chart and use it to open a PPS 5 day when MDSC comes in on Monday.

Page A-31 and 6-55

2/9/18


117

•When the resident dies or is discharged prior to the end of the look-back period for a required assessment, the ARD must be adjusted to equal the discharge date. A-31

•If the SNF fails to set the ARD of a scheduled PPS assessment prior to the end of the last day of the ARD window, including grace days, and the resident is no longer a SNF Part A resident, and as a result a Medicare-required assessment does not exist in the QIES ASAP for the payment period, the provider may not usually bill for days when an assessment does not exist in the QIES ASAP... If the resident was already discharged from Medicare Part A when this is discovered, an assessment may not be performed. 6-55

Questions/Discussion

Prepared by Judy Wilhide Brandt 2/1/15

Page 1Rehab RU

G controllling paym

ent?

Day 7 of COT count?

In window

of scheduled PPS ?

Higher Low

er

Combine Scheduled

with CO

T on COT

checkpoint. ARD + 7 is next CO

T checkpoint

Do not do COT. Set

scheduled ARD on or before CO

T checkpoint. ARD + 7 is next CO

T checkpoint

*COT count starts the day a�er an ARD in

which a Rehab RU

G is earned, even if it is not assigned due to CM

I. If this is the case, the CO

T is required only if it changes the overall paym

ent category.

Rehab RUG different

than controlling Rehab RU

G?

Do COT. ARD + 7 is

next COT checkpoint

3 day break in therapy?

Do EOT

Rehab RUG earned?

Yes

Yes

Yes

Yes

No

Rehab RUG earned?

Yes

No

No

Yes

No

If no 3 day break in therapy in 7 day lookback, there are 2 choices: Do scheduled PPS assessm

ent & CO

T count stops. O

R, combine

scheduled with CO

T to allow CO

T count to con�nue. GO

TO EO

T ALGO

RITHM

CAUTO

N: Scheduled

may only reset CO

T count if U

SED FOR

PAYMEN

T**

Yes

Use of these algorithm

s assumes thorough

understanding of instruc�ons in Ch 2 & 5 of current

RAI manual. CO

PYRIGHT: WILHIDE CO

NSU

LTING,

INC. Jan 2015. U

ser assumes all liability for correct

interpreta�on of RAI manual rules.

Same?

Do not do COT. Set

scheduled ARD on any day in w

indow. ARD + 7

is next COT checkpoint

**If scheduled assessment w

ill not set basis for paym

ent for any days, must do CO

T on COT

checkppoint. Ex: 30 day done on day 27, which is

COT checkpoint. DC on day 29. M

ay not use 30 day to reset CO

T count b/c it does not control paym

ent un�l day 31 is billed.

COT Algorithm


Page 1

Rehab RUG

controllling payment?

3 day break in therapy?

Yes

Yes

Will therapy resum

e on day 4 or 5 a�er last therapy day at the sam

e RUG level and sam

e plan of care per discipline?

Yes

Do EOT-‐R on day 1,2 or 3

a�er last therapy day. Resum

p�on date is day 1 of next CO

T lookback.

No

Will therapy start back at all?

No

No m

ore COT

counts. Con�nue PPS schedule.

Yes

All rehab discipines MUST do new

ini�al evalua�ons prior to

ANY further treatm

ent.

Choice: May

do either

Do SOT

Wait un�l net scheduled PPS assessm

ent to capture Rehab RU

G.

Do EOT on day 1,2 or

3 a�er last therapy day.

Go to SOT

algorithm

EOT Algorithm


Page 1

Non-‐Rehab RU

G* controllling paym

ent?

Regimen of

therapy begun?

Yes

Yes

Set SOT ARD on day 5, 6 or 7,

with earliest ini�al eval

date** as day 1.

**If more than one discipline, use earliest

ini�al eval date as day 1 for SOT count.

*Two possibli�es: Therapy is just

star�ng, or star�ng back a�er a 3 day break &

not eligible for EOT-‐R

Medicare Short Stay

SNF Stay < 8 days? *

*Day of discharge counts as a day for each step of the Short Stay Algorithm

Yes

THerapy start in last 4 days?*

Is RTM average

> 15 min?**

**Add reimbursable therapy

minutes (RTM

), then divide by # of days of therapy. Day of eval

counts as day 1 even if no RTM

given. Day of discharge counts l

Yes

Yes

Make sure:

1. Reason for assessment: 5 day/SO

T/Discharge 2. Day of discharge m

ust be = ARD, Discharge date & M

edicare end date 3. Therapy end date m

ust = "-‐" (dash)

S�ll not working?

1. Re=check accuracy of all the above, if accurate: 2. Does nursing RU

G on this assessment pay m

ore than Rehab RU

G earned on this assessment?

3. If so, take SOT off and send up as 5 D/DC only.

SOT Algorithm

Documents

The Prospective Payment System - Virginia Health Care ... · 2/9/18 Wilhide Consulting, Inc. (c) 3 Two Basic Types of PPS Assessments: Scheduled •Prescribed range of days from which