Harmony Healthcare Blog

MDS PPS Assessments Compliance (Part I): Late Assessments

Posted by Kris Mastrangelo on Tue, Jun 05, 2018


Edited by Kris Mastrangelo

C.A.R.E.

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


Concept showing doctors stethoscope and a clock face simulating an appointment-1Harmony Healthcare International (HHI) performs monthly auditing, monitoring and educational services to the healthcare industry. During our on-site monthly audits, we hone in on MDS Assessments.  Compliance of MDS content accuracy and timeliness are critical focus areas as they impact care planning and reimbursement. 

The MDS contains over 1,000 data elements.  Precision requires constant focus and implementation of systems with inherent checks and balances.  

The most frequently asked questions on HarmonyHelp relate to the parameters for timely MDS Completion. 

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MDS Timeliness 

For a Skilled Nursing Facility to receive Medicare Part A payment you must complete scheduled and unscheduled MDS Assessments. 

The ARD (Assessment Reference Date) must be within the defined ARD window.  If the ARD is outside the window, the claim will be paid at the default rate (AAA and equal to PAI) for the number of days the ARD is out of compliance. 

In addition, the pattern of assessment completion times may trigger an audit. For example, if the facility demonstrates a practice of early or late assessment scheduling then a review may ensue. 

Late Assessment (Still a SNF Part A Resident) 

If the facility fails to set the ARD within the defined ARD window for a Medicare-required assessment, including the grace days, and the resident is still on Part A, the SNF must complete a late assessment. 

The ARD can be no earlier than the day the error was identified. 

  1. If the ARD on the late assessment is set for prior to the end of the period during which the late assessment would have controlled the payment, had the ARD been set timely, and/or no intervening assessments occurred, the SNF will bill the default rate for the number of days that the assessment is out of compliance.

    This is equal to the number of days between the day following the last day of the available ARD window (including grace days when appropriate) and the late ARD (including the late ARD). The SNF bills the Health Insurance Prospective Payment System (HIPPS) code established by the late assessment for the remaining period of time that the assessment would have controlled payment.

    Example

    PPS 30-day assessment with an ARD of Day 41 is out of compliance for 8 days and therefore would be paid at the default rate for 8 days and the HIPPS code from the late 30-day assessment until the next scheduled or unscheduled assessment that controls payment. If there are no other assessments until the 60-day assessment, the remaining 22 days are billed according to the HIPPS code on the late assessment.

    Example

    COT OMRA completed with an ARD of Day 39, while Day 7 of the COT observation period was Day 37. In this case, the COT OMRA would be considered 2 days late and the facility would bill the default rate for 2 days and then bill the HIPPS Code from the late COT OMRA until the next scheduled or unscheduled assessment controls payment, in this case, for at least 5 days. 

  2. If the ARD of the late assessment is set after the end of the period during which the late assessment would have controlled payment, had the assessment been completed timely, or in cases where an intervening assessment occurred and the resident is still on Part A, the provider must still complete the assessment.

    The ARD can be no earlier than the day the error was identified. The SNF must bill all covered days during which the late assessment would have controlled payment had the ARD been set timely at the default rate regardless of the HIPPS code calculated from the late assessment.

    Example

    PPS 14-day assessment with an ARD of Day 32 is paid at the default rate for Days 15 through 30. A late assessment cannot be used to replace a different Medicare-required assessment. The late 14-day assessment would not be considered an assessment used for payment and would not impact the COT calendar because only an assessment used for payment can affect the COT calendar.


Our next blog post will discuss MDS PPS Assessments Compliance (Part II) Missed Assessments.  There is a difference between missed and late assessments.  

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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