As a “practical matter,” daily skilled services can be provided only in a SNF if they are not available on an outpatient basis in the area in which the individual resides or transportation to the closest facility would be: • An excessive physical hardship; • Less economical; or • Less efficient or effective than an inpatient institutional setting.
The availability of capable and willing family or the feasibility of obtaining other assistance for the patient at home should be considered. Even though needed daily skilled services might be available on an outpatient or home care basis, as a practical matter, the care can be furnished only in the SNF if home care would be ineffective because the patient would have insufficient assistance at home to reside there safely.
Now let’s go over the Other Medicare Required Assessments (or OMRAs) – The SOT is an optional assessment – CMS says to know your RUGs and your rates – clearly if these assessment would not positively impact the rate, it should not be done. The ARD for this assessment is set 5-7 dates after the start of therapy with the first therapy day counting as day one. Medicare payment will be impacted with the RUG rate as of the date of the earliest start of therapy.
This slide offers an example of when a SOT may be indicated. Consider that early in the Medicare-covered stay, the patient was so ill that therapy could not be started until day five. PT saw the patient for an evaluation on day five and also treated him for 30 minutes that day as well as two of the following three days. By day 8, the latest day that the 5-day ARD could be set, the patient had only had three days of therapy with a total of 90 minutes. He had a daily skilled service (such as observation and assessment) on each day. There was no restorative nursing. Based on the therapy delivered, there was no way to achieve a Rehab RUG on the five day. A SOT OMRA is indicated so long as the RUG will be higher than it was on the 5-day.
Here is an example in which therapy starts on day five but because there are two disciplines in, a rehab medium RUG will be achieved by the eight day (the ARD of the five day) and there is no need to do a SOT.This example will yield a RM RUG for now. The proposed Final Rule for 2014 (effective october 2013) addresses this issue. CMS always intended for a RM to be 5 distinct days of therapy, but due to software specification irregularities, the software will generate an RM RUG if the patient has (For example, PT on Mon, Tues, Wed and OT on Wed and Thu—only 4 calendar days). The proposed final rule will change the software specs so that the RM RUG will only yield if there are 5 distinct days of service.Skilled care qualifications are not only met by therapy, they are also met by nursing. The question becomes: Is provision of skilled services on a daily basis being supported in the medical record? This is where it is crucial to ensure that the nursing daily skilled services are being clearly shown in the Medical record documentation. If these skilled requirements for the daily provision of skilled services are not beng met the facility must evaluate if the Medicare benefit is being accurately accessed.
Here, therapy ended and the resident was discharged on the third day – here there is no EOT required but it is optional and the facility may combine it with the discharge assessment.
Payment begins on Day 1 of the COT observation period and continues for the remainder of the current payment period, unless the payment is modified by a subsequent COT OMRA or other (scheduled or unscheduled) PPS assessment
Here is an example of six weeks of a patient’s therapy as it relates to the COT. The ARD of the 5-day is the 8th day of Medicare. On the 9th, the team begins the first COT evaluation period which ends on the 15th Medicare day – there is no change in RUG so the team continues on. The team conducts the 14 day PPS assessment with an ARD of day 18. This assessment results in RUC. The next COT evaluation period is the 25th Medicare day when there is also no RUG change. The patient then misses three days of therapy on the 27th, 28th and 29th date necessitating an EOT OMRA. Day 27 begins the 30 day ARD window so the assessments (that is the EOT and the 30 day) are combined. Because therapy resumes at the same level and resumes within five days, the assessment is coded as an EOT-R. Now the day of resumption counts as day one of the COT evaluation period and the therapy will be again evaluated on the 36th Medicare day.
In this scenario the facility had a COT check point on day 20. No COT was needed. The next COT Check point is day 27. The patient’s RUG would be going down. The facility chooses to complete only the PPS assessment, with an ARD of day 27. The patient discharged on day 30 (expected/unexpected does not matter in this example).The COT is considered a missed assessment and the provider is liable for all days the COT would have controlled payment. In this case, days 21-30. Provider liable means that the days are deducted from the 100 day benefit, but reimbursed at $0.How do we prevent this from happening? We will talk about the encoding period in a few minutes. The encoding period is the key for preventing this scenario, because we can change the reason for assessment without penalty during the encoding period. The facility would simply change the reason for assessment from 30 day assessment to COT OMRA. They would get paid at the lower rehab RUG they were trying to avoid, but that is far preferable to provider liable (which is, again, ZERO).Lets continue with the COT discussion and clarify the interviews requirements, and then we will talk about the encoding period in more detail.
Remember our COT example about the patient who went home on day 30, but had the 30-day assessment completed rather than the COT? That COT was considered a “Missed Assessment”. This is your working definition of a missed assessment.
Top Ten Missed Opportunities in the Skilled Nursing Facility
Top Ten Missed Opportunities In
The Provider Unit
of Harmony Healthcare International, Inc.
Kris Mastrangelo, MBS, NHA, OTR/L
President and CEO