Basic OBRA Assessment/Record Sequencing Requirements Federal regulations at 42 CFR 483.20(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 Payment System (PPS)) purposes under Medicare Part A. For Medicaid case mix 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. 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 Point in Time Report will display accurate assessments resulting in an accurate facility average CMI; used to calculate your quarterly rate adjustment. General Concepts of Point in Time Methodology Point in Time Report The Point in Time Report provides information to the nursing facility regarding the last assessments/records transmitted on or prior to a specified quarter. The Point in Time Reports produced quarterly reflects 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 Prepared by Myers and Stauffer LC 1 DEDICATED TO GOVERNMENT HEALTH PROGRAMS
Assessment/Record Selection The Point in Time Report includes the last assessment/record with a target date on or prior to the point in time date. Target dates for assessments/records transmitted before the cutoff dates are listed on the Point in Time Report. The possible target dates include: A1600 entry date A2300 assessment reference date (ARD) A2000 discharge date Transmission Cutoff and Posting Dates Assessments/records included on the Preliminary Point in Time Report must be transmitted and accepted by the first day of the second month following the quarter. The Preliminary Point in Time Report is posted by the fifteenth day of the second month following the quarter. Assessments/records included on the Final Point in Time Report must be transmitted and accepted by the first day of the third month following the quarter. The Final Point in Time Report is posted by the fifteenth day of the third month following the quarter. Point in Time Report Schedule 12/31 03/31 06/30 09/30 Preliminary Report Cutoff date 02/01 05/01 08/01 11/01 Preliminary Report Posting date 02/15 05/15 08/15 11/15 Final Report Cutoff date 03/01 06/01 09/01 12/01 Final Report Posting date 03/15 06/15 09/15 12/15 Information Displayed on the Point in Time Report Includes the Following Identifying information for the resident: Resident name (last name, first name; alphabetical order) Resident ID number Identifying information for the assessment/record: Record type (A0310A / A0310B / A0310F) Target date RUG classification ADL Score (4-18) Additional information listed for the record: Case Mix Index (CMI) Payment source (Medicaid, Medicare, Other) Prepared by Myers and Stauffer LC 2 DEDICATED TO GOVERNMENT HEALTH PROGRAMS
Point in Time Report Rules and Conditions Point in Time Report Process 1. All residents with an assessment or entry record with a target date on or prior to the point in time date are included on the Report. 2. A resident whose last assessment/record is a Discharge or a combination Discharge with a target date on or prior to the point in time date is not included on the Report. 3. An assessment with a target date more than 121 days earlier than the point in time date will display a BC1 classification denoting delinquency and CMI of 0.59. Medicaid Active Assessment Definition For purposes of Louisiana Medicaid reimbursement only, each assessment may be considered active for up to 121 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, beginning on the 122 day, the assessment is considered an inactive assessment. The inactive assessment will be assigned the delinquent RUG classification of BC1 and a CMI of 0.59. Federal and State regulations require that an OBRA assessment be completed every 92 days for each resident in the facility. The 121-day active assessment definition is only applicable for Louisiana Medicaid reimbursement purposes. 4. When the target date of the Entry record is on or prior to the point in time date, the following criteria applies. General Entry Record Criteria The assessment detail displayed for the Entry record is determined by searching for a prior active assessment or discharge as follows: Step 1: Prior assessment search; a) When an active RUGgable assessment/record or Discharge-return anticipated combination immediately precedes the Entry record, the RUGgable assessment/record detail is displayed in place of the Entry record. b) When the prior record found is an Entry record or an assessment/record with a target date greater than 121 days from the point in time date, the Entry record is displayed with a BC1 classification and CMI of 0.59. c) When the prior record is a one of the following, search for a subsequent record; Discharge-return not anticipated (10) RUGgable or not Discharge-return anticipated (11) RUGgable or not with a target date greater than 30 days from the target date of the Entry record Death in facility discharge (12) No prior record is found Step 2: Subsequent assessment search; a) When an assessment or discharge (any kind) record follows the Entry record with a target date within 14 days of the entry date (A1600), the Entry record is displayed with a blank RUG, CMI, and payer. b) When an assessment or discharge (any kind) record does not follow the Entry record with a target date within 14 days of the entry date (A1600), the Entry record is displayed with a BC1 classification and CMI of 0.59. Prepared by Myers and Stauffer LC 3 DEDICATED TO GOVERNMENT HEALTH PROGRAMS
5. Assessments are assigned one of three payer types; Medicaid, Medicare or Other. The following are general rules regarding the payer source determination: Medicaid when A0700 equals one of the following: o A valid Medicaid number at A0700 o A0700 = +, P, p, PENDING, pending Medicare when the assessment is coded as a Medicare assessment; A0310B=01, 02, 03, 04, 05, 06, 07 Other when none of the criteria above applies Sample Final Point in Time Report Format Louisiana Case Mix System Final Point in Time Report for 03/31/2013 Assessments Transmitted and Accepted On or Before 06/01/2013 Provider Number: XXXXXXXXXXXX Provider Name: XXXXXXXXXXXXXXXXXXXXXX Print Date: Page: 1 of X Resident Name Resident ID Record Type Target Date RUG Class ADL Score Index Payment Source NAME Resid100 01/99/99 01/10/13 CC2 17 1.42 Medicaid NAME Resid200 NAME Resid300 NAME Resid400 Review of Preliminary Point in Time Report The purpose of the period between the receipt of the Preliminary Point in Time Report and the final transmission date (cutoff date) for the Final Point in Time report is to review the assessment listing for accuracy. Some review considerations might include but are not limited to: Determine if all the residents in the facility on the point in time date are listed on the report. Determine that discharged residents on or prior to the point in time date are not included on the report. Determine that the most current assessment/record as of the point in time date is represented. Determine the accuracy of each of the resident names. 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 any BC1 RUG classification. Keep in mind that assessments may have already been transmitted after the cutoff date of the Preliminary Point in Time Report and will automatically be listed on the Final report. Keep in mind, missing or corrected (if applicable) assessments that have been transmitted and accepted after the cutoff date(s) will not be reflected on the report (both preliminary and final). Refer to page 2 for cutoff 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. Prepared by Myers and Stauffer LC 4 DEDICATED TO GOVERNMENT HEALTH PROGRAMS
Review for accuracy of dates and or reasons for assessment by following the RAI manual instructions for modifications and inactivation s in Chapter 5. Verify the accuracy of the payer source. RUG-III 34 Grouper ADL CMI 1 SE3 Extensive Service (Count of 4-5) 7-18 2.10 2 SE2 Extensive Service (Count of 2-3) 7-18 1.79 3 SE1 Extensive Service (Count of 0-1) 7-18 1.54 4 RAD Rehabilitation 17-18 1.66 5 RAC Rehabilitation 14-16 1.31 6 RAB Rehabilitation 10-13 1.24 7 RAA Rehabilitation 4-9 1.07 8 SSC Special Care 17-18 1.44 9 SSB Special Care 15-16 1.33 10 SSA Special Care 7-14 1.28 11 CC2 Clinically Complex+Mood Symptoms 17-18 1.42 12 CC1 Clinically Complex 17-18 1.25 13 CB2 Clinically Complex+Mood Symptoms 12-16 1.15 14 CB1 Clinically Complex 12-16 1.07 15 CA2 Clinically Complex+Mood Symptoms 4-11 1.06 16 CA1 Clinically Complex 4-11 0.92 17 IB2 Impaired Cognition (2+RN Programs) 6-10 0.88 18 IB1 Impaired Cognition (0-1 RN Programs) 6-10 0.85 19 IA2 Impaired Cognition (2+RN Programs) 4-5 0.72 20 IA1 Impaired Cognition (0-1 RN Programs) 4-5 0.67 21 BB2 Behavior Problems (2+RN Programs) 6-10 0.86 22 BB1 Behavior Problems (0-1 RN Programs) 6-10 0.82 23 BA2 Behavior Problems (2+RN Programs) 4-5 0.71 24 BA1 Behavior Problems (0-1 RN Programs) 4-5 0.60 25 PE2 Reduced Physical Function (2+RN Programs) 16-18 1.00 26 PE1 Reduced Physical Function (0-1 RN Programs) 16-18 0.97 27 PD2 Reduced Physical Function (2+RN Programs) 11-15 0.91 28 PD1 Reduced Physical Function (0-1 RN Programs) 11-15 0.89 29 PC2 Reduced Physical Function (2+RN Programs) 9-10 0.83 30 PC1 Reduced Physical Function (0-1 RN Programs) 9-10 0.81 31 PB2 Reduced Physical Function (2+RN Programs) 6-8 0.65 32 PB1 Reduced Physical Function (0-1 RN Programs) 6-8 0.63 33 PA2 Reduced Physical Function (2+RN Programs) 4-5 0.62 34 PA1 Reduced Physical Function (0-1 RN Programs) 4-5 0.59 BC1 Delinquent 0.59 Prepared by Myers and Stauffer LC 5 DEDICATED TO GOVERNMENT HEALTH PROGRAMS
Item Set Code (ISC) The identification of the MDS 3.0 assessments on the Point in Time Report depends on the assessment coding at A0310A, A0310B, and A0310F as shown in the following table. An example of a record type shown on the Point in Time Report is an Entry tracking form (99/99/01) and an OBRA Quarterly not combined with a PPS or Discharge assessment (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 01 99 99 Quarterly NQ 02 99 99 Annual NC 03 99 99 Significant change in status NC 04 99 99 Significant correction of prior NC 05 99 99 full assessment Significant correction of prior NQ 06 99 99 quarterly assessment Medicare 5 day assessment NP 99 01 99 Medicare 14 day assessment NP 99 02 99 Medicare 30 day assessment NP 99 03 99 Medicare 60 day assessment NP 99 04 99 Medicare 90 day assessment NP 99 05 99 Medicare NP 99 06 99 Readmission/return assessment OMRA Start of therapy NS 99 07 99 OMRA SOT + Discharge NSD 99 07 10 or 11 OMRA End of therapy NO 99 07 99 OMRA Both start and end of NO 99 07 99 therapy OMRA Change of therapy NO 99 07 99 OMRA other + Discharge NOD 99 07 10 or 11 Entry/Re-entry NT 99 99 01 Discharge return not ND 99 99 10 anticipated Discharge return ND 99 99 11 anticipated Discharge death in facility NT 99 99 12 Inactivation XX Prepared by Myers and Stauffer LC 6 DEDICATED TO GOVERNMENT HEALTH PROGRAMS
General Case Mix Reimbursement Methodology Effective July 3, 2009 Basic Elements Annual rate period from July 1 through June 30 Five cost components o Direct care and care related component o Administrative and operating component o Capital component o Pass-through component o Adjustments Case mix portion of direct care component is adjusted for acuity Quarterly rate adjustments for changes in Medicaid acuity as of a snapshot date referred to as point in time date Quarterly rates effective July 1, October 1, January 1, April 1 Direct Care Cost Component The portion of the rate based on the following costs: (1) Salary costs including; Registered nurses (RN) salaries and wages, Licensed practical nurses (LPN) salaries and wages and Certified nurse aides (CNA) salaries and wages (2) Direct allowable cost of RN, LPN and CNA utilized from outside staffing companies (3) Proportionate allocation of employee benefits Care Related Cost Component The portion of the daily rate attributable to those costs indirectly related to providing clinical resident care services: (1) Nursing Administrative cost (excluding separately reimbursed nurse-aide training) (2) Social Service cost (3) Patient Activities cost (4) SNF/NF cost center non-salary ( other ) cost (excluding contract nursing included in Direct Care) (5) Allocated raw food cost (6) Proportionate allocation of employee benefit cost Administrative and Operating Component The portion of the rate attributable to the general administration and operation of the facility: (1) Administrative and general cost (excluding provider fees and separately reimbursed nurse-aide training) (2) Maintenance and repair cost (excluding any capital costs) (3) Operation of plant cost (4) Laundry and linen cost (5) Housekeeping cost (6) Dietary cost (excluding raw food) (7) Central services and supply cost (8) Pharmacy cost (excluding chargeable drugs) (9) Medical records cost (10) Proportionate allocation of the employee benefits cost Capital Cost Component The portion of the rate that is: (1) Attributable to depreciation (2) Capital related interest (3) Rent/lease (4) Amortization expenses Prepared by Myers and Stauffer LC 7 DEDICATED TO GOVERNMENT HEALTH PROGRAMS
Pass-through Component Includes a calculation of the facilities per diem property tax and property insurance cost: (1) Allowable facility property tax and property insurance costs (2) Provider fee add-on Adjustments Component Budgetary adjustments and other adjustments that may be made when changes occur that will eventually be recognized in updated cost report data (such as a change in the minimum wage, a change in FICA or a utility rate change). Details regarding the Medicaid rate setting method can be found at LAC Chapter 200 20005 Rate Determination Complete details regarding the reimbursement methodology can be found at LAC Chapter 200. Reimbursement Methodology Prepared by Myers and Stauffer LC 8 DEDICATED TO GOVERNMENT HEALTH PROGRAMS