Harmony Healthcare Blog

Clinical Components of ARD Management

Posted by Kris Mastrangelo, OTR/L, LNHA, MBA on Wed, Aug 14, 2013

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Edited by Kris Mastrangelo

October 1, 2011 CMS instituted changes to the PPS Assessment schedule. The changes in the Assessment Reference Date (ARD) windows impacted the coding and capture of services during the look back period.  As always, but now more than ever, facilities must maintain optimal organization of patient specific information.

The ARD marks the end date of the look back period. It must be set within the window of days allowed by the CMS MDS Assessment schedule. All medical data scored on the MDS is based on this date and the relevant look back period associated with items coded on the MDS. A randomly selected date will most likely result in a less than optimal RUG-IV category for Medicare billing.  The process for ARD selection requires extensive research on the patient’s clinical and medical status.  The medical record is the primary data source for this information.

While selecting the ARD, the medical record requires review.  All coded items on the MDS require supporting documentation within the medical record.  If staff interview or observation produces a different scenario (i.e., more physical assist to transfer) then the care provider needs to create a supplemental entry within the medical record. 

ARDs that are set outside the timetable established by the assessment schedule require billing the default code for all days up to the ARD date.  Default days can be nonexistent when a proper tracking system is implemented.  

Regardless of the SNF staff structure, ARD selection is a team discussion.   Multiple items impact the ARD selection process and include but are not limited to:

  • Expectation of the therapy intensity
  • Grace day usage
  • ADL support provided during the look back period
  • Identify skilled qualifiers
  • Last therapy treatment dates, SOT and EOT ARD dates
  • Skin and IV Medications
  • ADL assistance
  • Hospital and emergency room services
  • Physician visits, orders and consults
  • Respiratory Services
  • Interview Outcomes

The Change of Therapy Assessment added a new dimension to the ARD selection process.  On some level it really redefined the “prospective payment” back to a “retrospective payment” system.  Once the first PPS assessment is completed, (the 5 day assessment), the team is required to monitor the intensity and number of days delivered to the patient every seven days from the original ARD.  What does this mean? For claims that are being billed at a Rehabilitation RUG level, the facility is obligated under Medicare guidelines to establish an ARD for what is called a Change of Therapy Assessment (COT/OMRA).  This assessment is used to reset the payment rate when the intensity of therapy services varies from the original RUG level. This COT monitoring period takes place every seven days until another intervening MDS assessment is completed for billing purposes.  This seven day requirement begins after every additional ARD is submitted.  This intensifies the monitoring of therapy minutes and results in much more opportunity for error. 

In summary, adaptability is the name of the game in the ARD selection process.  Flexibility, cooperation, communication, and planning are all essential for success.  This approach will exponentially minimize mistakes, late ARD’s, missed assessments, unnecessary assessments or reimbursement disruptions.

 

MDS 3.0 Schedule

 

Previous

 

Medicare MDS Assessment Type

Assessment Reference Window Date

 

 

Grace Days

Reason for Assessment (A0310B)

 

Medicare Payment Days

5 day

Days 1-5

6-8

01

1 through 14

14 day

Days 11-14

15-19

02

15 through 30

30 day

Days 21-29

30-34

03

31 through 60

60 day

Days 50-59

60-64

04

61 through 90

90 day

Days 80-89

90-94

05

91 through 100

 

 

Current (as of October 1, 2011)

 

 

Medicare MDS Assessment Type

Assessment Reference Window Date

 

Grace Days

 

# of Days Eliminated

Reason for Assessment (A0310B)

Medicare Payment Days

5 day and Readm

Days 1-5

6-8

0

01 or 06

1 through 14

14 day

Days 13-14

15-18

3

02

15 through 30

30 day

Days 27-29

30-33

7

03

31 through 60

60 day

Days 57-59

60-63

7

04

61 through 90

90 day

Days 87-89

90-93

7

05

91 through 100

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