Harmony Healthcare Blog

MDS PPS Assessments Compliance (Part 2): Missed Assessments

Posted by Kris Mastrangelo on Thu, Jun 07, 2018


Edited by Kris Mastrangelo

C.A.R.E.

Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency


Magnifying glass showing assessment word on grey backgroundAs a continuation of Tuesday’s blog post, lets discuss missed assessments. The fundamental difference between a missed and late assessment is where the patient is at the time of the due assessment.  A late assessment occurs when the patient is still in the facility while a missed assessment occurs when the patient is no longer in the facility or denied Part A Benefits. 

Missed Assessment (No Longer a SNF Part A Resident) 

When PPS first began, MDS where completed on paper and transcribed into the data base for transmission to the state. Today, MDS completion occurs within the electronic system and the software tracks ARD setting, data input and completion time. 

Per the RAI User’s Manual, each Medicare Assessment requires the selection of the ARD within the ARD Window.  This applies to both scheduled and unscheduled assessments. The facility is required to set the ARD on the MDS form itself or in the facility software within the appropriate timeframe of the assessment.  Timeliness is defined by selecting an ARD within the prescribed ARD Window. 

The below table provides you with ARD Windows. 

Medicare Scheduled and Unscheduled MDS Assessment
ARD Schedule 

Assessment Type

Assessment Reference Date (ARD)
Can Be Set on any of the Following Days

Grace Days – ARD Can Also Be Set On These Days

Allowed ARD Window

5-Day

1-5

6-8

1-8

14-Day

13-14

15-18

13-18

30-Day

27-29

30-33

27-33

60-Day

57-59

60-63

57-63

90-Day

87-89

90-93

87-93

Start of Therapy OMRA

5-7 Days after the start of therapy, first day of therapy evaluation counts as day one.

End of Therapy OMRA

1-3 Days after all therapy services are discontinued.  The first non-therapy day counts as day one.

Change of Therapy OMRA

Day 7 of the COT observation period.

 

What are the consequences of a missed assessment? 

If the SNF fails to set the ARD of a scheduled PPS assessment prior to the end of the last day of the ARD window, including grace days, and the resident is no longer a SNF Part A resident, and as a result a Medicare-required assessment does not exist in the QIES ASAP for the payment period, the provider may not usually bill for days when an assessment does not exist in the QIES ASAP. 

When an assessment does not exist in the QIES ASAP, there is not an assessment based RUG the provider may bill. In order to bill for Medicare SNF Part A services, the provider must submit a valid assessment that is accepted into the QIES ASAP. The provider must bill the RUG category that is verified by the system. 

If the resident was already discharged from Medicare Part A when this is discovered, an assessment may not be performed! 

However, there are instances when the SNF may bill the default code when a Medicare-required assessment does not exist in the QIES ASAP system. 

These exceptions are: 

  1. The stay is less than 8 days within a spell of illness,
  2. The SNF is notified on an untimely basis of or is unaware of a Medicare Secondary Payer denial,
  3. The SNF is notified on an untimely basis of a beneficiary’s enrollment in Medicare Part A,
  4. The SNF is notified on an untimely basis of the revocation of a payment ban,
  5. The beneficiary requests a demand bill, or
  6. The SNF is notified on an untimely basis or is unaware of a beneficiary’s disenrollment from a Medicare Advantage plan. 

When an OBRA Admission Assessment does not exist, the SNF must have a valid OBRA assessment (except a stand-alone discharge assessment) in the QIES ASAP system that falls within the ARD window of the 5-day or the 14-day (including grace days) in order to receive full payment at the RUG category in which the resident grouped for days 1-14 or days 15-30. This assessment may only cover one payment period. If the ARD of the valid OBRA assessment falls outside the ARD window of the 5-day and 14-day PPS assessments (including grace days), the SNF must bill the default code for the applicable payment period. For covered days associated with the Medicare-required 30-day, 60-day, or 90-day assessments, the SNF must have a valid OBRA assessment (except a stand-alone discharge assessment) in the QIES ASAP system that falls within the ARD window of the PPS assessment (including grace days) in order to receive full payment at the RUG category in which the resident grouped. If the ARD of the valid OBRA assessment falls outside the ARD window of the PPS assessment (including grace days), the SNF must bill the default code. 

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Under all situations other than exceptions 1-5, the following apply when the SNF failed to set the ARD prior to the end of the last day of the ARD window, including grace days, or later and the resident was already discharged from Medicare Part A when this was discovered: 

  1. If a valid OBRA assessment (except a stand-alone discharge assessment) exists in the QIES ASAP system with an ARD that is within the ARD window of the PPS assessment (including grace days), the SNF may bill the RUG category in which the resident classified. 
  1. If a valid OBRA Assessment (except a stand-alone discharge assessment) exists in the QIES ASAP system with an ARD that is outside the ARD window of the Medicare-required assessment (including grace days), the SNF may not bill for any days associated with the missing PPS assessment. 
  1. If a valid OBRA assessment (except a stand-alone discharge assessment) does not exist in the QIES ASAP system, the SNF may not bill for any days associated with the missing PPS assessment. 

In the case of an unscheduled assessment if the SNF fails to set the ARD for an unscheduled PPS assessment within the defined ARD window for that assessment, and the resident has been discharged from Part A, the assessment is missed and cannot be completed. All days that would have been paid by the missed assessment (had it been completed timely) are considered provider-liable (the provider and not the beneficiary is liable under the social security Act.)

Harmony Healthcare International (HHI) is here to help. We understand how much work is involved for you and your staff to run an efficient, compliant, and fiscally sound facility.  

Harmony Healthcare International (HHI) can: 

  • Identify areas of risk and opportunity
  • Education on rules and regulations
  • Implement Systems (QAPI)
  • Monitor progress and performance

Harmony Healthcare International (HHI) performs monthly compliance audits. If you need help with this area, please contact us by clicking here.  Looking to train your staff?  Join us in person at one of our our upcoming Competency/Certification Courses.  Click here to see the dates and locations. 

Source:  MDS RAI User’s Manual


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