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Medicare Part A Required SNF PPS Assessments: Back to Basics (Part 2 of 3)

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


Assessments Concept. Word on Folder Register of Card Index. Selective Focus..jpegUnscheduled Assessments 

Last week we reviewed the PPS MDS Scheduled Assessments required for Medicare Part A Billing.  Often, situations arise in which the MDS Coordinator must complete an assessment outside of the planned assessments.  These types of assessments are known in the industry as “Unscheduled Assessments.”  There are six types of unplanned MDS Assessments: 

  1. Significant Change in Status Assessment (SCSA) 
  1. Significant Correction to Prior Comprehensive Assessment (SCPA) 
  1. Start of Therapy-Other Medicare Required Assessment (SOT-OMRA) 
  1. End of Therapy-Other Medicare Required Assessment (EOT-OMRA) 
  1. EOT-OMRA with Resumption (EOT-R) 
  1. Change of Therapy-Other Medicare Required Assessment (COT-OMRA) 

The below table is super helpful when calculating the Medicare Part A payment start and stop times as these unscheduled PPS MDS Assessments can be quite confusing to calculate. (Source: Section 2.8 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual.)

Assessment Type

AI

ARD Window

Medicare Payment Start

Medicare Payment End

Significant Change in Status Assessment (SCSA)

(SCSA)

01

No later than 14 days after significant change/error identified

Payment begins on the ARD

End of Standard Payment Period

Significant Correction to Prior Comprehensive Assessment (SCPA)

(SCPA)

01

No later than 14 days after significant change/error identified

Payment begins on the ARD

End of Standard Payment Period

Start of Therapy-Other Medicare Required Assessment (SOT-OMRA)

(SOT-OMRA)

02

5-7 days after the start of therapy

Day of First Therapy Evaluation

End of Standard Payment Period

End of Therapy-Other Medicare Required Assessment (EOT-OMRA)

(EOT-OMRA)

04

1-3 days after all therapy discontinued

The Day After all Therapy Discontinued

End of Standard Payment Period

EOT-OMRA with Resumption (EOT-R)

(EOT-R)

0A

1-3 days after all therapy discontinued

The Day After the Last Day of Therapy

The Day Before Therapy Resumes

Change of Therapy-Other Medicare Required Assessment (COT-OMRA)

(COT-OMRA)

0D

Day 7 (last day) of the COT observation period and then every 7th day until the next scheduled assessment

The First Day of the COT Observation Period

End of Standard Payment Period or Until Interrupted by the Next COT-OMRA

 

Unscheduled Assessments Descriptions 

  1. Significant Change in Status Assessment (SCSA) 

Called the Swing Bed Clinical Change Assessment for swing bed providers 

Complete when the SNF interdisciplinary team determines a resident meets the significant change guidelines for either decline or improvement. 

A significant change is a major decline or improvement in a resident’s status that meets all requirements: 

  • It will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical intervention, and the decline is not considered “self-limiting”
  • It impacts more than one area of the resident’s health status
  • It requires interdisciplinary review and/or revision of the care plan 

A significant change may require referral for a Pre-admission Screening and Resident Review evaluation if a mental illness, intellectual disability, or related condition is present or suspected. 

  1. Significant Correction to Prior Comprehensive Assessment (SCPA) 

Complete when a significant error was made in the prior comprehensive assessment.  

A significant error is an error in an assessment where both of the following are true: 

  • The resident’s overall clinical status is not accurately represented (that is, miscoded) on the erroneous assessment
  • The error was not corrected via submission of a more recent assessment. 

A significant change differs from a significant error because it reflects an actual significant change in the resident’s health status and is not due to incorrect coding of the MDS 3.0

RCS-1 Part 2 On-Demand

  1. Start of Therapy - Other Medicare Required Assessment (SOT-OMRA) 

Complete only to classify a resident into a RUG-IV Rehabilitation Plus Extensive Services or Rehabilitation group.  If the RUG-IV classification is not a Rehabilitation Plus Extensive Services or a Rehabilitation group, the Centers for Medicare & Medicaid Services (CMS) will not accept the assessment, and you may not use it for Medicare billing. 

  1. End of Therapy - Other Medicare Required Assessment (EOT-OMRA) 

Complete when all are true: 

  • The resident was in a RUG-IV Rehabilitation Plus Extensive Services or Rehabilitation group
  • The resident does not receive any therapy services for 3 or more consecutive calendar days
  • The resident continues to require Part A SNF-level services
  1. EOT-OMRA with Resumption (EOT-R) 

Complete when all are true: 

  • Therapy resumes after the EOT-OMRA
  • Therapy resumes within 5 days after the last day of therapy
  • Therapy resumes at the same RUG-IV classification level with the same therapy plan of care 
  1. Change of Therapy - Other Medicare Required Assessment (COT-OMRA) 

Generally, complete when both are true: 

  • The resident received a level of rehabilitation therapy to qualify for an Ultra High, Very High, High, Medium, or Low Rehabilitation RUG-IV category.
  • The intensity of therapy, as indicated by the total reimbursable therapy minutes delivered and other therapy qualifiers, such as the 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 based on the most recent assessment used for Medicare payment.

Complete for a resident who is not currently classified into a RUG-IV therapy group in rare cases where both are true: 

  • The Resident had qualified for a RUG-IV therapy group on a prior assessment during the resident’s current Medicare Part A stay.
  • No discontinuation of therapy services occurred between Day 1 of the COT observation period for the COT-OMRA that classified the resident into the current non-therapy RUG-IV group and the ARD of the COT-OMRA that reclassified the resident into a RUG-IV therapy group.

The COT observation periods are successive 7-day windows.  The first observation period begins on the day following the ARD set for the most recent scheduled or unscheduled assessment.  For example, if the ARD for a patients Medicare-required 30-day assessment is set for day 30 and there are no intervening assessments, the COT observation period ends on day 37.

Providers must complete scheduled assessments according to the information in Table 2.  Unscheduled Assessments.

  • Medicare payment days for unscheduled assessments vary by situation.
  • Unscheduled assessments do not have grace days. On Thursday, 3.29.18, Part III Blog post for this series will be on Discharge Assessments.

On Thursday, 3.29.18, Part III Blog post for this series will be on Discharge 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. 


Join us November 1st & 2nd, 2018 at Mohegan Sun Resort for harmony18
7th Annual LTPAC Symposium
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harmony20 October 29-30 2020 Encore Boston Harbor

Topics: PPS


Kris Mastrangelo, OTR/L, LNHA, MBA

WRITTEN BY

Kris Mastrangelo, OTR/L, LNHA, MBA
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