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Clinical RUG-IV

COT, SOT, EOT & Missed, Late, and Early PPS MDS

Part 2

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RUG-IV Part 2

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RUG-IV Part 2

POST TEST

1. Which of the following applies to End of Therapy?

a. It is optional to complete an EOT OMRA

b. End of Therapy OMRA changes the RUG effective the first day without therapy.

c. End of Therapy OMRA cannot be combined with a regular PPS MDS

d. All of the above

2. A COT will retrospectively change reimbursement to day one of COT count.

a. True

b. False

3. Which of the following applies to COT?

a. Must be completed if during the COT observation period the RUG would change from RUG from prior MDS.

b. A COT with an ARD of day of discharge is not required, but optional.

c. The End Date of Therapy disrupts COT count.

d. All of the above.

4. Which of the following is true?

a. Grace days are allowed to be used if needed to combine MDS

b. The Discharge Assessment can be combined with a PPS MDS

c. If third day without therapy is day of discharge, no EOT is required

d. All of the above


RUG-IV Part 2

Post Test Answers

1. Which of the following applies to End of Therapy?

a. It is optional to complete an EOT OMRA

b. End of Therapy OMRA changes the RUG effective the first day without therapy.

c. End of Therapy OMRA cannot be combined with a regular PPS MDS

d. All of the above

B

2. A COT will retrospectively change reimbursement to day one of COT count.

a. True

b. False

A

3. Which of the following applies to COT?

a. Must be completed if during the COT observation period the RUG would change from RUG from prior MDS.

b. A COT with an ARD of day of discharge is not required, but optional.

c. The End Date of Therapy disrupts COT count.

d. All of the above.

D

4. Which of the following is true?

a. Grace days are allowed to be used if needed to combine MDS

b. The Discharge Assessment can be combined with a PPS MDS

c. If third day without therapy is day of discharge, no EOT is required

d. All of the above

D


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PPS MDS Management

1


2



Assessment Indicator

• For each type of PPS MDS there is a designated Assessment Indicator for the claim

• For each type of combination PPS MDS with OBRA or another PPS MDS there is an Assessment Indicator

• The Assessment Indicator is assigned by the Grouper based on Reason for Assessment and is noted in Z0100 or Z0150

• The Assessment Indicator is also on the claim3


Assessment Indicator 1st Digit 1st Digit TYPE of PPS MDS Payment Period

0 Unscheduled PPS off-cycle Results in adjusted RUG rate

1 5-day Day 1-14

2 14-day PPS MDS Day 15-30




6 OBRA MDS used for PPS billing when Part A was not

known at time of completion

Used to establish RUG for payment

period4



Assessment Indicator 2nd Digit 2nd

DigitType of PPS MDS Do not use if:

0 Scheduled routine PPS not combined with another unscheduled MDS

N/A

1 Unscheduled OBRA e.g. SCSA , Discharge

PPS OMRA, Short Stay

2 Start of Therapy (SOT) OMRA Short Stay, EOT, Unscheduled OBRA

3 Start of Therapy (SOT) combined with unscheduled OBRA e.g. SCSA or Discharge

Short Stay, EOT

4 End of Therapy (EOT) whether or not combined with unscheduled OBRA

SOT, Short Stay

5 SOT combined with EOT Short Stay, Unscheduled OBRA

6 SOT combined EOT combined with Unscheduled OBRA

Short Stay

7 Medicare Short Stay designation 5


Section Z –Assessment Administration

RUC10

6

CC110



George #1

7


Validation Reports

• Verifies that the MDS has been transmitted to the QIES system

• Effective Oct. 2012, CMS built edits into the system that validates whether an accepted MDS exists prior to payment of claim

• Validation report should be reviewed by the Business Office prior to submitting claims

8



Validation Report Example

9


Validation Report Example

10



Assessment Reference Date (ARD)

• ARD is flexible day within allowable window.– All allowable days are equal

– Chose ARD which achieves the highest RUG

• Observation period ends at 11:59 pm ARD

• The ARD must be “set” while in the window of a scheduled PPS MDS and should not be back-dated into the window.

• CMS has defined “set” as 1) opened and set on MDS in computer or 2) on hardcopy MDS.

11


• A1700 – Type of Entry

• Admission – 1 - 1st admission or:

• Admitted after being Discharged Return Not Anticipated.

• Discharged Return Anticipated but did not return within 30 days. This applies to respite residents too.

• Readmission - 2

• Any reentry when Discharged Return Anticipated; and returned within 30 days. 12



13

• A1900 – Admission Date – First admission for this stay, stays the same date if Discharged Return Anticipated and returns within 30 days

• A2000 – Discharge Date – Day discharged or expired


Type of OBRA MDS

• Comprehensive Assessment: Admission• Annual• Quarterly• Significant Change in Status• Discharge Assessment

14



Discharge Designation

Only complete if A0310F = 10 or 11

1. Planned

2. Unplanned – less interview items• Unexpected transfer to hospital or ER

• Unexpectedly leaves AMA

• Unexpectedly deciding to go home or to another setting

15


Medicare Start and End Dates

16




A2400 – Medicare Stay

• A2400A Medicare stay since most recent entry?

• A2400B Start date of most recent Medicare stay

– First day Part A will be billed

– First covered day for this admission/readmission

– First day of Part A stay initiated within 30-day transfer rule.

17



A2400 – Medicare Stay

• A2400C End date of most recent Medicare stay

• If the Medicare Part A stay is ongoing, there will be no end date to report. Enter dashes to indicate that the stay is ongoing.

18



Medicare End Date/Discharge Date

• 100th day of benefit• Last day paid by Part A when

resident changes payer source the next day and remaining in SNF Medicare End Date

• Last paid day by Medicare, and the plan is for resident to discharge the next day.

Last Payable

day

• Unexpected Discharge off Part Day of Discharge

19


SNF PPS Assessments

20



Scheduled Medicare/PPS MDS

Medicare MDS Timing Requirements

• Scheduled MDS:

– Each PPS MDS has requirements for Assessment Reference Date Window (ARD) which must be complied with for accurate Part A Claims.

All PPS MDS Scheduled or OMRAs - Completion of all Medicare only MDSs (Z0500B) is no later than ARD + 14 days.

All PPS MDS Scheduled or OMRAs - Submission of Medicare only MDS is Completion Date + 14 days.

21


Scheduled Medicare PPS Assessments

Assessment Type

ARD Grace Days Payment Period

5‐day 1‐5 6‐8 1‐14

14‐day 13‐14 15‐18 15‐30

30‐day 27‐29 30‐33 31‐60

60‐day 57‐59 60‐63 61‐90

90‐day 87‐89 90‐93 91‐100

22



Scheduled PPS MDS

23


5-day PPS MDS

TYPE of MDS: 5-day • MDS Item Sets: NP• May be be combined

with OBRA MDS

• Assessment Indicator (AI):10

ARD Rules: 1-5 with grace days to day 6-8

Sets payment for days: 1-14

(Even if Length of Stay is 8 days or less, if Rehab RUG is achieved the Rehab RUG is paid starting on day one even if therapy did not start on day one)

24



5-day PPS MDS

• When the 5-day MDS achieves one of the upper 52 RUG-IV groups, SNF LOC definition is met up to and including the ARD of the 5-day MDS.

• SNF should ensure services prompting RUG are reasonable/medically necessary.

25


5-day PPS MDS

• Set ARD for Day 7 or 8

– Select ARD which captures highest Rehab RUG

– Allows for 14-day ARD to mitigate need for COT

– First day after ARD, start COT observation period

• Consider CMI if Medical RUG could be higher RUG/reimbursement.

• Even if length of stay is 8 days or less, if a Rehab RUG is achieved, no Short Stay designation is needed.

26



ARD and Discharge

• ARD must be set prior to discharge– If ARD for a Scheduled PPS MDS is not already set

prior to planned discharged off Part A, it is too late to set ARD, thus may be provider liability.

• When ARD has been set, if discharged prior to set ARD, then change ARD to day of discharge assuming it is needed for payment and within window for the PPS MDS.– ARD set for Day 8, resident discharges on Day 7,

change ARD to Day 7 for the 5-day MDS.27


ARD and Discharge

Change 5-day planned ARD to

day of discharge.

Set ARD at time of

admission.

28



ARD

not planned and set at time of admission –

must bill default .

29


14-day PPS MDS

TYPE of MDS: 14-day PPS MDS• Reason for Assessment:

A0310B=02• MDS Item Sets: NP• May be combined with OBRA

MDS

ARD Rules: 13-14 with grace days 15-18

Sets payment for days: 15-30 Bill RUG with highest CMI.

AI: 20

• May be combined with SOT/EOT/COT MDS as ARD rules allow.

• Choose ARD which captures the highest RUG/therapy minutes/days.

30



30-day PPS MDS


A0310B=03• MDS Item Sets: NP• May be combined with

OBRA MDS.


Sets payment for days: 31-60. Bill RUG with highest CMI.

AI: 30

31


60-day PPS MDS


A0310B=04• MDS Item Sets: NP• May be combined with

OBRA MDS



AI: 40

32



90-day PPS MDS


A0310B=05• MDS Item Sets: NP • May be combined with

OBRA MDS



AI: 50

33


Unscheduled Medicare PPS AssessmentsOMRA

1. Meets criteria for a Significant Change Status Assessment (SCSA).

2. Was receiving rehabilitation services, classified in rehabilitation group, all therapies discontinued, and skilled Part A services continue (EOT).

– This includes new EOT-R rules.

3. Change of Therapy (COT) required MDS for decrease or increase in RUG.

4. Voluntary Start of Therapy (SOT) when Therapy is started during a Part A stay.

34



Combining Scheduled & Unscheduled MDS

• If the ARD of an OMRA/unscheduled PPS MDS falls within the window (including grace days) of the Scheduled PPS MDS,

and

• If the ARD for the Scheduled PPS MDS would be set for a day AFTER that of the OMRA/unscheduled PPS MDS ARD, then MDS must be combined.

35



• Example:– If the ARD for an OMRA is Day 29 of a resident’s

stay and the 30-day PPS MDS is not set yet, then these 2 PPS MDS must be combined. In this example, ARD would be Day 29 to combine with OMRA.

If you do not combine, any Scheduled PPS MDS with an ARD after an OMRA ARD within window will not be used for payment purposes.

36



Scheduled ARD after OMRA ARD –Scheduled MDS is not used for payment

15 16 17 18 19 20 21

22 23 24 25 26 27 28

29 30 31 32 33 34 35

14-day

ARD

COT √

Only

OMRA ARD

If Day 30-33 is used as ARD for 30-day MDS; the ARD is AFTER the ARD of OMRA, it will not be

used for payment. 37


CHANGE OF THERAPYOMRA (COT)

38



Change of Therapy (COT)

COT OMRA Required when:

• Resident is receiving therapy and

• Resident is in a therapy RUG (Billing Rehab RUG) and

• The number of therapy minutes changes to such a degree that the RUG in effect is no longer an accurate reflection of the intensity of therapy received. (excludes ADL end-split)

39



OR:

• Receiving therapy and qualified for a rehab RUG but

• Resident is in a Medical RUG due to Index Maximizing (billing Medical RUG)– COT rules apply if therapy minutes change to such a

degree that the Rehab RUG category would change.

– For example, therapy minutes may go up a Rehab category, and with COT and Index Maximizing the RUG may change to a higher Rehab RUG. 40



COT OMRA and Index Maximization

• One: Resident qualifies for RMC but index maximizes into LE2. During the COT observation period, resident receives only enough therapy to qualify for RLB. COT OMRA not required because no change in the index maximized RUG category.

• Two: Resident qualifies for RMC but index maximizes into LE2. During the COT observation period, resident receives enough therapy to qualify for RUB. COT OMRA is required because of change in the index maximized RUG category.

41


What Could Trigger COT?

• Change in rehab intensity or adding a discipline

• Discontinuation of a discipline

• Missed Treatment sessions/poor communication– Resident illness

– Scheduling conflicts (appointments, not ready)

– Family visits/outings

– Withheld treatments

– Holidays with missed sessions

– Therapist illness or vacation days42




Scheduled PPS MDS ARD sets and resets rolling seven day period.

COT Day

7ARD

COT Day

6

COT Day

5

COT Day

4ARD

COT Day

3

COT Day

2

COT Day

1

RUG SetRUG

Review

COT Day 1 re-starts

Change in RUG category changes billing to new RUG back for the seven days of the COT period

43



• The 5-day PPS MDS sets first rolling 7 days

– Day 1 is first day after ARD

• The ARD for COT must be Day 7 of the rolling observation period

– ARD must be Day 7 and may “set” up to 1 or 2 days after Day 7

– Use EOT item set

– Rate changes retrospectively to Day 1 of COT observation period

44




• Scheduled MDS used for payment– Sets and resets COT observation period

– Count first day after ARD as day 1

– Scheduled MDS which could qualify for a Rehab RUG, but qualifies for a Medical RUG due to CMI, starts COT observation counting first day after ARD as day 1

• Start of Therapy (SOT) – starts COT count– Count first day after ARD as day 1

45


SUN MON TUES WED THU FRI SAT

1 2 3 4 5

6 COT

7

7 8 9 10 11 12


COT observation period is reset with each Scheduled MDS ARD.

Example: 14-day MDS with ARD of day 13

–COT 7= 20th, 27th

–30-day MDS ARD is day 29

–Resets rolling 7-day at days 30-36

Month 2

Month 1

SUN MON TU WED THU FRI SAT

1 2 3 4 5 6 7

8ARD

9COT1

10 11 12 13ARD

14COT 1

15 16 17 18 19 20 COT7

21 COT 1

22 23 24 25 26 27 COT7

28 COT 1

29 ARD

30 COT 1

46




• End of Therapy (EOT) “ends” COT observation period.

• EOT with Resumption Date – Resumption Date is day 1 of COT observation period.

47



• The COT and Other Assessments

– If the ARD of a PPS MDS used for payment is set on or prior to Day 7 of COT, then no COT is required.

• If the Scheduled PPS MDS ARD is earlier than Day 7, it will reset the COT calendar.

• If the Scheduled PPS MDS ARD is on Day 7, then the COT calendar does not change. The COT is not required, but optional.

48



COTStay ARD COT count

RUG Minutes Delivered

RUG Billed

1 RH RH

2 RH RH

3 RH RH

4 RH RH

5 RH RH

6 RH RH

7 RH RH

8 0 RH RH

9 1 RM RH

10 2 RM RH

11 3 RM RH

12 4 Scheduled ARD BEFORE COT ARD

RM RH

13 5 RM RH

14 6 14-day - resets COT RM RH

15 7 RUG changes on cycle RM RM

49




RUG Billed

15 14-day ARD 0 RH RH

16 1 RH RH

17 2 RH RH

18 3 RH RH

19 4 RH RH

20 5 RH RH

21 6 RH RH

22 7 COT Check - no COT RM RH

23 1 RM RH

24 2 RM RH

25 3 Scheduled ARD before COT ARD RM RH

26 4 RM RH

27 5 RM RH

28 6 30-day MDS RM RH

29 7 Rate changes

day 31 on-cycle

50





RUG Billed

15 14-day ARD 0 RH RH

16 1 RH RH

17 2 RH RH

18 3 RH RH

19 4 RH RH

20 5 RH RH

21 6 RH RH

22 7 COT Check - RH RM RH

23 1 RM RH

24 2 RM RH

25 3 30-day ARD on or before COT ARD

RM RH

26 4 COT is optional RM RH

27 5 RM RH

28 6 30-day MDS - Rate changes

day 31 on-cycle

RM RH51


COTDay ARD COT count


RUG Billed

1 RH RH

2 RH RH

3 RH RH

4 RH RH

5 5-day ARD

0 RH RH

6 1 RH RM

7 2 RH RM

8 3 RH RM

9 4 Weak 5-day MDS ARD Management

RM RM

10 5 RM RM

11 6 RM RM

12 7 COT required RM RM

13 1 RM RM

14 0 14-day MDS RM RM

15 1 Resets COT count RM RM52





RUG Billed

1 RH RH

2 RH RH

3 RH RH

4 RH RH

5 RH RH

6 RH RH

7 RH

8 0 RH

9 1 RV RV

10 2 RV RV

11 3 Scheduled ARD on COT ARD RV RV

12 4 COT – RUG going up RV RV

13 5 RV RV

14 6 RV

15 7 14-day with COT RV 53


COT and 1st 14 days

• With selection of Day 8 as ARD for 5-day MDS– The 14-day MDS ARD can be on or before the 7th

day of the COT observation period.

– Exception – RUG is going up; then combine COT with 14-day MDS.

• Next COT observation period e.g. Days 16 - 22 – monitor closely.

• Next COT observation period e.g. Days 23-29; can always set ARD for Scheduled MDS on or before the 7th day of COT.

54



Impact on COT ARD

• If 7th day of COT falls on Last Paid Day, and a COT is required; complete COT.

• If 7th day of COT falls on day of discharge off Medicare or from facility (not a payable day) then no COT is required.

– COT is optional; complete if RUG going up

55


COT required if 7th day falls on Last Paid Day

15 16 17 18 19 20 21

22 23 24 25 26 27 28

29 30 31 32 33 34 35

COT Due

Unplanned /Planned

Discharge

14-day ARD

COT √

Only

56



Unscheduled PPS MDS ARD Flexibility Period

• ARD of OMRAs may be set within 2 days of window.

– Referred to as 2-day flexibility period.

– The ARD of a COT is Friday, the ARD must be “set” no later than Sunday.

– This rule applies to EOT, SOT, and COTs.

57



Example: For a COT OMRA, where Day 7 of the COT observation period is Day 37, the ARD may be set for Day 37 no later than Day 39. Beginning on day 40, the ARD may be set for no earlier than the day on which the ARD was set, meaning the assessment is late.

58



Flexibility Period

29 30 31 32 33 34 35

36 37 38 39 40 41 42

43 44 45 46 47 48 49

30-day

COT Due/ARD

Can be used to set

ARD

If past 2 days, then must set the

late ARD when you discovered

the error.

59


Assessment Reference Date (ARD)

• Unplanned Discharges and OMRAs – For an unplanned discharge, ARD of an OMRA

can still be set within 2 days of ARD window –flexibility period still applies to unplanned discharges.

– For example, if 7th day of COT was a Thursday, and then the resident suddenly discharged on Friday the ARD for the COT can be set no later than Saturday for the 7th day of COT. This is after discharge, but since an unplanned discharge, the 2-day flexibility applies.

60



COT ARD and Unplanned Discharge

For unplanned discharge, the 14-day MDS is not used for payment, and the flexible 2-day rule applies to set ARD.1

Admit Date

2 3 4 5 6 7

8 9 10 11 12 13 14

15 16 17 18 19 20 21

2-day flexibility for ARD applies to required COT. 14-day is not used for payment

5-day ARD

14-day / COT Due

Unplanned DC Hospital

61


Case Study #1

• Resident admitted, the 5-day MDS ARD of Day 8 achieves Rehab Very High. The COT observation period are Days 9-15. On Day 7 of COT count, upon evaluation of the minutes/days, the RUG decreases to a Rehab High

• What should the MDSC do related to COT and Scheduled MDS, and what is the impact?

62



Day of Stay ARD COT Count ARD Management

1 1

2 2

3 3

4 4

5 5

6 6

7 7

8 8 ARD ARD

9 9 1

10 10 2

11 11 3

12 12 4

13 13 5

14 14 6

15 15 7

16 16 63


Day of Stay ARD COT Count ARD Management

1 1

2 2

3 3

4 4

5 5

6 6

7 7

8 8 ARD ARD

9 9 1

10 10 2

11 11 3

12 12 4

13 13 5

14 14 6 Select ARD for Scheduled MDS which resetsARD count for the COT

15 15 ARD 7 Or select this ARD, COT is optional; COTcount continues

16 16

ANSWER – CASE STUDY #1

64



Prior to Oct. 1 - COT Limitations

• Scenario: resident is receiving therapy, but from the most recent Scheduled MDS or OMRA COT, they do not qualify for any therapy RUG (Coded 4 days for RU, RV, RH combined with missing 5 distinct calendar days – so don’t qualify for RM either)

– COT count is broken, so even if 7 days later they would qualify for a Rehab RUG, no COT can be done

– Team must wait for the next scheduled MDS to be re-assigned to a Rehab RUG – can’t do COT

65


Revision to Change of Therapy Policy

• CMS has revised the COT policy which will permit providers to use the COT OMRA to reclassify a resident into a therapy RUG from a non-therapy RUG, but only in the following limited circumstances:– the resident had qualified for a therapy RUG in

Section Z on a prior assessment during the resident's current Medicare Part A stay

AND

66



Revision to Change of Therapy Policy

– had no discontinuation of therapy services (End Date) (planned or unplanned) between Day 1 of the COT observation period for the COT OMRA that classified the resident into his/her current non-therapy RUG and the 7th day/potential ARD of the COT OMRA that could potentially reclassify the resident into a therapy RUG.

• It must be a COT or COT combined with Scheduled MDS that caused the classification into the Medical RUG for a COT to be allowed to put back into Rehab RUG 67


COT Example #1Revised Rules

• Mr. A. was classified into RUA on his 30-day assessment with an ARD set for Day 29 of his stay

• On Day 36, he only received therapy on 4 distinct calendar days, which would make it impossible for him to qualify for Rehab Ultra High.

• COT completed with ARD of day 36

• Continue COT observation period

• 7 days later, qualifies for RUA again, meets both qualifiers - complete COT

68



COT Example #2 Revised Rules

• Same scenario as example #1, however, as opposed to the first example where the resident’s therapy continued during the week following the COT OMRA, let us assume the facility decides to discontinue his therapy services, with Day 39 representing the last day that Mr. A is provided therapy. This stops COT count. So no COT allowed.

• No EOT required since billing a Medical RUG

69


COT Example #2

• The only way to re-classify into a Therapy RUG is to initiate a new therapy program including new evaluation and completing Start of Therapy (SOT) Assessment or waiting to capture therapy on the next regularly Scheduled MDS

70



COT Example #3Revised Rules

• 30-day MDS qualified for LB1 and did not have 5 distinct calendar days so did not qualify for any Rehab RUG

• Team opts to NOT complete COT since ARD was on or before 7th day of 30-day MDS.

• On Day 36, qualifies again for RUA.

• No COT is allowed since the MDS which classified into non-therapy RUG was not a COT or COT combined with Scheduled MDS.

71


Reminder

REMINDER:

• If in a non-therapy RUG due to CMI, but also qualify for a Rehab RUG; and then therapy minutes drop lower so don’t even classify into any Rehab RUG; no COT is required since no impact on billing. (Already billing a Nursing RUG due to CMI.)– If therapy minutes go up enough to achieve a Rehab

RUG; do COT.72



COT/Therapy Best Practices

• Open and pre-set ARD for next MDS• Implement rolling 7-day ARD review by therapy team

leader with communication with MDS Nurse.– Each day, review residents reaching 7th day of COT

observation period. • Every day of the stay while billing Rehab RUG is in a

look-back period.– Must make up any missed minutes

– Must maintain level of RUG on treatment plan; PLAN

– Scheduling 73



• Assess any possible facility barriers to therapy care as residents not ready for therapy, meal schedules, interruptions, physician issues as timely orders, etc.

• Manage refusals with involvement of family and/or facility; change therapist assignment if necessary

• Consider staffing for 6-7 days a week of therapy

• Consider staggering therapist hours to maximize resident participation/treatment availability

74




• When Billing a Medical RUG but providing some therapy – Continue with 7-day look-back checks

– If Therapy increases and would qualify for a Rehab RUG, do a COT

– If therapy stops for 3 days and resumes, continue with 7 day COT checks

– If all therapy ends completely; stop COT count and no EOT is required since already billing a Medical RUG

– If therapy starts up again, complete an SOT. 75


START OF THERAPY OMRA

76



Start of Therapy

• Start of Therapy Other Medicare-Required Assessment (SOT OMRA) Overview

– Optional

– Complete only to classify into RUG-IV Rehabilitation group; (Rejected if non-therapy RUG)

– RUG changes earliest Start Date of Therapy

– ARD 5-7 day window after Start of Therapy. Set ARD within window, or set within 1 to 2 day flexible period after window.

77


SOT Case Study 1Day of

Stay

Therapy Start Date on MDS

SOT ARD Choice

30-day MDS ARD

Choice Therapy RUG

Discharge Date ARD

32 1 ARD Therapy RUG Starts

33 2 ARD

34 3

35 4

36 5

37 6

38 7

39

4078



Start of Therapy

• SOTs are optional

• Requires evaluation and start date on MDS

• COT count starts Day 1 after ARD of SOT.

• If on a Medical RUG because of CMI, the rolling 7-day COT count would capture an increase in minutes effective day one of the COT observation period

• Combined with Scheduled MDS if ARD falls within Scheduled PPS MDS window

79


END OF THERAPY OMRA(EOT)

80



Therapy End Date

Therapy End Date – “Record the date the most recent therapy regimen (since the most recent entry) ended. This is the last date the resident received skilled therapy treatment. Enter dashes if therapy is ongoing.”

Scenario One: End of Therapy date is planned. Once the last therapy is discontinued/end date is last day received; and resident stays on Part A for another skilled service; an End of Therapy MDS must be completed to bill Medical RUG.

Scenario Two: Resident is on Part A, still on case load, when unexpectedly discharged/died/change in payer. 81


End of Therapy (EOT) OMRA

TYPE of MDS: End of Therapy Reason for Assessment:A0310B= 07 and A0310C=2 MDS Item Sets: NO/SO,

NOD

ARD Rules: ARD within 1-3 from first day without therapy. ARD is not allowed for regular PPS MDS. First day without therapy is day one.

Sets payment for days: First day without therapy until end of billing cycle.

AI: 04• Counting last Therapy End Date (O0400A, B, or C 6) is day “0”

The ARD must be day 1, 2, or 3 counting first day without therapy as day one.

• Can be combined with OBRA, PPS Assessments.

• Choose an ARD that achieves the highest Medical RUG 82



End of Therapy

• Required when the resident was classified in a RUG-IV Rehabilitation Plus Extensive Services or Rehabilitation group and continues to need Part A SNF-level services after the planned or unplanned discontinuation of all rehabilitation therapies for three full or more consecutive days.– If already billing a Medical RUG, no EOT is required if

therapy ends. COT count would end also.

• Must be 15 minutes or more to be considered a “day” of therapy. If minutes under 15, then that is a missed day of therapy treatment. 83


Three Day Break in Therapy

EOT rules for a 3-day break in therapy:

– If no therapy for 3 full consecutive days regardless of reason an EOT must be completed to change RUG billed to a Medical RUG starting first day without therapy.

– Applies to holidays, weekends, illness, & refusals.

– ARD must be days 1-3, counting first day without therapy as day one. Set ARD within window, or set within 1 to 2 days flexible period after window.

84



Three Day Break in Therapy

• UNPLANNED EOT rules for a 3-day break in therapy:

– Must plan for coverage for three day holiday weekends.

– Daily communication with therapy.

– Must try to make up missed days/treatment.

85



Example: For EOT, if ARD window are days 19, 20, or 21, the ARD can be “set” for a day within the window no later than Day 23.

86



Flexibility Period

87


Resident Discharged on Third Day without Therapy

• No EOT required if third day falls on day of discharge off Part A

29 30 31 32 33 34 35

36 37 38 39 40 41 42

43 44 45 46 47 48 49

30-day

COT Done

EOT Due

Pt. DC88

Last Rehab

Treatment



Day of Stay

Therapy End Date on MDS

EOT ARD Choice

30-day MDS ARD Choice

Non-Therapy RUG

Discharge Date

22 End Date

23 1 ARD MedicalRUG Starts

Stops COT count

24 2 ARD

25 3 ARD

26 May still set ARD

27 May still set ARD

ARD

28 ARD

29 ARD

30 ARD

89


Therapy Best Practices – EOT OMRA

• Monitor and track all therapy days and minutes daily; “no prescribed Medicare week”

• Adjust therapy schedules to ensure there are no 3 day breaks in therapy especially during holidays – only one discipline required

• If resident refuses/misses on a Friday, make treatment up on Saturday if therapy available on Saturday

90



Therapy Best Practices – EOT OMRA

• Ensure all skilled time is accountable including caregiver education or care conference with resident present if therapeutic minutes

• Must have 15 minutes to be able to code as a “day of treatment”

– If provided a few minutes of therapy, but not 15 minutes or more, this counts as a “missed treatment” day.

91


92

Therapy Best Practices - EOT OMRA

• Analyze refusals for patterns and trends; discuss with the team resolution or strategies for refusals

• Ensure resident/caregiver is involved in goal setting and understands the merits of therapy

• Understand resident preferences and incorporate any specific needs as indicated during skilled intervention

92



RESUMPTION OF THERAPY (EOT-R) OMRA

93


EOT-R

EOT – Resumption

– Purpose – decrease number of necessary SOT MDS in light of changes in EOT rules.

– Does not apply if already billing a Medical RUG due to CMI.

TWO CRITERIA MUST BE MET:

1.Must resume therapy within 5 days AND

2.Upon resumption, therapy must be at same level for each involved discipline (excludes ADLs) from MDS prior to EOT.

• EOT ARD rules applies – days 1-3 94



EOT-R

• EOT – Resumption

– No new therapy evaluation would be required.• If resident had been ill, a re-evaluation may be

indicated.

– Complete EOT item set; only one MDS is completed.

– However, new O0450A and B are added to EOT item set.

95


EOT MDS indicates latest Therapy End Date.

Medical RUG begins first day without therapy. 96



ARD must be days 1, 2, or 3 starting day 1 as first day without therapy.

Same EOT would also indicate the earliest resumption of rehab date.

Rehab RUG that was being billed prior to EOT would be billed starting first day of resumption of therapy.

97


EOT – R End of

Therapy ARD

End of Therapy

Resume within 5

days

Resumption of Therapy RUG Billed

0 Last day received therapy

Rehab High

1 Day 1 ARD

1 Medical RUG

2 Day 2 ARD

2 Medical RUG

3 Day 3 ARD

3 Medical RUG

4 4 O0450A = Yes

O0405B = earliest resumption date – no new eval required

Rehab High

5 Rehab High 98



EOT-R

• If therapy does NOT resume within 5 days OR

• Therapy is not resuming at same level for all therapies (excluding ADLs)

– Must complete EOT - then complete an SOT

– Remember Rehab RUG starts on first day with therapy.

– or, wait until next scheduled MDS

** The above options are always available even if therapy resumed within 5 days.

99


EOT and SOT End of

Therapy ARD

End of Therapy

Resume within 5

days

Resumption of Therapy RUG Billed

0 Last day received therapy

Rehab High

1 Day 1 ARD

1 Medical RUG

2 Day 2 ARD

2 Medical RUG

3 Day 3 ARD

3 Medical RUG

4 4 Medical RUG

5 Medical RUG

6 New rehab RUG

100



Billing Communication

• Impact on billing is significant in terms of communication.– Assessment Indicator (AI) will indicate an EOT-R

• Medical RUG starts first day after latest end date

• Prior Rehab RUG starts on date of resumption

• Prior RUG will NOT be calculated in Section Z, so must be communicated to billing

101


Therapy must resume at same RUG level on day 4 or 5

15 16 17 18 19 20 21

22 23 24 25 26 27 28

29 30 31 32 33 34 35

14-day

ARD

Resumption on Day 4 or

5 COT count resumes on Resumption

Date

Last day of

Therapy EOT due

EOT due

Rehab High

Resumes at Rehab High

102



IMPACT OF END OF THERAPY DATE AND COT COUNT

103


Change of Therapy and Therapy End Dates

• RAI says: “If at any point, rehabilitation therapy ends before the last day of a Change of Therapy OMRA observation period and an End of Therapy OMRA is required, then the Change of Therapy evaluation process ends until the next PPS assessment which includes the resident receiving skilled therapy services again.”

104




Example: • COT observation period - Days 15-21. COT required.

• Three Consecutive Days without therapy are Days 20, 21, and 22. EOT is required.

• The last day Therapy was received was Day 19

• Complete EOT with ARD of Day 20 (day 1), or 21 (day 2)

– If chose ARD of Day 22, a COT and EOT would be required. ARD of EOT must be on or before 7th day of COT.

105


COTStay ARD COT EOT RUG Minutes Delivered

RUG Billed

14 14-day ARD

0 Rehab High RH RH

15 1 RM RH

16 2 RH

17 3 RM RH

18 4 RM RH

19 5 End Date

EOT ends COT count as End Date is prior to 7th

day

RM RH

20 6 1 ARD No therapy Med

21 7 2 ARD No Therapy Med

22 3 Do not pick this ARD. No Therapy Med

Complete EOT only 106




• COT and EOT ARDs:

• Example: – If the last day of the COT observation period is on

May 4, and the ARD of the EOT OMRA is set for May 4 or earlier, then SNF is not required to complete the COT.

– If the ARD of the EOT OMRA were set on May 5, then COT would be required and EOT would be required regardless of the day therapy ended.

107


ARD should be May 3 or 4th, complete EOT only

15 16 17 18 19May 1

20May 2

21May 3

22May 4

23May 5

24 25 26 27 28

29 30 31 32 33 34 35

14-day ARD

COT Due

Last day of Therapy

EOT due

EOT due

If select May 5th, then must complete COT & EOT.

108




• What if therapy ends on last day of COT observation period? – COT observation period - days 16-22. Evaluation of

minutes indicates a COT would be required.

– End Date for Therapy is day 22.

• Therapy was provided on day 22, but this day was followed by a 3 consecutive days without therapy OR resident was discharged off caseload after treatment; either way, this is the last day resident received therapy.

109


Must complete COT & EOT

15 16 17 18 19 20 21

22 23 24 25 26 27 28

29 30 31 32 33 34 35

14-day ARD

COT Due

Last day

Therapy EOT due

110



COT & EOT & SOT

CASE STUDIES

111


COT/EOT Case Study #1

End Date of Therapy Impact on COT:

• There are 3 consecutive days without therapy, and the resident continued on Part A for a nursing skilled RUG.

• What type of MDS must be completed and select ARD.

112



Day of Stay

ARD COT Count EOT Count ARD Management

1 1 Rehab RUG2 2 Rehab RUG3 3 Rehab RUG4 4 Rehab RUG5 5 Rehab RUG6 6 Rehab RUG7 7 Rehab RUG8 8 ARD Rehab RUG

9 9 Rehab RUG10 10 Rehab RUG11 11 End Date of

TherapyRehab RUG

12 12 Medical RUG13 13 Medical RUG14 14 Medical RUG15 15 Medical RUG

16 16 Medical RUG

Case Study #1

113


Day of Stay

ARD COT Count

EOT Count ARD Management

1 1 Rehab RUG2 2 Rehab RUG3 3 Rehab RUG4 4 Rehab RUG5 5 Rehab RUG6 6 Rehab RUG7 7 Rehab RUG8 8

ARDRehab RUG

9 9 1 Rehab RUG10 10 2 Rehab RUG11 11 3 End Date of

TherapyRehab RUG End Date of Therapy prior to 7th day of COT, stops COT.

12 12 StopsCOTCount

1Medical RUG Continues Part A for aMedical RUG

13 13 2 ARD choice

Medical RUG

14 14 3 ARD choice

Medical RUG

15 15 Medical RUG16 16 Medical RUG

Case Study #1 ANSWER

114




End Date of Therapy Impact on COT:

ANSWER

Complete EOT with 14 day MDS, use day 13 or 14. Select ARD that achieves highest Medical RUG.

115



End Date of Therapy and Resumption Date Impact on COT:

• There were 3 consecutive days without therapy, then therapy resumes on Day 4 of EOT count at same RUG level

• Which MDS should be done?

• When does COT count restart?

116



Day of Stay

ARD COT Count


1 1 Rehab High RUG

2 2 Rehab High RUG

3 3 Rehab High RUG

4 4 Rehab High RUG

5 5 Rehab High RUG

6 6 Rehab High RUG

7 7 Rehab High RUG

8 8 ARD Rehab High RUG

9 9 Rehab High RUG

10 10 Rehab High RUG

11 11 End Date ofTherapy

Rehab RUG

12 12 Medical RUG

13 13 Medical RUG

14 14 Medical RUG




Case Study #2

117


Day of Stay

ARD COT Count


1 1 Rehab High RUG

2 2 Rehab High RUG3 3 Rehab High RUG4 4 Rehab High RUG5 5 Rehab High RUG6 6 Rehab High RUG7 7 Rehab High RUG8 8 ARD Rehab High RUG9 9 1 Rehab High RUG10 10 2 Rehab High RUG11 11 3 End Date of

TherapyRehab RUG End Date of Therapy prior to 7th day of COT, stops COT.

12 12 Stops COT

1 ARD Choice Medical RUG

13 13 2 ARD Choice Medical RUG14 14 3 ARD Choice Medical RUG ARD CHOICE15 15 1 Resumption

starts COT countRehab High RUG

16 16 2 Rehab High RUG17 17 3 Rehab High RUG

Case Study #2 ANSWER

118




End Date of Therapy and Resumption Date Impact on COT:

ANSWER

The ARD of the EOT-R- falls within the window of the 14-day MDS, the two MDS are combinedusing days 13 or 14 as ARD. COT count starts on resumption date.

119



EOT ARD choice impact on COT

Therapy ended on Day 5 of COT count. This then made EOT choices, day 6, day 7 or day “8” of COT count. COT is indicated as well as the EOT.

What type of MDS should be completed and select ARD.

120



Day of Stay

ARD COT Count EOT Count ARD Management

1 1 Rehab High RUG2 2 Rehab High RUG3 3 Rehab High RUG4 4 Rehab High RUG5 5 Rehab High RUG6 6 Rehab High RUG7 7 Rehab High RUG8 8 ARD Rehab High RUG9 9 Rehab Medium RUG10 10 Rehab Medium RUG11 11 Rehab Medium RUG12 12 Rehab Medium RUG13 13 End Date of

TherapyRehab Medium RUG

14 14 Medical RUG15 15 Medical RUG

16 16 Medical RUG

17 17

Case Study #3

121


Day of Stay

ARD COT Count


1 1 Rehab High RUG

2 2 Rehab High RUG

3 3 Rehab High RUG

4 4 Rehab High RUG

5 5 Rehab High RUG

6 6 Rehab High RUG

7 7 Rehab High RUG

8 8 ARD Rehab High RUG

9 9 1 Rehab Medium RUG




13 13 5 End Date of Therapy

Rehab Medium RUG

14 14 6 ARD choice Medical RUG – ARD EOT choice

15 15 7 ARD choice Medical RUG – ARD EOT choice

16 16 ARD Do not use for EOT ARD, if selected, then a COT & EOT is required.

17 17

Case Study

Answer #3

122




EOT ARD choice impact on COT

ANSWER

Pick day 6 or 7 (days 1 or 2 of EOT) and only complete EOT. Do not pick day “8.” If pick day “8” both COT and EOT must be completed. The ARD of the EOT must be on or before 7th

day of COT.123


COT/Discharge Case Study #4

Last Payable Day and EOT:

• Therapy ends on day 5 of COT count. Last day of therapy is last payable day

What MDS do you need to complete?

124



Day of Stay

ARD COT Count


14 ARD Rehab High RUG

15 Rehab High RUG

16 Rehab High RUG

17 Rehab High RUG

18 Rehab High RUG

19 End Date ofTherapy

Rehab High RUGLast payable day.

20 Day ofDischarge

21

22

23

24

Case Study #4

125


Day of Stay

ARD COT Count



15 1 Rehab High RUG

16 2 Rehab High RUG

17 3 Rehab High RUG

18 4 Rehab High RUG

19 5 End Date ofTherapy

Rehab High RUG End Date of Therapy prior to 7th day of COT, stops COT count.Last payable day.

20 Day ofDischarge

Complete the Discharge MDS with theARD as the day of discharge.

21

22

23

24

Case Study

Answer #4

126




Last Payable Day and EOT:

ANSWER

Complete only Discharge MDS.

127



COT and Therapy End Date are both Last Payable Day:

• Therapy ends on 7th day of COT count which is also the Last Payable Day. Upon review of minutes/days, a COT is required.

• What type of MDS should be completed and select ARD

128



Day of Stay

ARD COT Count



15 1 Rehab Medium RUG






21 7 End Dateof Therapy

Rehab Medium RUGLast Payable Day.

22 Day ofDischarge

23

Case Study #5

129


Day of Stay

ARD COT Count









21 7ARDCOT

End DateofTherapy

Rehab Medium RUGMust complete COT if RUG would change. Last Payable Day.

22 ARD Day ofDischarge

Complete Discharge Assessment using dayof discharge as the ARD.

23

Case Study

Answer #5

130




COT and Therapy End Date are both Last Payable day:

ANSWER

• Both a COT with Day 7 as ARD, and a Discharge Assessment with ARD of day of discharge would be required

131


SCSA Impact on Medicare

TYPE of MDS: Significant Change in StatusReason for Assessment:

A0310A=04 and A0310B=07• MDS Item Sets: NC, can be

combined with PPS MDS.

ARD Rules: ARD within 14 days of determination of change and not allowed for a PPS MDS.

Sets payment for days: ARD until end of billing cycle AI: 01

• If ARD is within window, combined with PPS MDS• RUG changes on ARD, if a grace day is used, the rate changes

on cycle e.g. Day 33 is the ARD of a SCSA, but the rate changes on cycle on day 31

• Pick an earlier ARD if rate going up and a later ARD if rate is coming down 132



5-day and SCSA PPS MDS

• If this is a long stay resident who is now a re-admit on Medicare, a SCSA may be required in addition to the PPS MDS.

• If combining SCSA with 5-day use grace days to mitigate risk of billing default days.

133


5-day and SCSA Case Management

– Use grace days (or day 1) when 5-day MDS combined with SCSA to bill all days at RUG rate.

• If day 2, 3, 4, or 5 is used, then default must be billed up to the ARD of the combined SCSA with 5-day PPS MDS.

– Use grace days when combining a SCSA with a 5-day MDS and 14-day MDS.

– Exception: If combining a SCSA with a SOT or EOT, the rate changes based on End and Start Dates of Therapy.

134



14-day and SCSA PPS MDS

• If resident is a re-admit on Medicare, then a SCSA may be required.– If combined with 14-day MDS, use grace days so

RUG rate does not change prior to Day 15 unless RUG is going up.

135


ARD of SCSA Combined with Grace Days being Used

15 16 17 18 19 20 21

22 23 24 25 26 27 28

29 30 31 32 33 34 35

14-day combined with SCSA

ARD

Rate changes

on Cycle

effective Day 15

136



SCSA Combined not using Grace Days

1Admit Date

2 3 4 5 6 7

8 9 10 11 12 13 14

15 16 17 18 19 20 21

22 23 24 25 26 27 28

5-day ARD

SCSA and

14-day ARD

Rate changes off cycle

on day 13

137


Tracking Systems

• Therapy minute management Tracking system.

• MDS ARD Management Tracking system.– MDS Nurse uses to track COT and other off-cycle

MDS.

– See sample ARD tools

138



Summary

• Remember each set of rules for Off-cycle MDS.

• Understand combination MDS and ARD impact.

• Use quick reference and tracking tools.

139


Medicare Part A Prospective Payment System (PPS) MDS Schedule

Resource Utilization Group (RUG) ARD=Assessment Reference Date SCSA=Significant Change in Status Assessment EOT=End of Therapy EOT-R = Resumption SOT=Start of Therapy COT= Change in Therapy *NOTE: When SCSA/SCPA are combined with a PPS MDS, payment rate may not be effective on the ARD if grace days are used. For example, a 30-day PPS MDS with a Significant Change in Status Assessment with an ARD of day 33, a grace day, payment rate would become effective on day 31, not day 33.

Developed by Polaris Group 09.14 www.polaris-group.com Page 1 of 9

MDS Type/Reason for Assessment

Assessment Reference Date (ARD) Can be set on any of the following

days

Billing Cycle Used by the Business Office

Special Comments All Medicare MDS must be completed (Z0500B) no later than the ARD (A2300) + 14 days and submitted no later than Completion

Date (Z0500B) + 14 days.

AI AI

1st Digit 2nd digit

5-day NP A0310B=01

Days 1-5 Grace days 6-8

Sets payment rate for days 1-14. Bill RUG with highest CMI in Z0100 or Z0150.

Best practice to mitigate impact of COT is to use day 8 for ARD. Set ARD on day of admission to limit risk of default because resident was

discharged prior to ARD being set.

1 0

5-day combined with Admission or OBRA A0310A=01, 02, 03,04 and A0310B=01



May be combined with an Admission, Annual, SCSA, or Quarterly OBRA MDS.

Best practice to mitigate impact of COT is to use day 8 for ARD. When combined with OBRA assessment, use OBRA item set e.g. NC, NQ. Set ARD on day of admission to limit risk of default due to resident being

discharged prior to ARD being set. If combined with SCSA, always use a grace day to ensure billing cycle

starts on day of admission.

1

0

1

1(if combined with 04 or 05)

14-day NP A0310B=02



Select ARD to achieve the highest RUG. Select ARD earlier than required COT “day 7” when ARD rules allow and

RUG would go down. If Scheduled MDS ARD is on or before COT ARD, then no COT is

required. However it is optional, if RUG would go up, complete COT combined with Scheduled MDS.

May be combined with EOT OMRA if both ARD rules allow and 1st day of EOT payment change is day 15 or earlier. If payment change is day 16 or later, complete 14 day MDS then EOT.

May be combined with SOT if ARD rules allow.

2 0

14-day combined with Admission/OBRA A0310A=01 or 02 or 03 or 04 or 05 A0310B=02



Best practice as above with two exceptions: No grace days can be used if combined with the initial OBRA Admission

assessment. If combined with SCSA and days 13 or 14 are used, the rate will change

effective that day. If grace days are used, rate will change on-cycle. Select ARD carefully.

2 0 2

1(if combined with 04 or 05)







days




AI AI

1st Digit 2nd digit

30-day NP A0310B=03



Select ARD to achieve the highest RUG. If Scheduled MDS ARD is on or before COT ARD, then no COT is


May be combined with OBRA MDS. May be combined with EOT OMRA if both ARD rules allow and payment

day changes day 31 or earlier. Otherwise, complete 30 day MDS, then EOT.


3 0

60-day NP A0310B=04








4 0

90-day NP A0310B=05







May be combined with SOT OMRA if both ARD rules allow.

5 0

Discharge Assessment combined with PPS MDS or OMRA ND A0310B=01, 02, 03, 04, 05, or 07 And A0310F=10 or 11

ARD would be day of discharge (A2000).

ARD is allowed for PPS MDS.

N/A

May be combined with routine PPS MDS when ARD rules allow. Most commonly combined with a 5 day MDS.

On occasion, a discharge MDS can be combined with Scheduled PPS MDS using grace days.

See rules for SOT and COT. All may be combined with the Discharge Assessment when ARD rules allow under certain circumstances.

N/A N/A







days




AI AI

1st Digit 2nd digit

Change in Therapy (COT) NO/SO A0310B=07 and A0310C=4

ARD must be day 7 of the COT observation period.

Observation period is from ARD to ARD of scheduled MDS or SOT MDS.

Day one in 7 day count is first day after ARD.

Exception: For EOT-R day one is date of resumption (O0450B).

NOTE: Two day flexibility period for selecting ARD. Rate changes effective day one of the COT observation period through end of the billing cycle. Bill RUG in Z0100.

Rolling 7 day observation period; ARD to ARD. At the end of day 7; determine if minutes delivered over the past 7 days

matches Therapy RUG achieved on prior MDS; if minutes/days reflect that RUG would go up or down initiate a COT unless can mitigate with scheduled MDS ARD.

NOTE: If ARD of Scheduled MDS is on or before the 7th day of the COT count, no COT is required. Monitor therapy minutes daily. Make up minutes if needed.

Bill RUG Z0100 starting day one of the COT observation period. If End Date of therapy is prior to the 7th day of the COT count, the COT

count stops. If the End Date of therapy equals the 7th day of COT count, a COT would

still be required if RUG would change. If already billing a Medical RUG, but receiving some therapy, COT count

continues but no EOT is required when therapy ends, and COT count ends.

0 D

Change in Therapy (COT) combined with a PPS MDS or OBRA MDS or Discharge NO/SO/NOD A0310B=01, 02, 03, 04, 05, 07 and A0310C=4

ARD must be day 7 of the COT observation period.

Observation period is from ARD to ARD of scheduled MDS or SOT MDS.

Day one is first day after ARD.

Exception: For EOT-R day one is date of resumption (O0450B).

ARD is allowed for scheduled MDS.

Rate changes effective day one of the COT observation period through end of the billing cycle. Bill RUG in Z0100.

Monitor therapy minutes daily. Make-up minutes if needed. Rolling 7 day observation period; ARD to ARD. At the end of day 7; determine if minutes delivered over the past 7 days

matches Therapy RUG achieved on prior MDS; if minutes reflect that RUG would go up or down initiate a COT unless can mitigate using scheduled MDS ARD.

NOTE: If ARD of Scheduled MDS is on or before the 7th day of the COT count, no COT is required. Monitor therapy minutes daily. Make up minutes if needed.

Bill RUG Z0100 starting day one of the COT observation period. If Scheduled MDS ARD is on or before COT ARD, then no COT is


If 7th day of COT is day of discharge from SNF or Medicare, no COT is required. However, if the RUG would go up, combine COT with Discharge MDS.

Scheduled PPS MDS AI Digit

D







days




AI AI

1st Digit 2nd digit Start of Therapy (SOT) Other Medicare-required Assessment NS/SS A0310B=07 and A0310C=1 Can be combined with OBRA or Scheduled PPS MDS when ARD rules allow.

ARD must be day 5-7 counting first day of therapy as day one.

Therapy Start Date (O0400A, B, C 5) counts as day one.

NOTE: Two day flexibility period for selecting ARD. Regardless of the ARD choice, the rate changes the first day therapy was provided until end of billing cycle. Bill RUG in Z0100.

Voluntary assessment used to establish a Rehabilitation /Rehab Plus Extensive RUG.

Determine if Rehab RUG that will be achieved is a higher CMI/Rate than the current Medical RUG.

Choose day 5, 6, or 7, whichever achieves the highest minutes. The RUG rate changes effective first day with therapy until end of billing

cycle, bill Z0100 RUG. If ARD of SOT falls in the window of a Scheduled MDS and the Scheduled

MDS ARD has not been set, combine MDS. The COT count starts day one after ARD of this SOT.

0

2

Or Scheduled PPS MDS AI Digit

2

Start of Therapy (SOT) and Discharge Assessment NSD A0310B=07 and A0310C=1 and A0310F=10 or 11

ARD must be day of discharge (A2000) and 5-7 days after start of therapy (PT, OT, SLP).

Therapy Start Date (O0400 A, B, C 5) counts as day one.

Regardless of the ARD choice, the rate changes the first/earliest day any therapy was provided until discharge. Bill RUG in Z0100.

The RUG rate changes effective first day with therapy until end of stay, bill Z0100 RUG.

For a SOT/Discharge designation, the ARD must be date of discharge (A2000) and days 5-7 for a SOT MDS.

0

3

Both Start and End of Therapy NO/SO A0310B=07 and A0310C=3

The ARD must be day 5-7 for Start of Therapy and day 1-3 for End of Therapy.

NOTE: Two day flexibility period for selecting ARD. Bill Rehab RUG Z0100 from Start Date thru End Date, then bill Medical RUG Z0150 starting day after End Date through end of billing cycle.

Start date (O0400A, B, or C 5) and End date (O0400A, B, or C 6) are both noted on MDS.

ARD must meet both requirements for SOT and EOT. Rehab RUG rate billed range of days on therapy; then start billing Medical

RUG until end of billing cycle. The grouper will assign two RUGs, a therapy RUG in Z0100 and a Medical

RUG in Z0150 for billing purposes. If ARD of EOT falls in the window of a Scheduled MDS and the Scheduled

MDS ARD has not been set, combine MDS.

0 5







days




AI AI

1st Digit 2nd digit

Both Start and End of Therapy – Resumption A0310B=07 and A0310C=3

The ARD must be day 5-7 for Start of therapy and day 1-3 for End of Therapy.

NOTE: Two day flexibility period for selecting ARD.

Bill Rehab RUG Z0100 from Start Date thru End Date, then bill Medical RUG Z0150 starting day after End Date through day before resumption date. Then begin billing Rehab RUG rate from PPS MDS immediately prior to EOT.

All ARD rules must be met. May be combined with OBRA assessment. To complete one EOT MDS (versus an EOT then a SOT) therapy must

resume within 5 days; day one is first day without therapy and; Therapy must resume at same level for all disciplines as on MDS prior to EOT MDS.

If ARD of EOT falls in the window of a Scheduled MDS and the Scheduled MDS ARD has not been set, combine MDS.

No evaluation is required as the resident likely was not “discharged” from therapy but for whatever reason missed 3 or 4 days of therapy.

If resident was in fact “discharged off therapy” and therapy resumes, a new evaluation would be done and an SOT is a better choice of MDS.

Bill Z0150 Medical RUG starting the first day without therapy, then bill Rehab RUG from MDS prior to EOT starting on date of resumption.

The Resumption date is day one in starting the COT count. If the RUG is not achieved during the COT observation, a COT would be completed.

0 B

End of Therapy (EOT) NO/SO A0310B=07 and A0310C=2 Can combine with OBRA or Scheduled PPS MDS when ARD rules allow.

ARD day must be 1-3 days after all therapy (PT, OT, SLP) services are discontinued and resident continues to require skilled care.

Count End of Therapy date (O0400 A, B, C 6) as day “0” and first day without therapy as day one.

NOTE: Two day flexibility period for selecting ARD. Regardless of ARD choice, the RUG rate drops out of rehab to a Medical RUG starting the first day without any therapy until end of billing cycle. Bill RUG in Z0150.

If already billing a Medical RUG due to CMI or not enough minutes/days to qualify for a Rehab RUG, no EOT is required when therapy ends.

Complete only when there has been no therapy for three full consecutive days while resident is on Part A.

The ARD must be day 1, 2, or 3, counting first day without therapy as day 1.

Pick an ARD which achieves the highest Medical RUG. Start billing a non-therapy Z0150 RUG the first day without therapy until

end of billing cycle. May combine with scheduled PPS MDS when ARD rules allow. If End Date is prior to the 7th day of COT count, the COT count stops. If End Date equals the 7th day of COT count, the COT is required and

would be completed as well as EOT. If ARD of EOT falls in the window of a Scheduled MDS and the Scheduled

MDS ARD has not been set, combine MDS. If discharged from Part A prior to 3 full consecutive days without therapy,

no EOT is required. If the third day of EOT falls on day of discharge off Medicare or from SNF, no EOT is required.

0 4


4







days




AI AI

1st Digit 2nd digit

EOT- Resumption A0310B=07 and A0310C=2 or 3

EOT ARD rules apply. ARD day must be 1-3

days after all therapy (PT, OT, SLP) services are discontinued and resident continues to require skilled care.

Count End of Therapy date (O0400 A, B, C 6) as day “0” and first day without therapy as day one.

NOTE: Two day flexibility period for selecting ARD. Bill Medical RUG Z0150 starting day after End Date through day prior to Resumption Date. Then Bill prior MDS Rehab RUG Z0150 starting date of resumption.

If already billing a Medical RUG due to CMI or not enough minutes/days to qualify for a Rehab RUG, no EOT-R is required when therapy ends. Changes in therapy would be caught during 7 day COT observation period.

To complete one EOT MDS (versus an EOT then a SOT) therapy must resume within 5 days; day one is first day without therapy and; Therapy must resume at same level for each discipline as on MDS prior to EOT MDS.

No evaluation is required as the resident likely was not “discharged” from therapy but for whatever reason missed 3 or 4 days of therapy.

If resident was in fact “discharged off therapy” and therapy resumes, a new evaluation would be done and an SOT is a better choice of MDS.

Bill Z0150 Medical RUG starting the first day without therapy, then bill Rehab RUG from MDS prior to EOT starting on date of resumption.

The Resumption date is day one in starting the COT count. If the RUG is not achieved during the COT observation, a COT would be completed.

If ARD of EOT-R falls in the window of a Scheduled MDS and the Scheduled MDS has not been set, combine MDS.

0 A


A

Significant Change in Status Assessment for a resident on Part A (SCSA) NC A0310A=04 and A310B=07

If selected ARD is within the allowed ARD range of a scheduled PPS MDS, the two assessments must be combined.

ARD within 14 days from determination of significant change.

*Sets payment rate effective the ARD until end of billing cycle. If grace days are used, the payment changes “on cycle”.

May establish a new RUG classification effective the ARD of the SCSA. Select an earlier ARD if rate going up. Select a later ARD if rate is going down. A SCSA may be combined with a PPS MDS if ARD rules allow. The rate

changes effective the ARD of SCSA/Combo. Exception; if grace days are used, the rate changes “on cycle.”

See comments under 5 Day and 14 day MDS.

0 1


1

Significant Correction of Prior Comprehensive Assessment for a resident on Part A (SCPA) NC A0310A=05 and A310B=07

If selected ARD is within the allowed ARD range of a scheduled PPS MDS, the two assessments must be combined.

ARD within 14 days from determination of need for a significant correction.

*Sets payment rate effective the ARD until end of billing cycle.

May establish a new RUG classification effective the ARD of the SCSA. Select an earlier ARD if rate going up. Select a later ARD if rate is going down. A SCPA may be combined with a PPS MDS if ARD rules allow.

0 1


1





Medicare SHORT STAY RUG CATEGORY Designation: Purpose: The Special RUG-IV Short Stay therapy classification is designed to allow for some if not all of the days of a short stay to be paid at a Rehab RUG. This special category is for shorter stay residents who received therapy but did not achieve a Rehab RUG from the 5 day PPS MDS because the resident did not receive 5 days of therapy during their short stay or were only able to receive 1-4 days of therapy (Therapy Start Date through End of Therapy indicates 4 days or less). Step One: Resident is discharged off Medicare Part A (End of Medicare Stay A2400C) on or before day 8. The resident may or may not have been discharged from the SNF (A2000). End of Medicare Stay Date is either 1) “last covered day” noted on ABN/Termination/Generic Review notice or, 2) the Discharge Date (A2000) if discharged unexpectedly.

Step Two: 5 day PPS MDS will not or did not achieve a Rehab RUG because 5 days of therapy were not provided. STOP: If the 5 day PPS MDS achieves a rehab RUG; no special short stay classification is required, bill all covered days with the RUG achieved from the 5 day PPS MDS.

1. The earliest Therapy Start Date (O0400A, B, C 5) and latest Therapy End Date (O0400 A, B, C 6) did not indicate 5 days of therapy were provided; the date range indicates only 1-4 days were able to be provided; even with using allowable grace days.

2. Rehab must be provided 4 days or less including End of Medicare Stay Date (A2400C). The End of Medicare Stay Date minus the earliest Therapy Start Date is 3 days or less. The Start Date was Monday, and the Medicare End Date was Wed. The Start Date, Monday, plus 2 days meets requirement. The Start Date was Friday and the End of Medicare Date was Tuesday. The Start Date plus 4 days does not meet

requirement. In this scenario, the Start Date and End of Medicare Stay Date indicate 5 days of therapy were available even if the rehab RUG was not achieved.

Step Three: ARD Rules Rule One: The ARD (A2300) must be on or before the 8th day of the Part A stay. Rule Two: ARD (A2300) for a Start of Therapy MDS for a Short Stay must be End of Medicare Stay date (A2400C)

whether combined with 5 day PPS MDS or not. Rule Three: The ARD (A2300) may not be more than 3 days after the first Start of Therapy Date. The ARD would be days

1-4 from Start of Therapy Date indicating only able to have 1-4 days of therapy. Additional ARD Rule: If the PPS MDS is also a Discharge Assessment, the ARD for a Discharge Assessment must be

Discharge Date (A2000) which would match End of Medicare Stay Date for an unexpected discharge to the hospital.

Step Four: 5 day PPS MDS does not achieve Rehab RUG and therapy has been provided during this short stay. Decide which type of SOT combination of MDS will be completed for this short stay resident.





Step 4 continued: Remember: For the Short Stay classification the MDS must be a Start of Therapy (SOT) MDS.

Option One: Combine 5 day PPS MDS with Start of Therapy MDS. 5 day PPS MDS has not been completed yet; combine two MDS designations. A0310B= 01 AND A0310C=1 or 3. Use NP item set. Option Two: Complete Start of Therapy (SOT) MDS alone. 5 day PPS MDS has already been completed and submitted to CMS. If 5 day PPS MDS has been completed; then a SOT MDS is required in addition to the 5 day PPS MDS. A0310B=07 and A0310C=01. Use NS/SS type MDS. Option Three: If resident is both discharged off Medicare and discharged from SNF; this MDS can also be a Discharge Assessment. The ARD requirements for a both Short Stay designation and a Discharge Assessment must be End of Medicare Stay

(A2400C) and Discharge Date (A2000). Use NP if all combined. A0310F=10 or 11 combined with A0310B=01 and A0310C=1 or 3.

o Exception is Death. Death Tracking cannot be combined with any other OBRA or PPS MDS. Step 5: Rehab requirements:

At least one therapy continued through the End of Medicare Stay Date (A2400C) indicated by using “dashes” OR, Therapy End Date (O0400 A, B, or C 6) is the same date as End of Medicare Stay Date (A2400C).

Therapy is considered to be ongoing when: o The resident was discharged and therapy was planned to continue had the resident remained in the facility, or o The resident’s SNF benefit exhausted and therapy continued to be provided, or o The resident’s payer source changed and therapy continued to be provided.

Therapy must also be provided during the last four days of the stay including weekends. Therapy Start Date (O0400 A, B, C 5) is the first day of therapy. This date may or may not match the Medicare Start Date.

o Scenario One: If Medicare Start Date and Therapy Start Date are the same date, the Rehab RUG achieved from Short Stay designation can be billed starting on day one of Part A admission. When the Start of Therapy Date equals Medicare Start Date then the Part A stay must be 4 days or less.

o Scenario Two: If this Therapy Start Date is later than 1st Part A day; then a Medical RUG will be paid from day of admit up to Start Date of Therapy. As with all SOT type of MDS, the billing is “off-cycle.”

Step 6: The RUG group assigned to the Start of Therapy OMRA must be Rehabilitation Plus Extensive Services or a Rehabilitation group (Z0100A).





Codes for Assessments Required for Medicare

Assessment Reference Date

(ARD) Can be set on any of the

following days

Grace Days

ARD can also be set on these days

Billing Cycle Used

by the Business

Office

Grouper determines if Short Stay Criteria are met.

Special Comments

AI

1st Digit

AI

2nd digit

Start of Therapy for short stay combined with 5 day MDS that is also Discharge Assessment NP A0310B=01 and A0310C=1 and A0310F=10 or 11

ARD must be day of Discharge Date (A2000) and End of Medicare Stay Date (A2400C) and allowed for 5 day PPS MDS.

ARD rules including grace days for routine PPS MDS

Rehab RUG is billed from 1st day with therapy until end of stay.

The grouper will assign two RUGs, a therapy RUG and a medical RUG for billing purposes: Z0100 therapy RUG and Z0150 is non-therapy RUG.

If therapy starts on 1st day, Rehab RUG will be paid for entire short stay.

If therapy Start Date (O0400 A, B, or C 5) is later than 1st day; the Medical RUG to be billed for any days before first day of therapy.

Therapy must be still ordered. Either a “dash” for End of Therapy Date (O0400 A, B, C 6) or match date for End of Medicare Stay (A2400C) and Discharge Date (A2000).

1 7

Start of Therapy For a Short Stay MDS combined with 5 day Medicare MDS NP A0310B=1 and A0310C=1 or 3

ARD must be End of Medicare Stay Date (A2400C) and allowed for the 5 day PPS MDS.

ARD rules including grace days for routine PPS MDS

Rehab RUG is billed from 1st day with therapy until end of stay.

Combine with 5 day PPS MDS. The grouper will assign two RUGs, a therapy RUG and a medical

RUG for billing purposes: Z0100 therapy RUG and Z0150 is non-therapy RUG.

If therapy starts on 1st day; Rehab RUG will be paid for entire short stay.

If therapy Start Date (O0400 A, B, or C 5) is later than 1st day; the medical RUG will be billed for any days before first day of therapy.

Therapy must be still ordered. Either a “dash” for End of Therapy Date (O0400 A, B, C 6) or match date for End of Medicare Stay (A2400C) and Discharge Date (A2000).

1 7

Start of Therapy that is completed after the 5 day PPS MDS for Short stay. NS/SS A0310B=07 and A0310C=1

ARD must be End Date of Medicare Stay Date (A2400C)

Rehab RUG paid from Start Date of therapy.

Only complete if Rehab RUG was not achieved with 5 day PPS MDS and the 5 day PPS MDS was already submitted to CMS.

Non-therapy RUGs will be billed until Start Date of therapy. It is likely therapy started later in the stay. May also be combined with a Discharge Assessment.

0 7


Scheduled MDSs Free Standing – Unscheduled OMRAs MDS Type Available ARD MDS Type Available ARD

5-day Day 1-8 COT OMRA Day 7 14-day Day 13-18 SOT OMRA 5-7 days after earliest Start

Date 30-day Day 27-33 EOT OMRA & EOT-R 1-3 days after latest End Date 60-day Day 57-63 SOT & EOT 5-7 days after Start Date and 1-

3 days after latest End Date 90-day Day 87-93 Significant Change Status

Assessment No more than 14 days after

significant change is identified No flexibility in setting the ARD, it must be established before the last available day. Unscheduled OMRAs may shorten the time available for the Scheduled MDSs, since a Scheduled MDS cannot be after an OMRA MDS in the ARD window. Do not submit a Scheduled PPD MDS until it is confirmed the MDS is needed for the related payment cycle.

OMRAs have two day “flexibility period” for selecting the ARD. However, the “flexibility period” only applies while the resident is on Medicare or when there is an unplanned discharge. The flexibility period ends for planned discharges. The flexibility period does not provide more available ARDs, it merely provides more days in which to select the allowable ARD.

COMBINATION ASSESSMENTS: Combine MDS if the ARD of the OMRA falls within the window of Scheduled PPS MDS, unless Scheduled PPS MDS ARD is already set. In that case, then the OMRA ARD

can be a later date within the window. Scheduled PPS MDS and OMRA: When the ARD of an OMRA falls within the window of a Scheduled PPS MDS, the MDS should be combined. The ARD of the Scheduled PPS MDS should not be later than the ARD of the OMRA in same window, since it won’t be used for billing. If the Scheduled PPS MDS ARD is already set, the OMRA ARD can be later than the scheduled PPS MDS and the OMRA would take over billing. COT: COT rolling 7-day observation period: new RUG from COT starts day one of the observation period. Scheduled PPS MDS sets and reset rolling COT 7-day observation period. If resident is on any therapy even if on a Medical RUG due to CMI or not qualifying for Rehab RUG, monitor for change back into a Therapy RUG every 7 days. If the Scheduled PPS ARD is on or before Day 7 of COT, then no COT is required but is optional, assuming the Scheduled PPS MDS is used for payment. Exception: Complete combination if RUG would go up. If the 7th day falls on last paid day, then COT must be completed if required. If the 7th day falls on day of discharge off Medicare, then no COT is required, but optional if RUG would go up (May combine with Discharge Assessment). EOT: Medical RUG starts first day after latest End Date of Therapy. Must have three consecutive days without therapy (or less than 15 minutes per day) and billing a Rehab RUG. If the third day is day of discharge off Part A, then no EOT is required. ***No EOT is required when therapy ends if already billing a Medical RUG. If the EOT ARD is on or before the 7th day of a COT, no COT is required, just complete EOT. If the EOT ARD is after 7th day, then both COT and EOT would be required assuming the COT was also required. EOT-R: Resumption Date is day one of COT observation period. SOT: SOT optional. First day after ARD of SOT starts COT observation period.


Patient Pay Type Type of MDSs Complete

MDS Transmitted to

QIES

Cert/ Recerts

Non-Coverage

L tt

Daily Skilled

D t ti Medicare PPS & OBRA Al

Yes Yes Yes

Insurance Paid by Levels

OBRA Only OBRA Only Plan Specific Plan Specific Yes

MCO Paid by Levels (MCO specific)

OBRA/Admission RUG on Claim

OBRA Only Plan Specific Yes Yes

Insurance Paid by RUGs PPS & OBRA OBRA Only Plan Specific Plan Specific Yes MCO Paid by RUGs PPS & OBRA OBRA Only Yes Yes Yes Medicare Secondary

PPS & OBRA Al

Yes Yes Yes

Admitted Payor Type Changes Payor Type To How to Handle the MDS Process

MCO

Medicare

MDS Coordinator should complete all required PPS MDS (including OMRAs) with day 1 of the assessment cycle as the first day the resident resumes enrollment under Traditional Medicare. This date is usually the first day of the next month after disenrollment from the Managed Care Plan.

MCO - Scheduled Medicare MDS were completed but not submitted to QIES

Find out after discharge resident was Traditional Medicare

Billing is allowed under the Exception rules: “The SNF is notified on an untimely basis or is unaware of a beneficiary’s disenrollment from a Medicare Advantage plan.”

May use MDS completed for MCO for billing Medicare. Change A0410 as “1” Neither federal nor state required submission to “3” Federal required submission; then submit to QIES System.

MCO – Only OBRA Initial MDS completed

Billing can use OBRA Initial Assessment RUG for billing first 30

days.

MDS M-FIM (Modified Functional Independence Measure) 0 – Independent

7.0 = CI – Complete Independence: No assistance, no equipment 6.0 = MI – Independence: No assistance, but equipment, or extra time

1 – Supervision 5.0 = SBA – Stand By Assistance: No physical assistance other than set up - supervision for

safety/technique and or/ single cue to initiate

2 – Limited Assist 4.5 = CG – Contact Guard Assist (Guided Maneuvering) 3 – Extensive Assist

4.0 = Min: Occasional assistance (25% or less of the time or effort involved to complete task) 3.5 = Min Mod: Periodic assistance (25-40% of the time or effort involved to complete task) 3.0 = Mod: Frequent assistance (40 - 50% of the time or effort involved to complete task) 2.5 = Mod Max: Constant assistance (50 - 75% of the time or effort involved to complete task) 2.0 = Max: Constant assistance (75-90% of the time or effort involved to complete task) 1.7 = NTD – Near Total Dependence: Total assistance with only partial task completion

4 – Total Dependence 1.0 = CD – Complete Dependence: No contribution from patient; task done by others


100 DAY CALCULATION

Leap Year not included When calculating, be sure to count days in other facility. DO NOT COUNT HOSPITAL DAYS!

Admission Date

100th Day Admission

Date 100th Day Admission

Date 100th Day

Admission Date 100th Day Admission

Date 100th Day

1/01 4/10 2/12 5/22 3/26 7/03 5/07 8/14 6/18 9/25 1/02 4/11 2/13 5/23 3/27 7/04 5/08 8/15 6/19 9/26 1/03 4/12 2/14 5/24 3/28 7/05 5/09 8/16 6/20 9/27 1/04 4/13 2/15 5/25 3/29 7/06 5/10 8/17 6/21 9/28 1/05 4/14 2/16 5/26 3/30 7/07 5/11 8/18 6/22 9/29 1/06 4/15 2/17 5/27 3/31 7/08 5/12 8/19 6/23 9/30 1/07 4/16 2/18 5/28 4/01 7/09 5/13 8/20 6/24 10/01 1/08 4/17 2/19 5/29 4/02 7/10 5/14 8/21 6/25 10/02 1/09 4/18 2/20 5/30 4/03 7/11 5/15 8/22 6/26 10/03 1/10 4/19 2/21 5/31 4/04 7/12 5/16 8/23 6/27 10/04 1/11 4/20 2/22 6/01 4/05 7/13 5/17 8/24 6/28 10/05 1/12 4/21 2/23 6/02 4/06 7/14 5/18 8/25 6/29 10/06 1/13 4/22 2/24 6/03 4/07 7/15 5/19 8/26 6/30 10/07 1/14 4/23 2/25 6/04 4/08 7/16 5/20 8/27 7/01 10/08 1/15 4/24 2/26 6/05 4/09 7/17 5/21 8/28 7/02 10/09 1/16 4/25 2/27 6/06 4/10 7/18 5/22 8/29 7/03 10/10 1/17 4/26 2/28 6/07 4/11 7/19 5/23 8/30 7/04 10/11 1/18 4/27 3/01 6/08 4/12 7/20 5/24 8/31 7/05 10/12 1/19 4/28 3/02 6/09 4/13 7/21 5/25 9/01 7/06 10/13 1/20 4/29 3/03 6/10 4/14 7/22 5/26 9/02 7/07 10/14 1/21 4/30 3/04 6/11 4/15 7/23 5/27 9/03 7/08 10/15 1/22 5/01 3/05 6/12 4/16 7/24 5/28 9/04 7/09 10/16 1/23 5/02 3/06 6/13 4/17 7/25 5/29 9/05 7/10 10/17 1/24 5/03 3/07 6/14 4/18 7/26 5/30 9/06 7/11 10/18 1/25 5/04 3/08 6/15 4/19 7/27 5/31 9/07 7/12 10/19 1/26 5/05 3/09 6/16 4/20 7/28 6/01 9/08 7/13 10/20 1/27 5/06 3/10 6/17 4/21 7/29 6/02 9/09 7/14 10/21 1/28 5/07 3/11 6/18 4/22 7/30 6/03 9/10 7/15 10/22 1/29 5/08 3/12 6/19 4/23 7/31 6/04 9/11 7/16 10/23 1/30 5/09 3/13 6/20 4/24 8/01 6/05 9/12 7/17 10/24 1/31 5/10 3/14 6/21 4/25 8/02 6/06 9/13 7/18 10/25 2/01 5/11 3/15 6/22 4/26 8/03 6/07 9/14 7/19 10/26 2/02 5/12 3/16 6/23 4/27 8/04 6/08 9/15 7/20 10/27 2/03 5/13 3/17 6/24 4/28 8/05 6/09 9/16 7/21 10/28 2/04 5/14 3/18 6/25 4/29 8/06 6/10 9/17 7/22 10/29 2/05 5/15 3/19 6/26 4/30 8/07 6/11 9/18 7/23 10/30 2/06 5/16 3/20 6/27 5/01 8/08 6/12 9/19 7/24 10/31 2/07 5/17 3/21 6/28 5/02 8/09 6/13 9/20 7/25 11/01 2/08 5/18 3/22 6/29 5/03 8/10 6/14 9/21 7/26 11/02 2/09 5/19 3/23 6/30 5/04 8/11 6/15 9/22 7/27 11/03


100 DAY CALCULATION

Leap Year not included When calculating, be sure to count days in other facility. DO NOT COUNT HOSPITAL DAYS!

Admission Date

100th Day Admission

Date 100th Day Admission

Date 100th Day

Admission Date 100th Day Admission

Date 100th Day

2/10 5/20 3/24 7/01 5/05 8/12 6/16 9/23 7/28 11/04 2/11 5/21 3/25 7/02 5/06 8/13 6/17 9/24 7/29 11/05 7/30 11/06 8/30 12/07 9/30 1/07 10/31 2/07 12/01 3/10 7/31 11/07 8/31 12/08 10/01 1/08 11/01 2/08 12/02 3/11 8/01 11/08 9/01 12/09 10/02 1/09 11/02 2/09 12/03 3/12 8/02 11/09 9/02 12/10 10/03 1/10 11/03 2/10 12/04 3/13 8/03 11/10 9/03 12/11 10/04 1/11 11/04 2/11 12/05 3/14 8/04 11/11 9/04 12/12 10/05 1/12 11/05 2/12 12/06 3/15 8/05 11/12 9/05 12/13 10/06 1/13 11/06 2/13 12/07 3/16 8/06 11/13 9/06 12/14 10/07 1/14 11/07 2/14 12/08 3/17 8/07 11/14 9/07 12/15 10/08 1/15 11/08 2/15 12/09 3/18 8/08 11/15 9/08 12/16 10/09 1/16 11/09 2/16 12/10 3/19 8/09 11/16 9/09 12/17 10/10 1/17 11/10 2/17 12/11 3/20 8/10 11/17 9/10 12/18 10/11 1/18 11/11 2/18 12/12 3/21 8/11 11/18 9/11 12/19 10/12 1/19 11/12 2/19 12/13 3/22 8/12 11/19 9/12 12/20 10/13 1/20 11/13 2/20 12/14 3/23 8/13 11/20 9/13 12/21 10/14 1/21 11/14 2/21 12/15 3/24 8/14 11/21 9/14 12/22 10/15 1/22 11/15 2/22 12/16 3/25 8/15 11/22 9/15 12/23 10/16 1/23 11/16 2/23 12/17 3/26 8/16 11/23 9/16 12/24 10/17 1/24 11/17 2/24 12/18 3/27 8/17 11/24 9/17 12/25 10/18 1/25 11/18 2/25 12/19 3/28 8/18 11/25 9/18 12/26 10/19 1/26 11/19 2/26 12/20 3/29 8/19 11/26 9/19 12/27 10/20 1/27 11/20 2/27 12/21 3/30 8/20 11/27 9/20 12/28 10/21 1/28 11/21 2/28 12/22 3/31 8/21 11/28 9/21 12/29 10/22 1/29 11/22 3/01 12/23 4/01 8/22 11/29 9/22 12/30 10/23 1/30 11/23 3/02 12/24 4/02 8/23 11/30 9/23 12/31 10/24 1/31 11/24 3/03 12/25 4/03 8/24 12/01 9/24 1/01 10/25 2/01 11/25 3/04 12/26 4/04 8/25 12/02 9/25 1/02 10/26 2/02 11/26 3/05 12/27 4/05 8/26 12/03 9/26 1/03 10/27 2/03 11/27 3/06 12/28 4/06 8/27 12/04 9/27 1/04 10/28 2/04 11/28 3/07 12/29 4/07 8/28 12/05 9/28 1/05 10/29 2/05 11/29 3/08 12/30 4/08 8/29 12/06 9/29 1/06 10/30 2/06 11/30 3/09 12/31 4/09


Polaris Group Page 1 of 2

MDS ARD MANAGEMENT WORKSHEET Name:________________________________

Scheduled ARD

WINDOW

Case Day

Calendar Day

COT 7 day Obs Count

EOT Start date

ARD

EOT-R Date if applies

SOT Start date

ARD

Billing Cycle OMRA changes

Scheduled ARD

WINDOW

Case Day

Calendar Day

COT 7 day Obs Count

EOT Start date

ARD

EOT-R Date if applies

SOT Start date

ARD

Billing Payment Cycle Off-Cycle changes

1 1st Payment Cycle 39 2 40

3 41

4 42

5 43

6 44

7 45

8 46

9 47

10 48 11 49

12 50

13 51

14 52

15 2nd Payment Cycle 53

16 54

17 55

18 56

19 57

20 58

21 59 22 60

23 61 4th payment Cycle Starts

24 62

25 63

26 64

27 65

28 66

29 67

30 68 31 3rd Payment Cycled 69

32 70

33 71

34 72

35 73

36 74

37 75

38 76


Polaris Group Page 2 of 2

MDS ARD MANAGEMENT WORKSHEET Name:________________________________

• Medicare only MDS’s are due to be completed 14 days from the ARD date for PPS. The above is a recommended schedule. • SOT MDS must have ARD 5-7 days counting first day with therapy as day one. • EOT MDS must have ARD day 1-3 counting first day without therapy as day one. • COT is a rolling 7 days from ARD to ARD. • Discharge date must be ARD if combining with Discharge Assessment

Medicare MDS Assessment Type

Reason for Assessment (A0310B code)

Assessment Reference Date Window

Assessment Reference Date Grace Days

Applicable Medicare Payment Days

5 day* 01 Days 1-5 6-8 1 through 14 14 day 02 Days 13-14 15-18 15 through 30 30 day 03 Days 27-29 30-33 31 through 60 60 day 04 Days 57-59 60-63 61 through 90 90 day 05 Days 87-89 90-93 91 through 100 *Changes would also apply to Readmission/Return Assessment (A0310B code = 06)

Scheduled ARD WINDOW

Case Day

Calendar Day

COT 7 day Obs Count

EOT Start date

ARD EOT-R Date if applies

SOT Start date

ARD

Billing Cycle OMRA changes

77 78

79

80

81

82

83

84

85

86 87

88

89

90

91 5nd Payment Cycle Starts

92

93

94

95

96

97 98

99

100


ARD Selection Schedule

1 2 3 4 5 6 7

8 9 10 11 12 13 14

15 16 17 18 19 20 21

22 23 24 25 26 27 28

29 30 31 32 33 34 35

36 37 38 39 40 41 42

43 44 45 46 47 48 49

50 51 52 53 54 55 56

57 58 59 60 61 62 63

64 65 66 67 68 69 70

71 72 73 74 75 76 77

78 79 80 81 82 83 84

85 86 87 88 89 90 91

92 93 94 95 96 97 98

99 100 Remember to review the rules list on the back of this card for combining scheduled and unscheduled assessments.


Medicare MDS

Scheduled Assessment Type

Reason for Assessment

(A0310B code)



Grace Days+

Applicable Standard Medicare Payment

Days^

5-day Readmission/Return

01 06

Days 1-5 6-8 1 through 14

14-day 02 Days 13-14 15-18 15 through 30 30-day 03 Days 27-29 30-33 31 through 60 60-day 04 Days 57-59 60-63 61 through 90 90-day 05 Days 87-89 90-93 91 through 100

+Grace Days: a specific number of days that can be added to the ARD window without penalty. ^Applicable Standard Medicare Payment Days may vary when assessment types are combined. For example, when a provider combines an unscheduled assessment, such as a Significant Change in Status Assessment (SCSA), with a scheduled assessment, such as a 30-day Medicare-required assessment, the new resource utilization group (RUG) would take effect on the ARD of the assessment. If the ARD of this assessment was day 28, the new RUG would take effect on day 28 of the stay. The exception would be if the ARD fell within the grace days. In that case, the new RUG would be effective on the first day of the regular payment period. For example, if the ARD of an unscheduled assessment combined with the 60-day assessment, was day 62, the new RUG would take effect on day 61.

PPS Scheduled Assessment and Start of Therapy OMRA

ARD (Item A2300) must be set within the ARD window for the Medicare-required scheduled assessment and 5-7 days after the start of therapy (Item O0400A5 or O0400B5 or O0400C5, whichever is the earliest date). If both ARD requirements are not met, the assessments may not be combined.

If the ARD for the SOT OMRA falls within the ARD (including grace days) of a PPS scheduled assessment that has not been performed yet, the assessments MUST be combined.

Code the Item A0310 of the MDS 3.0 as follows: A0310A = 99 A0310B = 01, 02, 03, 04, 05, or 06 as appropriate A0310C = 1

PPS Scheduled Assessment and End of Therapy OMRA

ARD (Item A2300) must be set within the window for the Medicare scheduled assessment and 1-3 days after the last day therapy was furnished (Item O0400A6 or O0400B6 or O0400C6, whichever is the latest date). If both ARD requirements are not met, the assessments may not be combined.

If the ARD for the EOT OMRA falls within the ARD (including grace days) of a PPS scheduled assessment that has not been performed yet, the assessments MUST be combined.


PPS Scheduled Assessment and Start and End of Therapy OMRA

ARD (Item A2300) must be set within the window for the Medicare-required scheduled assessment and 5-7 days after the start of therapy (Item O0400A5 or O0400B5 or O0400C5, whichever is earliest) and 1-3 days after the last day therapy was furnished (Item O0400A6 or O0400B6 or O0400C6, whichever is latest). If all three ARD requirements are not met, the assessments may not be combined.

If the ARD for the EOT and SOT OMRA falls within the ARD (including grace days) of a PPS scheduled assessment that has not been performed yet, the assessments MUST be combined.


PPS Scheduled Assessment and Change of Therapy OMRA

If Day 7 of the COT observation period falls within the ARD window (including grace days) of a scheduled PPS Assessment, and the scheduled PPS assessment has not been performed yet, and a COT OMRA is deemed necessary upon completion of the change of therapy evaluation, then the SNF must combine the COT OMRA and the scheduled assessment.

Since the scheduled assessment is combined with the COT OMRA, the combined assessment will set payment at the new RUG-IV level beginning on Day 1 of the COT observation period and that payment will continue through the remainder of the current standard payment period and the next payment period appropriate to the given scheduled assessment, assuming no intervening assessments.


Assessment Indicator Table Combinations

Assessment Indicators Type of Assessment ARD

Days Grace Days

Payment Days Start End

Standard PPS Assessment (not combined with any other PPS assessment) 10 PPS 5 day 1-5 6-8 1 14 20 PPS 14 day 13-14 15-18 15 30 30 PPS 30 day 27-29 30-33 31 60 40 PPS 60 day 57-59 60-63 61 90 50 PPS 90 day 87-89 90-93 91 100 60 SCSA or SCPA and not a PPS Assessment Not a PPS Assessment

SCSA or SCPA Assessment SCSA: The ARD must be no later than 14 days after a significant change is identified. SCPA: Required when an uncorrected major error is discovered in a prior comprehensive assessment.

01 SCSA or SCPA (stand alone) (A0310A=04, A0310B=07, and A0310C=0) N/A

Payment changes on ARD unless ARD is a grace day, then standard payment period applies.

End of standard

payment period 11 SCSA or SCPA replacing 5 day PPS 1-5 6-8 14 21 SCSA or SCPA replacing 14 day PPS 13-14 15-18 30 31 SCSA or SCPA replacing 30 day PPS 27-29 30-33 60 41 SCSA or SCPA replacing 60 day PPS 57-59 60-63 90 51 SCSA or SCPA replacing 90 day PPS 87-89 90-93 100

SOT OMRA (Z0100A must be a therapy RUG or MDS is invalid) SOT OMRA is an optional assessment. If done, the ARD must be on day 5, 6, or 7 after the start of therapy.

02 SOT OMRA (stand alone) N/A

The first day of therapy

End of standard

payment period 12 SOT OMRA & 5 day PPS 1-5 6-8 14 22 SOT OMRA & 14 day PPS 13-14 15-18 30 32 SOT OMRA & 30 day PPS 27-29 30-33 60 42 SOT OMRA & 60 day PPS 57-59 60-63 90 52 SOT OMRA & 90 day PPS 87-89 90-93 100

SOT OMRA and SCSA or SCPA (Z0100A must be a therapy RUG or MDS is invalid) SCSA: The ARD must be no later than 14 days after a significant change is identified. SCPA: Required when an uncorrected major error is discovered in a prior comprehensive assessment. SOT OMRA is an optional assessment. If done, the ARD must be on day 5, 6, or 7 after the start of therapy and result in a Rehab RUG.

03 SOT OMRA combined with a SCSA/SCPA N/A

The first day of therapy

End of standard

payment period 13 SOT OMRA, SCSA/SCPA & 5-day PPS 1-5 6-8 14 23 SOT OMRA, SCSA/SCPA & 14-day PPS 13-14 15-18 30 33 SOT OMRA, SCSA/SCPA & 30-day PPS 27-29 30-33 60 43 SOT OMRA, SCSA/SCPA & 60-day PPS 57-59 60-63 90 53 SOT OMRA, SCSA/SCPA & 90-day PPS 87-89 90-93 100

EOT OMRA (with or without an SCSA/SCPA) EOT OMRA is required when all therapies are discontinued and a skilled level of care remains. The EOT OMRA ARD must be set on day 1, 2, or 3 after all rehabilitation therapies have been discontinued.

04 EOT OMRA N/A Use Z0150A (non-therapy RUG) from the day after the last day of therapy thru the end of the standard payment period (day 14, 30, 60, 90 or 100)

14 EOT OMRA & 5-day MDS 1-5 6-8 24 EOT OMRA & 14-day MDS 13-14 15-18 34 EOT OMRA & 30-day MDS 27-29 30-33 44 EOT OMRA & 60-day MDS 57-59 60-63 54 EOT OMRA & 90-day MDS 87-89 90-93




Days Grace Days


SOT OMRA (with or without an SCSA/SCPA) SOT OMRA is an optional assessment. If done, the ARD must be on day 5, 6, or 7 after the start of therapy. EOT OMRA is required when all therapies are discontinued and a skilled level of care remains. The EOT OMRA ARD must be set on day 1, 2, or 3 after all rehabilitation therapies have been discontinued.

05 SOT OMRA with EOT OMRA (stand alone) N/A Z0100A pays from first day of therapy thru last day of therapy and then Z0150A pays thru the end of the standard payment period (day 14, 30, 60, 90 or 100)

15 SOT OMRA, EOT OMRA & 5-day MDS 1-5 6-8 25 SOT OMRA, EOT OMRA & 14-day MDS 13-14 15-18 35 SOT OMRA, EOT OMRA & 30-day MDS 27-29 30-33 45 SOT OMRA, EOT OMRA & 60-day MDS 57-59 60-63 55 SOT OMRA, EOT OMRA & 90-day MDS 87-89 90-93

SOT OMRA, EOT OMRA & SCSA/SCPA (Z0100A must be a therapy RUG or MDS is invalid) SOT OMRA is an optional assessment. If done, the ARD must be on day 5, 6, or 7 after the start of therapy. EOT OMRA is required when all therapies are discontinued and a skilled level of care remains. The EOT OMRA ARD must be set on day 1, 2, or 3 after all rehabilitation therapies have been discontinued. SCSA: The ARD must be no later than 14 days after a significant change is identified. SCPA: Required when an uncorrected major error is discovered in a prior comprehensive assessment.

06 SOT OMRA, EOT OMRA & SCSA/SCPA N/A

Z0100A pays from first day of therapy thru last day of therapy and then Z0150A pays thru the end of the standard payment period (day 14, 30, 60, 90 or 100)

16 SOT OMRA, EOT OMRA, SCSA/SCPA & 5-day MDS 1-5 6-8





Short Stay MDS 07 Short Stay (Stand Alone) Day of

Discharge See Chapter 6 of the MDS User’s

Guide 17 Short Stay Combined with 5-day PPS End of Therapy with Resumption of Therapy (EOT-R)

0A EOT OMRA with Resumption (EOT-R) N/A Use Z0150A (non-therapy RUG) from the day after the last day of therapy thru the date therapy resumed in O0450B. Then use the Rehab RUG level from the immediately preceding MDS for resumption days through the end of the current payment period.

1A EOT-R OMRA & 5-day MDS 1-5 6-8 2A EOT-R OMRA & 14-day MDS 13-14 15-18 3A EOT-R OMRA & 30-day MDS 27-29 30-33 4A EOT-R OMRA & 60-day MDS 57-59 60-63 5A EOT-R OMRA & 90-day MDS 87-89 90-93

Same AI as above

For the resumption days use same AI as used for days billed at the non therapy RUG.

SOT OMRA Combined with EOT OMRA with Resumption (Z0100A must be a therapy RUG or MDS is invalid) 0B SOT OMRA with EOT-R N/A Use Z0150A (non-therapy RUG)

from the day after the last day of therapy thru the date therapy resumed in O0450B. Then use the Rehab RUG level from the immediately preceding MDS for resumption days through the end of the current payment period.

1B SOT OMRA with EOT-R & 5-day MDS 1-5 6-8 2B SOT OMRA with EOT-R & 14-day MDS 13-14 15-18 3B SOT OMRA with EOT-R & 30-day MDS 27-29 30-33 4B SOT OMRA with EOT-R & 60-day MDS 57-59 60-63 5B SOT OMRA with EOT-R & 90-day MDS 87-89 90-93

Same AI as above

For the resumption days use same AI as used for days billed at the non therapy RUG.




Days Grace Days


SOT OMRA Combined with EOT OMRA with Resumption with an Unscheduled OBRA Assessment (Z0100A must be a therapy RUG or MDS is invalid.) Applies only when combined SOT with EOT-R with SCSA or SCPA

0C

Use the Unscheduled MDS RUG (Z0100A) from the earliest SOT through the latest rehab end date. Use the Unscheduled Non-Therapy (Z0150A) from that date after the last rehab end date through the day before the O0450B (Resumption Date). Use the unscheduled MDS RUG (Z0100A) from the resumption therapy date to end of current payment Period.

Change of Therapy (COT) (COT cannot be combined with a 5-day MDS) COT OMRA cannot be combined with a 5-day PPS MDS

0D Change of Therapy OMRA N/A Use Z0100A from the day after the ARD of the prior PPS MDS (Scheduled or Unscheduled) through the end of the current pay period.

2D COT OMRA Combined with 14-day MDS 13-14 15-18 3D COT OMRA Combined with 30-day MDS 27-29 30-33 4D COT OMRA Combine with 60-day MDS 57-59 60-63 5D COT OMRA Combined with 90-day MDS 87-89 90-93

Default Rate (AAAxx) for MDSs that fail to comply with the MDS schedule.

Early MDSs: If an MDS is performed earlier than the schedule indicates, the provider will be paid at the default rate for the number of days the MDS was out of compliance (e.g. 14 day MDS with ARD done on day 10, 1 day early, would be paid at default for the first day of the payment period that begins on day 15). Use the AI associated with the early MDS with RUG AAA for days paid at default. (e.g. AAA20 for early 14 day PPS)

Late MDSs: If an MDS is performed after the grace period, payment will be made at the default rate from the first day of the coverage period to the ARD of the late MDS (e.g. 14 day MDS with ARD done on day 22, days 15-21 paid at default). Use the AI associated with the late MDS with RUG AAA for days paid at default. (e.g. AAA30 for a late 30 day PPS) If the ARD of the late MDS is set after the end of the payment period for the Medicare-required MDS that was missed and the resident is still on Part A, the provider must still complete an MDS. The SNF must bill all covered days at default.

Missed MDSs: No MDS in QIES ASAP. Can bill AAA00 only when exception requirements listed in Chapter 6 of the RAI 3.0 are met.


Scenario #1

Resident admitted on 10/01/XX and achieved a RUB RUG on 5-day of Day 8, and 14-day

MDS used Day 15, no COT required. Next COT check is day? On that day, a COT is

required, select COT ARD day. Indicate day RHB RUG starts from COT. Then on Day 27 the

last therapy was provided, and resident continues on Part A for a nursing skilled service.

Select ARD for EOT. Indicate day Medical RUG starts from EOT. Select ARD for 30-day MDS.

Resident is discharged off Part A on day 31.

COVERAGE

SCHEDULE

ARD COT

ARD

EOT

ARD

EOT-R SOT ARD COMMENTS

CASE DAY:

Reference 1 Admission Day 10/01/XX

Reference 2

Reference 3

Reference 4

Reference 5

(Grace) 6

(Grace) 7

(Grace) 8 ARD

10/08/XX

9 1

10 2

11 3 12 4

Reference 13 5

Reference 14 6 (Grace) 15 ARD 10/15/XX 7 (Grace) 16 1 (Grace) 17 2 (Grace) 18 3

19 4 20 5 21 6 22 7 23 1 24 2 25 3

26 4 Reference 27 5 Therapy ends Reference 28

Reference 29

Grace 30

Grace 31

Grace 32

Grace 33

34


Scenario #1 Answer

Resident admitted on 10/01/XX and achieved a RUB RUG on 5-day of day 8, and 14-day

MDS used day 15, no COT required. Next COT check is day? On that day, a COT is

required, select COT ARD day. Indicate day RHB rates starts from COT. Then on Day 27 the

last therapy was provided, and resident continues on Part A for a nursing skilled service.

Select ARD for EOT. Indicate day the Medical RUG starts. Select ARD for 30-day MDS.

Resident is discharged off Part A on day 31.

COVERAGE

SCHEDULE

ARD COT

ARD

EOT

ARD

EOT-R SOT ARD COMMENTS

CASE DAY:

Reference 1 Admission Day 10/01/XX

Reference 2

Reference 3

Reference 4

Reference 5

(Grace) 6

(Grace) 7

(Grace) 8 ARD

10/08/XX

RUB 9 1

10 2

11 3 12 4

Reference 13 5

Reference 14 6 (Grace) 15 ARD 10/15/XX 7 (Grace) 16 1 NEW RHB

RUG

STARTS

(Grace) 17 2 (Grace) 18 3

19 4 20 5 21 6 22 COT

Required

7

23 1

24 2 25 3

26 EOT must be

on or before 7th

day of COT

4

Reference 27 5 End

date

Reference 28 6 1 First day bill medical RUG

Reference 29 ARD 10/29/XX 7 2 Grace 30 3

Grace 31 Discharged No 30 day MDS needed

discharged on day 31. Grace 32

Grace 33

34


Scenarios #2

Resident admitted 10/04/XX, the 5-day MDS achieved a CC1 Medical RUG with ARD of Day

6. On Day 9 the earliest therapy started, so the Start Date of Therapy is Day 9 and the RUG

will be higher CMI than Medical RUG. What type of MDS do you complete and what should

be the ARD? Indicate what day the Rehab RUG (RHB) starts. Indicate when the COT count

starts.

RECOMMENDED MEDICARE MDS SCHEDULE & FLOWSHEET FOR 100 DAYS

COVERAGE

SCHEDULE

ARD COT

ARD

EOT

ARD

EOT-R SOT

ARD

Comments

CASE DAY:

Reference 1 Admission

Day

10/04/XX

Reference 2

Reference 3

Reference 4

Reference 5

3 GRACE days 6 Grace 10/09/XX CC1

May or may not 7 Grace

Be combined

with initial

OBRA

8 Grace

9 Start of Therapy

10

11

12

Reference 13

Reference 14

NO GRACE 15 (Grace)

Days allowed if 16 (Grace)

Combined with 17 (Grace)

Initial OBRA 18 (Grace)

admission MDS 19

20

21

22 23

24

25

26

Reference 27


Scenario #2 Answers

Resident admitted 10/04/XX, the 5-day MDS achieved a CC1 Medical RUG using day 6. On

Day 9 the earliest therapy started, so the Start Date of therapy is Day 9. The ARD choices

are days 5, 6, or 7 (10/13-10/15) counting earliest Start Date as day one. Choices of ARD are

days 13, 14, or 15 of the stay allowed for 14-day MDS. Combine the two MDS Assessments

(14-day with SOT) and the Rehab RUG starts on first day with therapy, which was Day 9.

If MDS were NOT combined, the Rehab RUG would not have started until Day 15 (on cycle).

RECOMMENDED MEDICARE MDS SCHEDULE & FLOWSHEET FOR 100 DAYS

COVERAGE

SCHEDULE

ARD COT

ARD

EOT

ARD

EOT-R SOT

ARD

Comments

CASE DAY:

Reference 1 Admission

Day

10/04/XX

Reference 2

Reference 3

Reference 4

Reference 5

3 GRACE days 6 Grace 10/09/XX

May or may not 7 Grace

Be combined

with initial

OBRA

8 Grace

9 Therapy

Start Date

Start

date 1

Start billing RHB

10 2 RHB

11 3 RHB

12 4 RHB

Reference 13 5 RHB

Reference 14 SOT ARD 10/17/XX COT

start

6 Combine with 14

day

RHB

NO GRACE 15 (Grace) 1 7

Days allowed if 16 (Grace) 2

Combined with 17 (Grace) 3

Initial OBRA 18 (Grace) 4

admission MDS 19 5

20 6

21 No COT

required

7

22 1 23 2

24 3 DISCHARGED 25 4

26 5

Reference 27 6


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