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CMS Changes Related to MDS Completion and SNF Medicare Billing

CMS Changes Related to MDS Completion and SNF Medicare Billing. Overview – Impact – Response Presented by: Darlene Thompson and Tami Johnson. Our industry is resilient and has a demonstrated track record for adapting to change.

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CMS Changes Related to MDS Completion and SNF Medicare Billing

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  1. CMS Changes Related to MDS Completion and SNF Medicare Billing Overview – Impact – Response Presented by: Darlene Thompson and Tami Johnson

  2. Our industry is resilient and has a demonstrated track record for adapting to change We will successfully navigate this change in the same way we adapted to the MDS 3.0 and RUGs IV transition in 2011

  3. Overview of Rule • Adjusted the CMIs and associated rates • Result in a reduction to skilled nursing facility payments by -12.6% • Adjustments Targeted the Nursing Component of the Rehab RUGs  • CMS applied a +2.7% Market Basket Adjustment • Reduced that by -1.0% percent multi-factor productivity (MFP) adjustment mandated by the Affordable Care Act  

  4. Urban Rate Comparisons  Based on average Urban Rate for 2011 and 2012

  5. Overview of PPS Rule 2012 • Group Therapy (RUGs Grouper Change) • MDS Changes • Changes to OMRA Assessment Types • Modified the End of Therapy (EOT) OMRA Requirements • Modified the EOT OMRA to allow Resumption of Therapy (EOT-R) • Introduced Change of Therapy OMRA (COT) to evaluate rehab intensity every 7-days • Changed Available Days for Scheduled MDSs • Transition Plan for 10/01/2011

  6. MDS Scheduling Changes

  7. Changes in the MDS Schedule • Reduces the number of days available for each scheduled MDS • Reduces the overlap of look back days between assessments • Impacts scheduling software and basic MDS patterns for centers • Evaluate combining of various MDSs types • Evaluate MDS timing • Evaluate timing of CAAs and Care Plans • Understand how and when to combine assessments

  8. Changes to Scheduling

  9. Transition Plan – Revised MDS Schedule • Any ARD set on or after October 1, 2010 must be a valid ARD date as defined by the new Valid Days Table This would mean after 10/01/2010 an ARD which fell on any of the following stay days would not be valid: Days 11-12, 19, 21-26, 34, 50-56, 64, 80-86, or 94

  10. Group Therapy

  11. Group Therapy • Group must be scheduledfor 4 patients performing the same or similar activities • Assigns group minutes by dividing the minutes by 4 for allocation to the RUG Group regardless of group size • Example: If PT conducts a 60 minute group with four patients. Each patient receives 15 minutes of treatment toward their RUG level. • Cap remains at 25% of the Reimbursable Therapy Minutes (RTM) • Plan of Care must support need for therapy

  12. Current Group Utilization • CMS Statistics Show: 8% of the minutes delivered in group • 2 – 3 patients per group currently is a common practice • Must be scheduled for 4 patients going forward • RTM divided by 4 even when on 3 patients treated • Changes in Group minutes impacts primarily RU, RV, and RH RUG categories

  13. Transition Plan – Group Therapy • Any MDS with an ARD 10/01/2011 or later, group therapy minutes will be allocated as 25% regardless of look back period

  14. Change of Therapy OMRA

  15. Change of Therapy (COT) • Requires the evaluation of rehab service delivery 7-days after ARD or COT check to determine if the RUG has been maintained • If RUG is unchanged, no assessment needed • If RUG (rehab intensity) increased, COT OMRA to increase RUG • If RUG is decreased, COT OMRA required to decrease RUG • Rates change with the first day of the Observation Period of the COT

  16. Change of Therapy OMRA 5 6 1 2 3 4 ARD Payment Changes ARD COT 1 1 2 3 4 COT 5 6 1 2 3 4

  17. What triggers a COT? • Drop in rehab minutes below the RUG threshold • Failure to meet the frequency (treatment days) criteria • A day of treatment must equal 15 minutes for each discipline • Missed minutes are easier to recover than missed days • Example: • RU requires 720 min. with 1 disc. 5x/wk. & one 3x/wk. • If we deliver 720 min. but only 4x/week w/ 2 disc., it drops to RM • If we deliver 719 min. but with 2 disc. at 5x/week, it drops to RV

  18. What triggers a COT OMRA? • Must complete COT check if in a rehab RUG or in a nursing RUG receiving rehab • If a patient has a change in the RUG category and the COT falls within the Regularly Scheduled Assessment Window (including grace days) and the MDS has not been completed, the COT must be combined with the Regularly Scheduled MDS.

  19. Change of Therapy (COT) • Uses the OMRA Item Set • Because the COT is required for patients in Rehab RUG or patients receiving Rehab but in Nursing RUG • Watch Index Maximization with Nursing RUGs • A center could drop their reimbursement by completing an unnecessary COT MDS

  20. Index Maximization - Urban

  21. What can trigger an COT? • Missed treatment sessions • Patient Illness • Scheduling conflicts (patient appointments, patient being ready) • Family Visits or Outings • Patient Refusals • Withheld treatments • Holidays with Missed Sessions • Therapist Illness or Vacation Days • Partial treatment sessions • Changes in rehab intensity and/or added disciplines • Discontinuation or initiation of one or more treating disciplines • Inconsistent Delivery of Care and Poor Communication • No flexibility in ARD Selection for COT

  22. IMPORTANT Every MDS Puts the ADL Coding Back Under Review Every patient will remain in an observation period for the entire duration of their stay.

  23. Impact of Change of TherapyBilled Minutes – Actual Minutes Delivered on 5, 14, 30-day MDS  Pt. sick and session missed 724 min 727 min 648 min 734 min 518 441 ARD RUB 30-day MDS ARD RUB 14-day MDS Change of Therapy RVB  ARD RUB 5-day MDS Change of Therapy RVB Change of Therapy RHB  Rate Change to on 1st day of Observation period Actual Minutes Delivered Below Billed RUG Level Billed MinutesMinutes DeliveredPPS Billing 10/01/2011

  24. Impact of COT on 30-day MDS 728 min. 702 min. 518 min. 423 min. 175 min. 7-days 7-days COTRVB 7-days ARD RUB 30-day MDS 7-days COT RVB COTRHB ARD RMB 60-day MDS Rate Change to on 1st day of Observation period Actual Minutes Delivered Below Billed RUG Level Billed MinutesMinutes DeliveredPPS RUG 10/01/2011

  25. Normal Admission Process ARD ARD Change Rate Change Rate 14-day COT COT COT Rate  14-day Change Rate COT Combo COT Rate  30-day COT 5-day MDS Pays Days 1-14  14-day MDS Pays Days 15-30  30-day 31-60

  26. Combining Scheduled and Unscheduled MDSs • If an unscheduled MDS is in a scheduled assessment window, the unscheduled MDS cannot be later in that window. • The two assessments must be combined.

  27. Combining Scheduled and Unscheduled MDSs ARD ARD Change Rate COT or Check Change Rate COT Combo If the COT is required, the days after the COT shown here in RED are no longer available as an ARD

  28. Frequency of COT Assessments ** Additional COT assessments can occur as EOT and SOT are completed. The effectiveness of rehab management and patient stability will impact frequency.

  29. Transition Plan – COT OMRA • The COT OMRA process becomes required for any scheduled or unscheduled MDS with an ARD of 10/01/2011 or later

  30. End of Therapy OMRA

  31. End of Therapy OMRAs • EOT OMRA Required with 3-missed days of rehab • Regardless if missed session is on a weekday, weekend or holiday • Regardless of weekend coverage at the center • Regardless of why session was missed • Medicare does not recognize holidays as an acceptable day of missed therapy • Treatment day must equal at least one discipline at 15 minutes of treatment to count as a treatment day • Reimbursed at a Nursing RUG for days without rehab

  32. End of Therapy OMRA ARD ARD ARD

  33. End of Therapy Resumption (EOT-R) • EOT triggers due to three consecutive days without treatment and • Rehab resumes within 5-days, triggers EOT-R and • Resumes at the same frequency/intensity • Paid at level prior to EOT on day rehab resumed, but paid at nursing RUG for days without treatment Equals date rehab resumes care

  34. End of Therapy - Resumption ARD ARD ARD Paid at Nursing RUG COT IMPORTANT: The date of rehab resumption becomes the rehab start date on the next MDS and it starts the COT Observation Period. Becomes the Rehab Start Date on the next MDS and becomes the trigger for the 7-day count for COT OMRA

  35. Transition Plan – EOT and EOT-R • Policy is effective for any ARDs 10/01/2011 or later • October 1st is a Saturday an if treatment is missed (regardless of cause or weekend coverage rules of the past) is will count as a missed day

  36. Transition Plan for Billing • Any MDS that has pay dates in September and October will generate two RUG scores when transmitted to the QIES ASAP repository • FY2011 RUGs scores reflected in Error Message #1059 (September billed Dates) • FY2012 RUGs scores reflected in Error Message #1060 (October billed Dates) • Problem: The QIES ASAP system will not be updated until 09/18. MDSs with ARDs between 08/22 and 09/17 may have pay dates in both September and October

  37. Combining the Changes

  38. The Most Complex Part • When Combining Assessments, we must meet the requirement for all of the Assessments • Scheduled Assessments (5, 14-day, etc.) • SOT Day 5-7 after 1st evaluation • EOT Day 1-3 after missed session • EOT-R 1-3 after missed session with resumption within 5-days • COT Day 7 after ARD • All MDSs and combinations of MDSs must meet the reimbursement requirements

  39. Scheduling MDSs OBRA Assessments Admission Quarterly …….......... Annual PPS Assessments – NEW ARD RANGES 5-day 14-day 30-day 60-day 90-day COT OMRA Assessments COT COT COT x3 COTx3 COT Unscheduled OMRA Assessments – EOT, SOT, SCSA

  40. Combining Scheduled and Unscheduled MDSs • If the ARD for the OMRA falls within the ARD (including grace days) of a PPS scheduled assessment that has not been performed yet, the assessments MUST be combined. • This includes EOT, SOT, E/SOT, and COT OMRAs

  41. MDS Based on Current Practice and Volume With clinically appropriate RUG management by rehab and nursing

  42. Here’s what we found • MDS-N tend to complete MDSs early • Results in un-used or over-written MDSs • Failure to combine MDSs when clinically appropriate • MDS-N complete additional MDSs due to lack of communication • Confusion on Rules for Combining Assessments

  43. Centers With the Greatest Impact: • Longer LOS • Decreased ability to provide weekend coverage • Rehab staffing challenges • Problems with scheduling rehab treatments • High patient refusals • Poor Communication • Poor ADL Management

  44. Common Strategies • Improve communication • Enhance MDS Scheduling – Increase understanding around combinable MDSs • Provide clinically appropriate rehab in the most appropriate method • Improve scheduling to decrease missed rehab sessions • Make-up missed sessions as clinically appropriate • Improve Productivity with existing staff • Improve consistency of weekend coverage • Increase staffing as necessary • Some causes of the COT or EOT cannot be mitigated

  45. Action Steps

  46. Center Level Focus • Increase communication • Monitor ADL Documentation • Evaluate and improve weekend coverage • Improve patient scheduling • Discuss missed sessions daily • Review how missed sessions are made up when clinically appropriate • Become diligent about discharge planning and when disciplines DC care • Evaluate current workload

  47. Our industry is resilient and has a demonstrated track record for adapting to change We will successfully navigate this change in the same way we adapted to MDS 3.0 and RUGs IV transition

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