Summary of CMS Final Rule for Fiscal Year 2012 PPS Payments to Skilled Nursing Facilities

The summary below is intended to highlight the major changes published, but is not intended to replace the source documents. We encourage you to refer to the source documents for additional context and content. This paper expands upon:

• When to invoke the Change of Therapy (COT) Other Medicare Required Assessment (OMRA)
• Circumstances when Skilled Nursing Facilities (SNFs) are mandated to report breaks of three or more consecutive days of therapy
• Eliminates distinguishing between facilities furnishing therapy services on a 5- or 7-day basis
• Streamline procedures for situations involving brief interruption in therapy
• What to do when therapy resumes without any change in the patient’s Resource Utilization Group (RUG-IV) classification level
• Group therapy: Allocation of a therapist’s time for group therapy

A New COT OMRA
Many facilities utilize the overlap between PPS assessments as a data collection strategy, most often for the first two scheduled assessments; the 5-day assessment and the 14-day assessment. The observation or look back period for any assessment is seven days and every assessment has both early start times and extended days (grace days). The strategy typically involves using grace days for the 5-day assessment (Day 8) and using the earliest day (Day 11) for the 14-day assessment. By doing so, services rendered for four out of the seven days on the 14-day assessment have already been captured on the first assessment (Days 5-8). The overlap effectively reduces the data collection period for the next PPS assessment, often maintaining the highest applicable RUG-IV level. Should the service intensity change between day 11 and day 14, the payments would not and the facility would continue to receive payments on resources no longer provided, until the next assessment period when the reduction in service intensity would be captured. In essence when overlap is used, payment is established for the first 30 days of the patient’s stay based on only 10 days of service, with four days overlapping between observation windows, rather than the intended 14 days of service with little to no overlap between observation periods. This explains the creation of a new OMRA; COT OMRA to capture changes in a patient’s therapy status sufficient to alter the RUG-IV classification and consequently the payment.

The COT assessment was clearly put into effect as a financial control on payments. Keep in mind it is intended to capture changes in a patient’s therapy status that would sufficiently affect the RUG-IV classification and hence payments. Implied allegations by CMS there was an industry-wide practice of enhancing service delivery during the assessment window to capture a RUG level, followed by decreasing services soon after the window closed, is evident in CMS’ response to concerns and comments submitted:

We would like to stress that if facilities tailor treatment time to the needs of each individual patient and continue to provide that therapy outside of the assessment window, facilities will be less likely to be required to complete as many COT OMRAs.

We believe the COT OMRA will allow us to track changes in the patient's condition and in the provision of therapy services more accurately, allowing reimbursement to reflect resource use more accurately, thereby improving the accuracy of reimbursement.

Be aware changes in minute provision is also cause for a COT and provision of minimum levels of treatment minutes increases the likelihood COTs will be completed if on a given day the number of minutes threshold is not met. We recommend continuing to provide care based on clinical indications and not thresholds designed to meet any given RUG-IV level. CMS’ response to the potential burden of having to complete a COT for minute capture vs. reduction of overall therapy is thus:

In response to the comment that a strict 7-day evaluation schedule could prompt a patient’s RUG category to change for as little as one lost minute of therapy, this is theoretically possible if the plan of care is designed to provide only the minimum number of minutes that qualify the patient for a specific therapy category.

While initial reaction may see the glass half full that the COT will ultimately result in reduction of payments, it is important to know it should be seen both ways. For example, residents who were receiving clinically indicated services that were not captured during the scheduled assessment would receive a higher RUG-IV payment for initiating a COT assessment that would yield a favorable reimbursement outcome for the facility, had those services been captured. We recommend close monitoring of these fluctuations in care, since the first day of the COT observation period is the day after the assessment reference date (ARD) of the previous assessment used for Medicare payment and would remain in effect until the next scheduled assessment. The COT OMRA would be billed starting the first day of the COT observation period for which the COT OMRA was completed, and would remain at this level until a new assessment is completed which changes the patient’s RUG-IV classification. So the facility has an opportunity to increase their reimbursement relative to the care they are providing.

Additionally, regarding past concerns that consistent use of grace days is viewed as a negative practice with inherent risk of prompting an audit, CMS debunks the concern with the following statement,

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.

With that understanding, facilities that have refrained from using grace days regularly due to concerns of triggering audits should begin to use grace days whenever and as often as such use will accurately capture the services rendered. The tables below illustrate the current MDS 3.0 Assessment schedule, followed by what to expect as of October 1, 2011.

TABLE 10A CURRENT MDS 3.0 ASSESSMENT SCHEDULE
Medicare MDS assessment type

TABLE 10B EFFECTIVE OCTOBER 1, 2011 MDS 3.0 ASSESSMENT SCHEDULE
Medicare MDS assessment type

Reporting breaks of three or more consecutive days of therapy
When the patient goes three consecutive days without therapy, regardless of the reason for discontinuation (illness, appointments, refusals, religious observance, etc.) an End of Therapy (EOT) assessment must be completed. Furthermore, CMS eliminates the distinction between facilities regularly furnishing therapy services on a 5- or 7-day basis for purposes of setting the date for the EOT OMRA; requiring

All facilities to set the ARD for the EOT ORMA by the third consecutive calendar day after a patient’s therapy services have been discontinued (76 FR 26390).

What to do when therapy resumes without any change in the patient’s RUG-IV classification level
CMS has streamlined procedures for documenting situations involving a brief interruption in therapy, where therapy resumes without any change in the patient’s RUG-IV classification level. Following completion of an EOT assessment, should services resume at the same RUG-IV category no more than five days since the last therapy session was provided, an End of Therapy Resumption (EOT-R) may be completed instead of a Start of Therapy (SOT) assessment. The EOT-R does not require a therapy evaluation to support the level of care provided; the presumption is the patient’s clinical condition has not changed. Careful monitoring of the number of missed days is imperative; implementing a tracking system is recommended. Every effort should be made to resume services on the first day resumption is clinically indicated and not on the first day services are typically rendered. Facilities should consider a flexible therapy delivery model, particularly those facilities that continue to provide five vs. seven days per week of services. Facilities offering primarily five days of therapy to patients are at an increased risk of having to complete an EOT assessment. Consider the patient scheduled Monday-Friday; as result that patient will consistently be missing two days of therapy every weekend. Therefore, the first Monday that patient misses therapy, regardless of the reason, the facility will need to complete an EOT assessment. The ruling states three consecutive days NOT three consecutive scheduled days.

Allocation of a therapist’s time for group therapy
Lastly, group therapy is altered. Since the inception of the SNF PPS in July 1998, group therapy was capped at four residents per therapist, and since 1999 a cap of 25 percent of the time treated in this mode was permitted toward determination of a RUG category per assessment period. These criterions remain unchanged; what has changed is the decision to allocate the treatment minutes equally amongst the four participants. The rationale provided by CMS is when a therapist treats four patients in one hour, it does not cost the facility four times the amount and the facility is not paying for four hours of labor. This is the basis for the decision to allocate the minutes equally across the four participants in order to reimburse for utilization and costs.

One or more of the four participants are unexpectedly absent from a session or cannot finish participating in the entire session, rather than discontinuing payment or requiring the session to be rescheduled, we will continue to deem the therapy session as meeting the definition of group therapy as long as the therapy program originally had been planned for four patients. In this situation, we will continue to assume that there are four patients and, therefore, will divide the therapy minutes by four in allocating group therapy minutes among the group therapy participants.

SNFs are expected to supply justification for using group therapy as part of the patient’s plan of care, to support medical necessity and the appropriateness of the prescribed plan. Moreover, CMS does not support the application of the group modality to all residents. Therefore, we recommend reviewing current policies and procedures with regard to initiating, monitoring and discontinuing the provision of group therapy, as well as assessing whether current documentation procedures meet the prescribed expectations.

Prepared by
Dr. Cheryl Ben-David, DPT
Practice Leader, Continuing Care
McGladrey
cheryl.ben-david@mcgladrey.com
(212) 372-1634

Sources:
http://www.ofr.gov/OFRUpload/OFRData/2011-19544_PI.pdf
http://www.gpo.gov/fdsys/pkg/FR-2011-05-06/pdf/2011-10555.pdf