1. MDS 3.0 LESSONS LEARNED Presented By: Roxanne Leon, RN Broussard Healthcare Consulting

2. NEW ASSESSMENTS WITH MDS 3.0 Short-stay Assessment OMRA’s – End of Therapy OMRA – Start of Therapy OMRA

3. MEDICARE SHORT STAY ASSESSMENT How do we determine if the assessment can be a Medicare Short Stay Assessment?? Look at the Medicare Short Stay Assessment Algorithm handout……

4. MEDICARE SHORT STAY ASSESSMENT Did at least one therapy discipline continue through the last day of the Medicare Part A stay?

5. MEDICARE SHORT STAY ASSESSMENT At least one of the therapy disciplines must have a dash-filled end of therapy date indicating ongoing therapy or an end of therapy date equal to the end of covered Medicare stay date (A2400C) Look at the Medicare End Date Algorithm A2400C handout……

6. MEDICARE SHORT STAY ASSESSMENT Therapy is considered to be ongoing when: – The resident was discharged and therapy was planned to continue had the resident remained in the facility, OR – The resident’s SNF benefit exhausted and therapy continued to be provided, OR – The resident’s payer source changed and therapy continued to be provided

7. MEDICARE SHORT STAY ASSESSMENT The RUG is calculated based on average daily minutes provided – 15-29 average daily tx minutes = RL – 30-64 average daily tx minutes = RM – 65-99 average daily tx minutes = RH – 100-143 average daily tx minutes = RV – 143 or greater average daily tx minutes = RU

8. MEDICARE SHORT STAY ASSESSMENT EXAMPLE #1 DAY 1DAY 2DAY 3DAY 4DAY 5DAY 6DAY 7 Medicare Start Date Medicare End Date ARD Therapy Eval Therapy Tx 40 minutes Therapy Tx 45 minutes Therapy Tx 40 minutes Does the resident meet short stay policy requirements?

9. MEDICARE SHORT STAY ASSESSMENT EXAMPLE #1 1.SOT OMRA 2.5-day assessment 3.Stay is 8 days or less (7 days) 4.ARD of SOT OMRA = end of Medicare stay date 5.ARD is not more than 3 days after start of therapy 6.Therapy started within last 4 days of stay 7.Therapy continued through last day of stay 8.RUG is Rehab group 1.RUG for days 4-7 = RM (Z0100A)

10. MEDICARE SHORT STAY ASSESSMENT EXAMPLE #2 DAY 1DAY 2DAY 3DAY 4DAY 5DAY 6DAY 7DAY 8 Medicare Start Date Medicare End Date ARD Therapy Eval No therapy Therapy Tx 40 minutes Therapy Tx 45 minutes Therapy Tx 40 minutes Does the resident meet short stay policy requirements?

11. MEDICARE SHORT STAY ASSESSMENT EXAMPLE #2 1.SOT OMRA 2.5-day assessment 3.Stay is 8 days or less (Day 8) 4.ARD of SOT OMRA = end of Medicare stay date 5.ARD is more than 3 days after start of therapy 6.Therapy did not start within last 4 days of stay 7.Therapy continued through last day of stay DOES NOT MEET REQUIREMENTS FOR SHORT STAY BECAUSE OF #5 AND #6

12. MEDICARE SHORT STAY ASSESSMENT EXAMPLE #3 DAY 1DAY 2DAY 3DAY 4DAY 5DAY 6DAY 7DAY 8 Medicare Start Date Medicare End Date ARD Therapy Eval 20 minutes No therapy Therapy Tx 30 minutes Diagnosis COPD, SOB while lying flat, sitting at rest and upon exertion Daily respiratory treatment, daily O2 PHQ-9 total severity score 18 ADL score 15

13. MEDICARE SHORT STAY ASSESSMENT EXAMPLE #3 Does the resident meet short stay policy requirements?

14. MEDICARE SHORT STAY ASSESSMENT EXAMPLE #3 1.SOT OMRA 2.5-day assessment 3.Stay is 8 days or less (7 days) 4.ARD of SOT OMRA = end of Medicare stay date 5.ARD is not more than 3 days after start of therapy 6.Therapy started within last 4 days of stay 7.Therapy continued through last day of stay

15. MEDICARE SHORT STAY ASSESSMENT EXAMPLE #3 What are the possible RUG assignments? What should you complete based on this information??

16. MEDICARE SHORT STAY ASSESSMENT EXAMPLE #3 RUGs – Therapy – RLB 20+30+30/4 = 20 minutes prorated ADL index 15 – Nursing – HE2, CE2 COPD w/ SOB lying flat => special care high Respiratory therapy 7 days =>special care high Daily O2 => clinically complex

17. MEDICARE SHORT STAY ASSESSMENT EXAMPLE #3 CMIs – RLB = 44 Rural, 44 Urban – HE2 = 46 Rural, 47 Urban – CE2 = 35 Rural, 35 Urban Do not complete SOT OMRA – While resident meets most of requirements for short stay, therapy RUG pays less than HE2 – Grouper will index maximize to HE2 and the SOT OMRA would be rejected

18. END OF THERAPY (EOT) OMRA End of Therapy (EOT) OMRA – Required – When a res was classified in a RUG-IV Rehab group and continues to need Part A SNF-level services after the d/c of all therapies – ARD (Item A2300) must be set on day 1, 2, or 3 after all rehab therapies have been d/c (Item O0400A6 or O0400B6 or O0400C6, whichever is the latest). The last day on which therapy treatment was furnished is considered day 0 when determining the ARD for the End of Therapy OMRA. Day 1 is the first day after the last therapy treatment (non-therapy day) was provided.

19. END OF THERAPY (EOT) OMRA – Day 1 would correspond to the first day on which therapy services would normally be provided after the last day therapy was provided. For example: » When a SNF provides rehab therapies Monday through Friday and the resident’s last day of therapy was on Tuesday, Day 1 is Wednesday » If the resident’s last day of therapy was Friday at the same SNF, Day 1 would be Monday » If a SNF therapy 6 days a week (for example, OT is provided Sunday – Friday, PT is provided Monday – Friday, and SLP is provided Tuesday – Friday). Day 1 would be Sunday, regardless of the type of therapy the resident received.

20. END OF THERAPY (EOT) OMRA – Must be completed (Item Z0500B) within 14 days after the ARD (ARD + 14 days) – Establishes a new non-therapy RUG and Medicare payment rate (Item Z0150A), which begins the day after the last day of therapy treatment – Must be submitted electronically to the QIES ASAP system and accepted into the QIES ASAP system within 14 days after completion (Item Z0500B) (completion + 14 days)

21. START OF THERAPY (SOT) OMRA Start of Therapy (SOT) OMRA – Optional – Completed only to classify a res into a RUG-IV Rehab group. If the RUG is not a Rehab group, the assessment will not be accepted by CMS and cannot be used for Medicare billing. – ARD (Item A2300) must be set on days 5-7 after the start of therapy (Item O0400A5 or O0400B5 or O0400C5, whichever is the earliest date). The date of the earliest therapy eval is counted as day 1 regardless if treatment is provided or not – Be attentive to Case Mix Indices (CMIs) – Be attentive to payment rates – Medicare payment begins on the day therapy started – Must be submitted electronically and accepted into the QIES ASAP system within 14 days after completion (Item Z0500B) (completion + 14 days)

22. FACTORS THAT COULD AFFECT REIMBURSEMENT – Non-Compliance with the PPS Assessment Schedule An assessment that does not have its ARD within the prescribed ARD window will be paid at the default rate for the number of days the ARD is out of compliance. Frequent early or late assessment scheduling practices may result in a review. The default rate takes the place of the otherwise applicable Federal rate. It is equal to the rate paid for the RUG group reflecting the lowest acuity level, and would generally be lower than the Medicare rate payable if the SNF had submitted an assessment in accordance with the prescribed assessment schedule.

23. FACTORS THAT COULD AFFECT REIMBURSEMENT – Early PPS Assessment If the assessment is performed earlier than the schedule indicates (the ARD is not in the defined window), the provider will be paid at the default rate for the number of days the assessment was out of compliance. Example: a 14 day assessment with the ARD of day 10 (1 day early) would be paid at the default rate for the first day of the payment period that begins on day 15.

24. FACTORS THAT COULD AFFECT REIMBURSEMENT – Late PPS Assessment If the SNF fails to set the ARD within the defined ARD window for a Medicare required assessment, including the grace days, and the res is still on Part A, the SNF must complete a late assessment The ARD can be no earlier than the day the omission was identified. If the ARD on the late assessment is set prior to the end of the payment period for the Medicare assessment that was missed, the SNF will bill all covered days up to the ARD at the default rate and on and after the ARD at the HIPPS rate code est by the late assessment.

25. FACTORS THAT COULD AFFECT REIMBURSEMENT Example: a 30 day assessment with an ARD of day 41 would be paid the default rate for days 31 through 40 and at the HIPPS classification from the assessment beginning on day 41. If the ARD of the late assessment is set after the end of the payment period for that Medicare required assessment that was missed and the res is still on Part A, the provider must still complete an assessment. The ARD can be no earlier than the day the omission was identified.

26. FACTORS THAT COULD AFFECT REIMBURSEMENT The SNF must bill all covered days for that payment period at the default rate regardless of the HIPPS code calculated from the late assessment. Example: a 14 day assessment with an ARD of day 32 would be paid at the default rate for days 15 through 30. A late assessment cannot be used to replace the next regularly scheduled Medicare required assessment. The SNF would then need to complete the 30 day assessment which covers days 31 through 60 as long as the beneficiary has SNF days remaining and is eligible for SNF Part A services.

27. FACTORS THAT COULD AFFECT REIMBURSEMENT – Missed PPS Assessment If the SNF fails to set the ARD prior to the end of the last day of the ARD window, including grace days, and the resident was already discharged from Medicare Part A when this is discovered, the provider cannot complete an assessment for SNF PPS purposes and the days cannot be billed to Part A.

28. COMBINING ASSESSMENTS Combining assessments occurs when one assessment is completed to satisfy both Medicaid and Medicare PPS assessment requirements. When considering combining assessments, the time frames for both types of assessments must coincide. The most stringent requirement must be met; therefore the nursing home staff must fully understand the requirements to remain in compliance.

29. COMBINING ASSESSMENTS Combining assessments ALLOWED: – Admission – Annual – Significant change in status assessment – Significant correction of prior comprehensive – Quarterly – Significant correction of prior quarterly – All Medicare assessments – Discharge assessment Return anticipated Return not anticipated

30. COMBINING ASSESSMENTS Combining assessments NOT ALLOWED: – Entry tracking record – Death in facility record

31. CALCULATION OF ADL SCORE FOR MEDICARE To calculate the ADL score for bed mobility, transfer, and toilet use Self- Performance Column 1 = Support Column 2 = ADL Score = -, 0, 1, 7, or 8AND(any number)0 2AND(any number)1 3AND-, 0, 1, or 22 4AND-, 0, 1, or 23 3 or 4AND34

32. CALCULATION OF ADL SCORE FOR MEDICARE To calculate the ADL score for eating Self- Performance Column 1 = Support Column 2 = ADL Score = -, 0, 1, 2, 7, or 8AND-, 0, 1, or 80 -, 0, 1, 2, 7, or 8AND2 or 32 3 or 4AND-, 0, or 12 3AND2 or 33 4AND2 or 34

33. CALCULATION OF ADL SCORE FOR MEDICAID To calculate the ADL score for bed mobility, transfer, and toilet use Self- Performance Column 1 = Support Column 2 = ADL Score = 0, 1, or 7AND(any number)1 2AND(any number)3 3 or 4AND0, 1, or 24 3, 4, or 8AND3 or 85

34. CALCULATION OF ADL SCORE FOR MEDICAID To calculate the ADL score for eating Self- Performance Column 1 = ADL Score = 0, 1, or 71 22 3, 4, or 83

35. FIVE STAR AND THE MDS 3.0 QM/QI rating will not be factored in the Five Star overall rating until Spring of 2012 CMS is still working on which items will be calculated from the MDS 3.0

36. RESIDENT INTERVIEWS TIPS ON COMPLETING ACCURATE RESIDENT INTERVIEWS – Introduce yourself – Be sure the res can hear what you are saying – Ask whether the res would like an interpreter (language or signing) – Find a quiet, private area where you are not likely to be interrupted or overheard

37. RESIDENT INTERVIEWS – Sit where the res can see you clearly and you can see his/her expressions – Establish rapport and respect – Explain the purpose of the questions to the res – Say and show the item responses – Ask the questions as they appear in the questionnaire – Break the question apart if necessary – Clarify using echoing (simply restating)

38. RESIDENT INTERVIEWS – Repeat the response options as needed – Move on to another question if unable to answer – Break up the interview if the res becomes tired or needs to leave for rehab, etc – Do not try to talk a res out of an answer – Record the res response – If the res becomes deeply sorrowful or agitated, sympathetically respond to his/her feelings

39. RESIDENT INTERVIEWS Section B0700 Makes Self Understood – 1 ST step is to determine if the resident is coded as rarely/never understood – This should be discussed as a team BEFORE the interviews are conducted – If the resident is rarely/never understood and coded as such in B0700, then NO interviews are to be conducted

40. RESIDENT INTERVIEWS Section B0700 Makes Self Understood – If the resident is coded as Understood, Usually Understood, or Sometimes Understood then ALL interviews should be attempted – If one interview section could not be completed due to any reason, the other interview sections MUST still be attempted

41. VALIDATION REPORTS How to stay on top of submission errors and reading validation reports Refer to handouts

42. QUESTIONS???

43. THANK YOU!! Roxanne Leon, RN rleon@thebroussardgroup.com Broussard Healthcare Consulting One Lakeside Plaza 127 West Broad Street, Suite 800 Lake Charles, LA 70601 (337) 439-6600 Website: www.broussardhealthcare.com www.broussardhealthcare.com www.synergycare.com