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PPS FY 2012 Final Rule: More Big Changes in Therapy Coding and Payment

PPS FY 2012 Final Rule: More Big Changes in Therapy Coding and Payment. September 13, 2012. What is Changing?. “ Recalibration ” of Nursing Case-Mix weights for all Rehab RUG Levels ARD schedule adjusted Group minute allocation guidelines Change Of Therapy (COT) OMRA

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PPS FY 2012 Final Rule: More Big Changes in Therapy Coding and Payment

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  1. PPS FY 2012 Final Rule: More Big Changes in Therapy Coding and Payment September 13, 2012

  2. What is Changing? • “Recalibration” of Nursing Case-Mix weights for all Rehab RUG Levels • ARD schedule adjusted • Group minuteallocation guidelines • Change Of Therapy(COT) OMRA • End Of Therapy(EOT) OMRA clarification, and newEOT-R(resumption) OMRA process

  3. Acronyms

  4. Recalibration of Certain Case-Mix Rates 4 4

  5. Concurrent & Group vs. 1:1 Utilization CMS (STRIVE) BEFORE 2011: CMS (Q1, 2011) AFTER 2011: 5 5

  6. Recalibration of Certain Case-Mix Weights The significant (and unexpected) changes came in the “Upper RUGs” categories. All “Rehab” RUGs “RU” and “RV” RUGs

  7. Recalibration of CMI • The daily payment that CMS pays providers for each RUG group is made up of 3 components: Nursing Case-Mix, Therapy Case-Mix and Non Case-Mix dollars. • Case Mix Indices (CMIs) are meant to represent the relative amount of staff time & expense built into each RUG level. • Nursing CMI selected as the means for the recalibration, because that is where FY2011 adjustments were added. • Nursing CMI will be decreased for all Rehab RUG groups (Rehabilitation Plus Extensive and Rehabilitation groups). • Range of recalibration is 11.3% - 12.9%, depending on facility type and location

  8. Recalibration Example Recalibrations taken here

  9. Impacts 21 of Top 30 Per Diem Groups 9

  10. Recalibration “We do not believe that the recalibration should negatively affect facilities, beneficiaries, or quality of care, or create an undue hardship on providers.” “In fact, notwithstanding the recalibration, the FY 2012 payment rates will actually be 3.4% higher than the rates established for FY 2010, the last period prior to the unintended spike in payment levels.”

  11. Change in ARD Schedule 11 11

  12. ARD Schedule Change • Current: allows for a larger number of observation days which can overlap from one period to another • CMS wanted to remove the potential for overlap

  13. Changes to ARD Schedule Current Future (10/1/11)

  14. Grace Days “We agree that in practice, there is no difference between regular ARD windows and grace days and we encourage the use of grace days if their use will allow a facility more clinical flexibility or will more accurately capture therapy and other treatments. Thus, we do not intend to penalize any facility that chooses to use the grace days for assessment scheduling or to audit facilities based solely on their regular use of grace days.”

  15. ARD Schedule Change - Risks • Potential increase risk of default days • Potential impact on ADL index • Potential impact on Rehab RUG

  16. Possible Strategies to Mitigate Risk • Develop (revive?) tools to assist with PPS Schedule • Automation of systems • ADL accuracy – retraining opportunity?

  17. ADL Scale “Staff Assistance” includes: Oversight Setup Verbal cues or encouragement Physical assist, etc. • Bed Mobility: • Moving from a lying position • Turning side to side • Positioning resident in bed or alternate furniture 17

  18. Group Minute Allocation 18 18

  19. Group Therapy • Effective October 1, 2011: Group therapy will be defined as therapy provided simultaneously to four patients (regardless of payer source) who are performing the same or similar activities, and group therapy time will be divided by four in determining the reimbursable therapy minutes (RTM) for each group therapy participant, and therefore, the appropriate RUG-IV group. • The 25% cap for group therapy remains in effect • 25% cap will apply after dividing by 4

  20. Group Therapy • CMS expects, “group therapy to be a structured, planned program with four participants for whom group therapy has been determined appropriate.”

  21. Group Therapy • Groups are required to have 4 participants • In situations where the definition of group therapy is not met, those minutes may not be coded on the MDS as group therapy • However, if one or more of the 4 participants are unexpectedly absent from a session or cannot finish participating in the entire session...CMS will deem the therapy session as meeting the definition of group therapy as long as the therapy program originally had been planned for 4 participants (Tx minutes will still be divided by 4)

  22. Group Therapy • The SNF will report the total unallocated group therapy minutes on the MDS 3.0 • Group Therapy Example: 60 min session with 4 participants • Therapy would document 60 minutes for each participant • MDS would document 60 minutes for each participant

  23. Group Therapy Documentation • CMS indicated that the documentation discussion in the Proposed Rule did not propose new documentation requirements for group therapy • The intent of the discussion (in the proposed rule) was to “clarify our expectations”

  24. Group Therapy Documentation “…we believe it is important to clarify our expectations regarding the clinical documentation needed to support each patient’s plan of care, including the patient’s prescribed group therapy interventions…”

  25. Group Therapy DocumentationAccording to the Proposed Rule “Because group therapy is not appropriate for either all patients or all conditions, and in order to verify that group therapy is medically necessary and appropriate to the needs of each beneficiary, SNFs should include in the patient’s plan of care an explicit justification for the use of group, rather than individual or concurrent, therapy”

  26. Group Therapy DocumentationAccording to the Proposed Rule “This description should include, but need not be limited to, the specific benefits to that particular patient of including the documented type and amount of group therapy; that is, how the prescribed type and amount of group therapy will meet the patient’s needs and assist the patient in reaching the documented goals”

  27. Possible Strategies to Mitigate Risk • Defined Therapy Schedule • Planned therapy appointments • Minimize conflicts with outside appointments • Training therapists on new definition of group • Careful planning of multi-patient combinations • Group documentation • Therapist time management

  28. Reimbursable Therapy Minutes

  29. Reimbursable Therapy Minutes Reimbursable Therapy Minutes = RTM • Allocated minutes used for RUG classification All Individual Minutes + 50% Concurrent Minutes + 25% Group Minutes then Adjusted for 25% Group Therapy Cap

  30. Change of Therapy (COT) OMRA 30 30

  31. COT OMRA Process • Current: Therapy minutes closely monitored and reported only during scheduled MDS assessment periods • Therapy minutes need to be monitored in consecutive 7-day periods, even outside of scheduled assessments • COT OMRA is required whenever the intensity/ disciplines/ days of therapy changes to such a degree that it would no longer reflect the RUG level from the most recent assessment used for Medicare payment

  32. COT OMRA Monitoring Reimbursable Therapy Minutes (RTM) Number of Therapy Disciplines • A “Therapy Day” is defined as a minimum of 15 minutes of skilled treatment – determined before adjustment of minutes Restorative Nursing (Rehab Low) Number of Therapy Days

  33. COT OMRA • The ARD for the COT OMRA is Day 7 following the last scheduled or unscheduled PPS assessment or Day 7 following the end of the last COT observation period (in cases where therapy had not changed sufficiently to require a COT OMRA assessment to be performed for the previous COT observation period) • In the case of an EOT-R, the resumption date is day 1 of the COT 7-day observation period

  34. COT OMRA – Late Submission • If a COT OMRA is required but is completed late, the facility is still required to submit the late COT OMRA to CMS • The facility will be paid at the default rate for any days not in compliance with the ARD requirement • The ARD of the late COT OMRA restarts the 7-day review period for the next COT OMRA

  35. COT OMRA – Combining Assessments • In cases where the COT OMRA is combined with a regularly scheduled assessment, the facility would complete the regular assessment, rather than the COT OMRA, since the COT OMRA only includes a subset of the required MDS data • Used to determine payment for both the COT OMRA observation period and the regular payment window for the scheduled assessment

  36. COT OMRA – Combining Assessments Example: • If Day 7 of the COT observation period falls within the ARD window of the 30-day PPS assessment, a provider would set the ARD for the 30-day assessment on day 7 of the COT OMRA observation period, and code the reasons for assessment as both the 30-day and the COT OMRA • RUG level would be effective starting the first day of the COT observation period

  37. COT Example 14 Day MDS on 7/15 = RUG of RU (at least 720 min) 7-22 look back = Pt received 720 min, no COT OMRA needed. 7-29 look back = Pt received only 560 mins (OT no longer treating). COT OMRA needed w/ARD of 7-29. Can be combo w/ 30 Day MDS. RV level (at least 500 mins) applied as of 7/23

  38. Possible Strategies to Mitigate Risk • Technology tracking and alerts • Close, frequent communication between MDS and rehab • Scheduled appointments for therapy • Back up strategies • MDS personnel • Rehab personnel

  39. End of Therapy (EOT) OMRA End of Therapy Resumption (EOT-R) OMRA 39 39

  40. EOT OMRA Change Current: EOT OMRA triggers whenever a patient receives no billable therapy (regardless of reason) for 3 consecutive days when therapy department is “open” EOT OMRA triggers whenever a patient receives no billable therapy (regardless of reason) for 3 CONSECUTIVECALENDARDAYS • Potential increase in number of EOT OMRAs needing to be completed

  41. EOT Example This is a “5 Day Tx Dept”, so no Tx provided Sat or Sun. Patientmisses Tx on 25th due to illness and returns on 26th. Current: Start counting the 3 days missed treatment on the 25th(NOT counting week-end) so EOT not needed New:Start counting the 3 days on the 23rd. 3 calendar days missed as of the 25th. EOT needed and nursing RUG billed for the 23rd, 24th and 25th.

  42. End of Therapy OMRA (EOT) Risks • Increase in number of EOT that will need to be completed • Potential increase in number of SOT OMRAs needed • Potential increase in default days • Resident / Family not understanding need for treatment on weekends / holidays

  43. EOT-R OMRA Current: Once an EOT OMRA is completed, the only way to get back to a Rehab RUG is to do a SOT OMRA with a new therapy evaluation If therapy subsequently resumes within 5 days of the last billed treatment, you may complete an End-Of-Therapy Resumption (EOT-R) OMRA if resumes at the same RUG level that had been in effect prior to the EOT OMRA

  44. EOT-R OMRA • Not a new assessment type • EOT OMRA with 2 additional items • O0450A • O0450B

  45. EOT-R Example Current: Once EOT OMRA is completed, a SOT OMRA would be needed to return to a Rehab RUG level. New:EOT completed and nursing RUG billed for 23rd, 24th and 25th. EOT-R (resumption of therapy) date entered on EOT OMRA for the 26th. Rehab RUG resumes on that date. No SOT OMRA required. No new therapy evaluation required.

  46. EOT-R Example EOT completed and nursing RUG billed for 23, 24 and 25. EOT-R date entered on EOT OMRA for 26th. Rehab RUG resumes on that date. No SOT OMRA required. EOT-R requires resumption date (26th). Minutes then monitored for 7 days from resumption date for COT OMRA.

  47. EOT-R OMRA • If the reason for missed therapy was clinical in nature (meaning there was a possibility that the resident’s clinical therapy status was affected by the missed therapy), it may not be appropriate for the facility to complete an EOT-R OMRA

  48. Possible Strategies to Mitigate Risk • Technology tracking and alerts • 6+ days per week Therapy • Expanded rehab department daily hours • Specific Therapy Schedule / Appointments • Education of patient/family at Admission of Therapy Schedule and Patient needs

  49. Possible Strategies to Mitigate Risk • Close communication between rehab and MDS – daily; BID? • Back up strategies • Rehab personnel • MDS personnel

  50. October 1, 2011Transition

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