OFFICE OF MEDICAID POLICY AND PLANNING TIME WEIGHTED CMI RESIDENT ROSTER REPORT GUIDELINES; 34 GROUP Version 2.0 (September 2013)

Transcription

1 Basic OBRA Assessment/Record Sequencing Requirements Federal regulations at 42 CFR (b)(1)(xviii), (g), and (h) 1) The assessment accurately reflects the resident s status 2) A registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals 3) The assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts The OBRA regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic MDS assessments for all their residents. MDS assessments are also required for Medicare payment (Prospective System (PPS)) purposes under Medicare Part A. For Medicaid case mix time-weighted reimbursement purposes, proper sequencing of assessments and records is essential for appropriate reimbursement to nursing homes. Sequencing includes not only accurate assessment/record selection, but accurate dates; such as the assessment reference date (ARD), entry date, discharge date and in some cases the discharge status. The following is basic sequencing requirements for OBRA assessment/records; however this is not an all inclusive list: 1) Entry Tracking record(s) must be completed for all entries and reentries. a. Type of entry must be accurate (A1700=1 admission or 2=reentry) 2) Admission assessment must be the first comprehensive assessment completed within 14 days of admission. 3) A comprehensive assessment must be completed at least 366 days following the previous comprehensive assessment. 4) A non-comprehensive assessment must be completed at least every 92 days following a previous OBRA assessment of any type. 5) A Discharge assessment must be completed when resident is discharged or if resident is out of the facility for greater than 24 hours. Leave of absence (LOA) is excluded from this requirement. 6) A Death in Facility record must be completed when resident dies in the facility or when on LOA. 7) Assessment/record completion requirements are determined by the ARD date. By following these simple requirements the Resident Roster Report will reflect an accurate count of days resulting in an accurate facility average CMI; used to calculate your quarterly rate adjustment. Prepared by Myers and Stauffer LC Page 1 of 18 DEDICATED TO GOVERNMENT HEALTH PROGRAMS

2 General Concepts of Time Weighted Methodology Time-Weighted CMI Resident Roster Report The Time-Weighted CMI Resident Roster Report provides information to the nursing facility regarding the assessments/records transmitted for a specified quarter. There is a Preliminary and Final CMI Resident Roster Report that is produced for the following periods: Quarter one: January 1 to March 31 Quarter two: April 1 to June 30 Quarter three: July 1 to September 30 Quarter four: October 1 to December 31 Record Selection Includes the assessment/record active on the first day of the quarter and all other assessments/records completed within the quarter. Target dates for assessments/records that fall within the quarter and that were transmitted before the cutoff date are listed on the Time-Weighted CMI Resident Roster Report. The possible target dates include: A1600 entry date A2300 assessment reference date (ARD) A2000 discharge date Transmission Cut-Off s Assessments/records included on the Preliminary CMI Resident Roster Report must be transmitted and accepted by the 15th day of the first month following the quarter. Assessments/records included on the Final CMI Resident Roster Report must be transmitted and accepted by the 15th day of the second month following the quarter. CMI Report Posting s Preliminary and Final CMI Resident Roster Reports will be posted to each facility s download directory on the CMS MDS 2.0 server. Transmission cutoff dates and CMI report posting dates pursuant to 405 IAC are as follows: Quarter s: 12/31 03/31 06/30 09/30 Transmission cut-off s: Preliminary 01/15 04/15 07/15 10/15 Final Roster 02/15 05/15 08/15 11/15 Report Posting s: Preliminary 01/25 04/25 07/25 10/25 Final Roster 03/07 06/07 09/07 12/07 Information Displayed on the CMI Report Includes the Following Identifying information for the resident: Resident name Resident ID number Identifying information for the assessment/record: Record type (A0310A/A0310B/A0310F) Target date RUG classification date date field date Additional information listed for the record: Number of active days during the quarter assigned to the assessment/record (CMI) source Prepared by Myers and Stauffer LC Page 2 of 18 DEDICATED TO GOVERNMENT HEALTH PROGRAMS

3 Days Counted for the Time-Weighted CMI Resident Roster Report Each assessment/record considered active during the quarter will have days calculated using one of the following six criteria: 1. Days are counted from the first day of the quarter until the day preceding the target date of the next assessment/record OR 2. From the Entry (A1600) date to the day preceding the target date of the next assessment/record OR 3. From the target date to the day preceding the target date of the next assessment/record OR 4. From the target date through the last day of the quarter OR 5. From the target date until the assessment/record is no longer considered active (i.e. delinquent) OR 6. From the target date to the day preceding the discharge date The facility average Time-Weighted CMI is calculated by summing the total CMI point values for all assessments/records and dividing by the total number of days for all assessments/records for the quarter. Other Time-Weighted Roster Guidelines An Admission assessment is required to be the first OBRA assessment and must be completed within 14 days of the resident s entry date (A1600). Days are counted and applied as follows: Day of admission/entry (A1600) is counted Day of discharge (A2000) is never counted Assessments are active for a maximum of 113 days (for Medicaid purposes only) Delinquent days are assigned a BC2 classification beginning day 114 Indiana Office of Medicaid Policy and Planning Time-Weighted CMI Resident Roster Report Format Preliminary Time-Weighted Resident Listing for the Quarter 01/01/ /31/2013 Records Received as of 04/15/2013 Provider Number: XXXXXXXXXXXX Provider Name: XXXXXXXXXXXXXXXXXXXXXX Resident Record Target RUG Resident Name ID Type Class NAME Resid100 NT/99/99/01 01/03/13 01/03/13 A /03/13 Days NC/01/99/99 01/10/13 CC2 01/03/13 A /01/ Medicaid ND/99/99/10 03/02/13 03/02/13 A /02/13 Total days 58 Days Counted 1) NT/99/99/01 (Entry Tracking record) with an entry date (A1600) of 01/03/13 displays no days 2) NC/01/99/99 (Admission assessment with an ARD date (target date) of 01/10/13 and an entry date of 01/03/13) will begin counting days beginning on the entry date (01/03/13) and continue until the day preceding the next assessment/record 3) ND/99/99/10 (Discharge return not anticipated) with a discharge date of 03/02/13 stops the days counted for the quarter 4) There are a total of 58 days (01/03/13 through 03/01/13) for this quarter Prepared by Myers and Stauffer LC Page 3 of 18 DEDICATED TO GOVERNMENT HEALTH PROGRAMS

4 Maximum Number of Days an Assessment May Be Considered Active For Medicaid Purposes ONLY For purposes of Indiana Medicaid reimbursement only, each assessment may be considered active for up to 113 days. Active days are measured between two consecutive assessments using the ARD dates of both assessments. If no new assessment is completed, transmitted, and accepted, the period beginning day 114 is considered an inactive assessment or expired assessment period. The days following an expired assessment (starting the 114 th day) through the day preceding the target date of the next assessment/record or the end of quarter, will be assigned the delinquent RUG classification of BC2 and a CMI of.48. Federal and State regulations require that an OBRA assessment be completed every 92 days for each resident in the facility. The 113-day active assessment period is only applicable for Indiana Medicaid reimbursement purposes. The following is an example of a delinquent Medicaid assessment: Example 1: The first assessment active at the start of the 3/31 quarter is a quarterly assessment (NQ/02/99/99) completed in the prior quarter (12/31). The quarterly assessment has an ARD of 10/14/12 and is active for 113 days, expiring on 02/03/13. Prior Quarter (12/31) Oct Nov Dec Days for quarter 3/31 will begin counting on the first day of the quarter, assigning days to the previous active assessment (NQ/02/99/99 A2300=10/14/2012), and continuing until the 113 th day (02/03/13). Resident Record Target RUG Resident Name ID Type Class Days NAME Resid101 NQ/02/99/99 10/14/12 SE2 01/01/13 02/03/ Medicaid NQ/02/99/99 10/14/12 BC2 02/04/13 03/14/ Medicaid NQ/02/99/99 03/15/13 SE2 03/15/13 A /31/ Medicaid Total Days 90 Jan Feb BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 March BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC Beginning on the 114 th day (02/04/2013), the classification for these days is replaced with a BC2, indicating delinquency, and a 0.48 CMI is assigned, which continues until either a new assessment/record is transmitted and accepted or end of quarter. In this example, there are 39 BC2 days (02/04/13 through 03/14/13, the day prior to the next assessment s target date). Days begin counting on the target date (A2300) of the next assessment and continue until the end of the quarter. In total, the resident was in the facility 90 days during the quarter. Prepared by Myers and Stauffer LC Page 4 of 18 DEDICATED TO GOVERNMENT HEALTH PROGRAMS

5 Maximum Number of Days an Assessment May Be Considered Active For Medicaid Purposes ONLY (continued) Example 2: Expired assessment ARD=04/01/2012 Resident Record Target RUG Resident Name ID Type Class Days NAME Resid102 NC/03/99/99 04/01/12 BC2 01/01/13 03/31/ Medicaid Total Days 90 Jan Feb March BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 This assessment has an ARD date in No assessment has been transmitted since the annual assessment (NC/03/99/99). In total, the resident was in the facility 90 days during the quarter; however there were 251 days since the expiration of the assessment. Prepared by Myers and Stauffer LC Page 5 of 18 DEDICATED TO GOVERNMENT HEALTH PROGRAMS

6 Entry Tracking Record Conditions Entry Tracking records are required to be submitted upon every entry or reentry into the facility. Since the entry date (A1600) indicates the exact date of entry/reentry, the time-weighted system will use this date to begin counting days. The type of entry (A1700) is used to determine how an assessment/record is evaluated and displayed. However, the Entry tracking record is not an assessment and therefore is unable to be classified. Example 3: Entry date begins the counting of days Resident Record Target RUG Resident Name ID Type Class Days NAME Resid103 NQ/02/99/99 11/15/12 SE2 01/01/13 01/05/ Medicaid ND/99/99/11 01/06/13 01/06/13 A /06/13 NT/99/99/01 03/01/13 03/01/13 A /01/13 NC/01/99/99 03/13/13 PD2 03/01/13 A /31/ Medicaid Total Days 36 Jan Feb March Days begin counting for the first assessment beginning January 1 (first day of the quarter) through the day prior to the discharge date (A2000) for a total of 5 days. The Entry tracking record is transmitted and is then followed by an Admission assessment. The Admission assessment that follows the Entry tracking record begins counting at the entry date (A1600) through the end of the quarter. In total, the resident was in the facility 36 days during the quarter. Note: An Entry tracking record where A1700=1 (admission) is required because there are more than 30 days after the Discharge return anticipated assessment followed with an Admission assessment. Example 4: Entry tracking record where A1700=2 (reentry) is not followed by another assessment but is preceded by an active assessment Resident Record Target RUG Resident Name ID Type Class Days NAME Resid104 NQ/02/99/99 12/30/12 SE2 01/01/13 01/05/ Medicaid State ND/99/99/11 01/06/13 01/06/13 A /06/13 NT/99/99/01 01/15/13 SE2 01/15/13 A /31/ Medicaid Total Days 81 Jan Feb March Days begin counting for the first assessment beginning January 1 (first day of the quarter) through the day prior to the discharge date (A2000) for a total of 5 days. Since no new assessment follows the Entry tracking record, the RUG classification is taken from the preceding active assessment. In total, the resident was in the facility 81 days during the quarter. Prepared by Myers and Stauffer LC Page 6 of 18 DEDICATED TO GOVERNMENT HEALTH PROGRAMS

7 Admission Assessment Conditions An Admission assessment is required for all new admissions that are in the facility 14 days or more. The following criterion applies: Criteria This is a resident s first stay OR The resident has just returned to the facility after being discharged as return not anticipated (Discharge/10) OR The resident has just returned to the facility after being discharged as return anticipated (Discharge/11) but more than 30 days has lapsed For time-weighted purposes, days begin counting on the entry date (A1600) of the Admission assessment. Example 5: Inclusion of the entry date and exclusion of the discharge date Resident Name Resident ID Record Type Target RUG Class NAME Resid105 NT/99/99/01 01/03/13 01/03/13 A /03/13 Days NC/01/99/99 01/11/13 CC2 01/03/13 A /01/ Medicaid ND/99/99/11 03/02/13 03/02/13 A /02/13 Total days 58 Jan Feb March Days begin counting on the entry date (A1600) beginning 01/03/2013 and stop counting on 03/01/2013, the date prior to the discharge date (A2000). In total, the resident was in the facility 58 days during the quarter. Admission assessment when there are more than 14 days between the entry date and the ARD date Since the Admission assessment must be completed within 14 calendar days of entry into the facility, the timeweighted system will compare the entry date (A1600) on the Entry tracking record to the entry date (A1600) on the Admission assessment. Should these dates not match, the time-weighted system evaluates these dates as follows: If the entry date on the Admission assessment is earlier than the entry date on the Entry tracking record, the days counted for the Admission assessment will begin on the ARD If the entry date on the Admission assessment is after the entry date on the Entry tracking record, the days counted for the Admission assessment will begin on the entry date from the Admission assessment When there are greater than 14 days between these dates, any remaining days beginning on day 15 through the day prior to the ARD date of the assessment will be displayed as delinquent days (BC2) Prepared by Myers and Stauffer LC Page 7 of 18 DEDICATED TO GOVERNMENT HEALTH PROGRAMS

8 Admission Assessment Conditions (continued) Example 6: Admission assessment with more than 14 days between the entry date and the ARD date Entry date A1600 on the Entry tracking record=01/12/2012 Entry date A1600 on the Admission assessment =01/12/2012 ARD date A2300=01/24/2013 In this example, the entry date (A1600) is earlier than the ARD date (A2300). Therefore, the start of the quarter is assigned delinquent days until the day prior to the ARD date of the Admission assessment. Resident Record Target RUG Resident Name ID Type Class Days NAME Resid106 NT/99/99/01 01/12/12 BC2 01/01/13 01/23/ Medicaid NC/01/99/99 01/24/13 CC2 01/24/13 A /01/ Medicaid ND/99/99/11 03/02/13 03/02/13 A /02/13 Total days 60 Jan BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC Feb March Delinquent days begin on the start of the quarter because the entry date 01/12/2012 (A1600) is greater than 14 days prior to the ARD date of the Admission assessment. Days begin counting on the ARD date 01/24/2013 (A2300 date) of the Admission assessment through the date prior to the discharge date (A2000). In total, the resident was in the facility 60 days during the quarter. Out of sequence Admission assessment When an Admission assessment follows another assessment in error, the days will begin counting on the ARD date (A2300) of the Admission assessment instead of the entry date (A1600). Example 7: Admission assessment is preceded by another RUGgable assessment Resident Name Resident ID Record Type Target RUG Class Days NAME Resid107 NQ/02/99/99 01/01/13 SSB 01/01/13 A /14/ Medicaid NC/01/99/99 01/15/13 SE1 01/15/13 A /29/ Medicaid NC/04/99/99 01/30/13 SE1 01/30/13 A /31/ Medicaid Total Days 90 Jan Feb March When the Admission assessment is preceded with another RUGgable assessment, the days begin counting for the Admission assessment from the ARD date (A2300). In total, the resident was in the facility 90 days during the quarter. Prepared by Myers and Stauffer LC Page 8 of 18 DEDICATED TO GOVERNMENT HEALTH PROGRAMS

9 Discharge Assessment Definitions and Entry/Discharge Conditions Discharge Assessment/10 Return not Anticipated This record is required when it is determined that the resident is being discharged with no expectation of return. If the resident is formally discharged (Discharge/10) from the facility and returns at a later date, this will require a new Entry tracking record followed by a new Admission assessment that includes the latest Entry date (A1600). Discharge Assessment/11 Return Anticipated This record reports a more temporary discharge from the facility, when it is expected that the resident will return for continued nursing facility services. When the resident returns to the facility within 30 days, an Entry tracking record where A1700=2 (reentry) must be completed to report the return of the resident. However, if the resident is discharged (Discharge/11) from the facility and returns more than 30 days later, a new Entry tracking record where A1700=1 (admission) must be completed followed by a new Admission assessment with the latest Entry date (A1600). Discharge Death in Facility Record/12 This is a tracking record that reports a death in the facility. Transmitting the proper discharge is very important. When Discharge assessment/10 and or Discharge assessment/11 are submitted in sequential order (with no assessments/records between the discharges), the first discharge assessment stops days counted. Example 8: Sequential Discharge assessments Days begin counting from January 1 (first day of the quarter) through the day prior to the discharge date (A2000). Resident Record Target RUG Resident Name ID Type Class Days NAME Resid108 NQ/02/99/99 12/10/12 PB1 01/01/13 01/14/ Other ND/99/99/11 01/15/13 01/15/13 A /15/13 ND/99/99/10 02/01/13 02/01/13 A /01/13 Total Days 14 Jan Feb March The earliest discharge assessment (ND/99/99/11 discharge return anticipated) stops the days counted on the day prior to the discharge date (01/15/13). Should the resident not return to the facility for any reason, no discharge return not anticipated is required. In total, the resident was in the facility 14 days during the quarter. Prepared by Myers and Stauffer LC Page 9 of 18 DEDICATED TO GOVERNMENT HEALTH PROGRAMS

10 Discharge Assessment Definitions and Entry/Discharge Conditions (continued) Entry/Discharge Condition When a RUG Classification is Applied In the time-weighted system, a resident who entered the facility and discharged prior to completing an initial Admission assessment will be classified in one of the following RUG classifications for the days the resident is in the facility (not to exceed 14 days). The RUG assigned is based on the coding in section A2100, discharge status*. SSB classification will be assigned for a resident where the reason for discharge was death or transfer to hospital (A2100 value of 03, 05, 08, or 09) CC1 classification will be assigned for a resident where the reason for discharge was other than death or transfer to hospital; other than a psychiatric hospital (A2100 value of 01, 02, 04, 06, 07, or 99) This scenario is active for a maximum of 14 days Example 9: An Entry tracking record and Discharge assessment are the first record/assessment for a new admission (with no Admission assessment) Entry date A1600=12/25/2012 Discharge date A2000=01/07/2013 Discharge status A2100=03 Resident Record Target RUG Resident Name ID Type Class Days NAME Resid109 NT/99/99/01 12/25/12 SSB 01/01/13 01/06/ Medicaid ND/99/99/10 01/07/13 01/07/13 A /07/13 Total Days 6 Jan Feb March When an Entry tracking record is the first and only record for a new resident that is followed by a Discharge assessment, the RUG classification and associated CMI are assigned using the above criteria. Days apply starting with the entry date (A1600) and continue until the day prior to the discharge date (A2000), not to exceed 14 days. In total, the resident was in the facility 6 days during the quarter. *Note: Discharge Status Key (A2100) 01. Community 06. ID/DD facility 02. Another nursing home 07. Hospice 03. Acute hospital 08. Deceased 04. Psychiatric hospital 09. Long Term Care hospital 05. Inpatient rehabilitation facility Prepared by Myers and Stauffer LC Page 10 of 18 DEDICATED TO GOVERNMENT HEALTH PROGRAMS

11 Discharge Assessment Definitions and Entry/Discharge Conditions (continued) When an Entry tracking record is the first and only record for a new resident that is followed by a Discharge assessment and there are more than 14 days between the entry date (A1600) and the discharge date (A2000), days begin counting from the entry date (A1600) and continue counting until the 14 th day. On the 15 th day, BC2 delinquent days begin counting until the day prior to the discharge date (A2000). Example 10: There are more than 14 days between the entry date and the discharge date, and no assessment precedes the Discharge assessment Entry date A1600=01/02/2013 Discharge date A2000=01/26/2013 Resident Record Target RUG Resident Name ID Type Class Days NAME Resid110 NT/99/99/01 01/02/13 CC1 01/02/13 A /15/ Medicaid NT/99/99/01 01/02/13 BC2 01/16/13 01/25/ Medicaid ND/99/99/11 01/26/13 01/26/13 A /26/13 Total Days 24 Jan BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC2 BC Feb March Since there are more than 14 days between the entry date and the discharge date, days begin counting from the entry date (01/02/2013) and continue until the 14 th day (01/15/2013). On the 15 th day (01/16/2013), BC2 delinquent days begin counting until the day prior to the discharge date (01/25/2013). In total, the resident was in the facility 24 days during the quarter. Note: The requirement for completion of a Discharge assessment is not associated with bedhold status. A Discharge assessment form is required whenever a resident is discharged, regardless of bedhold status. Prepared by Myers and Stauffer LC Page 11 of 18 DEDICATED TO GOVERNMENT HEALTH PROGRAMS

12 Low Needs RUG Classification Effective January 1, 2010 (405 IAC ) For purposes of Indiana Medicaid reimbursement only, Medicaid residents that meet all the following conditions are considered low needs and will be assigned alternate CMIs. (1) The Medicaid resident classifies into one (1) of the following Reduced Physical Function RUG groups: PB2, PB1, PA2, PA1 (2) The resident has a cognitive status indicated by a brief interview of mental status score (BIMS) greater than or equal to ten (10) or, if there is not a BIMS score, then a cognitive performance score (CPS) of 0, 1 or 2 (3) The resident is not experiencing occasional, frequent, or complete bowel incontinence control (4) The resident has not been admitted to any Medicaid-certified nursing facility before January 1, 2010 (5) Any qualifying low needs assessments that are subsequently determined to be delinquent shall be assigned ninety-six percent (96%) of the CMI associated with the RUG low needs group Note: The low needs CMI is not applied in the Normalization process Example 11: Quarterly assessment meeting low needs criteria ARD (A2300) 12/10/12 Discharge date (A2000) 01/15/13 Resident Name Resident ID Record Type Target RUG Class Days NAME Resid111 NQ/02/99/99 12/10/12 PB1- (LN) 01/01/13 01/14/ ^ Medicaid ND/99/99/11 01/15/13 01/15/13 A /15/13 Total Days 14 ^CMI 0.28 for PB1 reflects low needs CMI Jan Feb March Since the Annual assessment met the low needs criteria, the RUG classification reflects the low needs RUG (PB1- LN) and associated CMI (0.28). In total, the resident was in the facility 14 days during the quarter. Prepared by Myers and Stauffer LC Page 12 of 18 DEDICATED TO GOVERNMENT HEALTH PROGRAMS

13 Review of Preliminary Time Weighted CMI Resident Roster Report The purpose of the period between the posting of the Preliminary Resident Roster Report and the final transmission date (cut-off date) for the Final Resident Roster Report is to review the assessment listing for accuracy. Some review considerations might include: Determine if all the residents in the facility on the first day of the quarter or during the quarter are listed on the Resident Roster. Determine if each resident is identified only once. If the same resident appears as if they were two separate residents, contact the State RAI Coordinator for assistance in merging resident records. Review the listed assessments and tracking forms for each listed resident to determine if each record is accounted for on the Resident Roster. Review the start date and end date for accuracy. Review any BC2 RUG classification. Keep in mind that assessments may have already been transmitted after the cut-off date of the Preliminary Resident Roster and will automatically be listed on the Final Resident Roster. Review the RUG classification attributed to the discharge status (A2100) for residents in the facility less than 14 days and have not completed and transmitted an Admission assessment. Keep in mind, missing or corrected (if applicable) assessments that have been transmitted and accepted after the cut-off date(s) will not be reflected on the Time-Weighted CMI Resident Roster Report (both preliminary and final). Refer to page 2 for cut-off dates. Review for missing or corrected (if applicable) assessments that may have been transmitted and not accepted by the QIES ASAP system. Review errors, make corrections and retransmit, if applicable. Review for accuracy of dates and or reasons for assessment by following the RAI manual instructions for modifications and inactivation s in Chapter 5. Review the type of Entry tracking record (A1700=1 [admission] or A1700=2 [reentry]) to ensure that the reason fits the sequence of records displayed. Prepared by Myers and Stauffer LC Page 13 of 18 DEDICATED TO GOVERNMENT HEALTH PROGRAMS

14 RUG-III 34 Grouper ADL CMI CMI- LN 1 SE3 Extensive Service (Count of 4-5) SE2 Extensive Service (Count of 2-3) SE1 Extensive Service (Count of 0-1) CMI- LN- BC2 4 RAD Rehabilitation RAC Rehabilitation RAB Rehabilitation RAA Rehabilitation SSC Special Care SSB Special Care SSA Special Care CC2 Clinically Complex+Mood Symptoms CC1 Clinically Complex CB2 Clinically Complex+Mood Symptoms CB1 Clinically Complex CA2 Clinically Complex+Mood Symptoms CA1 Clinically Complex (0-1 RN Programs) IB2 Impaired Cognition (2+RN Programs) IB1 Impaired Cognition (0-1 RN Programs) IA2 Impaired Cognition (2+RN Programs) IA1 Impaired Cognition (0-1 RN Programs) BB2 Behavior Problems (2+RN Programs) BB1 Behavior Problems (0-1 RN Programs) BA2 Behavior Problems (2+RN Programs) BA1 Behavior Problems (0-1 RN Programs) PE2 Reduced Physical Function (2+RN Programs) PE1 Reduced Physical Function (0-1 RN Programs) PD2 Reduced Physical Function (2+RN Programs) PD1 Reduced Physical Function (0-1 RN Programs) PC2 Reduced Physical Function (2+RN Programs) PC1 Reduced Physical Function (0-1 RN Programs) PB2 Reduced Physical Function (2+RN Programs) PB1 Reduced Physical Function (0-1 RN Programs) PA2 Reduced Physical Function (2+RN Programs) PA1 Reduced Physical Function (0-1 RN Programs) BC2 Delinquent 0.48 Prepared by Myers and Stauffer LC Page 14 of 18 DEDICATED TO GOVERNMENT HEALTH PROGRAMS

15 Item Set Code (ISC) The identification of the MDS 3.0 assessments on the Resident Roster depends on the assessment coding at A0310 as shown in the following table. In many instances, facilities combine reasons for assessment. For purposes of identifying these records, the MDS 3.0 records are identified on the Resident Roster using the codes in A0310A, A0310B, and A0310F in addition to the Item Subset Code (ISC). An example of a Record Type shown on the Resident Roster is an Entry tracking form (NT/99/99/01) and an OBRA Quarterly not combined with a PPS or Discharge assessment (NQ/02/99/99). (Examples highlighted in table.) The table below displays standalone assessments including the item set code (ISC) and associated values for A0310A, A0310B, and A0310F. This does not include any combination assessments. Assessment (ISC) (A0310A) (A0310B) (A0310F) Admission NC Quarterly NQ Annual NC Significant change in status NC Significant correction of prior NC full assessment Significant correction of prior NQ quarterly assessment Medicare 5 day assessment NP Medicare 14 day assessment NP Medicare 30 day assessment NP Medicare 60 day assessment NP Medicare 90 day assessment NP Medicare NP Readmission/return assessment OMRA of therapy NS OMRA SOT + Discharge NSD or 11 OMRA of therapy NO OMRA Both start and end of NO therapy OMRA Change of therapy NO OMRA Other + Discharge NOD or 11 Entry/Re-entry NT Discharge return not ND or 11 anticipated or return anticipated Inactivation record XX Prepared by Myers and Stauffer LC Page 15 of 18 DEDICATED TO GOVERNMENT HEALTH PROGRAMS

16 General Reimbursement Components The Medicaid reimbursement system is based on recognition of the provider s allowable costs for the administrative, capital, direct care, indirect care and therapy components, plus potential add-on payments. The following is not an attempt to be all inclusive regarding the rate calculation; rather it is to provide a summary of the various rate components. Administrative component The portion of the Medicaid rate that shall reimburse providers for allowable administrative services and supplies, including prorated employee benefits based on salaries and wages. Administrative services and supplies include the following: (1) Administrator and co-administrators, owners' compensation (including director's fees) for patient-related services. (2) Services and supplies of a home office that are: (A) Allowable and patient-related; and (B) Appropriately allocated to the nursing facility. (3) Office and clerical staff. (4) Legal and accounting fees. (5) Advertising. (6) All staff travel and mileage. (7) Telephone. (8) License dues and subscriptions. (9) All office supplies used for any purpose, including repairs and maintenance charges and service agreements for copiers and other office equipment. (10) Working capital interest. (11) State gross receipts taxes. (12) Utilization review costs. (13) Liability insurance. (14) Management and other consultant fees. (15) Qualified mental retardation professional (QMRP). (16) Educational seminars for administrative staff. (17) Support and license fees for all general and administrative computer software and hardware such as accounting or other data processing activities. Capital component The portion of the Medicaid rate that shall reimburse for the use of allowable capital-related items. Fair rental value allowance Property taxes Property insurance Direct care component The portion of the Medicaid rate that shall reimburse providers for allowable direct patient care services and supplies, including prorated employee benefits based on salaries and wages. Direct care services and supplies include all of the following: (1) Nursing and nursing aide services. (2) Nurse consulting services. (3) Pharmacy consultants. (4) Medical director services. (5) Nurse aide training. (6) Medical supplies. (7) Oxygen. (8) Medical records costs. (9) Rental costs for low air loss mattresses, pressure support surfaces, and oxygen concentrators. Rental cost for these items are limited to $1.50 per resident day. Prepared by Myers and Stauffer LC Page 16 of 18 DEDICATED TO GOVERNMENT HEALTH PROGRAMS

17 (10) Support and license fees for software utilized exclusively in hands-on resident care support, such as MDS assessment software and medical records software. (11) Replacement dentures for Medicaid residents provided by the facility that exceed state Medicaid plan limitations for dentures. (12) Legend and nonlegend sterile water used for any purpose. (13) Educational seminars for direct care staff. Indirect care component The portion of the Medicaid rate that shall reimburse providers for allowable indirect patient care services and supplies, including prorated employee benefits based on salaries and wages. Indirect care services and supplies include the following: (1) Dietary services and supplies. (2) Raw food. (3) Patient laundry services and supplies. (4) Patient housekeeping services and supplies. (5) Plant operations services and supplies. (6) Utilities. (7) Social services. (8) Activities supplies and services. (9) Recreational supplies and services. (10) Repairs and maintenance. (11) Cable or satellite television throughout the nursing facility, including residents' rooms. (12) Pets, pet supplies and maintenance, and veterinary expenses. (13) Educational seminars for indirect care staff. (14) All costs related to nonambulance travel and transportation of residents. Therapy component The portion of the direct costs for therapy services, including prorated employee benefits based on salaries and wages, rendered to Medicaid residents that are not reimbursed by other payers. Potential Add-on component Ventilator add-on o Must provide inpatient services to more than eight (8) ventilator-dependent residents Special care unit (SCU) for Alzheimer s disease or dementia add-on o Determined based on specific criteria Assessment add-on o Determined based on specific criteria ISDH report card or quality add-on o Determined based on specific criteria Complete details regarding the Medicaid rate calculation can be found at 405 IAC Prepared by Myers and Stauffer LC Page 17 of 18 DEDICATED TO GOVERNMENT HEALTH PROGRAMS

18 General Corrective Remedy and Appeal Components MDS Audit Periodic MDS audits are conducted. MDS audits performed on the initial and expanded sample of assessments resulting in greater than twenty percent (20%) unsupported will receive the following corrective remedy. The administrative component of the Medicaid rate effective for the calendar quarter following completion of the MDS field audit shall be reduced as follows: o First MDS field audit 15% reduction o Second consecutive MDS field audit 20% reduction o Third consecutive MDS field audit 30% reduction o Fourth consecutive MDS field audit 50% reduction o All remaining consecutive MDS field audits 50% reduction Reimbursement lost as a result of any corrective remedies shall not be recoverable Complete details regarding the MDS audit can be found at 405 IAC 1-15 Administrative Reconsideration; Appeal Reconsideration requests regarding the Medicaid rate or allowable cost determinations shall be in writing and include the following: Specifics as to issue(s) and rationale to be considered Received no later than 45 days after release of the rate Following review of the reconsideration o Medicaid rate may be amended o Challenged procedure may be amended o Affirm the original Medicaid rate o Provider shall be notified of final decision within 45 days of receipt of request After completion of the reconsideration procedure the provider may initiate an Appeal Complete details regarding the Administrative reconsideration process can be found at 405 IAC Complete details regarding the Appeal process can be found at IC Note: Indiana Administrative Code (IAC) and Indiana Code (IC) are subject to change. Please check the most current version of the statute and rule. Prepared by Myers and Stauffer LC Page 18 of 18 DEDICATED TO GOVERNMENT HEALTH PROGRAMS