MDS 3.0 & RUG-IV
The Impact on Reimbursement
Aging Services of California
2011 Annual Conference
Monterey, CA
Presenter
Michael Lesnick
714-323-5968
MikeL@axiomhc.com
Jeannette Munkittrick
951-741-7195
Jeannettem@letrehab.com
Axiom Healthcare Group
RUG-IV Overview
• What Are The Thirty (30) Most Critical Things
To Know About RUG-IV?
3
RUG-IV Overview
• What Are The Thirty (30) Most Critical Things
To Know About RUG-IV?
MDS 3.0, MDS 3.0, MDS 3.0, MDS 3.0. MDS
3.0, MDS 3.0, MDS 3.0, MDS 3.0, MDS 3.0.
MDS 3.0, MDS 3.0, MDS 3.0, MDS 3.0, MDS
3.0. MDS 3.0, MDS 3.0, MDS 3.0, MDS 3.0,
MDS 3.0. MDS 3.0, MDS 3.0, MDS 3.0, MDS
3.0, MDS 3.0. MDS 3.0, MDS 3.0, MDS 3.0,
MDS 3.0, MDS 3.0, MDS 3.0
4
RUG-IV Overview
Implementation Date
• Originally 10-1-2011
• Now Payment Under RUG-IV Effective 10-1-2010
With A “Catch”
• Starting 10-1-10 you will be paid under the 66
category RUG-IV classification system, BUT, you
will be earning the 53 category “RUG-III HYBRID”
rates
• GREAT NEWS – RUG IV Delay Is Repealed! There
will NOT be a RUG III Hybrid To Deal With
5
RUG-IV Adjustment to RUG-III HYBRID
•
•
•
Currently the only “Grouper Software” that will function under MDS 3.0 will only produce the RUG-IV grouping
In other words CMS can NOT comply with the law that mandates a RUG-III payment under the MDS 3.0
Therefore, you get paid RUG-IV rates now and sometime in the coming months CMS will figure out how to take the difference between
RUG-IV and RUG-III HYBRID rates back from you
• GREAT NEWS – RUG IV Delay Is Repealed! There will NOT be a RUG
III Hybrid To Deal With!
• Happy Holidays! President Obama has delivered the LTC
industry with a holiday gift by signing into law the Medicare and
Medicaid Extenders Act of 2010. Section 202 of the MMEA repeals
the delay of the Skilled Nursing Facility (SNF) PPS RUG-IV
classification system. Therefore, RUG- IV will continue to remain in
effect from October 1, 2010, as previously implemented by the final
SNF payment regulation for FY 2011. All claims processing
activities shall proceed in accordance with the existing instructions.
(Big Sigh) And to All a Good Night!
6
NEW Rates Look GREAT!!!!
Or Do They????????????????
• If you simply compare the “Old Rates” (FY 10
Rates) to the New Rates (the FY 11 Rates) It looks
like you will have a very significant increase.
• Please be aware that under MDS 3.0 and the new
rules about Therapy Minutes and Look Back
Periods, it will be much more difficult to achieve
the higher RUG categories and to get Therapy
minutes recorded.
• Also, remember you are earning only the RUG-III
Hybrid rates that are lower than the RUG-IV rates
7
New Conditions for Classification
• Six new conditions added to the system to aid
in the classification of resident care
– Ventilator or Respirator Care
– Tracheostomy Care
– Isolation for Active Infectious Disease
– Shortness of Breath when Lying Flat Combined
with Emphysema or COPD
– Parkinson’s Disease
– Respiratory Failure with Oxygen Therapy
Why Is It More Difficult To Get Into
Various RUG Categories?
• Extensive
• Rehabilitation
• ADL scale changes
9
More Difficult To Get Into Extensive
Categories
To date, the vast majority of the extensive qualifiers occurred in
the acute care hospital before admission to the SNF
• Look Back Periods will be modified to prohibit providers from
taking credit for certain services (specifically the extensive
qualifiers) that occur in the acute care hospital before admission to
the SNF
• For RUG-IV purposes, the look back period for section P1a items
will NOT include any services rendered before the patient was
admitted to the SNF
• Services prior to admission (those provided in the hospital) are still
recorded, but, only for Care Planning purposes, not for
reimbursement purposes
10
More Difficult To Get Into Extensive
Categories
Qualifiers for Extensive Categories Have Changed
• The Number of Extensive “qualifiers” is reduced
• The Remaining Extensive qualifiers are:
– Existing - Tracheotomy Care – IN THE NURSING HOME
ONLY
– Existing - Ventilator / Respirator Care – IN THE NURSING
HOME ONLY
– NEW – Isolation – “QUARANTINE” for an active infectious
disease – IN THE NURSING HOME ONLY
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What Is Isolation – QUARANTINE?
• Examples Of Conditions That Do Qualify
–
–
–
–
Active Cases of TB
Neutropenic Precautions – Isolation (look it up)
Active Shingles (Airborne)
MSRA In The Respiratory Tract with Wet Productive
Cough (Airborne)
• Examples of Conditions That Do NOT Qualify
–
–
–
–
“Normal” MDROs (Multi Drug Resistant Organisms)
MSRA
VRE
Not What SNFs Typically Call Isolation
12
Criteria for QUARANTINE
Must meet the following criteria:
1. Active contagious disease
2. Precautions over and above standard
precautions
3. Alone in a room
4. Cannot come out of the room
13
Extensive Qualifiers That Have Been
Eliminated
• Some of the services that were formerly
extensive “qualifiers” will be moved to other
categories
– Parenteral / IV Feeding moves to Special Care –
High
– IV Medications moves to Clinically Complex
– Suctioning has been dropped completely as a
qualifier
14
Why Is It More Difficult To Get Into
REHAB Categories?
• Section T Eliminated
• Counting Minutes Modified
– Concurrent Therapy
– Aide Time
15
Counting Rehab Minutes
RUG-IV Significant Changes
• Revisions to calculation of Therapy minutes
will be implemented. You will need to indicate
on the MDS 3.0 what delivery “mode” is being
used for rehab services:
– Individual Therapy
– Group Therapy
– Concurrent Therapy
16
Counting Rehab Minutes
• Aide Time – Is essentially limited to set up
time
• The old practice of counting all of the aides
time (for a Part-A patient) under line of sight
supervision by a licensed therapist is no longer
acceptable, only the setup time is counted
while in direct line-of -sight
17
Counting Rehab Minutes
• The manner in which Therapy minutes are
counted has been modified
• Method Of Rehab Delivery
– Individual Therapy – No Change
– Group Therapy – No Change (Be Careful About
Coverage Criteria)
– Concurrent Therapy – Minutes Will be allocated /
Limited to 2 patients (1/2 of time counted for
reimbursement purposes)
18
Calculating Therapy Minutes
• Residents can receive different modes of therapy on
one day, or even in one treatment session
– Each mode of therapy and the time spent on each must be
recorded
• Reportable treatment time begins when the patient
starts the first task or activity, and ends when they
finish with the last task, or piece of equipment
– Count the total number of minutes spent on therapeutic
activities, subtracting any time spent on breaks, or other
activities that do not qualify as therapeutic
Calculating Therapy Minutes
• Only include minutes spent on skilled therapy
• When Individual therapy occurs intermittently
throughout the day, the total number of minutes
from all sessions will be recorded as a daily count
• When reporting therapy time, report the actual
minutes of therapy
– Do not round to the nearest 5th minute
– The system will automatically do any necessary rounding, so
report actual therapy minutes
– The claim may not match the MDS exactly
ADL Changes
RUG-III
• Maximum number of
ADL points was 15
• Scale that ranged from
4 to 18
• Three areas scored
from 1 to 5, with
eating being given a
score from 1 to 3
RUG-IV
• Maximum number of ADL
points is 16
• Scale ranges from 0 to 16
• Each of the four areas are
given a score from 0 to 4
• New scores in the SelfPerformance Score for ADLs
– Will produce an overall score of
zero for that ADL
ADL Changes
ADL Category
Self-Performance
Score
Support Score
ADL Score
Bed Mobility
-,0,1,7, or 8
2
3
4
3 or 4
(any #)
(any #)
-, 0-2
-, 0-2
3
0
1
2
3
4
-,0,1,2,7, or 8
-,0,1,2,7, or 8
3 or 4
3
4
-,0,1 or 8
2 or 3
-,0,1 or 8
2 or 3
2 or 3
0
2
2
3
4
Transfer
Toilet Use
Eating
New MDS 3.0 Item Sets
• Medicare short stay
• EOT OMRA
• SOT OMRA
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End of Therapy (EOT) OMRA
• Patient was receiving rehabilitation services
• Was classified to a rehabilitation RUG
• Discontinues all rehabilitation services
• Continues to have a skilled level of care
requirement
End of Therapy (EOT) OMRA
• Assessment Reference Date (ARD) must be set
on Day 1, 2 or 3 after the last day of any
rehabilitation
– Day 1 corresponds to the first day on which your
facility would have normally provided therapy
services
– Whether the resident would have received
therapy that day or not
End of Therapy (EOT) OMRA
• Payment rate changes beginning the day following the
last day of therapy
– Indicated in Item Z0150A of the MDS
– Regardless of the ARD
• No penalty for an early ARD if set on a day that therapy
is not normally provided
• May be combined with a scheduled assessment, but
may not replace it
Start of Therapy (SOT) OMRA
• New assessment type
• Optional assessment type
• Can be done at any time during the resident’s stay
to obtain a therapy RUG
• ARD must be five to seven days after the start of
the first therapy
Start of Therapy (SOT) OMRA
• Payment rate starts on the first day that therapy
services were received
• This assessment should not be combined with the
5-Day PPS assessment
• Should only be completed if doing so will place the
resident in a therapy RUG
– Assessment will reject on the validation report
Start of Therapy (SOT) OMRA
• Pay close attention to your case mix indices
– May not be in the facility’s best financial interest
to place the resident in a therapy RUG
– Optional assessment
– Should only be completed if there is financial
benefit
Medicare Short Stay Assessment
• Before the eighth day of the covered SNF stay
– Resident dies
– Resident is discharged from the SNF
– Resident is discharged from a Medicare-Part A
covered level of care
Medicare Short Stay Assessment
• Allows the resident to be classified to a
Rehabilitation category when a resident was
not able to have received five days of therapy
• Eight conditions, and all must be met
Medicare Short Stay Assessment
• Must be a Start of Therapy OMRA (A0310C = 1
or 3)
– May be completed alone or combined with any
OBRA assessment
– May be combined with a PPS 5-day or
readmission/return assessment
– May not be combined with a PPS 14-day, 30-day,
60-day, or 90-day assessment
Medicare Short Stay Assessment
• PPS 5-day (A0310B = 01) or readmission/
return assessment (A0310B = 06) has been
completed
– May be completed alone or combined with the
Start of Therapy OMRA
• ARD (A2300) of the Start of Therapy OMRA
must be on or before the 8th day of the Part A
Medicare stay
Medicare Short Stay Assessment
• ARD (A2300) of the Start of Therapy OMRA
must be the last day of the Medicare Part A
stay
– Start of Therapy OMRA ARD must equal the end of
Medicare stay date (A2400C)
– End of the Medicare stay date is the date Part A
ended
Medicare Short Stay Assessment
• ARD (A2300) of the Start of Therapy OMRA
may not be more than 3 days after the start of
therapy date
– Item O0400A5, O0400B5 or O0400C5, whichever
is earliest
• Rehabilitation therapy (PT, OT, or SLP) started
during the last 4 days of the Medicare Part A
covered stay (including weekends)
Medicare Short Stay Assessment
• At least one therapy discipline continued
through the last day of the Medicare Part A
stay
– Must have a dash-filled end of therapy date
(O0400A6, O0400B6 or O0400C6), or
– End of therapy date equal to the end of covered
Medicare stay date (A2400C)
Medicare Short Stay Assessment
• RUG group assigned to the Start of Therapy
OMRA must be Rehabilitation Plus Extensive
Services or a Rehabilitation group (Z0100A)
– If the RUG group assigned is not a Rehabilitation
Plus Extensive Services or a Rehabilitation group,
the assessment will be rejected
Medicare Short Stay Assessment
• If all eight of these conditions are met, then
MDS Item Z0100C (Medicare Short Stay
Assessment indicator) is coded 'Yes'
• Assignment of the RUG-IV rehabilitation
therapy classification is calculated based on
average daily minutes actually provided
Medicare Short Stay Assessment
• Resulting RUG-IV group is recorded in MDS Item Z0100A
(Medicare Part A HIPPS Code)
– 15-29 average daily therapy minutes - Rehabilitation Low category (RLx)
– 30-64 average daily therapy minutes - Rehabilitation Medium category
(RMx)
– 65-99 average daily therapy minutes - Rehabilitation High category (RHx)
– 100-143 average daily therapy minutes - Rehabilitation Very High
category (RVx)
– 144 or greater average daily therapy minutes - Rehabilitation Ultra High
category (RUx)
Medicare Short Stay Assessment
• If the earliest start of therapy date is the first
day of the short stay, use the Medicare Short
Stay assessment Medicare Part A RUG (Z0100)
from the beginning of the short stay through
the end of the stay
– Dates in Items O0400A5, O0400B5 or O0400C5
– Medicare stay must be 4 days or less
Medicare Short Stay Assessment
• If the earliest start of therapy date is after the first
day of the short stay
– If a 5-day or readmission/return assessment was
completed prior to Medicare Short Stay assessment,
• Use the Medicare Part A RUG (Z0100A) from that
assessment for the first day of the short stay through the day
before therapy started;
• Then use the Medicare Part A RUG (Z0100A) from the
Medicare Short Stay assessment from the day therapy
started through the end of the short stay
Medicare Short Stay Assessment
• If the earliest start of therapy date is after the
first day of the short stay
– If the Start of Therapy OMRA is combined with a
5-day or readmission/return assessment,
• Use the Medicare Part A non-therapy RUG (Z0150A) for
the first day of the short stay through the day before
therapy started;
• Use the Medicare Part A RUG (Z0100A) from the day
therapy started through the end of the short stay
Early Assessments
• If an assessment is performed earlier than the
schedule indicates, the provider will be paid at the
default rate for the number of days the assessment
was out of compliance
• No penalty if an End of Therapy OMRA is
performed early if the ARD is set on a day that
therapy services are not normally available at your
facility
Late Assessment
• If the ARD on the late assessment is set before
the end of the payment period for that
assessment
– SNF will receive the default rate from the
beginning of the payment period until the day
before the ARD
– From the ARD to the end of that payment period,
it will receive the HIPPS rate identified by the
assessment
Late Assessment
• PPS assessments must be timely, in order to bill
the RUG generated by the assessment
• If the assessment is missed and the resident is no
longer on Part A when discovered, Medicare Part
A cannot be billed at all! No one else can be billed
for those days either. The facility is liable
•
A PPS assessment is timely if the ARD is set:
– On the MDS
– Within the prescribed ARD window
– Before the end of the last day of the window
RUG-IV Impact
Impact On Rates / Payments
• Overall Payments to SNFs Are expected to be
“Budget Neutral”, BUT, there will be a
SIGNIFICANT re-shuffling of the payments
among categories
46
RUG-IV Impact
Winners & Losers
• In a very global sense, therapy services will be
worth less and complex medical services
(actually performed in the SNF) will be worth
more
47
RUG-IV Impact
Winners & Losers
• SNF Most Likely to be negatively affected
– SNFs with a high percentage, over 35% of “X”s and
“L”s (Rehab PLUS Extensive category patients) that
are based on “extensive” services provided in the
acute care hospital
– SNFs with a high percentage of Rehab Category
Patients (over 75% to 80%)
48
RUG-IV Impact
Winners & Losers
• Payments for the Special Care (High & Low)
and Clinically Complex categories will be
worth more relative to the old RUG-III rates
49
RUG-IV Impact
RUG-IV Categories
• Total Number of Categories will change from
53 to 66
• There will be a variety of changes within the
categories
50
RUG-IV Impact
• RUG-IV Categories:
– Extensive plus Rehab Services
– Rehab Categories
– Extensive Services
– Special Care High
– Special Care Low
– Clinically Complex
– Behavioral & Impaired Cognition
– Reduced Physical Function
51
RUG-IV Impact
RUG-IV Other Issues
Level of Care / “Presumption of Coverage”
• # of categories will change where there is at
least an initial presumption of coverage.
• 52 Upper
• 14 Lower
52
RUG-IV Strategy
RUG-IV Strategies
• Work with your therapy vendors as soon as possible
to adapt to RUG-IV. Focus on the following with
them:
• New Methods for counting minutes
• Concurrent Therapy
• Group Therapy – Does It Meet Coverage Criteria?
• New Payment Levels for Rehab Categories
• Use of Therapy Aides
53
Concurrent & Group Therapy
• Concurrent & Group Therapy are GOOD if
utilized PROPERLY
• Concurrent and Group Therapy are still
allowable and should be used in the
appropriate situations
• However, you need to understand the LIMITS
that apply to each mode of delivery
54
RUG-IV Strategy
RUG-IV Strategies
• Work with your clinical staff to enhance your
capacity to provide clinically complex services
such as Ventilator/Respirator and quarantine,
IN YOUR SNF
55
RUG-IV Strategy
RUG-IV Strategies
• Enhance Your capacity to complete complex
services including, but not limited to:
– IV Services
– Complex Wound Care
– Respiratory & Cardio Respiratory Programs
56
RUG-IV Strategy
• Understand NEW assessment types.
• Providers may opt NOT TO COMPLETE the SOT
OMRA, if the non rehab RUG calculated by the
most recent assessment has a HIGHER rate
than a SOT OMRA would provide
• Again test the “what if” scenarios with your
RUGs rate sheet; just like you should do with
your ARD!
RUG-IV Strategy
• DANGER – What Medicare Gives, the OIG and
Take Away
• Please Read the OIG Report “Questionable
Billing Practices By Skilled Nursing Facilities”
• After you have read this report, take the
appropriate actions to protect yourself against
and billing problems.
58
RUG-IV Overview
• Q&A
59