Navigating Your Financial Future: The Top SNF PPS Final
Contents
1. as possible Bring an HCPro long term care consultant to your facility for help in any of the following areas E Survey readiness E Revenue cycle and case mix analysis E Medicare compliance audits E Documentation improvement For more information or to request a facility specific needs analysis contact Client Relations Manager Adrienne Trivers at atrivers hcpro com or 781 639 1872 Ext 3207 09 11 LG1511 This special report is published by HCPro Inc 75 Sylvan St Suite A 101 Danvers MA 01923 e Copyright 2011 HCPro Inc All rights reserved Except where specifi cally encouraged no part of this publication may be reproduced in any form or by any means without prior written consent of HCPro Inc or the Copyright Clearance Center at 978 750 8400 Please notify us immediately if you have received an unauthorized copy For editorial comments or questions call 781 639 1872 or fax 781 639 7857 e Opinions expressed are not necessarily those of the editors Mention of products and services does not constitute endorsement Advice given is general and readers should consult professional counsel for specific legal ethical or clinical questions HCPro Inc is not affiliated in any way with The Joint Commission which owns the JCAHO and Joint Commission trademarks 2011 HCPro Inc WWW HCPRO COM2. be required if that resident goes three consecutive calendar days without being furnished any therapy ser vices regardless of whether the facility provides therapy five six or seven days a week Q If a resident misses PT for three consecutive days but receives OT on one of those days do we need to com plete an EOT and a COT The EOT OMRA would not be required but effective October 1 A 2011 you will be required to determine every week whether it is necessary to complete a COT For example let s assume this resident s 14 day Medicare PPS assessment had been completed with an ARD of day 14 In this case day 21 would become the ARD of a COT if it is necessary To determine necessity of this additional assessment you would calculate whether the minutes received during the assessment window have increased or decreased enough to change the current RUG score If during that timeframe from day 15 to day 21 the resident missed PT for three consecutive days it is very likely that the decreased minutes that were delivered would impact the RUG score thereby making the COT assessment necessary Have more questions Our team of experts have years of experience in the long term care industry and can bring their specialized expertise to your organization to solve your greatest challenges We arm you with the practical customized solutions you need to ensure your organization is as efficient compliant and profitable
3. HCPro Navigating Your Financial Future The Top SNF PPS Final Rule Questions Answered iii ne IY by Diane L Brown BA rd he Centers for Medicare amp Medicaid Services CMS released the final and Mackenzie Kimball rule for SNF PPS and consolidated billing for fiscal year FY 2012 on July 29 An important provision included in this rule will reduce Medicare SNF PPS payments in FY 2012 by 3 87 billion 11 1 lower than payments for FY 2011 CMS states that the reason for this rate reduction is to correct an unintended spike in payment levels and better align Medicare payments with costs CMS is committed to providing high quality care to those in skilled nursing facilities and to pay those facilities properly for that care CMS Administrator Donald M Berwick MD said in a CMS press release The adjustments to the payment rates for next year reflect that policy CMS is blaming the spike in payment levels on a forecast error that occurred with the transition from RUG II to RUG IV According to the CMS press release the parity adjustment made in FY 2011 which was intended to ensure that the RUG IV system would not change overall spending levels from the prior year instead resulted in a significant increase in Medicare expenditures This increase was mainly due to shifts in the utilization of therapy modes under RUG IV that differed significantly from the projections on which the parity adjustment was based Facilitie
4. dent time spent with SNF patients consistent with our existing policy as set forth in the RAI Manual Chapter 3 Section O pages O 20 through O 22 as the therapy student is under the direction of the supervising therapist even if no longer required to be under line of sight supervision the time the student spends with a patient will continue to be billed as if it were the supervising therapist alone providing the therapy In other words the therapy student for the purpose of billing is treated as sim ply an extension of the supervising therapist rather than being counted as an additional practitioner It should be noted that all policies and definitions related to the type of therapy provided individual concurrent and group apply to the supervising therapist and therapy student as set forth in the RAI Manual Chapter 3 Section O pages O 20 through O 22 even if the student is no longer required to be under line of sight supervision Here are some tips to help you code therapy once the line of site supervision requirement is removed m Individual therapy Code as individual therapy when the therapist or student is treating one resident while the other is not treating supervising any other residents therapy students WWW HCPRO COM 2011 HCPro Inc NAVIGATING YOUR FINANCIAL FUTURE September 2011 m Concurrent therapy Code as concurrent therapy when the therapist and stu dent are treating one resident each while n
5. edicare Part A ser vices Do we need to do the EOT each time we discharge physi cal therapy PT occupational therapy OT and Medicare Part A services An EOT OMRA only needs to be done when all therapy ser A vices cease for three consecutive days and the resident remains on Medicare Part A The purpose of the EOT OMRA is to switch the resi dent from the rehab RUG to a new RUG based on the nursing services and other skilled care he or she is receiving If you are discharging the resident from both therapy and Medicare Part A you would not need to do an EOT OMRA because you would not need to obtain a new RUG score for Medicare Part A payment For the COT MDS what date is covered by the new COT RUG score Does payment change on the ARD A The new RUG IV group resulting from the COT OMRA would be billed starting the first day of the COT observation period and would remain at this level until a new assessment is completed that changes the resident s RUG IV classification Q For the COT do you have to choose the ARD date on the specific date that the RUG changes and what are your options for ARD choice A The ARD for the COT OMRA would be set for day seven of the observation period which is a rolling seven day window beginning on the day following the ARD set for the most recent scheduled or unscheduled PPS assessment and ending every seven calendar days thereafter In cases whe
6. estions to help you survive the FY 2012 cuts Let these answers be your guide in navigating the ever changing world of long term care Do you need to do both an EOT OMRA and an Q EOT R OMRA A You must complete an EOT OMRA when therapy services cease for three consecutive days regardless of the reason Then if therapy resumes within five days after the last day of therapy at the same RUG IV classification level you have the option of completing an EOT R OMRA rather than the EOT OMRA It is not mandatory just an option In situations where an EOT R OMRA can be completed the therapist will not need to conduct a new therapy evaluation or establish a new care plan because the resident will be resuming therapy at the same level However if that level changes or if the resident goes more than five days from the last day of therapy before resuming therapy services the therapist would be required to conduct a new evaluation and establish a new care plan Also the facility could complete the optional SOT OMRA to ensure payment at the new RUG rate amp Does the COT allow us to re RUG to a higher rehab level Also does the new RUG category take effect the day after the COT ARD A If a resident starts receiving enough therapy to classify into a RUG IV category that is higher than his or her current category then yes completing a COT would allow you to re RUG at the higher more appropri ate RUG l
7. evel The ARD for the COT OMRA would be set for day seven of the observation period which is a rolling seven day window beginning on the day following the ARD set for the most recent scheduled or unscheduled PPS assessment and ending every seven calendar days thereafter In cases where the last assessment was an EOT R then the COT observation period WWW HCPRO COM 2011 HCPro Inc NAVIGATING YOUR FINANCIAL FUTURE September 2011 begins on the resumption date listed in O0450B The new RUG IV group resulting from the COT OMRA would be billed starting the first day of the COT observation period and would remain at this level until a new assess ment is completed that changes the resident s RUG IV classification Let s look at an example If a SNF sets the ARD for its 14 day assessment to day 14 then day one for the purposes of the COT observation period would be day 15 of the SNF stay and the facility would be required to review its therapy minutes for that resident for the week consisting of days 15 21 If the SNF determines that the total therapy minutes received has changed such that the RUG classification from the 14 day assessment is no longer accurate then the SNF would complete a COT OMRA with an ARD of day 21 Payment at the RUG rate determined by the COT OMRA would begin on the first day of the COT observation period which was day 15 Does the EOT need to be done for all discontinuation of therapy or just those receiving M
8. ly the PT OT speech therapy sections for days and minutes Can a clerical staff member compare what was billed on the therapy database to what was entered on the MDS and then sign Or does the verification need to be from a therapist A The MDS 3 0 RAI User s Manual states Legally it is an attestation of accuracy with the primary responsibility for its accuracy with the person selecting the MDS item response Although an attorney would need to determine the legalities and associated risk of a clerical staff person sign ing at Z0400 for the accuracy of the therapy minutes delivered having a cleri cal person sign for therapy minutes that they cannot ensure were delivered is not a recommended process or a best practice Keep in mind that the person who signs is verifying the accuracy of the minutes delivered the type of minutes and the start and stop dates The question you need to ask yourself before implementing this practice would be Can this person attest to the accuracy of therapy delivery without being present With all the added emphasis on appropriate therapy delivery it would be a much better and less risky practice to have the attestation state ment signed by the therapist Q Would the SNF PPS Non Therapy Ancillary Payment reimburse for trach supplies vent supplies oxygen and respiratory therapists The Federal Register column that you reference SNF PPS Non A Therap
9. n of the Change of Therapy COT OMRA Effective for services provided on or after October 1 SNFs will be required to complete a COT OMRA for patients classified into a RUG IV therapy group whenever the intensity of therapy that is the total reimbursable therapy minutes provided 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 that resident s most recent assessment used for Medicare payment The assessment reference date ARD of the COT OMRA would be set for day seven of a COT observation period which is a successive WWW HCPRO COM September 2011 2011 HCPro Inc NAVIGATING YOUR FINANCIAL FUTURE 3 seven day window beginning on the day following the ARD set for the most recent scheduled or unscheduled PPS assessment and ending every seven calendar days thereafter m Changes to MDS 3 0 SNF PPS assessment schedule The final rule modifies the Medicare required assessment schedule to incor porate new assessment windows and grace days which will more appropriately capture patient status changes in services and treat ments provided over the course of the stay This will also reduce the possibility that information from the same days of the stay may be used on different scheduled MDS assessments You asked we answered Surviving the impending reduction in payment may seem daunting so HCPro s long term care experts answered 25 tough qu
10. or she has missed the other therapies you would not have to complete an EOT Q If the COT OMRA indicates a reduction in therapy when does the decreased payment take effect A The new RUG IV group resulting from the COT OMRA would be billed starting the first day of the COT observation period and would remain at this level until a new assessment is completed that changes the resident s RUG IV classification Q What tracking tools will be available for COT Will my software recognize the change A Most software vendors that we have contacted state that they are planning to provide tools to assist with COT tracking in time WWW HCPRO COM September 2011 2011 HCPro Inc NAVIGATING YOUR FINANCIAL FUTURE 7 for implementation on October 1 Please contact your vendor to determine its approach Q In between assessments should I only be looking at days one through seven for the COT changes or do need to look for changes every seven days A You need to look for changes every seven days The COT observa tion period is a rolling seven day window beginning on the day following the ARD set for the most recent scheduled or unscheduled PPS assessment and ending every seven calendar days thereafter In cases where the last assessment was an EOT R then the COT observation period begins on the resumption date listed in OO450B Q Who can sign the MDS to verify Section O specifical
11. ot treating supervising any other residents therapy students Code as concurrent therapy if the therapist is treating two residents while the student is not treating any residents Ifthe student is treating two residents while the therapist is not treating any residents m Group therapy The time for a group session may only be counted if the full group of four participants is being run by either the supervising therapist or the student while the other may not be supervising any other therapists or treating residents Q If a resident has a five day only and therapy ends do we need to do a EOT OMRA A An EOT OMRA only needs to be done when all therapy services end and the resident remains on Medicare Part A The purpose of the EOT OMRA is to switch the resident from the rehab RUG to a new RUG based on the nursing services and other skilled care he or she is receiving If you are discharging the resident from both therapy and Medicare Part A you would not need to do an EOT OMRA because you would not need to obtain a new RUG score for Medicare Part A payment Q If a resident is on two or more therapies and misses three days of one therapy but receives five days of another therapy is an EOT assessment required An EOT OMRA only needs to be completed when all therapy ceases A for three consecutive days If a resident is still receiving enough of one therapy to qualify for a rehab RUG even if he
12. re the last assessment was an EOT R then the COT observation period begins on the resumption date listed in O0450B WWW HCPRO COM September 2011 2011 HCPro Inc NAVIGATING YOUR FINANCIAL FUTURE 5 What happens when you only have two residents in Q group therapy According to the final rule a group MUST be planned for A four participants only not two three or five in order to be a valid group However a resident may not be able to participate on a given day for a variety of reasons In that case the total minutes would still be divided by four regardless of how many members actually participated that day Q How much do minutes need to change in order to do a COT A SNFs must complete a COT whenever the intensity of therapy min utes 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 Q How will the therapy minutes provided by a student count for a Medicare Part A MDS now that the line of site supervision requirement is removed Presently a student and supervisor treating different patients must log minutes as concurrent and minutes are split but how would that work now that the line of site supervision is removed A CMS responded in the final rule as follows In response to those commenters concerned with how to bill therapy stu
13. s that are primarily focused on rehab will experience the hardest hit due to these rate cuts But those facilities that have a more traditional case mix that balances residents in therapy and residents spread across the clinical RUG categories won t feel the effects of a full 11 1 decrease A final rule breakdown Along with the payment updates the SNF PPS final rule for FY 2012 includes a few other significant changes for nursing facilities Some of these changes are as follows FEATURES m Affordable Care Act initiatives CMS is in the process of developing the SNF value based purchasing plan and will submit a report to Congress by October 1 E You asked we answered 3 E Have more questions 9 The Secretary of the U S Department of Health and Human Services HHS will evaluate the possibility of expanding 2011 HCPro Inc WWW HCPRO COM 2011 HCPro Inc NAVIGATING YOUR FINANCIAL FUTURE September 2011 the hospital acquired condition policy from acute care hospitals to a variety of other settings including SNFs and will submit a report to Congress by January 1 2012 The nursing home transparency and improvement act will require SNFs to report expenditures separately for direct care staff wages and benefits on the Medicare cost report and for cost reporting periods beginning on or after two years after enactment and also requires the Secretary of HHS to perform certain related activities Therapy st
14. t window For example from day 30 to day 60 do you monitor the COT each week A Yes The COT observation period is a rolling seven day window beginning on the day following the ARD set for the most recent scheduled or unscheduled PPS assessment and ending every seven calendar days thereafter In cases where the last assessment was an EOT R then the COT observation period begins on the resumption date listed in OO450B Q Is there a problem if we use the ARD grace days on all the MDS assessments A There is no penalty for using grace days on MDS assessments The MDS 3 0 RAI User s Manual states that reasons for using a grace day include illness of the RN assessor a high volume of assessments due at approximately the same time or capturing the best payment rate Q Do the COT OMRASs follow side by side with the SNF PPS assessments such as 14 30 60 and 90 day assessments A The COT OMRAs examine each seven day interval between SNF PPS assessments and will adhere to a strict schedule The scheduled Medicare assessments follow the new assessment schedule outlined in the final rule Q If a facility does not offer therapy services on a Sunday do we now have to count Sunday in the three consecu tive days for EOT WWW HCPRO COM September 2011 NAVIGATING YOUR FINANCIAL FUTURE 9 Yes Effective October 1 an EOT OMRA for a resident in A a RUG IV therapy group would
15. udent supervision The final rule will discontinue the policy requiring line of sight supervision of therapy students in SNFs Instead effective October 1 each SNF will determine for itself the appropriate manner of therapy student supervision consistent with state and local laws and practice standards Group therapy clarifications Effective October 1 group therapy will be defined as therapy provided simultaneously to four patients who are performing the same or similar activities and group ther apy time will be divided by four in determining the reimbursable therapy minutes for each group therapy participant and therefore the appropriate RUG IV group Five or seven day a week therapy clarification The final rule will eliminate the distinction between facilities regularly furnishing therapy services on a five or seven day basis for purposes of set ting the date for the End of Therapy EOT Other Medicare Required Assessment OMRA Introduction of the End of Therapy Resumption EOT R OMRA Effective for services provided on or after October 1 when an EOT OMRA has been completed and therapy subse quently resumes SNFs may complete an EOT R OMRA rather than a Start of Therapy SOT OMRA in cases where the resump tion of therapy date is no more than five consecutive days after the last day of therapy provided and the therapy services have resumed at the same RUG IV level that had been in effect prior to the EOT OMRA Introductio
16. y Ancillary Payment is a budgetary allocation of dollars rather than a payment category SNF PPS reimbursement is governed by the RUG IV categories and those supplies and services you mention are included in the RUG IV categories Each category is an all inclusive rate with very few exceptions which are addressed by the consolidated billing rules WWW HCPRO COM 2011 HCPro Inc NAVIGATING YOUR FINANCIAL FUTURE September 2011 Q Will activities of daily living ADL changes affect a COT assessment or is the COT focusing specifically on therapy services without ADL changes The final rule addresses the relationship between ADLs and the A COT OMRA The purpose and trigger for completion of the COT OMRA is to ensure that the patient is placed in the appropriate therapy RUG category based only on minutes of therapy delivered However if the patient requires a COT then ADLs will be captured to classify the resident into the correct RUG category Q Is the EOT R OMRA an optional or required assessment A The EOT R is an optional assessment If therapy resumes after the completion of an EOT OMRA and the criteria for an EOT R OMRA are met the SNF would have the option of performing the EOT R OMRA and SOT OMRA or waiting until the next regularly scheduled PPS assess ment to assess the resident s condition Q Do you monitor each week after the assessment for the COT until the next assessmen
Download Pdf Manuals
Related Search