Harmony Healthcare Blog

Medicare Rehabilitation Medium and Low RUG Categories - Distinct Days

Posted by Kris Mastrangelo, OTR/L, LNHA, MBA on Tue, Dec 10, 2013

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Edited by Kris Mastrangelo

CMS released the Final Rule in August 2013 solidifying the changes to the calculation for classification into the Medicare Rehabilitation Medium and Low RUG categories for RUG-IV. The changes began with assessment dates with an ARD on or after October 1, 2013.

The Final Rule adds an additional MDS 3.0 item (MDS Item 00420) for Calendar Days of Therapy that will require reporting of distinct calendar days of therapy provided. Distinct calendar days represents the different days therapy was provided in the ARD or COT review look back period. In other words, on how many different days were rehabilitation services provided for greater than 15 minutes over the last seven days?

For example:  

PPS Day   

1

2

3

4

5

6

ARD

7

 

   9/25   

   9/26   

   9/27   

   9/28   

   9/29   

   9/30   

   10/1   

PT

30

 

 

30

 

 

30

OT

 

30

 

 

30

 

 

ST

 

 

30

 

 

30

 

Total

30

30

30

30

30

30

30

 

This would be reported as:

  • Speech Therapy 2 days for a total of 60 minutes
  • Occupational Therapy 2 days for a total of 60 minutes
  • Physical Therapy 3 days for a total of 90 minutes
  • 7 Distinct Calendar Days

In addition, the RUG-IV grouper will only calculate a Rehabilitation Medium RUG category when 150 minutes of therapy is provided across 5 distinct calendar days. In other words, within the 7 day observation period of the MDS or COT review, therapists must deliver services to the patient on at least 5 of the 7 days in the observation period from the Assessment Reference Date (ARD). If this criterion is not met, regardless of the number of minutes or total of combined discipline visits of rehabilitation services provided, the RUG score generated will reduce to a Nursing RUG.

For example:

PPS Day

1

2

3

4

5

6

ARD

7

8

 

9/25

9/26

9/27

9/28

9/29

9/30

10/1

10/2

PT

0

40

50

60

0

0

30

R

OT

0

30

50

40

0

0

50

R

ST

 

0

0

30

0

0

30

R

Total

0

70

100

130

00

0

110

0

 

In the example above:

  • Speech Therapy 2 days for a total of 60 minutes
  • Occupational Therapy 4 days for a total of 170 minutes
  • Physical Therapy 4 days for a total of 180 minutes
  • 4 Distinct Calendar Days

Although Therapy was provided for a total of 10 visits, the Rehabilitation Medium criteria will not be met and a Nursing RUG classification will apply. Prior to October 1, 2013, the MDS RUG-IV Grouper allowed the classification criteria to be met for the Medium Rehabilitation category without 5 distinct days of therapy. Within the ARD observation period, resources were measured and the Rehabilitation Medium RUG criteria would be met if 150 minutes of therapy were provided and greater than 5 visits of therapy across a combination of disciplines occurred.

For Ultra High, Very High and High categories, at least one discipline must provide 5 days in the observation period in addition to meeting the criteria for total minutes. This will not change under FY2014 requirements. Distinct calendar days will affect the Rehabilitation Low categories as therapy will need to be provided on 3 or more distinct calendar days.

The above scenario may occur when a patient has an unplanned discharge to the hospital or home. If this occurs on a 5 day PPS MDS or Return MDS, the facility may want to consider applying the Short Stay Policy. It is recommended that facilities review the requirements for a Short Stay assessment as the incidence of its use will increase with these new requirements.

Harmony (HHI) reminds facilities that the COT process for review cannot begin until an MDS is completed with sufficient minutes to meet a Rehabilitation category. It is the reporting in Section O of the MDS that must be considered versus the paying RUG category. An MDS may have sufficient minutes to meet a category yet index maximize to a higher paying Nursing category. Conversely, a Nursing RUG with therapy involved may not necessarily have sufficient minutes and days of therapy. Providers are reminded to look at the number of minutes, days per discipline and now distinct calendar days of therapy to ensure the COT process can begin. In the example above, a COT cannot be completed 7 days after the ARD because a Rehabilitation category is no longer achieved without 5 distinct days of therapy.

The RUG generated by the MDS should not be confused with skilled coverage criteria. If rehabilitation is the primary reason for a skilled level of care, the facility has to ensure therapy is clinically indicated at least 5 days per week in order for the patient to meet Medicare skilled coverage criteria. For example, if physical therapy is furnished on 3 days each week and occupational therapy is furnished on 2 other days each week, the “daily basis” criteria may be met. Note that CMS reinforces that the daily skilled requirement would only be satisfied if there were a valid medical reason why both cannot be furnished on the same day. The frequency a service is performed does not, by itself, make it a skilled service. The services must be reasonable and necessary for the treatment of the patient’s condition. 

As detailed in Chapter 8 of the Medicare Benefit Policy Manual, “Unless there is a legitimate medical need for scheduling a therapy session each day, the “daily basis” requirement for SNF coverage would not be met.” Facilities may need to schedule medically necessary therapies less than 5 days per week from multiple disciplines due to the patient’s inability to tolerate 2 therapies 5 times per week. Medical complexities may also include scheduled medical treatments like dialysis, radiation or chemotherapy that impact toleration of therapy.

By adding Calendar Days of Therapy to the Rehabilitation Medium RUG requirement, facilities will have to factor this in to the ARD selection and Change of Therapy (COT) review requirements to ensure all MDS scheduling requirements are met. A Change of Therapy (COT) MDS is required when either or both the days of therapy and minute requirements are not met within the COT observation period from the previously established RUG. There is the potential for a greater occurrence of COT assessments.

Medical complexities may also include patients with behavior and cognitive impairments. It is common for these patients to require skilled therapy interventions and have challenges receiving medically necessary therapy. Without Clinically Complex or Special Care High and Low RUG qualifiers, there is the potential for a lower 14 Nursing RUG classification to yield. These patients may also be more likely to refuse a therapy session and require a COT assessment. Given the national trend of Governmental Medical Record reviews for the lower 14 RUG categories, facilities must be prepared for these potential Additional Documentation Requests (ADRs).

Free_RUG_Analysis_Long

 

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Tags: CMS, MDS 3.0, RUG-IV;

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