PPS FY 2012 Final Rule:
More Big Changes in
Therapy Coding and
Payment
September 13, 2012
What is Changing?
• “Recalibration” of Nursing Case-Mix weights
for all Rehab RUG Levels
• ARD schedule adjusted
• Group minute allocation guidelines
• Change Of Therapy (COT) OMRA
• End Of Therapy (EOT) OMRA clarification, and
new EOT-R (resumption) OMRA process
Acronyms
RTM
Reimbursable Therapy Minutes
EOT–R OMRA
End of Therapy OMRA Resumption
COT OMRA
Change of Therapy OMRA
Recalibration of
Certain
Case-Mix Rates
4
Concurrent & Group vs. 1:1 Utilization
CMS (STRIVE) BEFORE 2011:
CMS (Q1, 2011) AFTER 2011:
1:1
Concurrent
Group
1:1
Concurrent
Group
5
Recalibration of Certain Case-Mix Weights
The significant (and unexpected) changes came in the “Upper RUGs”
categories.
All “Rehab” RUGs
“RU” and “RV” RUGs
Recalibration of CMI
• The daily payment that CMS pays providers for each RUG group is
made up of 3 components: Nursing Case-Mix, Therapy Case-Mix and
Non Case-Mix dollars.
• Case Mix Indices (CMIs) are meant to represent the relative amount of
staff time & expense built into each RUG level.
• Nursing CMI selected as the means for the recalibration, because that
is where FY2011 adjustments were added.
•
Nursing CMI will be decreased for all Rehab RUG groups
(Rehabilitation Plus Extensive and Rehabilitation groups).
• Range of recalibration is 11.3% - 12.9%, depending on facility type and
location
Recalibration Example
Recalibrations taken here
Impacts 21 of Top 30 Per Diem Groups
9
Recalibration
“We do not believe that the recalibration should
negatively affect facilities, beneficiaries, or quality
of care, or create an undue hardship on
providers.”
“In fact, notwithstanding the recalibration, the FY
2012 payment rates will actually be 3.4% higher
than the rates established for FY 2010, the last
period prior to the unintended spike in payment
levels.”
Change in ARD
Schedule
11
ARD Schedule Change
• Current: allows for a larger number of observation days
which can overlap from one period to another
• CMS wanted to remove the potential for overlap
Changes to ARD Schedule
Current
Future (10/1/11)
Grace Days
“We agree that in practice, there is no difference
between regular ARD windows and grace days
and we encourage the use of grace days if their
use will allow a facility more clinical flexibility or
will more accurately capture therapy and other
treatments. Thus, we do not intend to penalize
any facility that chooses to use the grace days for
assessment scheduling or to audit facilities based
solely on their regular use of grace days.”
ARD Schedule Change - Risks
• Potential increase risk of default days
• Potential impact on ADL index
• Potential impact on Rehab RUG
Possible Strategies to Mitigate Risk
• Develop (revive?) tools to assist with PPS
Schedule
• Automation of systems
• ADL accuracy – retraining opportunity?
ADL Scale
Bed Mobility:
• Moving from a lying position
• Turning side to side
• Positioning resident in bed or alternate furniture
“Staff Assistance” includes:
• Oversight
• Setup
• Verbal cues or encouragement
• Physical assist, etc.
17
Group Minute
Allocation
18
Group Therapy
•
Effective October 1, 2011: Group therapy will be
defined as therapy provided simultaneously to four
patients (regardless of payer source) who are
performing the same or similar activities, and group
therapy time will be divided by four in determining the
reimbursable therapy minutes (RTM) for each group
therapy participant, and therefore, the appropriate
RUG-IV group.
– The 25% cap for group therapy remains in effect
– 25% cap will apply after dividing by 4
Group Therapy
• CMS expects, “group therapy to be a
structured, planned program with four
participants for whom group therapy has been
determined appropriate.”
Group Therapy
• Groups are required to have 4 participants
• In situations where the definition of group therapy is
not met, those minutes may not be coded on the
MDS as group therapy
• However, if one or more of the 4 participants are
unexpectedly absent from a session or cannot finish
participating in the entire session...CMS will deem
the therapy session as meeting the definition of
group therapy as long as the therapy program
originally had been planned for 4 participants (Tx
minutes will still be divided by 4)
Group Therapy
• The SNF will report the total unallocated
group therapy minutes on the MDS 3.0
• Group Therapy Example: 60 min
session with 4 participants
– Therapy would document 60 minutes for each
participant
– MDS would document 60 minutes for each
participant
Group Therapy Documentation
• CMS indicated that the documentation
discussion in the Proposed Rule did not
propose new documentation requirements for
group therapy
• The intent of the discussion (in the proposed
rule) was to “clarify our expectations”
Group Therapy Documentation
“…we believe it is important to clarify our expectations
regarding the clinical documentation needed to
support each patient’s plan of care, including the
patient’s prescribed group therapy interventions…”
Group Therapy Documentation
According to the Proposed Rule
“Because group therapy is not appropriate for either
all patients or all conditions, and in order to verify
that group therapy is medically necessary and
appropriate to the needs of each beneficiary, SNFs
should include in the patient’s plan of care an
explicit justification for the use of group, rather
than individual or concurrent, therapy”
Group Therapy Documentation
According to the Proposed Rule
“This description should include, but need not be
limited to, the specific benefits to that particular
patient of including the documented type and
amount of group therapy; that is, how the
prescribed type and amount of group therapy will
meet the patient’s needs and assist the patient in
reaching the documented goals”
Possible Strategies to Mitigate Risk
• Defined Therapy Schedule
– Planned therapy appointments
– Minimize conflicts with outside appointments
• Training therapists on new definition of group
– Careful planning of multi-patient combinations
– Group documentation
• Therapist time management
Reimbursable
Therapy Minutes
Reimbursable Therapy Minutes
Reimbursable Therapy Minutes = RTM
– Allocated minutes used for RUG classification
All Individual Minutes
+
50% Concurrent Minutes
+
25% Group Minutes
then
Adjusted for 25% Group Therapy Cap
Change of Therapy
(COT) OMRA
30
COT OMRA Process
Current: Therapy minutes closely monitored and reported only
during scheduled MDS assessment periods
Therapy minutes need to be monitored in consecutive 7day periods, even outside of scheduled assessments
• COT OMRA is required whenever the intensity/ disciplines/
days of therapy changes to such a degree that it would no
longer reflect the RUG level from the most recent assessment
used for Medicare payment
COT OMRA Monitoring
Reimbursable
Therapy Minutes
(RTM)
Number of
Therapy Days
Number of Therapy
Disciplines
Restorative Nursing
(Rehab Low)
• A “Therapy Day” is defined as a minimum of 15
minutes of skilled treatment – determined before
adjustment of minutes
COT OMRA
• The ARD for the COT OMRA is Day 7 following
the last scheduled or unscheduled PPS
assessment or Day 7 following the end of the
last COT observation period (in cases where
therapy had not changed sufficiently to
require a COT OMRA assessment to be
performed for the previous COT observation
period)
– In the case of an EOT-R, the resumption date is
day 1 of the COT 7-day observation period
COT OMRA – Late Submission
• If a COT OMRA is required but is completed
late, the facility is still required to submit the
late COT OMRA to CMS
– The facility will be paid at the default rate for any
days not in compliance with the ARD requirement
– The ARD of the late COT OMRA restarts the 7-day
review period for the next COT OMRA
COT OMRA – Combining Assessments
• In cases where the COT OMRA is combined
with a regularly scheduled assessment, the
facility would complete the regular
assessment, rather than the COT OMRA, since
the COT OMRA only includes a subset of the
required MDS data
– Used to determine payment for both the COT
OMRA observation period and the regular
payment window for the scheduled assessment
COT OMRA – Combining Assessments
Example:
– If Day 7 of the COT observation period falls within the
ARD window of the 30-day PPS assessment, a provider
would set the ARD for the 30-day assessment on day 7
of the COT OMRA observation period, and code the
reasons for assessment as both the 30-day and the COT
OMRA
• RUG level would be effective starting the first day of the COT
observation period
COT Example
7/15
14 Day MDS
7/16
7/17
7/18
7/19
7/20
7/21
7/22
720 mins
7/23
7/24
7/25
7/26
7/27
7/28
7/29
560 mins
COT/ 30
Day MDS
RU
RV
14 Day MDS on 7/15 = RUG of RU (at least 720 min)
7-22 look back = Pt received 720 min, no COT OMRA needed.
7-29 look back = Pt received only 560 mins (OT no longer treating). COT
OMRA needed w/ARD of 7-29. Can be combo w/ 30 Day MDS.
RV level (at least 500 mins) applied as of 7/23
Possible Strategies to Mitigate Risk
• Technology tracking and alerts
• Close, frequent communication between MDS
and rehab
• Scheduled appointments for therapy
• Back up strategies
– MDS personnel
– Rehab personnel
End of Therapy
(EOT) OMRA
End of Therapy
Resumption
(EOT-R) OMRA
39
EOT OMRA Change
Current: EOT OMRA triggers whenever a patient
receives no billable therapy (regardless of reason) for
3 consecutive days when therapy department is
“open”
EOT OMRA triggers whenever a patient
receives no billable therapy (regardless of reason) for
3 CONSECUTIVE CALENDAR DAYS
• Potential increase in number of EOT OMRAs needing to be
completed
EOT Example
Mon Tues Wed Thurs
18th 19th 20th 21st
Tx
Tx
Tx
Tx
Fri
Sat Sun Mon
22nd 23rd 24th 25th
Tx
Missed
Tx
Tues
26th
Resumed
Tx
This is a “5 Day Tx Dept”, so no Tx provided Sat or Sun. Patient misses
Tx on 25th due to illness and returns on 26th.
Current: Start counting the 3 days missed treatment on the 25th (NOT
counting week-end) so EOT not needed
New: Start counting the 3 days on the 23rd. 3 calendar days missed as
of the 25th. EOT needed and nursing RUG billed for the 23rd, 24th and
25th.
End of Therapy OMRA (EOT) Risks
• Increase in number of EOT that will need to be
completed
• Potential increase in number of SOT OMRAs
needed
• Potential increase in default days
• Resident / Family not understanding need for
treatment on weekends / holidays
EOT-R OMRA
Current: Once an EOT OMRA is completed, the only way to
get back to a Rehab RUG is to do a SOT OMRA with a new
therapy evaluation
If therapy subsequently resumes within 5 days of
the last billed treatment, you may complete an End-OfTherapy Resumption (EOT-R) OMRA if resumes at the same
RUG level that had been in effect prior to the EOT OMRA
EOT-R OMRA
• Not a new assessment type
• EOT OMRA with 2 additional items
– O0450A
– O0450B
EOT-R Example
Mon Tues
18th 19th
Tx
Tx
Wed Thurs
20th 21st
Tx
Tx
Fri
Sat Sun Mon
22nd 23rd 24th 25th
Tx
Missed
Tx
Tues
26th
Resumed
Tx
Current: Once EOT OMRA is completed, a SOT OMRA would
be needed to return to a Rehab RUG level.
New: EOT completed and nursing RUG billed for 23rd, 24th
and 25th. EOT-R (resumption of therapy) date entered on
EOT OMRA for the 26th. Rehab RUG resumes on that date.
No SOT OMRA required. No new therapy evaluation
required.
EOT-R Example
Mon Tues
18th 19th
Tx
Tx
Wed
20th
Tx
Thurs
21st
Tx
Fri
Sat
Sun Mon
Tues 26th
22nd 23rd 24th 25th
Missed Tx Resumed
Tx
Tx
EOT completed and nursing RUG billed for 23, 24 and
25. EOT-R date entered on EOT OMRA for 26th.
Rehab RUG resumes on that date. No SOT OMRA
required.
Tues
26th
Wed
27th
Thur
28th
Fri
29th
Tx -
Tx
Tx
Tx
Resume
Sat
30th
Sun
31st
Mon
1st
Tx
EOT-R requires
resumption date
(26th). Minutes
then monitored for
7 days from
resumption date
for COT OMRA.
EOT-R OMRA
• If the reason for missed therapy was clinical in
nature (meaning there was a possibility that
the resident’s clinical therapy status was
affected by the missed therapy), it may not be
appropriate for the facility to complete an
EOT-R OMRA
Possible Strategies to Mitigate Risk
•
•
•
•
•
Technology tracking and alerts
6+ days per week Therapy
Expanded rehab department daily hours
Specific Therapy Schedule / Appointments
Education of patient/family at Admission of
Therapy Schedule and Patient needs
Possible Strategies to Mitigate Risk
• Close communication between rehab and MDS
– daily; BID?
• Back up strategies
– Rehab personnel
– MDS personnel
October 1, 2011
Transition
Transition
COT OMRA
– effective for all assessments with an ARD on or after
10/1
Allocation of Group Therapy
– On any assessments with an ARD on or after 10/1,
group therapy minutes will be allocated regardless of
whether the look back period extends prior to 10/1
Transition
Revised MDS Assessment Schedule
– Any ARDs set after 10/1 must be in line with the updated
assessment schedule. NOTE: When 10/1 is Day 9, 34, 64 or 94 of
the stay, assessments should be completed by 9/30 or the
assessments will be considered late and payment penalties will
apply
EOT OMRA
– Effective 10/1, facilities will be considered 7-day facilities for
purposes of setting the ARD for an EOT OMRA. Saturday, 10/1,
should be counted as a day of missed therapy if a patient does
not receive any therapy services on that day
EOT-R OMRA
– Effective for all EOT OMRA assessments with an ARD on or after
10/1
Questions ?
Thank You!