Harmony Healthcare Blog

MDS 3.0 OMRA Management: Change of Therapy (COT) and Start of Therapy (SOT)

Posted by Kris Mastrangelo, OTR/L, LNHA, MBA on Thu, May 18, 2017

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Edited by Kris Mastrangelo


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

pt_wheelchair.jpgWhat is trending this week? A bit of confusion with OMRA Assessment completion. Let’s simplify.

Defining Start of Therapy OMRA

  1. Optional Assessment: 
    • Completed only to classify a resident into a Rehabilitation group after therapy initiates
    • Not required if current nursing rate is higher
  2. ARD must be set on Days 5-7 after the start of therapy
    • First evaluation date equals Day 1
  3. Medicare payment rate begins on the day the first therapy evaluated as recorded on MDS

Defining Change of Therapy (COT) OMRA

  1. Of discussion, CMS specifically clarifies that if day 7 of the COT observation period falls within the ARD window of a scheduled PPS Assessment, the SNF may choose to complete the PPS Assessment alone by setting the ARD of the scheduled PPS assessment for an allowable day that is on or before day 7 of the COT observation period.
  2. Alternatively, the SNF may choose to combine the COT OMRA and scheduled assessment.  Per the RAI User’s Manual, Chapter 2 page 53, further supports this concept.

    “The facility completes a 30-Day assessment for Mr. E, with an ARD set for day 29, on which he qualifies for LB1, but opts not to combine this 30-Day assessment with a COT OMRA (as permitted under the COT rules outlines in Section 2.9 of the MDS 3.0 Manual).”

Example of Change of Therapy (COT) OMRA 

If the 5-Day MDS has an ARD of 12/21 (day 8) a COT review is required on 12/28 (Day 15) and the 14-Day PPS Assessment is scheduled with an ARD of day 15, there is no requirement to combine the COT and the scheduled assessment. 

  • If day 15 is chosen, however, the assessments may be combined and payment of the combined 14-Day and COT will initiate on Day 9 in this scenario. Facilities should closely review ARD Selection of the standard scheduled assessments. 
  • If the COT review date is on the ARD of the scheduled assessment, and COT requirements are met, facilities must review whether it is financially beneficial to combine the COT assessment with the scheduled assessment.

New Call-to-actionSteps of the Change of Therapy (COT) OMRA

Requirements and Exceptions 

  1. The COT process for review every 7 days begins when a scheduled assessment, SOT or Significant Change Assessment has sufficient minutes and days to achieve a Rehabilitation Category.
    • This is true even if a Nursing RUG Level is calculated due to index maximizing.
    • In other words, if a 5-Day Assessment yields a RUG Score of a CA1 with 4 days and 100 minutes of therapy, the COT process of review does not begin.
    • Conversely, if a 5-Day Assessment yields a RUG Score of a HE2 and 5 distinct calendar days of therapy and 150 minutes of therapy, the COT process of review begins.
  2. The COT review process schedule is based on the most recent assessment and therefore, is reset with each new PPS MDS.
  3. A COT is required for completion

    “when the resident was receiving a sufficient level of rehabilitation therapy to qualify for an Ultra-High, Very High, High, Medium, or Low Rehabilitation category and when the intensity of therapy (as indicated by the total reimbursable therapy minutes (RTM) delivered, and other therapy qualifiers such as number of therapy days and disciplines providing therapy) changes to such a degree that it would no longer reflect the RUG-IV Classification and payment assigned for a given SNF resident based on the most recent assessment used for Medicare payment.”

  4. If the ARD of a scheduled assessment is the same as the required COT review date (from the previous assessment) combining the assessment with a COT is essentially optional.
  5. If the patient discharges from the facility on the required COT review date, completing a COT is essentially optional.
    • For example, the patient is an RV Level on the 30-Day Assessment with an ARD of day 30. On day 37 the patient is a RH Level.
    • The patient discharges from the facility on day 37 (a non-paid day), a COT is not
    • Conversely, if the RUG Level increases to the RU Level, a COT may be completed. Note, a COT may be combined with a discharge assessment.
  6. If the patient’s last covered day is on a required COT review date and the RUG Level changes, a COT is required.
    • For example, the patient is an RV Level on the 30-Day assessment with an ARD of day 30. On day 37 the patient is an RH Level. The patient’s last covered day is day 37 (the facility will bill Medicare for this day) a COT is required.
  7. Per the policy finalized in the FY2015 SNF PPS final rule, a COT OMRA may be used to reclassify a resident into a RUG-IV Level therapy group when the resident was classified into a RUG-IV Non-Therapy Level by a previous COT OMRA (which may have been combined with another assessment).

    Harmony Healthcare International (HHI) emphasizes that the COT Process continues only when a Non-Therapy RUG was obtained on a Change of Therapy (COT).  This rule does not apply when a Non-Therapy RUG was obtained on a stand-alone scheduled Assessment (not combined with a COT).
  8. If the RUG Level currently paying is a Non-Therapy RUG Level due to index maximizing, a COT is only required when the total Reimbursable Therapy Minutes (RTM) would not result in a RUG Level classification change, and all other therapy category qualifiers have remained consistent with the patient’s current RUG Level classification, then the COT OMRA would not be completed.
  9. The COT process of review stops on the ARD of the End of Therapy (EOT) Assessment. 

We hope these examples and tips help with clarifying industry questions on the proper completion of the OMRA Assessments.  Harmony Healthcare International (HHI) is available to assist with any questions or concerns that you may have.  You can 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. 

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Tags: OMRA, Change of Therapy

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