pps scheduling may 2017.pptx - virginia health care ... · 7/3/14 7/4/14 7/5/14 7/6/14 7/7/14...

4/17/17

WilhideConsul1ng,Inc.(c) 1

TheProspec1vePaymentSystemMay2016

1

[email protected]

Source:

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• 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






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


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


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


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


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


7/31/14 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?

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•  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.

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•  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

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•  IfbeneficiaryisdischargedfromtheSNFortransferredtoanotherpayersourcebeforeorontheeighthdayofthecoveredSNFstay,theprovidershouldprepareaMedicare-requiredassessmentascompletelyaspossibleandsubmittheassessmentasrequired.

•  “DischargedfromtheSNF”=leavesthecer1fiedbed•  “Transferstoanotherpayersource”=remainsinthecer1fiedbedbutnolongerbillingPartAforthestay.

ResidentDischargedBeforeorOntheEighthDayofSNFStay

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•  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.

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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

4/17/17


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


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


Therapyends

EOTARD

•  Resump1ondate,notdayaIerARD,isday1ofnextCOTcount.

COTCheckCOT

Check

66

2-51

4/17/17


IfunabletodoEOT-R

•  Mustdonewtherapyevalua1onsforalldisciplinespriortorestar1ng–  Ifnewevalsarenotdone,thentherecanbenotherapyminutesonsubsequentMDSs

•  MaydoSOTorwaitun1lnextscheduledassessmenttorecaptureRehabRUG

67

Awordabouttherapyevalua1ons

•  Ini1alEvalua1on:– Requiredforeachdisciplinepriortostar1ngacourseoftherapy

– Requiredforeachdisciplineuponeachreentryaqerdischargeassessment

•  NotrequiredforLOA– RequiredaqerathreedaybreakintherapyifEOT-Risnotpermihed

– Dateofini1alevalua1onremainsasthe‘therapystartdate’un1lanewcourseoftherapywithanewini1alevalua1on.

68


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

4/17/17


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


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

4/17/17


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

4/17/17


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


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✓


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


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

4/17/17


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

4/17/17


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


•  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

4/17/17



•  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


12 13 14 15 16

17 18

EOTARD

14DayARD

•  Reminder:ScheduledpriortoEOTARDisallowed,but,theEOTwillpayday12–15,andthenon-therapyRUGfromthe14day(Z0150)willpaybeginningonday16.–Page6-11

108


12 13 14 15 16

17 18

EOTARD

14DayARD

•  BestPrac1ce:IfyoucancombineanEOTorSOTwithscheduled,thatisthethingtodo.•  COTisdifferent:MaydoscheduledwithoutCOTbefore

oronCOTcheckpoint.

4/17/17


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

4/17/17


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

4/17/17


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

4/17/17


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

4/17/17


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


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

pps scheduling may 2017.pptx - virginia health care ... · 7/3/14 7/4/14 7/5/14 7/6/14 7/7/14...

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