1. SNF RUGS

6. SNF PPS: RUG-IV Categories & Characteristics
Major RUG-IV
Category
RUG-IV Score
Characteristics Associated With Major RUG-Category
Rehabilitation Plus Extensive Service
RUX, RUL, RVX, RVL, RHX, RHL, RMX, RML, RLX
Resident satisfying all of the following three conditions:
Having a minimum activity of daily living (ADL) dependency score of 2 or more
Receiving physical therapy, occupational therapy, and/or speech-language pathology services while a resident.
Ultra (U)-720+ minutes, 2 disciplines required : at least 1 discipline for 5 days, 2nd
discipline at least 3 days within past 7 days from ARD
Very High (V) min, At least one discipline 5 days with past 7 days from ARD
High(H) min, Requires 1 discipline 5 days with past 7 days from ARD
Medium (M) min, Requires 5 days across 3 disciplines combination within
past 7 days from ARD
Low (L) min, 3 treatment days within past 7 days from ARD, Combined with
with nursing restorative capture of 6 days with 2 RNP prog.
Rehabilitation Plus
RUA, RUB, RUC, RVA, RVB, RVC, RHA, RHB, RHC, RMA, RMB, RMC, RLA, RLB
Resident receiving physical therapy, occupational therapy, and/or speech-language pathology services while a resident.
ADL Score
* = C
* 6-10 = B
* 0-5 = A

7. Counting Minutes

8. Counting Rehab Minutes
RUG-IV Significant Changes
Revision to calculation of Therapy minutes will be implemented. You will need to indicate on the MDS 3.0 what delivery “mode” is being used for rehab services:
- Individual Therapy
- Group Therapy
- Concurrent Therapy (same area two different disciplines)
- Co-Treat two different disciplines working on two different areas

9. Counting Rehab Minutes
Aide Time – Is essentially limited to set up time
The old practice of counting all of the aides time ( for a Part-A patient) under line of sight supervision by licensed therapist is no longer acceptable, only the setup time is counted while direct line-of-sight

10. Counting Rehab Minutes
The manner in which Therapy minutes are counted had been modified
Method Of Rehab Delivery
- Individual Therapy – No Change
- Group Therapy – No Change (Be careful about coverage criteria)
- Concurrent Therapy – Minutes will be allocated/limited to 2 patient
(1/2 of time counted for reimbursement purposes)
Co-Treat – minutes x2 unless working on same area

11. Counting Minutes for Timed Codes
Units
Number of Minutes 1
≥ 8 minutes through 22 minutes 2
≥ 23 minutes through 37 minutes 3
≥ 38 minutes through 52 minutes 4
≥ 53 minutes through 67 minutes 5
≥ 68 minutes through 82 minutes 6
≥ 83 minutes through 97 minutes 7
≥ 98 minutes through 112 minutes 8
≥ 113 minutes through 127 minutes

12. Calculating Therapy Minutes
Only include minutes spent on skilled therapy
When Individual therapy occurs intermittently throughout the day, the total number of minutes from all sessions will be recorded as a daily count
When reporting therapy time, report the actual minutes of therapy
- Do not round to the nearest 5th minute
- The system will automatically do any necessary rounding, so reporting actual
therapy minutes
- Report timed minutes and untimed separately

13. Calculating Therapy Minutes
Resident can receive different modes of therapy on one day, or even in one treatment session
- Each mode of therapy and the time spent on each must be
recorded
Reportable treatment time begins when the patient started the first task or activity. And ends when they finish with the last task, or piece of equipment.
- Count the total number of minutes spent on therapeutic activities,
subtracting any time spent on breaks, or other activities that do not
qualify as therapeutic

14. Why Is It More Difficult To Get Into REHAB Categories
Section T Eliminated
Counting Minutes Modified
- Concurrent Therapy
- Aide Time

15. Therapy Distinct Days

16. Rehab Medium & Low Distinct Days
The Final Rule adds an additional MDS 3.0 item (MDS Item 00420) for the Calendar Days that Will require reporting of distinct calendar days of therapy provider. Distinct calendar days represents different days therapy was provided in the ARD or COT review look back period. In other words, on how many different days were rehabilitation services provided for greater than 15 minutes over the last seven days? This would be reported as: Speech Therapy 2 days for a total 60 minutes Occupational Therapy 2 days for a total of 60 minutes Physical Therapy 3 days for a total of 90 minutes 7 Distinct Calendar Days
PPS Day 1 2 3 4 5 6 7
9/25
9/26
9/27
9/28
9/29
9/30
10/1 PT 30 OT ST
Total

17. Distinct Calendar Days Not Met
In addition, the RUG-IV grouper will only calculate a Rehabilitation Medium RUG category when 150 minutes of therapy is provided across 5 distinct calendar days. In other word, within the 7 days observation period of the MDS or COT review, therapist must deliver services to the patient on at least 5 of the 7 days in the observation period from the Assessment Reference Date (ARD). If this criteria is not met, regardless of the number of minutes or total of combined disciplines visits of Rehabilitation services provided, the RUG score generated will reduce to a Nursing RUG. Cont.

18. For Example
Medicare Rehab Med. & Low RUG Categories - Distinct Days ARD
In Example above:
Speech Therapy 4 days for a total of 60 minutes
Occupational Therapy 4 days for a total of 170 minutes
Physical Therapy 4 days for a total of 180 minutes
4 Distinct Calendar Days
PPS Day 1 2 3 4 5 6 7 8
9/25
9/26
9/27
9/28
9/29
9/30
10/1
10/2 PT 40 50 60 30 R OT ST
Total 70
100
130
110

19. Time Documentation Part-B
Total treatment time
- Includes the minutes for both
Timed code treatment
- The procedure is defined by specific timeframe
Untimed code treatment
- The procedure is not defined by a specific
timeframe

20. 15 Minute Timed Code What Time Counts Towards 15 Minute Timed Codes?
- Report the code for time actually spent in delivery of the
modality
- Pre and post delivery service are not counted in determinig
the treatment time

21. Billing Units Part-B Documentation shows
- 33 minutes of therapeutic exercise (97110)
- 7 minutes of manual therapy (97140)
- 40 minutes total timed minutes
Appropriate billing is 3 units
= 2 unit
= 1 unit

22. Billing Unit Part-B Documentation shows
- 18 minutes of therapeutic exercise (97110)
- 13 minutes of manual therapy (97140)
- 10 minutes of gait training (97116)
- 8 minutes of ultrasound (97035)
- 40 Total timed minutes
Appropriate billing is 3 units
= 1 unit
= 1 unit
= 1 unit

23. Proof of Therapy Minutes Required for Part A & Part B

24. Therapy MDS

25. PPS Assessment Schedule
Medicare MDS
Assessment Type
Reason for
Assessment
(A0310B code)
Reference Date
Window
Grace Days
Applicable Medicare
Payment Days
5 days 01
Days 1 - 5
6 – 8
1 through 14
14 day 02
Days 13 – 14
15 – 18
15 through 30
30 day 03
Days 27 – 29
30 – 33
31 through 60
60 day 04
Days 57 – 59
60 – 63
61 through 90
90 day 05
Days 87 – 89
90 – 93
91 through 100

26. Stat of Therapy (SOT) OMRA
New assessment type
Optional assessment type
Can be done at any time during the residents’ stay to obtain a therapy RUG
ARD must be five to seven days after the start of the first therapy

27. SOT OMRA
Payment rate starts on the first day that therapy services were received
This assessment should not be combined with the 5-day PPS assessment
Should only be completed if doing so will place the resident in a therapy RUG
“Assessment will reject on the validation report”

28. SOT OMRA SOT OMRA Example Pay close attention to your case mix indices
- May not be in the facility’s best financial interest
to place the resident in a therapy RUG
- Optional assessment
- Should only be completed if there is financial
benefit
SOT OMRA Example
Resident Admitted 1/3
5-day assessment, 1/8 CB2
14-day assessment, 1/16 CB2
Therapy imitated on 1/20
SOT completed, ARD 1/25, RHB
30-day Assessment, 1/29 RVB

29. End of Therapy (EOT) OMRA
Patient was receiving rehabilitation services
Was classified to a rehabilitation RUG
Discontinues all rehabilitation services
Continues to have skilled level of care requirements

30. EOT OMRA
Assessment Reference Date (ARD) must be set on Day 1, 2 or 3 after the last day of any rehabilitation
- Day 1 corresponds to the first day on which your
facility would have normally provided therapy
services
- Whether the resident would have received
therapy that day or not

31. EOT OMRA
Payment rate changes beginning the day following the last day of therapy
- Indicated in Item Z0150A of the MDS
- Regardless of the ARD
No penalty for an early ARD is set in day that therapy is not normally provided
May be combined with a scheduled assessment, but may not replace it
EOT OMRA
Resident admitted on 1/3/14
5-day assessment, 1/8 RHB
14-day assessment. 1/16 RVB
All therapy ended on 1/22
EOT completed, ARD 1/24 LCI

32. EOT-R
End of Therapy Resumption
Requirements for completion:
1. Therapy resume within 5 calendar
days of last treatment date
2. Therapy resumes at same level of intensity
Payment at the same Rehab RUG level begins on therapy resumption date .
EOT – R Example
Resident admitted on 1/3/14
5-day assessment, 1/8 RHB
14-day assessment. 1/16 RVB
Resident misses therapy on 1/22, 1/23 and 1/24
EOT completed, ARD 1/23 LCI
Therapy Resumes 1/25, EOT-R completed, RVB resumes

33. Medicare Short Stay Assessment
Before the eight day of the covered SNF stay
- Resident dies
- Resident is discharged from SNF
- Resident is discharged from a Medicare-Part A
Covered level of care

34. Medicare Short Stay Assessment
Allows the resident to be classified to a Rehabilitation category when resident was not able to have received five days of therapy
Eight conditions, and all must be met

35. Medicare Short Stay Assessment
Must be a start of Therapy OMRA (A0310C = 1 or 3)
- May be completed alone or combined with any
OBRA assessment
- May be combined with a PPS 5-day or readmission
return assessment
- May not be combined with a PPS 14-day, 30-day,
60-day, or 90-day assessment

36. Medicare Short Stay Assessment
PPS 5-day (A0310B = 01) or readmission/return assessment (A0310b = 06) has been completed
- May be completed alone or combined with the
Start or Therapy OMRA
ARD (A2300) of the Start of Therapy OMRA must be on or before the 8th day of the part A Medicare stay

37. Medicare Short Stay Assessment
ARD (A2300) of the Start of Therapy OMRA must be the last day of the Medicare Part A stay
- Start of Therapy OMRA ARD must equal the end of
Medicare stay date (A2400C)
- End of the Medicare stay date is the date Part A
ended

38. Medicare Short Stay Assessment
ARD (A2300) of the Start of Therapy OMRA may not be more than 3 days after the start of therapy date
- Item O0400A5, O0400B5 or O400C5, whichever
is earliest
Rehabilitation therapy (PT, OT, or SLP) started during the last 4 days of the Medicare Part A covered stay (including weekends )

39. Medicare Short Stay Assessment
At least one therapy discipline continued through the last day of the Medicare Part A stay
- Must have dash-filled end of therapy date
(O0400A6), O0400B6) or O0400C6)
- End of therapy date equal to the end of covered
Medicare stay date (A2400C)

40. Medicare Short Stay Assessment
RUG group assigned to the Start of Therapy OMRA must be Rehabilitation Plus Extensive Services or Rehabilitation group (Z0100A)
- If the RUG group assigned is no t a Rehabilitation Plus Extensive Services pr a Rehabilitation group, the assessment will be rejected

41. Medicare Short Stay Assessment
If all of these conditions are met, then MDS Item Z0100C (Medicare Short Stay Assessment indicator) is coded “YES”
Assignment of the RUC-IV rehabilitation therapy classification is calculated based on average daily minutes actually provided

42. Medicare Short Stay Assessment
Resulting RUG-IV group is recorded in MDS Item Z0100A (Medicare Part A HIPPS Code)
average daily therapy minutes – Rehabilitation Low category (RLx)
average daily therapy minutes – Rehabilitation Med. category (RMx)
average daily therapy minutes – Rehabilitation High category (RHx)
average daily therapy minutes – Rehabilitation Very High
category (RVx)
- 144 or greater average daily therapy minutes – Rehabilitation Ultra High
category (RUx)

43. Medicare Short Stay Assessment
If the earliest start of therapy date is the first day of the short stay, use the Medicare Short Stay assessment Medicare Part A RUG (Z0100) from the beginning of the short stay through the end of the stay.
- Dates in Items O0400A5, O0400B5 or O0400C5
- Medicare stay must be 4 days or less

44. Medicare Short Stay Assessment
If the earliest start of therapy date is after the first day of short stay.
- If a 5-day or readmission/return assessment was
completed prior to Medicare Short Stay assesment,
* Use the Medicare Part A RUG (Z0100A) from
that assessment for the first day of the short stay
through the day before therapy
* Then use the Medicare Part A RUG (Z0100A) from the
Medicare Short Stay assessment from the day therapy
short through the end of the short stay

45. Medicare Short Stay Assessment
If the earliest start of therapy date is after the first day of the short stay
- If the Start of Therapy OMRA is combined with a 5-day
or readmission/return assessment,
* Use the Medicare Part A non-therapy RUG (Z0150A) for the first day of the short stay through the day before therapy
started;
* Use the Medicare Part A RUG (Z0100A) from day therapy
started through the end of the short stay

46. Early Assessments
If an assessment is performed earlier than the schedule indicated, the provider will be paid at be default rate for the number of days the assessment was out of compliance
No penalty is an End of Therapy OMRA is performed early if the ARD is set on a day that therapy services are not normally available at your facility

47. Late Assessment
If the ARD on the late assessment is set before the end of the payment period for that assessment
- SNF will receive the default rate from the beginning of the
payment period until the day before the ARD
- From the ARD to the end of that payment period, it will
receive the HIPPS rate identified by the assessment

48. Late Assessment
PPS assessment must be timely, in order to bill the RUG generated by the assessment
If the assessment if missed and the resident is no longer Part A when discovered, Medicare Part A cannot be billed AT ALL!!!!! No one else can be billed for those days either. The facility is liable
A PPS assessment is timely if the ARD is set:
- On the MDS - Within the prescribed ARD window
- Before the end of the last day of the window

49. COT’S

50. COT OMRA
Effective for all assessments with an ARD on or after October 1, 2011 a COT OMRA is required if the therapy received during the COT observation period does not reflect the RUG-IV classification level on the patient’s most recent PPS assessment used for payment
COT Observation Period: A successive 7-day window beginning the day following the ARD of the resident’s last PPS assessment used for payment.
Maybe used to classify a patient into a Higher or Lower RUG Category

51. COT OMRA
In order to determine if a COT OMRA is required, providers should perform an informal change of therapy evaluation that considers the intensity of the therapy the patient received during the COT observation period.
But what must a facility actually consider?
√Total Reimbursable Therapy √ Number of Therapy
Minutes (RTM) Disciplines
√ Number of Therapy Days √ Restorative Nursing (for
patients in a Rehab Low
category)

52. COT OMRA
A COT OMRA is required in cases where the therapy received during the COT observation period would cause the patient to be classified into a different RUG Category.
RUG Category Shortcut = Second character in RUG code
RUC: Ultra-High Rehab RVX: Very-High Rehab
RMA: Medium Rehab RHL: High Rehab
AS LONG AS THE SECOND CHARACTER DOES NOT CHANGE NO COT OMRA IS REQUIRED

53. When is a COT OMRA required Is the patient receiving skilled services?
Yes No
Perform COT Evaluation
Is the therapy the patient received during the COT observation period consistent with the patient’s current RUG-IV classification
No COT OMRA required
YES No
No COT OMRA
Required
COT OMRA is Required

54. COT OMRA and SNF Billing
The COT OMRA retroactively establishes a new RUG beginning Day 1 of the COT Observation Period used the next scheduled or unscheduled PPS assessment.
Example: A resident’s 30-day assessment is perfomred with an ARD set for Day 30. Based on the 30-day assessment ARD, the therapy services provided to this resident are evaluated on Day 37. If a COT OMRA is required, then payment would be set back to Day 31.

55. COT OMRA AND INDEX MAXIMIZATION
Index maximization: In some situations a resident may simultaneously meet the qualifying criteria for both a therapy and a non-therapy RUG. For some of these cases the RUG-IV per diem payment rate for the non-therapy RUG will be higher; therefore, although the resident is receiving services, the index maximized RUG is a non-therapy RUG.
A facility is required to complete a change of therapy evaluation for all patients receiving any amount of skilled therapy services, including those who have index maximized into a non-therapy RUG group.

56. COT OMRA AND INDEX MAXIMIZATION
A COT OMRA is only required for residents in such cases that the therapy services during the COT observation period is no longer reflective of the RUG-IV category after considering index maximization. Consider the following two exmaples:
Resident qualifies for RMB but index maximizes into HC2. During the COT observation period, resident receives only enough therapy to qualify for RLB.
COT OMRA not Required because no change to index maximized RUG Category
Resident qualifies for RMB but index maximizes into HC2. During the COT observation period, resident receives enough therapy to qualify for RUB
COT OMRA is required because of change to index maximized RUG category

57. Recent Clarifications
COT OMRA and Day of Discharge
If Day 7 of the COT observation period is also the day of discharge, then a COT OMRA would not be required.
COT OMRA and Scheduled PPS Assessments
If the ARD of a scheduled PPS assessment is set for on or prior to Day 7 of the COT observation period, then no COT OMRA would be required .

58. COT OMRA Clarification
A COT cannot be completed for a resident that is not a therapy RUG
Therefore, a SNF cannot complete a COT for a resident whose reimbursement is at a clinical RUG, even if they are now receiving enough therapy to increase to a higher Case Mix Index (CMI) at a rehab category.
Therapy and nursing personnel must consider various strategies to help the facility receive the proper reimbursement for resident whose therapy intensity changes during their stay.

60. SNF LOA Use Caution Work with MDS Coordinator to properly calculate
Could affect the RUG classification
Call MLC Consulting for help!!!!

61. Therapy MDS & HMO’s, Insurance
Do COT’s
Print out MDS and Keep record
Do Not Transmit MDS
Record COT change or no change for billing purpose
Humana requires hard copy of MDS in Medical review.
Has to match billing

62. Therapy MDS Impact

63. Urban

64. Urban $75.59 = Difference/Day RUC - $ 531.87 RVC - $456.28
$75.04 x 30days = $2,267.70/month
$2, x 10 patients = $22,677.00/month
RUB - $395.13
RHB - $357.85
$37.28 = Difference/Day
$37.28 x 30 days = $1,118.40/month
$1, x 10 patients = $11,184.00/month less

65. Rural

66. Rural RUC - $506.38 RHC - $428.34 $78.04 – Difference/Day
$78.04 x 30 days = $ /month
$ x 10 patients = $ 23,412.00/ month
RVB - $375.09
RHB - $333.70
$41.39 – Difference/Day
$41.39 x 30 days = $
$ x 10 patients $12,417.00

67. Section G

68. Section G Nursing fills out
- Is for what is currently going on with resident
- Needs to match the problems therapy is treating for
Coordinate with Therapy and Nursing
- Team effort
- Communication
- Fill out nursing
Debility Issus's that therapy should be addressing and work towards better outcomes

71. Geri Psych Admits To SNF

72. Denials

73. Therapy Denials
Physicians Signature: One of the first areas auditors look id the physician signature on therapist POC. Most therapist handwrite the POC, fax it to the Physician for signature. Receive signed form and scan into electronic file.
Therapist Signature & signature logs
Medical Necessity: Therapist must prove medical necessity of patients therapy services, whether physical therapy, speech therapy or occupational therapy. Therapist needs to show why patient requires skilled services.
Functional Progress: Therapist need to show patients progress in there ability to complete daily life actives through each therapy session.
- “Functional progress is how to this patient more independent in certain activities of mobility and daily living. Documentation is conveying increased range of motion or strength , but its not tied onto how the patient is walking up and down stairs, or how it affects the patients function in daily actives (the claim) will be denied.
5. Medicare Caps: $1920 initial cap $3700 prompts medical review prior to payment
Cloning : When documentation has not been changed across therapy sessions.
Patient Self-Discharge : Some patients will simply stop going without notifying the therapist or rehab program, leaving documents for patient incomplete, such as without a discharge summary.

74. 8. Recertification : Patients need to be recertified by Medicare every 90 calendar days 9. Overbilling or Inappropriate use of CPT codes and modifiers : Electronic rehab systems will alert the point-of-care therapist to any charge where the treatment time does not match the units billed or requires .modifiers

75. Skilled Nursing Facility
Review this information when filing claims top prevent denials to ensure their claims are processed timely.