Overview of Rule. CMS Changes Related to MDS Completion and SNF Medicare Billing. Overview Impact Response

Transcription

1 CMS Changes Related to MDS Completion and SNF Medicare Billing Overview Impact Response Presented by: Darlene Thompson and Tami Johnson Our industry is resilient and has a demonstrated track record for adapting to change We will successfully navigate this change in the same way we adapted to the MDS.0 and RUGs IV transition in 20 2 Overview of Rule Adjusted the CMIs and associated rates Result in a reduction to skilled nursing facility payments by -2.6% Adjustments Targeted the Nursing Component of the Rehab RUGs CMS applied a +2.7% Market Basket Adjustment Reduced that by -.0% percent multi-factor productivity (MFP) adjustment mandated by the Affordable Care Act

2 Urban Rate Comparisons RUG RUC RVC RMC RMB ES ES2 ES HE2 PPS 20 $64.27 $55.5 $44.7 $40.7 $66.20 $57.58 $462.4 $ PPS 202 $ $479.8 $66.95 $44.47 $ $ $ $ Based on average Urban Rate for 20 and Overview of PPS Rule 202 Group Therapy (RUGs Grouper Change) MDS Changes Changes to OMRA Assessment Types Modified the End of Therapy (EOT) OMRA Requirements Modified the EOT OMRA to allow Resumption of Therapy (EOT-R) Introduced Change of Therapy OMRA (COT) to evaluate rehab intensity every 7-days Changed Available Days for Scheduled MDSs Transition Plan for 0/0/20 5 MDS Scheduling Changes 6 2

3 Changes in the MDS Schedule Reduces the number of days available for each scheduled MDS Reduces the overlap of look back days between assessments Impacts scheduling software and basic MDS patterns for centers Evaluate combining of various MDSs types Evaluate MDS timing Evaluate timing of CAAs and Care Plans Understand how and when to combine assessments 7 Changes to Scheduling MDS Type 5-day Current -8 0/0/20-8 Change None Most Common Today Day 8 4-day -9-8 days Day 0-day days Day 2 60-day days Day day days Day 84 8 Transition Plan Revised MDS Schedule Any set on or after October, 200 must be a valid date as defined by the new Valid Days Table This would mean after 0/0/200 an which fell on any of the following stay days would not be valid: Days -2, 9, 2-26, 4, 50-56, 64, 80-86, or 94 9

4 Group Therapy 0 Group Therapy Group must be scheduled for 4 patients performing the same or similar activities Assigns group minutes by dividing the minutes by 4 for allocation to the RUG Group regardless of group size Example: If PT conducts a 60 minute group with four patients. Each patient receives 5 minutes of treatment toward their RUG level. Cap remains at 25% of the Reimbursable Therapy Minutes (RTM) Plan of Care must support need for therapy Current Group Utilization CMS Statistics Show: 8% of the minutes delivered in group 2 patients per group currently is a common practice Must be scheduled for 4 patients going forward RTM divided by 4 even when on patients treated Changes in Group minutes impacts primarily RU, RV, and RH RUG categories 2 4

5 Transition Plan Group Therapy Any MDS with an 0/0/20 or later, group therapy minutes will be allocated as 25% regardless of look back period Change of Therapy OMRA 4 Change of Therapy (COT) Requires the evaluation of rehab service delivery 7-days after or COT check to determine if the RUG has been maintained If RUG is unchanged, no assessment needed If RUG (rehab intensity) increased, COT OMRA to increase RUG If RUG is decreased, COT OMRA required to decrease RUG Rates change with the first day of the Observation Period of the COT 5 5

6 Change of Therapy OMRA SUN 27 4 COT 5 MON TUE 29 6 WED THU 8 5 FRI SAT Payment Changes COT What triggers a COT? Drop in rehab minutes below the RUG threshold Failure to meet the frequency (treatment days) criteria A day of treatment must equal 5 minutes for each discipline Missed minutes are easier to recover than missed days Example: RU requires 720 min. with disc. 5x/wk. & one x/wk. If we deliver 720 min. but only 4x/week w/ 2 disc., it drops to RM If we deliver 79 min. but with 2 disc. at 5x/week, it drops to RV 7 What triggers a COT OMRA? Must complete COT check if in a rehab RUG or in a nursing RUG receiving rehab If a patient has a change in the RUG category and the COT falls within the Regularly Scheduled Assessment Window (including grace days) and the MDS has not been completed, the COT must be combined with the Regularly Scheduled MDS. 8 6

7 Change of Therapy (COT) Uses the OMRA Item Set Because the COT is required for patients in Rehab RUG or patients receiving Rehab but in Nursing RUG Watch Index Maximization with Nursing RUGs A center could drop their reimbursement by completing an unnecessary COT MDS 9 Index Maximization - Urban RUX RUL RVC RLX HC2 HB2 CD2 LE PE CD ES ES LD2 RMB PD2 RVX RVL RUA HE2 HE RHB CE PE2 CC2 PD RUC HD2 CE2 HC LC RUB RMX RHC RVB RMC RLB HB LD2 RMA CC ES2 RML RVA LE2 HD LC2 RHA LB2 CB2 LB 20 What can trigger an COT? Missed treatment sessions Patient Illness Scheduling conflicts (patient appointments, patient being ready) Family Visits or Outings Patient Refusals Withheld treatments Holidays with Missed Sessions Therapist Illness or Vacation Days Partial treatment sessions Changes in rehab intensity and/or added disciplines Discontinuation or initiation of one or more treating disciplines Inconsistent Delivery of Care and Poor Communication No flexibility in Selection for COT 2 7

8 IMPORTANT Every MDS Puts the ADL Coding Back Under Review Every patient will remain in an observation period for the entire duration of their stay. 22 Impact of Change of Therapy Billed Minutes Actual Minutes Delivered on 5, 4, 0-day MDS Pt. sick and session missed 724 min 727 min 648 min 74 min RUB 5-day MDS RUB 4-day MDS Change of Therapy RVB RUB 0-day MDS Change of Therapy RVB Rate Change to on st day of Observation period Change of Therapy RHB Actual Minutes Delivered Below Billed RUG Level Billed Minutes Minutes Delivered PPS Billing 0/0/20 Impact of COT on 0-day MDS 728 min. 702 min. 58 min. 42 min. 75 min. RUB 0-day MDS 7-days COT RVB 7-days COT RVB 7-days COT RHB Rate Change to on st day of Observation period 7-days RMB 60-day MDS Actual Minutes Delivered Below Billed RUG Level Billed Minutes Minutes Delivered PPS RUG 0/0/20 8

9 Normal Admission Process day COT COT 9 Change Rate Rate 4-day COT Combo COT 4 Change Rate 2 Change Rate Rate 0-day COT COT day MDS Pays Days -4 4-day MDS Pays Days day Combining Scheduled and Unscheduled MDSs If an unscheduled MDS is in a scheduled assessment window, the unscheduled MDS cannot be later in that window. The two assessments must be combined. 26 Combining Scheduled and Unscheduled MDSs COT or Check Combo COT 4 Change Rate 2 Change Rate If the COT is required, the days after the COT shown here in RED are no longer available as an 27 9

10 Frequency of COT Assessments MDS Type 5-day 4-day 0-day 60-day 90-day MDS Pays Potential # COT after the Likely Combined w/ 4-day Likely Combined w/ 0-day ** Additional COT assessments can occur as EOT and SOT are completed. The effectiveness of rehab management and patient stability will impact frequency. Transition Plan COT OMRA The COT OMRA process becomes required for any scheduled or unscheduled MDS with an of 0/0/20 or later 29 End of Therapy OMRA 0 0

11 End of Therapy OMRAs EOT OMRA Required with -missed days of rehab Regardless if missed session is on a weekday, weekend or holiday Regardless of weekend coverage at the center Regardless of why session was missed Medicare does not recognize holidays as an acceptable day of missed therapy Treatment day must equal at least one discipline at 5 minutes of treatment to count as a treatment day Reimbursed at a Nursing RUG for days without rehab End of Therapy OMRA Sun Mon Tue Wed Thu Fri Sat PT/OT 2 PT PT/OT 4 PT/OT 5 PT 6 No Rehab 7 No Rehab 8 No Rehab 9 No Rehab 0 PT/OT resumes 2 2 End of Therapy Resumption (EOT-R) EOT triggers due to three consecutive days without treatment and Rehab resumes within 5-days, triggers EOT-R and Resumes at the same frequency/intensity Paid at level prior to EOT on day rehab resumed, but paid at nursing RUG for days without treatment Equals date rehab resumes care

12 End of Therapy - Resumption Sun Mon PT/OT Tue 2 PT Wed PT/OT Thu 4 PT/OT Fri 5 PT Sat 6 No Rehab 7 No Rehab 8 No Rehab 9 No Rehab Paid at Nursing RUG PT/OT Resumes 7 COT IMPORTANT: Becomes the Rehab Start Date on the next MDS and becomes The date of rehab resumption becomes the trigger for the 7-day rehab count start date on the next MDS and it starts for COT the OMRA COT Observation Period. 4 Transition Plan EOT and EOT-R Policy is effective for any s 0/0/20 or later October st is a Saturday an if treatment is missed (regardless of cause or weekend coverage rules of the past) is will count as a missed day 5 Transition Plan for Billing Any MDS that has pay dates in September and October will generate two RUG scores when transmitted to the QIES ASAP repository FY20 RUGs scores reflected in Error Message #059 (September billed Dates) FY202 RUGs scores reflected in Error Message #060 (October billed Dates) Problem: The QIES ASAP system will not be updated until 09/8. MDSs with s between 08/22 and 09/7 may have pay dates in both September and October 6 2

13 Combining the Changes 7 The Most Complex Part When Combining Assessments, we must meet the requirement for all of the Assessments Scheduled Assessments (5, 4-day, etc.) SOT Day 5-7 after st evaluation EOT Day - after missed session EOT-R - after missed session with resumption within 5-days COT Day 7 after All MDSs and combinations of MDSs must meet the reimbursement requirements 8 Scheduling MDSs OBRA Assessments Admission Quarterly... Annual PPS Assessments NEW RANGES 5-day 4-day 0-day 60-day 90-day COT OMRA Assessments COT COT COT x COTx COT Unscheduled OMRA Assessments EOT, SOT, SCSA 9

14 Combining Scheduled and Unscheduled MDSs If the for the OMRA falls within the (including grace days) of a PPS scheduled assessment that has not been performed yet, the assessments MUST be combined. This includes EOT, SOT, E/SOT, and COT OMRAs 40 MDS Based on Current Practice and Volume Change in MDS Volume With clinically appropriate RUG management by rehab and nursing Sep-0 MDS.0 Oct Here s what we found MDS-N tend to complete MDSs early Results in un-used or over-written MDSs Failure to combine MDSs when clinically appropriate MDS-N complete additional MDSs due to lack of communication Confusion on Rules for Combining Assessments 42 4

15 Centers With the Greatest Impact: Longer LOS Decreased ability to provide weekend coverage Rehab staffing challenges Problems with scheduling rehab treatments High patient refusals Poor Communication Poor ADL Management 4 Common Strategies Improve communication Enhance MDS Scheduling Increase understanding around combinable MDSs Provide clinically appropriate rehab in the most appropriate method Improve scheduling to decrease missed rehab sessions Make-up missed sessions as clinically appropriate Improve Productivity with existing staff Improve consistency of weekend coverage Increase staffing as necessary Some causes of the COT or EOT cannot be mitigated 44 Action Steps 45 5

16 Center Level Focus Increase communication Monitor ADL Documentation Evaluate and improve weekend coverage Improve patient scheduling Discuss missed sessions daily Review how missed sessions are made up when clinically appropriate Become diligent about discharge planning and when disciplines DC care Evaluate current workload 46 Our industry is resilient and has a demonstrated track record for adapting to change We will successfully navigate this change in the same way we adapted to MDS.0 and RUGs IV transition 47 6