Harmony Healthcare Blog

Modifying the PPS Assessment Reason for Assessment After Transmission

Posted by Kris Mastrangelo, OTR/L, LNHA, MBA on Sat, Jun 15, 2013

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Edited by Kris Mastrangelo

Providers have long struggled with items that may not be modified on the MDS 3.0 assessment.  Occasionally, a typographical or data entry error will cause an assessment to be submitted with the Reason for Assessment (RFA) coded incorrectly in one of the many fields in Section A0310A-G.  Providers only option was to inactivate the assessment with the error and complete a new assessment when the error was discovered with the current date as the ARD.  If the resident was no longer covered under Medicare Part A when the error was discovered the facility would be unable to replace the inactivated assessment.  

Beginning on May 19, 2013, providers will have the option to modify this item on the MDS when the facility identifies an error in the RFA.  Providers will be able to modify the assessment to correct an error in this field, provided the assessment item set does not change.  The ability to modify the RFA on an assessment that is otherwise valid eliminates financial penalties that resulted under the previous policy, which required the assessment to be inactivated resulting in a late or missed assessment.  Modifying the assessment would enable the facility to appropriately bill the HIPPS code generated for the number of day covered by the assessment type. 

There are ten possible item sets that could be completed and the coding of the reason for assessment determines which item set is selected for completion.  

For example, the comprehensive item set (NC) is a full item set that includes the CAA process.  Scheduled Medicare assessments are completed using the PPS (NP) item set.  When a scheduled Medicare assessment is dually coded as an OMRA assessment in section A310C, the PPS item set would be used.  In situations where the facility completes an unscheduled OMRA assessment, the item set selected could differ depending on the type of OMRA completed.  Specifically, the End of Therapy (EOT) OMRA and Change of therapy (COT) OMRA are both completed using the same EOT OMRA (NO) item set.  When an unscheduled Start of Therapy (SOT) OMRA is completed, the SOT (NS) item set used is significantly shorter.  Since the only objective of this assessment is to calculate a rehabilitation RUG category, the item that would be required to calculate a non-therapy RUG category are not included in this item set.

Listed below are some examples of situations in which a modification in the reason for assessment field will be allowed due to the item set not changing from this modification subsequent to acceptance in the QIES database:

  • The RFA could be appropriately modified when an assessment was completed and submitted to the QIES ASAP database with an ARD of day 27 and was intended to be the scheduled 30 day Medicare MDS. This assessment was incorrectly coded as a 14 day Medicare assessment.  In this case, the PPS item set is completed for both types of assessments and modification of the RFA would be the appropriate corrective action.
  • Similarly, if the facility correctly completed an assessment three days after the last therapy treatment session and incorrectly coded the RFA as a COT instead an EOT, the OMRA (NO) item set is completed for both assessment types and the reason for assessment could be modified.
  • If the facility completed a discharge assessment that is also coded as a 5 day Medicare Assessment then the PPS item set is completed.  This assessment should have also been coded as a SOT OMRA, but the omission was not discovered until after transmission.  The item set will not be altered by modifying section A0310C to indicate the assessment is also a SOT OMRA.  As a result completing a modification to correct the coding of this assessment is an acceptable course of action.  

Examples of situations in which a modification for RFA would not be accepted, due to the fact that the item set is not the same, include the following:

  • If the facility completed and transmitted a quarterly MDS and subsequently discovered a Significant Change in Status Assessment (SCSA) should have been completed a modification would not be permitted.  In this situation, the SCSA requires the use of the Comprehensive (NC) item set, which is a full item set with CAAs.  The Quarterly assessment that was completed used the shorter Quarterly (NQ) item set.  The CAAs are not a component of this item set.  Since the item set completely differs from the item set desired the modification is not allowed.  In this case, the only acceptable “fix” to this error is to complete a new MDS with the current ARD and use the correct item set by coding the MDS as SCSA in section A0310A.
  • In a situation where the facility intended to complete a 14 day Medicare and a SOT OMRA as a combined assessment, but incorrectly coded the assessment as an unscheduled SOT OMRA a modification would not be allowed.  The SOT OMRA (NS) item completed is significantly shorter than the PPS (NP) item set required for completion of a combined 14 day/SOT OMRA assessment.  In this case, the correct course of action would be determined based on whether the beneficiary was still covered under Medicare Part A when the error was identified.  

In the case that a beneficiary is still covered under Medicare Part A and has not been discharged, a 14 day MDS should be completed with a current ARD.  This will allow the facility to bill the default rate for any Medicare days covered by this assessment.  If the error was not discovered until after Medicare Part A coverage has ended, the 14 day MDS would be a missed assessment and provided liable days are applied to any days covered by this assessment.

Providers are encouraged to maintain good practices, such as the use of the 7 day encoding period, to keep these corrections to a minimum.  In the event an error is identified post transmission, providers are encouraged to use the item set code (ISC) reference table found in Chapter 2 of the RAI User's Manual on page 2-77 to determine whether modifying a RFA field will impact the item set code of a completed assessment.  Because of these changes, the facility may see two new warning error messages could appear on validation reports.  

-1061:  A change in the target date or RFA in combination with a change in the clinical item listed may indicate improper coding.


-1062:  A change in the target date or RFA in combination with a change in the clinical item listed and Medicare RUG may indicate improper coding.  

In addition, facilities will see a fatal error in case where the modified record contains a change in the item set code, (ISC).

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Tags: Denial Management

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