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SNF 2014 RUGS

SNF PPS: RUG-IV Categories & CharacteristicsMajor RUG-IVCategory RUG-IV ScoreCharacteristics Associated With Major RUG-CategoryRehabilitation Plus Extensive Service RUX, RUL, RVX, RVL, RHX, RHL, RMX, RML, RLXResident satisfying all of the following three conditions:Having a minimum activity of daily living (ADL) dependency score of 2 or moreReceiving physical therapy, occupational therapy, and/or speech-language pathology services while a resident. Ultra (U)-720+ minutes, 2 disciplines required : at least 1 discipline for 5 days, 2nd discipline at least 3 days within past 7 days from ARD Very High (V)-500-719 min, At least one discipline 5 days with past 7 days from ARD High(H)-325-499 min, Requires 1 discipline 5 days with past 7 days from ARD Medium (M)-150-324 min, Requires 5 days across 3 disciplines combination within past 7 days from ARD Low (L)-45-149 min, 3 treatment days within past 7 days from ARD, Combined with with nursing restorative capture of 6 days with 2 RNP prog. Rehabilitation Plus RUA, RUB, RUC, RVA, RVB, RVC, RHA, RHB, RHC, RMA, RMB, RMC, RLA, RLBResident receiving physical therapy, occupational therapy, and/or speech-language pathology services while a resident. Ultra (U)-720+ minutes, 2 disciplines required : at least 1 discipline for 5 days, 2nd discipline at least 3 days within past 7 days from ARD Very High (V)-500-719 min, At least one discipline 5 days with past 7 days from ARD High(H)-325-499 min, Requires 1 discipline 5 days with past 7 days from ARD Medium (M)-150-324 min, Requires 5 days across 3 disciplines combination within past 7 days from ARD Low (L)-45-149 min, 3 treatment days within past 7 days from ARD, Combined with with nursing restorative capture of 6 days with 2 RNP prog. ADL Score * 11-16 = C * 6-10 = B * 0-5 = ACounting Minutes

Counting Rehab Minutes RUG-IV Significant Changes

Revision to calculation of Therapy minutes will be implemented. You will need to indicate on the MDS 3.0 what delivery mode is being used for rehab services: - Individual Therapy - Group Therapy - Concurrent Therapy (same area two different disciplines) - Co-Treat two different disciplines working on two different areasCounting Rehab MinutesAide Time Is essentially limited to set up time

The old practice of counting all of the aides time ( for a Part-A patient) under line of sight supervision by licensed therapist is no longer acceptable, only the setup time is counted while direct line-of-sight

Counting Rehab Minutes The manner in which Therapy minutes are counted had been modified

Method Of Rehab Delivery - Individual Therapy No Change - Group Therapy No Change (Be careful about coverage criteria) - Concurrent Therapy Minutes will be allocated/limited to 2 patient (1/2 of time counted for reimbursement purposes)Co-Treat minutes x2 unless working on same area

Counting Minutes for Timed Codes Units Number of Minutes 1 8 minutes through 22 minutes2 23 minutes through 37 minutes3 38 minutes through 52 minutes4 53 minutes through 67 minutes 5 68 minutes through 82 minutes 6 83 minutes through 97 minutes7 98 minutes through 112 minutes8 113 minutes through 127 minutes Calculating Therapy Minutes Only include minutes spent on skilled therapyWhen Individual therapy occurs intermittently throughout the day, the total number of minutes from all sessions will be recorded as a daily count When reporting therapy time, report the actual minutes of therapy - Do not round to the nearest 5th minute - The system will automatically do any necessary rounding, so reporting actual therapy minutes - Report timed minutes and untimed separately

Calculating Therapy Minutes Resident can receive different modes of therapy on one day, or even in one treatment session - Each mode of therapy and the time spent on each must be recorded Reportable treatment time begins when the patient started the first task or activity. And ends when they finish with the last task, or piece of equipment. - Count the total number of minutes spent on therapeutic activities, subtracting any time spent on breaks, or other activities that do not qualify as therapeutic

Why Is It More Difficult To Get Into REHAB CategoriesSection T Eliminated

Counting Minutes Modified - Concurrent Therapy - Aide Time

Therapy Distinct Days

Rehab Medium & Low Distinct Days The Final Rule adds an additional MDS 3.0 item (MDS Item 00420) for the Calendar Days that Will require reporting of distinct calendar days of therapy provider. Distinct calendar daysrepresents different days therapy was provided in the ARD or COT review look back period.In other words, on how many different days were rehabilitation services provided for greater than 15 minutes over the last seven days?

This would be reported as:

Speech Therapy 2 days for a total 60 minutes Occupational Therapy 2 days for a total of 60 minutesPhysical Therapy 3 days for a total of 90 minutes 7 Distinct Calendar Days PPS Day12345679/259/269/279/289/299/3010/1PT303030OT 3030ST 3030Total 30303030303030Distinct Calendar Days Not Met In addition, the RUG-IV grouper will only calculate a Rehabilitation Medium RUGcategory when 150 minutes of therapy is provided across 5 distinct calendar days.In other word, within the 7 days observation period of the MDS or COT review, therapist must deliver services to the patient on at least 5 of the 7 days in the observation period from the Assessment Reference Date (ARD). If this criteria is notmet, regardless of the number of minutes or total of combined disciplines visits ofRehabilitation services provided, the RUG score generated will reduce to a Nursing RUG.

Cont.

For Example Medicare Rehab Med. & Low RUG Categories - Distinct Days ARD

In Example above:Speech Therapy 4 days for a total of 60 minutes Occupational Therapy 4 days for a total of 170 minutesPhysical Therapy 4 days for a total of 180 minutes 4 Distinct Calendar Days PPS Day123456789/259/269/279/289/299/3010/110/2PT04050600030ROT03050400050RST00300030RTotal 070100130001100Time Documentation Part-B Total treatment time - Includes the minutes for both Timed code treatment - The procedure is defined by specific timeframe Untimed code treatment - The procedure is not defined by a specific timeframe

15 Minute Timed Code What Time Counts Towards 15 Minute Timed Codes? - Report the code for time actually spent in delivery of the modality - Pre and post delivery service are not counted in determinig the treatment time

Billing Units Part-BDocumentation shows - 33 minutes of therapeutic exercise (97110) - 7 minutes of manual therapy (97140) - 40 minutes total timed minutes Appropriate billing is 3 units - 97110 = 2 unit - 97140 = 1 unit Billing Unit Part-BDocumentation shows - 18 minutes of therapeutic exercise (97110) - 13 minutes of manual therapy (97140) - 10 minutes of gait training (97116) - 8 minutes of ultrasound (97035) - 40 Total timed minutes Appropriate billing is 3 units - 97110 = 1 unit - 97116 = 1 unit - 97140 = 1 unit

Proof of Therapy MinutesRequired for Part A & Part B

Therapy MDS

PPS Assessment Schedule Medicare MDSAssessment Type

Reason for Assessment (A0310B code)Assessment Reference DateWindow Assessment Reference DateGrace Days Applicable MedicarePayment Days 5 days01Days 1 - 5 6 8 1 through 1414 day02Days 13 1415 18 15 through 3030 day 03Days 27 29 30 3331 through 6060 day 04Days 57 5960 63 61 through 9090 day05Days 87 8990 9391 through 100Stat of Therapy (SOT) OMRANew assessment type Optional assessment type Can be done at any time during the residents stay to obtain a therapy RUGARD must be five to seven days after the start of the first therapy

SOT OMRA Payment rate starts on the first day that therapy services were receivedThis assessment should not be combined with the 5-day PPS assessment Should only be completed if doing so will place the resident in a therapy RUG Assessment will reject on the validation reportSOT OMRA Pay close attention to your case mix indices - May not be in the facilitys best financial interest to place the resident in a therapy RUG - Optional assessment - Should only be completed if there is financial benefit SOT OMRA Example Resident Admitted 1/3 5-day assessment, 1/8 CB2 14-day assessment, 1/16 CB2 Therapy imitated on 1/20 SOT completed, ARD 1/25, RHB 30-day Assessment, 1/29 RVB End of Therapy (EOT) OMRA Patient was receiving rehabilitation services Was classified to a rehabilitation RUG Discontinues all rehabilitation services Continues to have skilled level of care requirements

EOT OMRA Assessment Reference Date (ARD) must be set on Day 1, 2 or 3 after the last day of any rehabilitation - Day 1 corresponds to the first day on which your facility would have normally provided therapy services - Whether the resident would have received therapy that day or not

EOT OMRAPayment rate changes beginning the day following the last day of therapy - Indicated in Item Z0150A of the MDS - Regardless of the ARD No penalty for an early ARD is set in day that therapy is not normally provided May be combined with a scheduled assessment, but may not replace it EOT OMRA Resident admitted on 1/3/14 5-day assessment, 1/8 RHB 14-day assessment. 1/16 RVB All therapy ended on 1/22EOT completed, ARD 1/24 LCIEOT-R End of Therapy Resumption Requirements for completion: 1. Therapy resume within 5 calendar days of last treatment date 2. Therapy resumes at same level of intensity Payment at the same Rehab RUG level begins on therapy resumption date . EOT R Example Resident admitted on 1/3/14 5-day assessment, 1/8 RHB 14-day assessment. 1/16 RVB Resident misses therapy on 1/22, 1/23 and 1/24EOT completed, ARD 1/23 LCITherapy Resumes 1/25, EOT-R completed, RVB resumes

Medicare Short Stay Assessment Before the eight day of the covered SNF stay - Resident dies - Resident is discharged from SNF - Resident is discharged from a Medicare-Part A Covered level of careMedicare Short Stay Assessment Allows the resident to be classified to a Rehabilitation category when resident was not able to have received five days of therapy

Eight conditions, and all must be met

Medicare Short Stay Assessment Must be a start of Therapy OMRA (A0310C = 1 or 3) - May be completed alone or combined with any OBRA assessment - May be combined with a PPS 5-day or readmission return assessment - May not be combined with a PPS 14-day, 30-day, 60-day, or 90-day assessment Medicare Short Stay Assessment PPS 5-day (A0310B = 01) or readmission/return assessment (A0310b = 06) has been completed - May be completed alone or combined with the Start or Therapy OMRA ARD (A2300) of the Start of Therapy OMRA must be on or before the 8th day of the part A Medicare stay

Medicare Short Stay Assessment ARD (A2300) of the Start of Therapy OMRA must be the last day of the Medicare Part A stay - Start of Therapy OMRA ARD must equal the end of Medicare stay date (A2400C) - End of the Medicare stay date is the date Part A ended Medicare Short Stay Assessment ARD (A2300) of the Start of Therapy OMRA may not be more than 3 days after the start of therapy date - Item O0400A5, O0400B5 or O400C5, whichever is earliestRehabilitation therapy (PT, OT, or SLP) started during the last 4 days of the Medicare Part A covered stay (including weekends ) Medicare Short Stay Assessment At least one therapy discipline continued through the last day of the Medicare Part A stay - Must have dash-filled end of therapy date (O0400A6), O0400B6) or O0400C6) - End of therapy date equal to the end of covered Medicare stay date (A2400C)

Medicare Short Stay Assessment RUG group assigned to the Start of Therapy OMRA must be Rehabilitation Plus Extensive Services or Rehabilitation group (Z0100A) - If the RUG group assigned is no t a Rehabilitation Plus Extensive Services pr a Rehabilitation group, the assessment will be rejected

Medicare Short Stay Assessment If all of these conditions are met, then MDS Item Z0100C (Medicare Short Stay Assessment indicator) is coded YES

Assignment of the RUC-IV rehabilitation therapy classification is calculated based on average daily minutes actually provided

Medicare Short Stay Assessment Resulting RUG-IV group is recorded in MDS Item Z0100A (Medicare Part A HIPPS Code) - 15-24 average daily therapy minutes Rehabilitation Low category (RLx) - 30-64 average daily therapy minutes Rehabilitation Med. category (RMx) - 65-99 average daily therapy minutes Rehabilitation High category (RHx) - 100-143 average daily therapy minutes Rehabilitation Very High category (RVx) - 144 or greater average daily therapy minutes Rehabilitation Ultra High category (RUx) Medicare Short Stay Assessment If the earliest start of therapy date is the first day of the short stay, use the Medicare Short Stay assessment Medicare Part A RUG (Z0100) from the beginning of the short stay through the end of the stay. - Dates in Items O0400A5, O0400B5 or O0400C5 - Medicare stay must be 4 days or less

Medicare Short Stay Assessment If the earliest start of therapy date is after the first day of short stay. - If a 5-day or readmission/return assessment was completed prior to Medicare Short Stay assesment, * Use the Medicare Part A RUG (Z0100A) from that assessment for the first day of the short stay through the day before therapy * Then use the Medicare Part A RUG (Z0100A) from the Medicare Short Stay assessment from the day therapy short through the end of the short stay Medicare Short Stay Assessment If the earliest start of therapy date is after the first day of the short stay - If the Start of Therapy OMRA is combined with a 5-day or readmission/return assessment, * Use the Medicare Part A non-therapy RUG (Z0150A) for the first day of the short stay through the day before therapy started; * Use the Medicare Part A RUG (Z0100A) from day therapy started through the end of the short stay

Early Assessments If an assessment is performed earlier than the schedule indicated, the provider will be paid at be default rate for the number of days the assessment was out of compliance

No penalty is an End of Therapy OMRA is performed early if the ARD is set on a day that therapy services are not normally available at your facility

Late AssessmentIf the ARD on the late assessment is set before the end of the payment period for that assessment - SNF will receive the default rate from the beginning of the payment period until the day before the ARD - From the ARD to the end of that payment period, it will receive the HIPPS rate identified by the assessment

Late Assessment PPS assessment must be timely, in order to bill the RUG generated by the assessment If the assessment if missed and the resident is no longer Part A when discovered, Medicare Part A cannot be billed AT ALL!!!!! No one else can be billed for those days either. The facility is liable

A PPS assessment is timely if the ARD is set: - On the MDS- Within the prescribed ARD window - Before the end of the last day of the window

COTS

COT OMRA Effective for all assessments with an ARD on or after October 1, 2011 a COT OMRA is required if the therapy received during the COT observation period does not reflect the RUG-IV classification level on the patients most recent PPS assessment used for payment COT Observation Period: A successive 7-day window beginning the day following the ARD of the residents last PPS assessment used for payment.Maybe used to classify a patient into a Higher or Lower RUG Category

COT OMRAIn order to determine if a COT OMRA is required, providers should perform an informal change of therapy evaluation that considers the intensity of the therapy the patient received during the COT observation period. But what must a facility actually consider? Total Reimbursable Therapy Number of Therapy Minutes (RTM) Disciplines

Number of Therapy Days Restorative Nursing (for patients in a Rehab Low category) COT OMRAA COT OMRA is required in cases where the therapy received during the COT observation period would cause the patient to be classified into a different RUG Category.

RUG Category Shortcut = Second character in RUG code RUC: Ultra-High Rehab RVX: Very-High Rehab RMA: Medium Rehab RHL: High Rehab

AS LONG AS THE SECOND CHARACTER DOES NOT CHANGE NO COT OMRA IS REQUIRED COT OMRA When is a COT OMRA required

Is the patient receiving skilled services? Yes No YES No No COT OMRA Required COT OMRA is Required Perform COT Evaluation Is the therapy the patient received during the COT observation period consistent with the patients current RUG-IV classification No COT OMRA required COT OMRA COT OMRA and SNF Billing The COT OMRA retroactively establishes a new RUG beginning Day 1 of the COT Observation Period used the next scheduled or unscheduled PPS assessment. Example: A residents 30-day assessment is perfomred with an ARD set for Day 30. Based on the 30-day assessment ARD, the therapy services provided to this resident are evaluated on Day 37. If a COT OMRA is required, then payment would be set back to Day 31.COT OMRA AND INDEX MAXIMIZATION Index maximization: In some situations a resident may simultaneously meet the qualifying criteria for both a therapy and a non-therapy RUG. For some of these cases the RUG-IV per diem payment rate for the non-therapy RUG will be higher; therefore, although the resident is receiving services, the index maximized RUG is a non-therapy RUG.

A facility is required to complete a change of therapy evaluation for all patients receiving any amount of skilled therapy services, including those who have index maximized into a non-therapy RUG group. COT OMRA AND INDEX MAXIMIZATION A COT OMRA is only required for residents in such cases that the therapy services during the COT observation period is no longer reflective of the RUG-IV category after considering index maximization. Consider the following two exmaples:Resident qualifies for RMB but index maximizes into HC2. During the COT observation period, resident receives only enough therapy to qualify for RLB. COT OMRA not Required because no change to index maximized RUG Category Resident qualifies for RMB but index maximizes into HC2. During the COT observation period, resident receives enough therapy to qualify for RUB COT OMRA is required because of change to index maximized RUG category

Recent ClarificationsCOT OMRA and Day of Discharge If Day 7 of the COT observation period is also the day of discharge, then a COT OMRA would not be required.COT OMRA and Scheduled PPS Assessments If the ARD of a scheduled PPS assessment is set for on or prior to Day 7 of the COT observation period, then no COT OMRA would be required .

COT OMRA Clarification A COT cannot be completed for a resident that is not a therapy RUG Therefore, a SNF cannot complete a COT for a resident whose reimbursement is at a clinical RUG, even if they are now receiving enough therapy to increase to a higher Case Mix Index (CMI) at a rehab category.Therapy and nursing personnel must consider various strategies to help the facility receive the proper reimbursement for resident whose therapy intensity changes during their stay.

SNF LOA Use Caution Work with MDS Coordinator to properly calculateCould affect the RUG classification Call MLC Consulting for help!!!!

Therapy MDS & HMOs, Insurance Do COTs Print out MDS and Keep record Do Not Transmit MDS Record COT change or no change for billing purpose Humana requires hard copy of MDS in Medical review.Has to match billingTherapy MDS Impact

Urban Urban RUC - $ 531.87RVC - $456.28 $75.59 = Difference/Day $75.04 x 30days = $2,267.70/month $2,267.70 x 10 patients = $22,677.00/monthRUB - $395.13RHB - $357.85 $37.28 = Difference/Day $37.28 x 30 days = $1,118.40/month $1,118.40 x 10 patients = $11,184.00/month less

Rural Rural RUC - $506.38RHC - $428.34 $78.04 Difference/Day $78.04 x 30 days = $2341.20/month $2341.20 x 10 patients = $ 23,412.00/ month RVB - $375.09RHB - $333.70 $41.39 Difference/Day $41.39 x 30 days = $1241.70 $1241.70 x 10 patients $12,417.00

Section G Section G Nursing fills out - Is for what is currently going on with resident - Needs to match the problems therapy is treating forCoordinate with Therapy and Nursing - Team effort - Communication - Fill out nursing Debility Issus's that therapy should be addressing and work towards better outcomes

Geri Psych Admits To SNF

Denials

Therapy DenialsPhysicians Signature: One of the first areas auditors look id the physician signature on therapist POC. Most therapist handwrite the POC, fax it to the Physician for signature. Receive signed form and scan into electronic file.Therapist Signature & signature logs Medical Necessity: Therapist must prove medical necessity of patients therapy services, whether physical therapy, speech therapy or occupational therapy. Therapist needs to show why patient requires skilled services. Functional Progress: Therapist need to show patients progress in there ability to complete daily life actives through each therapy session. - Functional progress is how to this patient more independent in certain activities of mobility and daily living. Documentation is conveying increased range of motion or strength , but its not tied onto how the patient is walking up and down stairs, or how it affects the patients function in daily actives (the claim) will be denied. 5. Medicare Caps: $1920 initial cap $3700 prompts medical review prior to paymentCloning : When documentation has not been changed across therapy sessions.Patient Self-Discharge : Some patients will simply stop going without notifying the therapist or rehab program, leaving documents for patient incomplete, such as without a discharge summary.

8. Recertification : Patients need to be recertified by Medicare every 90 calendar days9. Overbilling or Inappropriate use of CPT codes and modifiers : Electronic rehab systems will alert the point-of-care therapist to any charge where the treatment time does not match the units billed or requires .modifiers

Skilled Nursing Facility

Review this information when filing claims top prevent denials to ensure their claims are processed timely.