SNF 2014 RUGS

1. SNF 2014 RUGS

6. SNF PPS: RUG-IV Categories & Characteristics

7. Counting Minutes

8. 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 areas

9. Counting Rehab Minutes • Aide Time – Is essentially limited to set up time • The old practice of counting all of the aides time ( for a Part-A patient) under line of sight supervision by licensed therapist is no longer acceptable, only the setup time is counted while direct line-of-sight

10. 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

11. Counting Minutes for Timed Codes

12. Calculating Therapy Minutes • Only include minutes spent on skilled therapy • When Individual therapy occurs intermittently throughout the day, the total number of minutes from all sessions will be recorded as a daily count • When reporting therapy time, report the actual minutes of therapy - Do not round to the nearest 5th minute - The system will automatically do any necessary rounding, so reporting actual therapy minutes - Report timed minutes and untimed separately

13. 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

14. Why Is It More Difficult To Get Into REHAB Categories • Section T Eliminated • Counting Minutes Modified - Concurrent Therapy - Aide Time

15. Therapy Distinct Days

16. 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 days represents 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 minutes Physical Therapy 3 days for a total of 90 minutes 7 Distinct Calendar Days

17. Distinct Calendar Days Not Met In addition, the RUG-IV grouper will only calculate a Rehabilitation Medium RUG category 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 not met, regardless of the number of minutes or total of combined disciplines visits of Rehabilitation services provided, the RUG score generated will reduce to a Nursing RUG. Cont.

18. 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 minutes Physical Therapy 4 days for a total of 180 minutes 4 Distinct Calendar Days

19. Time 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

20. 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

21. Billing Units Part-B • Documentation 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

22. Billing Unit Part-B • Documentation 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

23. Proof of Therapy MinutesRequired for Part A & Part B

24. Therapy MDS

25. PPS Assessment Schedule

26. Stat of Therapy (SOT) OMRA • New assessment type • Optional assessment type • Can be done at any time during the residents’ stay to obtain a therapy RUG • ARD must be five to seven days after the start of the first therapy

27. SOT OMRA • Payment rate starts on the first day that therapy services were received • This assessment should not be combined with the 5-day PPS assessment • Should only be completed if doing so will place the resident in a therapy RUG “Assessment will reject on the validation report”

28. SOT OMRA • Pay close attention to your case mix indices - May not be in the facility’s best financial interest to place the resident in a therapy RUG - Optional assessment - Should only be completed if there is financial benefit

29. 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

30. 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

31. EOT OMRA • Payment rate changes beginning the day following the last day of therapy - Indicated in Item Z0150A of the MDS - Regardless of the ARD • No penalty for an early ARD is set in day that therapy is not normally provided • May be combined with a scheduled assessment, but may not replace it

33. 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 care

34. Medicare 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

35. 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

36. 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

37. 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

38. 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 earliest • Rehabilitation therapy (PT, OT, or SLP) started during the last 4 days of the Medicare Part A covered stay (including weekends )

39. 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)

40. 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

41. 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

42. 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)

43. 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

44. 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

45. 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

46. 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

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

48. 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

49. COT’S

50. 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 patient’s most recent PPS assessment used for payment • COT Observation Period: A successive 7-day window beginning the day following the ARD of the resident’s last PPS assessment used for payment. Maybe used to classify a patient into a Higher or Lower RUG Category