SNF PPS and RUG-IV SNF PPS Assessments and …

1 SNF PPS and RUG-IVSNF PPS Assessments and PoliciesSeptember 1, 2010 minimum data Set (MDS) PPS & RUG-IV2 Agenda SNF PPS Assessments SNF Part A PoliciesoEarly assessmentoLate assessmentoMissed assessmentoMedicare Short Stay ExamplesPPS AssessmentsMinimum data Set (MDS) PPS & RUG-IV4 PPS Assessments1 OBRA, PPS, and Tracking Records SNFsoAll OBRA requirements oPPS requirementsoTracking records Swing BedsoDischarge assessmentsoPPS requirementsoTracking recordsMinimum data Set (MDS) PPS & RUG-IV5 PPS Assessments2 Scheduled A0310Bo5-dayo14-dayo30-dayo60-dayo90-day oReadmission/returnMinimum data Set (MDS) PPS & RUG-IV6 PPS Assessments3 Scheduled A0310 BoPredetermined assessment window and grace days May not combine scheduled assessmentsoOne scheduled may notreplace another scheduledoMust be completed sequentiallyoPredetermined payments days, which may be impacted by unscheduled assessmentMinimum data Set (MDS) PPS & RUG-IV7 PPS Assessments4 assessment TypeAssessment ReasonARDARD Grace DaysStandard Medicare Payment Days5-dayReadmission01061-56-81-1414-day 0211-1415-1915-3030-day0321-2930-3431-60 60-day0450-5960-6461-9090-day0580-8990-9 491-100 Modified tabled see page 2-42 of MDS RAI manualMinimum data Set (MDS)

2 PPS & RUG-IV8 PPS Assessments5 5-day & Readmission/returnoARD 1-5oGrace days 6-8oPayment days 1-14oA0310B = 01 or 06 minimum data Set (MDS) PPS & RUG-IV9 PPS Assessments6 14-dayoARD 11-14oGrace days 15-19oPayment days 15-30oA0310B = 02 minimum data Set (MDS) PPS & RUG-IV10 PPS Assessments7 30-dayoARD 21-29oGrace days 30-34oPayment days 31-60oA0310B = 03 minimum data Set (MDS) PPS & RUG-IV11 PPS Assessments8 60-dayoARD 50-59oGrace days 60-64oPayment days 61-89oA0310B = 04 minimum data Set (MDS) PPS & RUG-IV12 PPS Assessments9 90-dayoARD 80-89oGrace days 90-94oPayment days 91-100oA0310B = 05 minimum data Set (MDS) PPS & RUG-IV13 PPS Assessments10 Unscheduled A0310A,B,C,DoMay occur any time during stay when requirements metoMay be combined with a PPS scheduled assessmentoMay be combined with each other^^Significant change in status and significant correction of prior comprehensive may not be combinedMinimum data Set (MDS)

3 PPS & RUG-IV14 PPS Assessments11 Unscheduled A0310A,B,C,DoSignificant change in status/clinical change IDT determines meets significant change guidelines A decline or improvement in a resident s status that: Will not normally resolve itself without intervention or by implementing standard disease-related clinical intervention Impacts more than one area of resident s health status Requires IDT review and/or revision of care plan Manual lists examples notall inclusive list Individuallybased New RUG maybe established, payment change on ARDM inimum data Set (MDS) PPS & RUG-IV15 PPS Assessments12 Unscheduled A0310A,B,C,DoSignificant correction to prior comprehensive IDT determines prior comprehensive assessment contains significant error Significant error is an error in an assessment where.

4 Resident s overall clinical status is not accurately represented; and Error has not been corrected via submission of a more recent assessment New RUG maybe established, payment change on ARDM inimum data Set (MDS) PPS & RUG-IV16 PPS Assessments13 Unscheduled A0310A,B,C,DoOther Medicare Required assessment (OMRA) Two types Start of Therapy (SOT) End of Therapy (EOT) Shortened Assessments May not replace a scheduled PPS assessment New RUG willbe established, payment change according to rulesMinimum data Set (MDS) PPS & RUG-IV17 PPS Assessments14 SOT OMRAoNew assessment typeoOPTIONALoTo obtain therapy RUG* any time during stay (Z0100A)

5 OARD 5-7 days after start of first therapy (day 1 = day therapy started)oPayment starts first day of therapyoOnly complete if therapy RUG (index maximized), otherwise rejectedoBe attentive when combining*Rehabilitation or Extensive Services Plus RehabilitationMinimum data Set (MDS) PPS & RUG-IV18 PPS Assessments15 EOT OMRAoNot new assessmentoNot optionaloComplete only when skilled care continuesoTo obtain a non-therapy RUG (Z0150A)oARD 1-3 days after last day of therapy provided (day 1= the next day therapy normally available)oPayment changes day after last day of therapy oNo penalty for early ARD when set on day therapy not normally availableSNF Part A PoliciesMinimum data Set (MDS) PPS & RUG-IV20 SNF Policies Short Stay Early assessment Late assessment Missed assessmentMinimum data Set (MDS) PPS & RUG-IV21 Medicare Short Stay New Must be discharged from Part A on or before day 8 of Part A stay Payment policy only To obtain a therapy RUG Therapy is prorated based on averagedaily therapy minutesoRLx 15-29 minutesoRMx 30-64 minutesoRHx 65-99 minutesoRVx 100-143 minutesoRUx 144 or > minutesMinimum data Set (MDS)

6 PPS & RUG-IV22 Short Stay OMRA (A0310C = 1or 3) 5-day or readmission/return assessment (A01310B = 01or 06) combined with SOT OMRA or prior to SOT (A2300) SOT OMRA must be day 8 or earlier (A2400B) must be last day of Medicare stay (A2400C) may not be more than 3 days after start of therapy (O0400A5, O0400B5, O0400C5) started during last 4 least one therapy (O0400A6, O0400B6, O0400C6) continued through last day of Part A stay (dash or ARD = EOT date) must be Rehab + ES or Rehab group (Z0100A) minimum data Set (MDS) PPS & RUG-IV23 Short Stay earliest SOT date is 1stday of short stay, use short stay assessment Z0100A entire earliest SOT date is after 1stday of stayoIf 5-day assessment before short stay assessment : use Z0100A from 5-day from 1stday of stay to day before earliest SOT date, then use Z0100A from SOT date to end of stayoIf SOT OMRA combined w/ 5-day.

7 Use Z0150A from 1stday of stay to day before therapy, then use Z0100A from SOT date to end of stayMinimum data Set (MDS) PPS & RUG-IV24 Early assessment Not new Paid default rate for # of days assessment out of compliance Not applicable for EOT OMRA when ARD set on day therapy not normally availableMinimum data Set (MDS) PPS & RUG-IV25 Late assessment Not new ARD may not be earlier than the date the omission of assessment is identified ARD set prior to end of payment periodoDefault rate up to day before ARDoHIPPS rate ARD and on ARD set after payment period and stay is still coveredoDefault rate for related payment period Stay is no longer covered.

8 ARD would be after payment period oNot able to complete an assessment which would cover days - ARD would be after SNF coverage ended (this is missed assessment ) minimum data Set (MDS) PPS & RUG-IV26 Missed assessment Not less than 8 days (short stay may apply) untimely of MSP denial* untimely of revocation payment ban* bill request* untimely of dis-enrollment from MA plan**may use OBRA admission assessment for 5 must have assessment w/ARD in window of 30,60,90-day for non-default RUGM inimum data Set (MDS) PPS & RUG-IV27 Late vs. Missed assessment Late assessmentoOmission is discovered while resident is in SNF Part A stay and a SNF PPS assessment is then completedoARD is during SNF Part A stay Missed assessmentoOmission is discovered after SNF Part A stay and an assessment already existsoARD is during SNF Part A stayExamplesMinimum data Set (MDS) PPS & RUG-IV29 SOT OMRA-Example 11 Resident on Part A for skilled nursingoOT eval TuesdayoPT eval WednesdayoSLP eval Friday What are the possible ARDs for SOT OMRA?

9 minimum data Set (MDS) PPS & RUG-IV30 SOT OMRA-Example 12 Saturday, Sunday, Monday ARD for SOT OMRA must be day 5, 6, or 7, with day 1 being earliest therapy start date (therapy start date = therapy eval date) minimum data Set (MDS) PPS & RUG-IV31 SOT OMRA-Example 2111/411/511/611/711/811/911/10 Therapy start 22minNo txNo txTx63minTx67minTx72minTx70minSOT OMRA ARD-------- Day 5 Day 6 Day 7 Resident in HD2 (CMI 43 - Urban)Start of therapy 11 must be 5-7 days => 11/8, 11/9, 11/10 minimum data Set (MDS) PPS & RUG-IV32 SOT OMRA-Example 22 SOT OMRA ARDo11/8 3 therapy days, 152 minuteso11/9 4 therapy days, 224 minuteso11/10 5 therapy days, 294 minutes 11/10 = RMB (CMI 41 -Urban) minimum data Set (MDS) PPS & RUG-IV33 SOT OMRA-Example 23 OutcomeoDo not complete SOToSOT is optionaloTherapy RUG will pay less than nursing RUG because of ADL change from 11-14 to 6-10 ADL index may change and you must consider the ADL index when determining if SOT is beneficialMinimum data Set (MDS)

10 PPS & RUG-IV34 SOT OMRA-Example 3111/411/511/611/711/811/911/10 Therapy start 22minNo txNo txTx63minTx67minTx72minTx70minSOT OMRA ARD-------- Day 5 Day 6 Day 7 Resident in LD2 (CMI 38 - Urban)Start of therapy 11 must be 5-7 days => 11/8, 11/9, 11/10 minimum data Set (MDS) PPS & RUG-IV35 SOT OMRA Example 32 SOT OMRA ARDo11/8 3 therapy days, 152 minuteso11/9 4 therapy days, 224 minuteso11/10 5 therapy days, 294 minutes 11/10 = RMB (CMI 41 -Urban) minimum data Set (MDS) PPS & RUG-IV36 SOT OMRA Example 33 OutcomeoComplete SOToTherapy RUG higher than current nursing RUGoTherapy RUG begins 11/4 minimum data Set (MDS) PPS & RUG-IV37 EOT OMRA Example 11 Resident is classified in RHxoTherapy ends MondayoSkilled nursing services continue Is an EOT OMRA required?