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WilhideConsul1ng,Inc.(c) 1
TheProspec1vePaymentSystemMay2016
1
Source:
2
• CurrentRAIManual,Chapter2&6(‘resources’www.judywilhide.com)
• Chapter2:• 2.8:TheSNFPPSAssessmentSchedule• 2.9:MDSMedicareAssessmentsforSNFs• 2.10:CombiningMedicareScheduledandUnscheduledAssessments• 2.11:CombiningMedicareAssessmentsandOBRAAssessments• 2.12:MedicareandOBRAAssessmentCombina1ons• 2.13:FactorsImpac1ngtheSNFMedicareAssessmentSchedule• 2.14:ExpectedOrderofMDSRecords• 2.15:DeterminingItemSetforMDSRecords
Source:• Chapter6:
– 6.1:SNFPPSBackground– 6.2:UsingtheMDSintheMedicareProspec1vePaymentSystem
– 6.3:RUG-IVOverview– 6.4:Rela1onshipbetweentheassessmentandtheclaim– 6.5:SNFPPSEligibilityCriteria– 6.6:RUG-IV66-GroupModelCalcula1onWorksheetforSNFs
– 6.7:SNFPPSPolicies– 6.8:Non-compliancewiththeSNFPPSAssessmentSchedule
3
WhatisSNFPPS?
OriginalMedicareA
• Not:• MedicareHealthPlan• MedicareAdvantage• StateDual-EligibleHMO• Privateinsurance• Tricare
WetransmitPPSassessmentsonOriginalMedicareAonly.
judywilhide.com 4
TwoBasicTypesofPPSAssessments:
Scheduled• Prescribedrangeofdaysfromwhichto
select.• Penal;esforimproperselec;on.
Unscheduled
• Prescribedscenariosthatfacilitymustcorrectlyiden;fyinwhichtheassessmentisrequired.
• Penal;esforimproperselec;on.
5
HIPPS&MDS3.0
6
HIPPSCodewillbecalculatedbyGrouper.
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Comple1on/SubmissionofPPS-onlyassessments
• Mustbecompleted(Z0500b)nolaterthanARD(A2300)+14days
• Mustbesubmihednolaterthancomple1on(Z0500b)+14days
7
Thereisnofinancialpenaltyforlatecomple1onortransmission!
OtherusesofscheduledPPSassessments
QualityMeasures• OBRA&ScheduledPPS
assessmentsusedforcalcula1ngShortandLongTermmeasures– Survey– PublicRepor1ng– FiveStar
SNFQRP• ScheduledPPSAssessments
&SNFPPSDischargeusedtocalculateMDSbasedSNF-QRPmeasures
• Ini1alassessmentwillbeusedtocalculateriskadjustmentsandexclusionsforSNF-QRP
8
ScheduledPPSAssessments
Type ARD/GraceDayWindow
PaymentDays
5day 1-8 1-14
14Day 13-18 15-30
30Day 27-33 31-60
60Day 57-63 61-90
90Day 87-93 91-100
9
Day1–FirstMedicareday
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
5/8/14 5/9/14 5/10/14 5/11/14 5/12/14 5/13/14 5/14/14Thu Fri Sat Sun Mon Tue Wed15 16 17 18 19 20 21
5/15/14 5/16/14 5/17/14 5/18/14 5/19/14 5/20/14 5/21/14Thu Fri Sat Sun Mon Tue Wed22 23 24 25 26 27 28
5/22/14 5/23/14 5/24/14 5/25/14 5/26/14 5/27/14 5/28/14Thu Fri Sat Sun Mon Tue Wed29 30 31 32 33 34 35
5/29/14 5/30/14 5/31/14 6/1/14 6/2/14 6/3/14 6/4/14Thu Fri Sat Sun Mon Tue Wed36 37 38 39 40 41 42
6/5/14 6/6/14 6/7/14 6/8/14 6/9/14 6/10/14 6/11/14Thu Fri Sat Sun Mon Tue Wed43 44 45 46 47 48 49
6/12/14 6/13/14 6/14/14 6/15/14 6/16/14 6/17/14 6/18/1410
Thu Fri Sat Sun Mon Tue Wed
50 51 52 53 54 55 56
6/19/14 6/20/14 6/21/14 6/22/14 6/23/14 6/24/14 6/25/14
Thu Fri Sat Sun Mon Tue Wed
57 58 59 60 61 62 63
6/26/14 6/27/14 6/28/14 6/29/14 6/30/14 7/1/14 7/2/14
Thu Fri Sat Sun Mon Tue Wed
64 65 66 67 68 69 70
7/3/14 7/4/14 7/5/14 7/6/14 7/7/14 7/8/14 7/9/14
Thu Fri Sat Sun Mon Tue Wed
71 72 73 74 75 76 77
7/10/14 7/11/14 7/12/14 7/13/14 7/14/14 7/15/14 7/16/14
Thu Fri Sat Sun Mon Tue Wed
78 79 80 81 82 83 84
7/17/14 7/18/14 7/19/14 7/20/14 7/21/14 7/22/14 7/23/14
Thu Fri Sat Sun Mon Tue Wed85 86 87 88 89 90 91
7/24/14 7/25/14 7/26/14 7/27/14 7/28/14 7/29/14 7/30/14Thu Fri Sat Sun Mon Tue Wed92 93 94 95 96 97 98
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 8/8/14 11
Can I combine a PPS MDS with an OBRA Discharge MDS?
12
• AscheduledPPSARDmustbeonaMedicarebenefitday.
• DischargemustbeaMedicarebenefitday(2-64)
• IfDischargeisa"erlastcoveredday,maynotcombine.
• ItisimportanttonotethatwhentheOBRAandMedicarePPSassessment1meframescoincide,
• oneassessmentmaybeusedtosa1sfybothrequirements.Insuchcases,themoststringent
• requirementforMDScomple1onmustbemet.(2-1)
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Examples
Planneddischarge• LastCoveredDayisDay15,
residentdischargesonday16.Day15isarequiredCOTARD.– COTARDmustbeday15.
OBRADischargeARDmustbeday16.
– CANNOTCOMBINE
Unplanneddischarge• Residentemergently
dischargestothehospitalonday7.– 5day/OBRAdischarge
combina1onallowedonday7.
13
• A2400C(Medicareend)iswhicheveroccursfirst:– DateSNFbenefitexhaustsor– DateoflastdaycoveredasrecordedonNOMNCor– DatepayersourcechangesfromMedicareAtoanotherpayer(regardlessiftheresidentwasmovedtoanotherbedornot)or
– Dateresidentwasdischargedfromthefacility.
Always = A1600 entry date
Never dashes on ANY discharge
A2400 does not include stays
billable to Medicare Advantage
HMO plans.
PartAPPSDischarge(NPE)
WhatisaPPSDischarge?(NPE)
GGDCFunc1onalStatus
J1800&J1900:FallssinceentryorlastOBRA/PPSMDS
M0210,M0300,M0800Current&Worsened
PressureUlcers
“Youshallriseandshowrespecttotheaged.
WhenisPPSDCRequired?
“May”(MUST)becombinedwithOBRADCwhenPartAstayendsandresidentphysicallydischargesfromSNFonoronedayaqerlastPartAday(A2400C)
NOTrequiredwhenPartAstayendsindeath
PartAstayends&residentstaysinSNF
PPSDC/OBRADischarge(ND)
GGDischargeFxlAbili1es
Falls PressureUlcers
Cogni1vePaherns,Mood,Behaviors,FxlStatus,Bowel/Bladder,Diagnoses,Pain,OtherHealthCondi1ons,Swallowing/Nutri1on,PUdimensions,Meds,SpecialTx,Restraints,DischargePlan
Anyexcept03
Atleast3days
RAorRNA&planned
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PPSDC/OBRADischarge(ND)
Falls PressureUlcers
Cogni1vePaherns,Mood,Behaviors,FxlStatus,Bowel/Bladder,Diagnoses,Pain,OtherHealthCondi1ons,Swallowing/Nutri1on,PUdimensions,Meds,SpecialTx,Restraints,DischargePlan
UnplannedORToacutehospitalORPartAstay<3days Firstforcedcombina1oninMDShistory
OBRADischargeandPPSDischargemustbecombinedwhenbotharedue.• A2400C=A2000DischargeDate• A2400ConedaypriortoA2000DischargeDate
• PPSDCdoesn’talwayshaveDischargeFxlAbili1esSec1onGG
• PPSDCalwayshasitemstocalculateQRPFallsw/majorinjuryandQRPnew/worsenedpressureulcers
Reminder:Youjusthavetoremembertodothestand-alonePPSDischarge!
21
FactorsImpac1ngtheSNFPPSSchedule
Sec1on2.13
22
ResidentExpiresBeforeorOntheEighthDayofSNFStay• Ifbeneficiarydiesbeforeoron8thdayofSNFstay,shouldprepare&submitaPPSMDSascompletelyaspossible.
• IfPPSMDSnotcompleted,providermustbillthedefaultrateforanyMedicaredays.
• MedicareShortStayPolicymayalsoapply.MustalsocompleteaDeathinFacilityTracking
23
• IfbeneficiaryisdischargedfromtheSNFortransferredtoanotherpayersourcebeforeorontheeighthdayofthecoveredSNFstay,theprovidershouldprepareaMedicare-requiredassessmentascompletelyaspossibleandsubmittheassessmentasrequired.
• “DischargedfromtheSNF”=leavesthecer1fiedbed• “Transferstoanotherpayersource”=remainsinthecer1fiedbedbutnolongerbillingPartAforthestay.
ResidentDischargedBeforeorOntheEighthDayofSNFStay
24
• IfthereisnotaPPSMDSintheQIESASAPsystem,theprovidermustbillthedefaultrateforanyMedicaredays.
• IfPartAstayends&beneficiaryremainsinthefacility,aPartAPPSDischargeassessmentisrequired.
• Whenphysicallydischarged,mustalsocompleteanOBRADischargeassessmentwhichmaybecombinedwithaPPSassessmentifallrequirementsforbotharemet.
ResidentDischargedBeforeorOntheEighthDayofSNFStay
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ShortStay• Ifbeneficiarydies,isdischargedfromtheSNF,ordischargedfromPartAlevelofcareonorbeforetheeighthdayofcoveredSNFstay,theresidentmaybeacandidatefortheshortstaypolicy.
• TheshortstaypolicyallowstheassignmentintoaRehabilita1onPlusExtensiveServicesorRehabilita1oncategorywhenaresidentreceivedrehabilita1ontherapyandwasnotabletohavereceived5daysoftherapyduetodischargefromMedicarePartA.SeeChapter6,Sec1on6.4forgreaterdetail.
25
ResidentisAdmiLedtoanAcuteCareFacilityandReturns• IfaMedicarePartAresidentisadmihedtoanacutecarefacilityandlaterreturnstotheSNF(eveniftheacutestayfacilityislessthan24hoursand/ornotovermidnight)toresumePartAcoverage,theMedicareassessmentscheduleisrestartedwithaPPS5dayassessment.
26
27
• Ifaresidentisoutofthefacility• overamidnight,• lessthan24hours,and• isnotadmihedtoanacutecarefacility,theMedicareassessmentscheduleisnotrestarted.
• ThedaytheresidentwasabsentatmidnightisnotacoveredPartAday.Thisthe“midnightrule.”
• TheMedicareassessmentschedulemustthenbeadjustedtoskipthedayincalcula1ngwhenthenextMedicareassessmentisdue.
• ScheduledPPSMDSmayNOTbeonLOA/skipday• UnscheduledPPSMDSmaybeonLOA/skipday
ResidentIsSenttoAcuteCareFacility,NotinSNFoverMidnight,andIsNotAdmiLedtoAcuteCareFacility
IfresidentgoestoERat10p.m.Wednesday,day22ofhisPartAstay,andreturnsat3a.m.thenextday,WednesdayisnotbillabletoPartA.Asaresult,thedayofhisreturntotheSNF,Thursday,becomesday22ofhisPartAstay.
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 6/2/1528
LeaveofAbsence:Page2-12
• LeaveofAbsence(LOA),whichdoesnotrequirecomple1onofeitheraDischargeassessmentoranEntrytrackingrecord,occurswhenaresidenthasa:– Temporaryhomevisitofatleastonenight;or– Therapeu1cleaveofatleastonenight;or– Hospitalobserva1onstaylessthan24hoursandthehospitaldoesnotadmitthepa1ent.
29
• ForscheduledPPSARDs,theschedulemustbeadjustedtoexcludetheLOAbecausetheARDmaynotbeonanon-benefitperiodday.– ThescheduleisnotrestarteduponreturnfromLOA
30
• LeqSNFat6:00pmonWednesday,whichisDay27oftheresident’sstay• ReturnstotheSNFonThursdayat9:00am• LOAdaymayNOTbeusedasARDforaPPSscheduledassessment(page2-75)• LOAdayMAYbeusedasARDforaPPSunscheduledassessment
Wed Thu
27 27Non-billable
LOAandScheduledARD
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WhenaSNFplanstocombineascheduledandunscheduledassessmentonagivenday,&thatdaybecomesanLOAdayfortheresident:• LOAdaymays1llbeusedastheARDofthe
unscheduledassessment,• LOAdaycannotbeusedastheARDofthescheduled
assessment.
2-75
May105dayARD
May17
May18
COT14day
31
WhenaSNFplanstocombineascheduledandunscheduledassessmentonagivenday,&thatdaybecomesanLOAdayfortheresident:• LOAdaymays1llbeusedastheARDofthe
unscheduledassessment,• LOAdaycannotbeusedastheARDofthescheduled
assessment.
2-75
May105dayARD
May17
May18
LOA
COT 14day
14-daywouldneedtohaveanARDthatfallsononeoftheresident’sMedicareAbenefitdays.(priortooraqerLOAday,dependingonARDrange)
32
Review
33
ARD COTARD
LOA
ARDPT
PT
PT
PT
PT
SicknoPT
COTARDLOAtoERnoPT
BackfromLOA,noPT
EOTCount
Reminder:IfLOAisnottohospital,itcanbemorethanonenight.
34
• DoPPSDC• Ifresidentremainsincer1fiedbed,OBRAschedulecon1nues.
• NoreasontochangetheOBRAschedulewhenPartAbenefitsresume.(ConsiderSigChange)
• StartMedicarescheduleagainwithaPPS5dayMDS
• DotheGGassessmentin1stthreedaysofSNFstay• Theoriginaldateofentry(ItemA1600)isretained.• NewMedicareStartDateinA2400
ResidentDischargedfromPartASkilledServicesandReturnstoSNFPartASkilledLevelServices(30daytracking)
• WhenthebeneficiaryrequiresandreceivesSNFlevelofcareserviceswithin30daysfromthehospitaldischarge,Day1fortheMedicareassessmentscheduleisthedayonwhichSNFlevelofcareservicesbegins.
• RememberGGadmissionassessmentonfirst3daysofSNFstay.
35
DelayinRequiringandReceivingSkilledServicesCh6,Sec6.7
• Example:– HospitaldischargeAugust1
• DischargeisDayZero(Ch8,BenefitPolicyManual,Sec1on20.2.1)
– SNFdeterminesonAugust31thatbeneficiaryrequiresskilledserviceforacondi1onthatwastreatedduringthequalifyinghospitalstay,thentheSNFwouldstarttheMedicareassessmentschedulewitha5-dayMedicare-requiredassessment,withAugust31asDay1forschedulingpurposes.
• OBRAAdmissionassessmentwouldhavealreadybeencompletedbyday14ofthestay.
36
DelayinRequiringandReceivingSkilledServices
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UnscheduledPPSAssessments
37
Justafewsimplerules!OMRAs
38
Therapy
Change
End
Start
CodingTipsandSpecialPopula;ons(OMRAs)2-55
• WhencodingstandaloneOMRAs:– COT,SOT,EOT
• Facili1esmustsettheARDfortheassessmentforadaywithintheallowableARDwindowforthatassessmenttype,butmayonlydosonomorethantwodaysaqerthewindowhaspassed.– Eveniftheresidentdischargesduringthistwodayperiod
39
StandaloneCOTARD
40
1ARD
2 3 4 5 6 7
8COT
9 10 11 12 13 14
1 2 3 4 5 6
7
COTcheckpointFriday
41
1ARD
2 3 4 5 6 7
8FriCOT
9Sat
10Sun
11Mon
12 13 14
TooLate!
Tip:OpenFridaybeforeyougohome.DeleteMondayifnotneeded.
SevngARDforStandaloneEOT/SOT
42
1
2Lasttherapy
3 4 5 6 7
8
9 10 11 12 13 14
1 2 3
SOTworksthesameway!
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2.12MedicareandOBRAAssessmentCombina;ons
• WhenanyOMRAiscombinedwithadischargeassessment,theARDforthatcombina1onassessmentmaybesetoneortwodaysaqerthedayofdischarge.
43
OMRA/
Discharg
e
OMRAsandInterviews:Page2-55
• WhencodingastandaloneOMRA,theinterviewitemsmaybecodedusingtheresponsesprovidedbytheresidentonapreviousassessmentonlyiftheDATEoftheinterviewresponsesfromthepreviousassessment(asdocumentedinitemZ0400)wereobtainednomorethan14dayspriortotheDATEofcomple1onfortheinterviewitemsontheunscheduledassessment(asdocumentedinitemZ0400)forwhichthoseresponseswillbeused.
44
OMRAsandInterviews:Page2-55
• Note:Inlimitedcircumstances,itmaynotbeprac1cabletoconducttheresidentinterviewpor1onsoftheMDS(Sec1onsC,D,F,J)onorpriortotheARDforastandaloneunscheduledPPSassessment.Insuchcaseswheretheresidentinterviews(andnotthestaffassessment)aretobecompletedandtheassessmentisastandaloneunscheduledassessment,providersmayconducttheresidentinterviewpor1onsofthatassessmentuptotwocalendardaysaqertheARD(ItemA2300).-2-55
45
Da1ngInterviews
• MustsignZ0400withthedateeachinterviewwasactuallycompleted.– YoumaysignZ0400morethanonceifyoudointerviewsandotherassessmentitems.
• Chapter3,PageZ-7:– AllstaffwhocompletedanypartoftheMDSmustentertheirsignatures,1tles,sec1onsorpor1on(s)ofsec1on(s)theycompleted,andthedatecompleted.
– IfastaffmembercannotsignZ0400onthesamedaythatheorshecompletedasec1onorpor1onofasec1on,whenthestaffmembersigns,usethedatetheitemoriginallywascompleted.
46
OMRASpecifics:Adeeperdive
47
SOT
EOT
COT
StartofTherapy(SOT)OMRA2-47
• Op1onal.• CompletedonlytoclassifyaresidentintoaRehabRUG.IftheRUGassignedisnotRehab,willnotbeacceptedintoCMSdatabase.
• ARDmustbesetondays5-7aqerthestartoftherapywiththeexcep1onoftheShortStayAssessment.
• Thedateoftheearliesttherapyevalua1oniscountedasday1whendeterminingtheARD,regardlessiftreatmentisprovidedornotonthatday.
• MaybecombinedwithscheduledPPSassessments.
48
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StartofTherapy(SOT)OMRA2-47
• SOTnotnecessaryifrehabilita1onservicesstartwithintheARDwindow(includinggracedays)ofthe5-dayassessment,sincethetherapyratewillbepaidstar1ngDay1oftheSNFstay.
• ARDmaynotprecedetheARDoffirstscheduledPPSassessmentoftheMedicarestay(5-dayassessment).
49
SOTillustra1on
1 2 3 4
5PTEval
6OTEval
7
8 9 10 11 12 13 14
50
SOTRange
SOTcontrolspaymentbeginningontheearliestTherapyStartDate
NursingRUGControlspayment
MedicareShortStayAssessment
• UniqueGroupercalcula1onforonepurpose:– AssignsaRehab/Rehab+ExtRUGunderveryspecificcircumstanceswhenaresidentreceivedRehabilita1onServicesfor<4daysinaMedicarestaythatis<8days.
51
MedicareShortStayAssessment:All8mustbetrue
1. MustbeSOTOMRA.– MaybecombinedwithanyOBRAassessmentifallrules
met.
2. 5daymustbecompleted.– MaybecombinedwiththisSOTOMRA
3. ARDmustbeNLTDay8ofPartAStay.4. ARDmustbelastdayofPartAStay*.
52
MedicareShortStayAssessment:All8mustbetrue
5. ARDmustbeNLT3daysaqerSOT.6. Rehabmusthavestartedinlast4daysofPartAstay.7. Rehabmustcon1nuethroughlastdayofPartAstay.
– Atleastonedisciplinemusthave:• Endoftherapydate=theendofcoveredMedicarestaydate,or• Dash-filledendoftherapydateindica1ngongoingtherapy,e.g.:
– Residentdischargedandtherapywasplannedtocon1nuehadresidentstayedinfacility.
– PartAstoppedandtherapycon1nued(eg:Exhaustorpaysourcechange)
8. RUGofthisassessmentmustbeRehaborRehab+Ext.– AqerCaseMixMaximizing.
53
MedicareShortStayRehabCategories
• AverageDailyMinutes:– Ultra:>=144– Very:100-143– High:65-99– Medium:30-64– Low:15–29
• NoRehabcategoryfor<15minutes
54
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55
1
2 3 4 5Eval+60
660
760
8ToER
• Do5d/SOT/PPSDC/OBRADCcombina1on• SetARDfordayofdischarge• EnsureA2400C=ARD• Ensureonedisciplinehasdashesintherapyenddate
• 180/4=45RMx
RMxZ0150non-therapy
EndofTherapy(EOT)OMRA:2-48
56
15min
10min
0min
0min
EOTRequired
Dayoftherapy=15minbyadiscipline
AlwaysuseZ0150HIPPSforEOTOMRA,tobeginpayingthedayaqerlasttherapy
57
“Youshallriseandshowrespecttotheaged.
58
S M T W Th F SaPT 0 75 75 75 75 75 0OT 0 75 75 75 75 75 0Tot 750
5Day RUB
S M T W Th F SaPT 0 75 75 75 Sick 75 0 OT 0 75 75 75 75 0 Tot 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 NoEOT
NoRehabRUG:NoEOT
EOTrules:Page2-49
• IfresidentdischargedfromtheSNFonorpriortothethirdconsecu1vedayofmissedtherapyservices,thennoEOTisrequired.
• IfaSNFchoosestocompletetheEOTOMRAinthissitua1on,theymaycombinetheEOTOMRAwiththedischargeassessment.
• Review:EOTpurposeistoresettheRUGfromtherapytonon-therapy–usuallylessmoney– ChoosingEOTisusuallyNOTAGOODCHOICE,butitisallowed:no
providerliability
59
EOTrules:Page2-48
Therapyends
60
Discharge
1 2 3
EOTALLOWEDBUTNOTREQUIRED
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EOTrules:Page2-48
Therapyends
61
DischargefromPartA:EOTRequired
Providerliabilityifmissed
Sec1on2.9
Therapyends
62
1 2 3
LCD Remainsonanotherpay
source
EOTRequired
63
EOTaffectonCOT
ARDRUB
31 32 33 34 35Lasttx
36 37COTCheck
38
Ifatanypoint,rehabilita1ontherapyendsbeforethelastdayofaCOTobserva;onperiodandanEndofTherapyOMRAisperformedwithanARDsetforonorpriortoDay7oftheCOTobserva1onperiod,thenthechangeoftherapyevalua1onprocessendsun1lthenextPPSassessmentusedforpaymentreflec1ngtheu1liza1onofskilledtherapyservices.-6-13
Bestprac1ce:DoEOTtoavoidCOT
IFEOTonday36or37,noCOT.IfEOTonday38,COTrequired.
EOT-R
• Whenresump1onoftherapydateisnomorethan5consecu1vecalendardaysaqerthelastdayoftherapyprovided,and
• TherapyserviceshaveresumedatthesameRUG-IVclassifica1onlevel,and
• WiththesametherapyplanofcarethathadbeenineffectpriortotheEOTOMRA,anEndofTherapyOMRAwithResump1on(EOT-R)maybecompleted.
64 2-50
Therapyends
EOTARD
• Resump1oncriteria:• StartbackatsameRUGlevelandsametherapyplanof
care
65
“Youshallriseandshowrespecttotheaged.
Therapyends
EOTARD
• Resump1ondate,notdayaIerARD,isday1ofnextCOTcount.
COTCheckCOT
Check
66
2-51
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IfunabletodoEOT-R
• Mustdonewtherapyevalua1onsforalldisciplinespriortorestar1ng– Ifnewevalsarenotdone,thentherecanbenotherapyminutesonsubsequentMDSs
• MaydoSOTorwaitun1lnextscheduledassessmenttorecaptureRehabRUG
67
Awordabouttherapyevalua1ons
• Ini1alEvalua1on:– Requiredforeachdisciplinepriortostar1ngacourseoftherapy
– Requiredforeachdisciplineuponeachreentryaqerdischargeassessment
• NotrequiredforLOA– RequiredaqerathreedaybreakintherapyifEOT-Risnotpermihed
– Dateofini1alevalua1onremainsasthe‘therapystartdate’un1lanewcourseoftherapywithanewini1alevalua1on.
68
“Youshallriseandshowrespecttotheaged.
69
EOT-R Billing Review
31 32 33 34 35 36 37 ARD: RUC 38 39 40 41 42 43 44
EOT-R ARD
45 46 47 48 49 50 51 Resume
52 53 54 55 56 57 58
59 60
Whentherapyresumes,theRUGineffectpriortothebreakintherapycontrolspayment
ChangeofTherapy(COTOMRA)beginson2-51
• Requiredwhen1. residentwasreceivingasufficientlevelof
rehabilita1ontherapytoqualifyforaRehabilita1oncategoryand
2. intensityoftherapychangestosuchadegreethatitwouldnolongerreflecttheRUG-IVclassifica;onandpaymentassignedforagivenSNFresidentbasedonthemostrecentassessmentusedforMedicarepayment
70
71
Intensity of Therapy Earned
R
L
M
H
V
U
A
B
C
L
XCOTRules2-51
• ARDissetforDay7ofaCOTobserva1onperiod.• COTobserva1onperiodsaresuccessive7-daywindows
withthefirstobserva1onperiodbeginningonthedayfollowingtheARDsetforthemostrecentscheduledorunscheduledPPSassessment,exceptforanEOT-Rassessment.Forexample:
• IfARDfor30-dayassessmentissetforday30,andtherearenointerveningassessments,thentheCOTobserva1onperiodendsonDay37.
• IftheARDforthepa1ent’smostrecentCOT(whethertheCOTwascompletedornot)wasDay37,thenextCOTobserva1onperiodwouldendonDay44.
72
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COTRules2-51:• IncaseswherethelastPPSAssessmentwasanEOT-R,theendofthefirstCOTobserva1onperiodisDay7aqertheResump1onofTherapydate(O0450B)ontheEOT-R,ratherthantheARD.Theresump1onoftherapydateiscountedasday1whendeterminingDay7oftheCOTobserva1onperiod.Forexample:– IftheARDforanEOT-Rissetforday35andtheresump1ondateistheequivalentofday37,thentheCOTobserva1onperiodendsonday43.
73 74
COT Rules 2-51
• TheCOTwouldbecompletedifthepa1ent’stherapyintensity,asdescribedabove,haschangedtoclassifytheresidentintoahigherorlowerRUGcategory.Forexample:
14RHB
15 16 17
18 19 20
COTRequired
21:RURVRMRL
OrANYNsgRUGifRehabearnedwasNOTRH
“Youshallriseandshowrespecttotheaged.
75
COT Rules 2-51
• TheCOTwouldbecompletedifthepa1ent’stherapyintensity,asdescribedabove,haschangedtoclassifytheresidentintoahigherorlowerRUGcategory.Forexample:
14RHB
15 16 17
18 19 20
COTNOTRequired
21:RHwithANYlastleher,oranursingRUGwhileRHwasearnedbutnot
assigned76
COTRules2-51TheCOTwouldbecompletedifthepa1ent’stherapyintensity,asdescribedabove,haschangedtoclassifytheresidentintoahigherorlowerRUGcategory.Forexample:
14RVB
15 16 17
18 19 20
21COTcheckpoint
22 23 24 25 26 27
28COTcheckpoint
WhetherCOTwasrequiredonday21ornot,day22isday1ofthenextCOTcount
COTRules2-51:
• IfDay7oftheCOTobserva1onperiodfallswithintheARDwindowofascheduledPPSAssessment,theSNFmaychooseto1. completethePPSAssessmentalonebysevngthe
ARDofthescheduledPPSassessmentforanallowabledaythatisonorpriortoDay7oftheCOTobserva1onperiod.Thiseffec1velyresetstheCOTobserva1onperiodtothe7daysfollowingthatscheduledPPSAssessmentARD.OR
2. combinetheCOTOMRAandscheduledassessmentfollowingtheinstruc1onsdiscussedinSec1on2.10.
77 78
Illustra1onofchoices:CompletethePPSAssessmentalonebysevngtheARDofthescheduledPPSassessmentforanallowabledaythatisonorpriortoDay7oftheCOTobserva1onperiod:2-51
7 8RUB
9 10
11 12 13RUC
14RVC
15Day15RVC
16 17 18 19 20
Day13,14or15areallowedARDsforthestandalone14dayassessment
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WilhideConsul1ng,Inc.(c) 14
79
Illustra1onofchoice:CombineCOTwithscheduledassessment:2-51
7 8RVB
9 10
11 12 13
14
15Day15RUB
16 17 18 19 20
Schedulea14day/COTwithARDonday15
• COTsetspaymentfromday1ofCOTlookbackgoingforward.
• Thissome1mescausesascheduledPPSassessmentnottobeusedforpayment– Butthescheduledassessmentiss1llrequired.
80
23 24 25 26
27 28 2930DayRUB
30
31 32 33 34 35 36COTRVB
KeyPoint:Payment
Whattochoose?
81
WhenRUGstaysthesame:UseanydayinlookbackforscheduledMDSandrestartCOTcountthenextday.
Combine
Replace*
When COT checkpoint is day of discharge
82
• Whenaresident’sdischargefromtheSNFisonorpriortoDay7oftheCOTobserva1onperiod,thennoCOTOMRAisrequired.
• IfaSNFchoosestocompletetheCOTOMRAinthissitua1on,theymaycombinetheCOTOMRAwiththedischargeassessment.-Page2-52
• COTisallowedbutnotrequiredifcheckpointisthedayofdischarge.• ShoulddoCOTifRUGishigher
• Emergentdischarge?• ShouldnotdoCOTifRUGislower
• But,noproviderliabilityforeitherchoice,aslongasday7ofCOTcountischosenforCOTARD.
1 2 3 4
5 6 7COTcheck
8
RUCcontrollingpayment RVC
LCD
LTC
DC
Ifyouaregoingtobillday7andtheRehabRUGchanges,COTnotop1onal!
83
IfthedatelistedinA2400CisonoraqerDay7oftheCOTobserva1onperiod,thenaCOTOMRAwouldberequiredifallothercondi1onsaremet.2-52
COTRules2-51:• TheCOTARDmaynotprecedetheARDofthefirstscheduled
orunscheduledPPSassessmentoftheMedicarestayusedtoestablishthepa1ent’sini1alRUG-IVtherapyclassifica1oninaMedicarePartASNFstay.
84
5DAYRUG Rehab?
Nursing? RehabRUGearned?
COTcountbegins
NoCOTcountbegins
No
Yes
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WilhideConsul1ng,Inc.(c) 15
COTRules:2-52
• Exceptasdescribedbelow,aCOTOMRAmayonlybecompletedwhenaresidentiscurrentlyclassifiedintoaRUG-IVtherapygroup(regardlessofwhetherornottheresidentisclassifiedintothisgroupforpayment),basedontheresident’smostrecentassessmentusedforpayment.
85 86
• TheCOTOMRAmaybecompletedwhenaresidentisnotcurrentlyclassifiedintoaRUG-IVtherapygroup,butonlyifbothofthefollowingcondiLonsaremet:1. ResidenthasbeenclassifiedintoaRUG-IVtherapygroup
onapriorassessmentduringtheresident’scurrentMedicarePartAstay,and
2. Nodiscon1nua1onoftherapyservices(plannedorunplanneddiscon1nua1onofallrehabilita1ontherapiesforthreeormoreconsecu1vedays)occurredbetweenDay1oftheCOTobserva1onperiodfortheCOTOMRAthatclassifiedtheresidentintohis/hercurrentnon-therapyRUG-IVgroupandtheARDoftheCOTOMRAthatreclassifiedtheresidentintoaRUG-IVtherapygroup.
2-52
Illustra1onofruleonslide64:
87
S M T W Th F SaPT 0 75 75 75 75 75 0OT 0 75 75 75 75 75 0Tot 750
30DayARD RUB
S M T W Th F SaPT 0 75 75 75 Sick 75 0OT 0 75 75 75 75 0Tot 600 0
COT✓
S M T W Th F SaPT 0 75 75 75 75 75 0OT 0 75 75 75 75 75 0Tot 750
COT✓
NotherapyRUG,&no3daybreakintherapy:DoCOT
COTCountcon1nues:MayDoCOT
RehabRUGestablished
NoRehabRUGearned
MorerulesCOT2-52
• Underthesecircumstances[slide64],comple1ngtheCOTOMRAtoreclassifytheresidentintoatherapygroupmaybeconsideredop1onal.
• Addi1onally,theCOTOMRAwhichclassifiesaresidentintoanon-therapygrouportheCOTOMRAwhichreclassifiestheresidentintoatherapygroupmaybecombinedwithanotherassessment,pertherulesforcombiningassessmentsdiscussedinSec1ons2.10through2.12ofthismanual.
88
MoreCOTRules2-53
• ACOTOMRAmaybeusedtoreclassifyaresidentintoaRUG-IVtherapygrouponlywhentheresidentwasclassifiedintoaRUG-IVnon-therapybyapreviousCOTOMRA(whichmayhavebeencombinedwithanotherassessment,pertherulesforcombiningassessmentsdiscussedinSec1ons2.10through2.12ofthismanual).
89
S M T W Th F SaPT 0 75 75 0 75 75 0OT 0 75 75 0 75 75 0Tot Day29 600
NursingRUGearned
Illustra1onofruleonslide67:
90
S M T W Th F SaPT 0 75 75 75 75 75 0OT 0 75 75 75 75 75 0Tot 750
14DayARD 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✓
Day22:NoCOTdue-RehabRUG
same
RehabRUGNOTearnedonPPS30dayonday29,soCOT
countSTOPS.NOCOTonday36unless30daycombinedwith
COT
ARDDay15
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WilhideConsul1ng,Inc.(c) 16
MoreRules:Chapter6,pg6-14
• IfanewPPSassessmentusedforpaymentoccurswithanARDsetforonorpriortothelastdayofaCOTobserva1onperiod,thenaChangeofTherapyOMRAisnotrequiredforthatobserva1onperiod.Example:– AnSCSAisperformedwithanARDofDay10.Anevalua1onfortheChangeofTherapyOMRAwouldoccuronDay17butthe14-DayassessmentinterveneswithARDonDay15.AChangeofTherapyOMRAisnotperformedwithanARDonDay17.Rather,theCOTOMRAevalua1onprocessisrestartedwiththe14-dayassessmentwithARDonDay15.Day1ofthenextCOTobserva1onperiodisDay16andthenewCOTOMRAevalua1onwouldbedoneonDay22.
91
June Sunday 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
Page2-56USEDFORPAYMENT
Anassessmentisconsideredtobe“usedforpayment”inthatiteither:1. Controlsthepaymentforagivenperiodor,2. Withscheduledassessmentsmaysetthe
basisforpaymentforagivenperiod.
93
To‘setthebasisforpaymentforagivenperiod”atleastonedayinthatperiodmustbebilledtoMedicarePartA
ControlsvsSevngBasisforPayment
94
7RUC5day
8
9 10 11 12 13 14RVC14day
15 16
17 18 19 20 21RUCCOT
22 23 24 25 26
27 28RUC
29 30
• 5day:RUCsetsbasisANDcontrolspaymentfor1-14• 14day:RVCsetsbasisfor15–30• COT:RUCcontrolspaymentfor15–30
21COTRVB
22 23 24 25 26 27 28 29
30
31 32 33 34 35 36 37 38 39 40
RMB30D
Ifscheduledassessmentdoesnotsetthebasisforagivenperiod,itmaynotbeusedinplaceofCOT.IftheCOTisnotdone,itismissed:providerliability
Illustra1on:PPSscheduledassessmentisnot‘usedforpayment’soitcannotreplaceaCOT
ProviderLiability DC
95
6-14
21COTRVB
22 23 24 25 26 27 28 29
30
31 32 33 34 35 36 37 38 39 40
RMB30D
Change30DtoCOTbeforetransmidng,using7dayencoding/edi;ngperiod
COTIllustra1on
DC
96
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WilhideConsul1ng,Inc.(c) 17
7DayEncoding/Edi1ngPeriod
• Page5-8:Facili1eshaveupto7daystoencode(enterintothesoqware)andeditanMDSassessmentaIertheMDShasbeencompleted.
• Changesmaybemadetotheelectronicrecordforanyitemduringtheencodingandedi1ngperiod,providedtheresponsereferstothesameobservaLonperiod.
97
Op1ons:
• IfscheduledPPSassessmentsubmihed,maymodifytoaddCOT(5-11)
• MaynotmodifyCOTtoaddscheduledassessment(5-11)– TypeofAssessmentmaybemodifiedwhenitdoesnotchangetheItemSetCode(ISC)
• IfscheduledassessmentnotonCOTARD(early)maymodifyandtakedefaultdays,asopposedtoproviderliability.
98
ItemSetCode2-86
99
EARLY/LATECOT
100
Non-compliancewithPPSSchedule:COT
• IFCOTARDissetearly,day1fornextCOTisthedayaqertheearlyCOTARD.
101
130DayARD
2 3 4 5
6COT
7 8 9 10
11 12 13COT
1 2 3 4 5 1 2 3 4
5 6 7
Willreceivedefaultfor“thetwodaystheearlyCOTwasoutofcompliance”-6-53
November
Non-compliancewithPPSSchedule:COT
• IFCOTARDissetlate,withnointerveningassessment,day1fornextCOTisthedayaqerthelateCOTARD.
102
730DayARD
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
Willreceivedefaultfor“thetwodaysthelateCOTwasoutofcompliance”-6-54
4 5 6 7
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WilhideConsul1ng,Inc.(c) 18
Non-compliancewithPPSSchedule:COT
• IFCOTARDissetlate,aqeraninterveningassessment,thelateCOTdoesnotresettheCOTcount.
103
18 19 20 21 22
23 24 25 26 2730Day
28 29 30 31 32 33 34 35 36 37
1 2 3 4 5 6 7
1 2 3
WillreceivedefaultforthedaysthelateCOTshouldhavecontrolledpayment,un1l30day
kicksinonday31.
4 5 6 7 1 2 3
LateCOT
Default
Default
6-54
MissedAssessment:Page2-74
104
5-Day 14-Day 1 15 2 16 3 17 4 18 5 19 6 20 7 21 8 22 9 23
10 24 11 25 12 26 13 27 14 28
29 30 30DayARD
30-Day 31 32 33 34 35 36 37 COTCheck38 LastTx39 40 EOTARD41 42 43 DISCHARGE44 45 46
ProviderLiability:
Day31-38
Requiredbutnotdone
2.10CombiningMedicareScheduledandUnscheduledAssessments2-56
• IfanunscheduledPPSassessmentisrequiredintheassessmentwindow(includinggracedays)ofascheduledPPSassessmentthathasnotyetbeenperformed,thenfacili1esmustcombinethescheduledandunscheduledassessmentsbysevngtheARDofthescheduledassessmentforthesamedaythattheunscheduledassessmentisrequired.
• AscheduledPPSassessmentcannotoccuraqeranunscheduledassessmentintheassessmentwindow—thescheduledassessmentmustbecombinedwiththeunscheduledassessmentusingtheappropriateARDfortheunscheduledassessment.
105
Sec;on2.10CombiningMedicareScheduledandUnscheduledAssessments
• IncaseswhenafacilityfailstocombineascheduledandunscheduledPPSassessmentasrequiredbythecombinedassessmentpolicy,thepaymentiscontrolledbytheunscheduledassessment.-Page2-56
106
7 8 9 10 11LastTherapy
12 13 14 15 16
17 18
EOTARD
14DayARD
Notallowed
Sec;on2.10CombiningMedicareScheduledandUnscheduledAssessments
• Inthiscase,14daywillnotbeusedforpayment.TheEOTwillpayfromDay12intothe14daypaymentperiodun1lthenextscheduledorunscheduledassessmentusedforpayment.
107
7 8 9 10 11LastTherapy
12 13 14 15 16
17 18
EOTARD
14DayARD
• Reminder:ScheduledpriortoEOTARDisallowed,but,theEOTwillpayday12–15,andthenon-therapyRUGfromthe14day(Z0150)willpaybeginningonday16.–Page6-11
108
7 8 9 10 11LastTherapy
12 13 14 15 16
17 18
EOTARD
14DayARD
• BestPrac1ce:IfyoucancombineanEOTorSOTwithscheduled,thatisthethingtodo.• COTisdifferent:MaydoscheduledwithoutCOTbefore
oronCOTcheckpoint.
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WilhideConsul1ng,Inc.(c) 19
Note:
• AmissedCOTisproviderliability– EveniftheRUGwouldhavegoneup
• AmissedPPSassessmentisproviderliability– Itisalwaysbehertodoitlatefordefaultrate
109
SignificantChange2-54
• SCSAorSCPAwillalsoactasanunscheduledPPSassessment.– WillsetpaymentonARD– IfcombinedwithscheduledPPSMDS,willsetpaymentonARDunlesssetonagraceday
• Ifsetongracedaywillsetpaymentonday1ofthebillingcycleforthescheduledassessment.
110
Whataboutotherinsurance?
• AssessmentsthatarecompletedforpurposesotherthanOBRAandSNFPPSreasonsarenottobesubmihed,e.g.,privateinsurance,includingbutnotlimitedtoMedicareAdvantagePlans.-Page5-1RAIManual
• OBRAschedulemustbefollowedforanyoneinaMedicareorMedicaidcer1fiedbed.– Residentpaysourceisnotrelevant– Cer1fica1onofthebedisallthatisrelevant.
• Chapter2,page2-2
111
Whataboutotherinsurance?
112
Choices:• Dotwo:AdmissionandPPS5day
– Soqwaredependent• Doone:AdmissionandsendRUGfromthatassessmenttotheinsurancecompany
• Discussion?
113
WhatifIdojusttheAdmission,thenneeda5dayforOriginalMedicarelater?
• Choices:– ModifyAdmission,add5day&MedicaredatesinA2400
• YoumaymodifythereasonforassessmentwhentheISCdoesnotchange.Page5-11
– UsetheAdmissionassessmenttobillthedays,withoutthePPS5dayorA2400dates-page6-56
– Discussion?
114
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WilhideConsul1ng,Inc.(c) 20
Page6-55:
SNFmaybillthedefaultcodewhenaMedicare-requiredassessmentdoesnotexistintheQIESASAPsystemwhen:1. Thestayislessthan8dayswithinaspellofillness,2. TheSNFisno1fiedonanun1melybasisoforis
unawareofaMedicareSecondaryPayerdenial,3. TheSNFisno1fiedonanun1melybasisofa
beneficiary’senrollmentinMedicarePartA,4. TheSNFisno1fiedonanun1melybasisofthe
revoca1onofapaymentban,5. Thebeneficiaryrequestsademandbill,or6. TheSNFisno1fiedonanun1melybasisorisunaware
ofabeneficiary’sdisenrollmentfromaMedicareAdvantageplan.
115 116
Page6-55:
• Insitua;ons2-6,youmayuseAdmissionassessmenttobillforalldaysofcoveredcareassociatedwithMedicare-required5-&14-dayassessments,evenifthebeneficiaryisnolongerreceivingtherapyservicesthatwereiden1fiedunderthemostrecentclinicalassessment.– Ifyoudon’tneedtouseitforall30days,becauseyouhavetheotherPPSassessments,itcanbeusedforthedayspaidbythePPS5dayMDS.
• TheARDoftheOBRAAdmissionassessmentmaybebeforeorduringtheMedicarestayanddoesnothavetofallwithintheARDwindowofthe5-dayor14-dayassessment.
• Forcovereddaysassociatedwith30,60,or90-dayMDSs,theSNFmusthaveavalidOBRAMDSinQIESASAPsystemthatfallswithintheARDwindowofthePPSassessmentinordertoreceivefullpaymentattheRUGcategoryinwhichtheresidentgrouped.• IfARDofthevalidOBRAassessmentfallsoutsidetheARDwindowofthePPSassessment,theSNFmustbillthedefaultcode.
Note:StandaloneOBRAorPPSDischargeAssessmentsdonotproduceaRUGandcouldnotbeusedforpayment.
117
Scenarios:
• BOreportsprivateinsuranceispaying,andtheyneedlevels.Latertheysaytheinsurancewouldnotpay.THISISSITUATION#2.
• Choices:– UsetransmihedAdmissionassessment
• TheRUGfromthatonewillpayupto30days– Thinkthatthrough
– FollowPPSschedulebutdon’tsubmit,incaseyouneedthem.
• MayhavemoreaccurateRUGstobill– Mayormaynotbeagoodthing
118
Scenarios:
• BOsaysMedicareHMOispayingandtheydon’tneedRUGs.LatertheysayitshouldhavebeenOriginalMedicareandtheyneedRUGs.THISISSITUATION#6.– Sameop1ons
• OR:BOsaysMedicareHMOispayingandtheydon’tneedRUGs,butlatertheysaytheMedicareHMOneedsRUGs:– IftheysaytheyfollowMedicareguidelines,therulesinChapter6apply.
119
Whatifit’snotanyofthoseexcep1ons&Ijustdon’thavethePPSMDSthatIneed?(6-55)
• WhentheSNFfailedtosettheARD1melyandresidentwasalreadydischargedfromPartAwhenthiswasdiscovered:
• IfavalidOBRAassessmentexistsintheQIESASAPsystemwithanARDthatisonanallowabledayforthePPSMDS,theSNFmaybilltheRUGcategoryinwhichtheresidentclassified.– (Standalonedischargeassessmentdoesnotcount)
• So,youcanusetheAdmissionassessment,withoutthePPS5daycombined,tobillforthedaysaPPS5dayisresponsiblefor.– OraSigChange,oranAnnual,oraQuarterly,oraSigCorrecJon
120
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WilhideConsul1ng,Inc.(c) 21
HIPPSCodeRefresher
121
RUC
10
RUC10
RUG
AI
HIPPSCodes
122
HIPPSCodewillbecalculatedbyGrouper.
judywilhide.com 123
Compliance: Setting a PPS ARD
• ThefacilityisrequiredtosettheARDontheMDSItemSetorinthefacilitysoqwarewithintheappropriate;meframeoftheassessmenttypebeingcompleted.-p2-8– HavinganARDonascheduleisnotsufficient.
124
1
2 3 4 5 6 7
8
9 10 11 12 13 14
PPS5DayMDS
Page6-55
• IftheSNFfailstosettheARDwithinthedefinedARDwindowforaMedicare-requiredassessment,includingthegracedays,andtheresidentiss1llonPartA,theSNFmustcompletealateassessment.TheARDcanbenoearlierthanthedaytheerrorwasiden1fied.
125
LatePPSassessments–Page6-54
IftheARDissetforpriortotheendoftheperiodduringwhichthelateassessmenta) wouldhavecontrolledthepayment,andb) nointerveningassessmentshaveoccurred,
theSNFwillbillthedefaultrateforthenumberofdaystheassessmentisoutofcompliance,toincludetheARDdateofthelateassessment.
126
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LateARDsetoutsidepaymentperiod,and/oraqerinterveningassessment:Page6-54
• IfARDoflateassessmentissetaqertheendoftheperiodduringwhichthelateassessmentwouldhavecontrolledpayment,orincaseswhereaninterveningassessmenthasoccurredandtheresidentiss1llonPartA,theprovidermusts1llcompletetheassessment.TheARDcanbenoearlierthanthedaytheerrorwasiden1fied.
• TheSNFmustbillallcovereddaysduringwhichthelateassessmentwouldhavecontrolledpaymenthadtheARDbeenset1melyatthedefaultrateregardlessoftheHIPPScodecalculatedfromthelateassessment.
127
PPS14DayARD:Illustra1on:Late,aqerpaymentcycle,aqerintervening
assessment
128
5-Day 14-Day 1 9/28/2009 15 10/12/2009 2 9/29/2009 16 10/13/2009 3 9/30/2009 17 10/14/2009 4 10/1/2009 18 10/15/2009 5 10/2/2009 19 10/16/2009 6 10/3/2009 20 10/17/2009 7 10/4/2009 21 10/18/2009 8 10/5/2009 22 10/19/2009 9 10/6/2009 23 10/20/2009
10 10/7/2009 24 10/21/2009 11 10/8/2009 25 10/22/2009 12 10/9/2009 26 10/23/2009 13 10/10/2009 27 10/24/2009 14 10/11/2009 28 10/25/2009
29 10/26/2009 30 10/27/2009
30-Day 31 30 DAY ARD 32 10/29/2009 33 10/30/2009 34 10/31/2009 35 14 DAY ARD 36 11/2/2009 37 11/3/2009 38 11/4/2009 39 11/5/2009 40 11/6/2009 41 11/7/2009 42 11/8/2009 43 11/9/2009 44 11/10/2009 45 11/11/2009 46 11/12/2009
Notusedforpayment
COTCheckpoint
SevngPPSARDs
• ASNFmaynotuseadateoutsidetheSNFPartAMedicareBenefit(i.e.,100days)astheARDforascheduled*PPSassessment.
• Forexample,theresidentreturnstotheSNFonDecember11followingahospitalstay,requiresandreceivesSNFskilledservices,andhas3daysleqintheSNFbenefitperiod.
• SNFmustsettheARDforthePPSassessmentonDecember11,12,or13tobillfortheRUGcategoryassociatedwiththeassessment.
129 Pg6-56*MayuseLOAdayasARDforunscheduledPPSAssessments
Defaultfordaysoutof
compliance
EarlyARD
LateARD
130
ProviderLiability*
NoARD
131
Tips:
• Haveaback-uptoopenPPSAssessments.• CommunicatedailywithRehab.• ReviewPPSschedulerspreadsheets(orothermethodoftracking)veryfrequently,ifnotdaily.
132
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133
Scenario:• ResidentadmihedFridayaqernoonanddiesSundaynightpriortomidnight.MDSCcomesinonMonday.NoPPS5dayARDwassetandnowtheresidentisnotonaPartAstay.NextSteps?
YoumaynotsetanARDnow.TherewasnotonesetandtheresidentisnotonPartAnow.Sincethestayislessthan8days,youmaybilldefaultrateforthetwodays.ConsiderpaperMDSinadmissionchartforresidentwithARDsetonpaperform.KeepthatforminthechartanduseittoopenaPPS5daywhenMDSCcomesinonMonday.
PageA-30and6-55134
• Whentheresidentdiesorisdischargedpriortotheendofthelook-backperiodforarequiredassessment,theARDmustbeadjustedtoequalthedischargedate.A-30
• IftheSNFfailstosettheARDofascheduledPPSassessment
priortotheendofthelastdayoftheARDwindow,includinggracedays,andtheresidentisnolongeraSNFPartAresident,andasaresultaMedicare-requiredassessmentdoesnotexistintheQIESASAPforthepaymentperiod,theprovidermaynotusuallybillfordayswhenanassessmentdoesnotexistintheQIESASAP...IftheresidentwasalreadydischargedfromMedicarePartAwhenthisisdiscovered,anassessmentmaynotbeperformed.6-55
QUESTIONS?
135
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
Prepared by Judy Wilhide Brandt 2/1/15
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
Prepared by Judy Wilhide Brandt 2/1/15
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