1. 1 Implementing the New SNF PPS Provisions Thursday, September 8, 2011 Megan Hamilton, MS, CCC, SLP Darrell Shreve, Ph.D.

2. 2 AGENDA Student Supervision Change MDS Assessment Schedule Allocation of Group Therapy Minutes ABN & Generic Notice EOT OMRA and EOT-R OMRA New PPS Assessment: COT OMRA

3. 3 Revised Student Supervision Requirements Line of sight supervision no longer required State and Local Regs Practice standards/Acts For billing purposes, the student is considered an extension of the therapist.

4. 4 Revised Student Supervision Requirements APTA, AOTA, and ASHA have provided recommendations on student supervision guidelines. Their guidance is available on the SNF PPS website at: www.cms.gov/SNFPPS/Spotlight.asp

5. Student Supervision Requirements ASHA, AOTA and APTA Consolidated Students who have been approved by the supervising therapist to practice independently in selected Pt situations can perform the selected clinical services without line of sight supervision. Amount and type of supervision determined by the therapist must be appropriate for the student’s documented level of knowledge, experience and competence. 5

6. Student Supervision Requirements ASHA, AOTA and APTA Consolidated Students who have been approved by the supervising therapist to perform…….. Can perform the selected services without line of sight supervision. Supervising therapist must be physically present in the facility and immediately available to provide observation, guidance and feedback when the student is providing services Supervising therapist is required to review and sign all students’ patient documentation for all levels of clinical experience and retains full responsibility for the care of the patient 6

7. Student Supervision Requirements ASHA, AOTA Consolidated Students who have not been approved by the supervising SLP/OT to practice independently in selected patient situations: – Require line of sight supervision – Supervising therapist must have direct contact with the patient during each visit 7

8. 8 Coding Student Supervision Code as individual therapy when: 1.The therapist or student is treating one resident, and 2.The other is not treating or supervising any other residents or assistants or students

9. 9 Coding Student Supervision Code as concurrent therapy when: 1.The therapist and student are each treating one resident, and neither is treating or supervising any other residents or students or assistants, or 2.The therapist is treating 2 residents while the student is not treating any residents, or 3.The student is treating two residents, and the therapist is not treating any residents or supervising any other students or assistants.

10. 10 Group Therapy and Student Supervision The time for a group session may only be counted if the full group is being run by either the supervising therapist or the student, while the other may not be supervising any other students or assistants or treating residents. If the therapist and the student each treat two of the four residents, the time may not be counted.

11. 11 Recommendations for Implementation of Student Supervision Changes PTA supervising a PTA student OTA supervising an OTA student. Structured approval Documentation of the basis for approval Documentation of measures considered for approval

12. 12 New MDS Assessment Schedule Effective for all assessments with an ARD which falls on or after October 1, 2011 Purposes: – Reduce overlap between look back periods. – Reduce gap between look-back period and payment window. Areas of change are the assessment reference window and the grace days.

13. 13 New MDS Assessment Schedule Old Assessment Schedule Assmt TypeARD Window Days Grace Days 5 Day 1-56-8 14 Day 11–1415-19 30 Day 21-2930-34 60 Day 50-5960-64 90 Day 80-8990-92 New MDS Schedule ARD on 10/01/11 or after Assmt Type ARD Window Days Grace Days 5 Day 1 – 5 6 - 8 14 Day 13 – 14 15 – 18 30 Day 27 – 29 30 – 33 60 Day 57 – 59 60 – 63 90 Day 87 - 89 90 - 93

14. 14 Reduction in Potential ARD Window Overlap Old – 5-day : ARD Day 8, Look-back Window: Days 2 – 8 – 14-day :ARD Day 11, Look-back Window: Days 5 – 11 – Overlap: Days 5 – 8 (four days) New – 5-day: ARD Day 8, Look-back: Days 2 – 8 – 14-day :ARD Day 13, Look-back: Days 7 – 13 – Overlap: Days 7 – 8 (two days)

15. 15 Reduction in ARD Look-Back Window Overlap Old – 14-day ARD Day 19, Look-back Window: Days 13 - 19 – 30-day ARD Day 21, Look-back Window: Days 15 – 21 – Overlap: Days 15 – 19 (five days) – Longest time to payment window: 16 days New – 14-day ARD Day 18, Window: Days 12 – 18 – 30-day ARD Day 27, Window: Days 21 – 27 – Overlap: None – Longest time to payment window: 10 days

16. 16 If the ARD is set on day 19, you will get: Penalty for late assessment Must fill default RUG for Days 15 –18. If the ARD is set on Day 12, you will get: Penalty for early assessment Must bill default RUG for first day of the next payment period (Day 15) Two Pitfalls for 14-Day Assessment on or after October 1, 2011

17. 17 Affects 14-day, 30-day, 60-day, and 90-day PPS assessments Days 19, 34, 64, 94 are no longer grace days An ARD on these days will be penalized because late Solution: set ARD at least one day earlier Pitfall: Loss of a Grace Day

18. 18 Implementation Suggestions Identify all residents with ARD window that includes October 1, 2011 Make sure ARD not later than day 18, 33, 63, or 93, as appropriate If ARD will be day 19, 34, 64, or 94 on Oct. 1, set ARD date on Sept. 30 or earlier Setting ARD on Sept. 30 or earlier also gets you the earlier start date for ARD window Make sure key staff understand the changes

19. 19 You must combine scheduled and unscheduled assessments if: 1. The ARD for the unscheduled assessment falls within the ARD window for the scheduled assessment, and 2. The scheduled assessment has not been completed If both conditions are not met, you cannot combine them Combining Scheduled and Unscheduled Assessments

20. 20 When you combine scheduled and unscheduled assessments: Use the Item Set for the scheduled assessment—it has more items Use the ARD for the unscheduled assessment Use the appropriate A1 code for the combination Combining Scheduled and Unscheduled Assessments

21. 21 Allocation of Group Therapy Minutes Group therapy is defined as therapy provided to four patients (regardless of payer source) who are performing the same or similar activities. Implemented 10/01/11 regardless of whether the look back period extends back before 10/01/11.

22. 22 Allocation of Group Therapy Minutes Current OT Upper Extremity Tx Tues 9:00 to 10:00 am Participants include Mrs. A, Mr. B and Ms. C. Minutes: 60 minutes recorded and 60 minutes allocated for each one October 1, 2011 OT Upper Extremity Tx Tues 9:00 to 10:00 am Participants include Mrs. A, Mr. B and Ms. C. Minutes : 60 minutes recorded for each one, but zero minutes allocated !

23. Allocation of Group Therapy Minutes All group therapy time reported on the MDS will be divided by four when determining each Patient’s RUG. The 25% cap is still in effect Implemented 10/01/11 regardless of whether the look back period preceded 10/01/11. 23

24. 24 Documentation Requirements Ensure resident care follows a prescribed and documented plan of care Documentation in patient’s medical record should be sufficient to justify plan of care and to identify potential changes in patient’s medical condition. Skilled services, particularly therapy services, should be properly tailored to the individualized goals of the resident.

25. 25 Allocation of Group Therapy Minutes Current OT Upper Extremity Tx Tues 9:00 to 10:00 am Participants include Mrs. A, Mr. B, Ms. C. and Mr. D. Minutes: 60 minutes are recorded and 60 minutes are allocated for each of the four residents October 1, 2011 OT Upper Extremity Tx Tues 9:00 to 10:00 am Participants include Mrs. A, Mr. B, Ms. C. and Mr. D Minutes: 60 minutes are recorded for each resident, but only 15 minutes are allocated for each resident. A resident needs four hours of group Tx in order to be allocated 1hour

26. 26 Allocation of Group Therapy Minutes Scheduled group treatment of four patients performing the same or similar activities with unintentional or unavoidable reduction to three patients may be counted as group treatment. Group treatment minutes will be divided by four when only three of the four scheduled Patients are able to partake in group tx.

27. 27 Allocation of Group Therapy Minutes Planned/Scheduled: OT Upper Extremity Tx Tues 9:00 to 10:00 am Participants include Mrs. A, Mr. B, Ms. C, and Mr. D Minutes: 60 minutes are recorded for each resident, and 15 minutes are allocated to each resident: Unexpectedly Missed Tx: OT Upper Extremity Tx Tues 9:00 to 10:00 am Participants include Mrs. A, Mr. B and Ms. C. Mr. D is not there. Minutes: 60 minutes are recorded for the three participants, and they each are allocated 15 minutes Mr. D has no minutes recorded or allocated

28. 28 ABN & End of Therapy OMRA Do you have to give an ABN (advance beneficiary notice) whenever the resident goes without therapy for three consecutive days? Example: SNF does not provide therapy on weekend, and resident doesn’t feel up to therapy on Monday Not unless you determine that the resident will not resume therapy or receive skilled nursing over the next several days

29. 29 ABN & End of Therapy – Medicare has never required therapy seven days a week for Part A coverage (the beneficiary does not lose coverage because the SNF does not provide therapy on the weekends or holidays, for example) – Notices of Medicare non-coverage are not issued when care ends at the beneficiary’s initiative or for provider business reasons, such as the SNF’s decision not to offer therapy on certain days of the week

30. 30 ABN & End of Therapy OMRA If you are planning to end the Part A coverage: – Give the generic notice two days before – Give the ABN on last day of coverage – You may want to do an EOT if the resident appeals the generic notice or requests a demand bill

31. 31 ABN & End of Therapy If you expect the resident to resume therapy shortly, you should not end Part A coverage; you should complete the EOT If you subsequently decide that Part A coverage is not warranted, give the generic notice two days in advance and then the ABN on the last day of Part A coverage

32. 32 End of Therapy OMRA Not a new PPS assessment Three consecutive calendar days of treatment missed for any reason. (planned, unplanned, unavoidable) EOT OMRA reclassifies into a non-therapy RUG ARD for an EOT OMRA must be set for 1 to 3 days after the last therapy session All facilities considered “7 day” SNFs, as of 10/1/11

33. 33 End of Therapy – Resumption OMRA (EOT-R) Reclassifies patient into the same therapy RUG they were in prior to the EOT Therapy must be resumed within 5 calendar days of the last day of therapy provided EOT-R must have an ARD on or after 10/1/2011 Optional. Modifies the EOT assessment with two additional items to indicate therapy resumed Advantage: No SOT and new therapy evaluation

34. End of Therapy OMRA SunMonTuesWedThursFriSat RVRV 100 RV 0 RV 100 0 (1)0 (2) 0 (3) ARD for EOT OMRA must be set for Day 1, 2, or 3 after the date of last therapy treatment Non-Rehab RUG payment begins on Day 1 or the day following the last day of therapy SunMonTuesWedThursFriSat RV $460 PA1 $182 34

35. End of Therapy OMRA  EOT-R Therapy resumes:  At the same level  Within 5 days of last therapy session SunMonTuesWedThursFriSat RV PA1 RV 35

36. EOT OMRA & Start of Therapy OMRA SunMonTuesWedThursFriSat RV PA1 RM 36

37. 37 Creating the EOT-R If the EOT OMRA has not been submitted and accepted when therapy resumes: Code the EOT-R items (O0450A and O0450B) on the EOT assessment and submit the combined EOT/EOT-R record Modify the EOT with the actual date of resumption of therapy services in item If tx does not resume at same level with in 5 consecutive days, there is no option of completing the EOT-R. The only options remaining would be SOT OMRA and a new therapy eval or wait until the next scheduled assessment.

38. 38 Creating the EOT-R If the EOT OMRA without the EOT-R items has already been submitted and accepted: Submit a modification request for that EOT OMRA Complete the two EOT-R items Check X0900E to indicate that the reason for modification is the addition of the resumption of therapy date.

39. 39 Advantages of the EOT-R The advantages of the EOT-R: – Start of Therapy (SOT) assessment not required – New therapy evaluation not required – New therapy plan not required If therapy resumes after five days or at a different therapy RUG level: – EOT-R cannot be used – Complete SOT OMRA, new therapy evaluation and plan, or – Wait until next scheduled PPS assessment

40. EOT OMRA Implementation Recommendations Communicate expectations – Pt resuming at same level (--> EOT-R) – Pt resuming at different level (no EOT-R) – Pt not resuming plan of care (EOT or ABN) We recommend that you complete EOT-R at same time as the EOT—but they should not have the same ARD date 40

41. 41 Change of Therapy (COT) OMRA Problem: Assessments looked back to establish therapy RUGs, but therapy services were paid prospectively, regardless of whether they were delivered Purpose: To align the payment for therapy services with the services actually provided Process: Rolling seven-day therapy evaluation period, and completion of mandatory COT OMRA if the RUG classchanges Result:Accurate payment for therapy services delivered

42. 42 The COT OMRA Evaluation required for any resident in a therapy RUG OR would be in one except for index maximization The new class and payment rate are retroactive to the first day of the evaluation period on which the COT is based This RUG class and rate continue until the next scheduled or unscheduled PPS assessment Uses the MDS 3.0 OMRA (NO/SO) form

43. 43 Change of Therapy (COT) OMRA ARD is day 0 Day 7 of the COT Observation Period demonstrates 740 min No COT Day 14 of the COT Observation Period demonstrates 736 min No COT Day 21 of the OCT Observation Period demonstrates 650. COT is required and the observation period re-sets. Day 7 of the COT observation period demonstrate 780 min, hence a COT is required and the observation period resets. Day 7 of COT observation period shows 733 minutes, no action needed Day 7 of COT observation period demonstrates 830 min, no action is needed Day 21 of COT observation period demonstrates 621 min, a COT is required. 1 RU 234567 740 891011121314 736 15161718192021 650 1234567 780 1234567 733 891011121314 830 15161718192021 621

44. 44 The COT OMRA What factors can change the therapy RUG? – Change in reimbursable minutes – Change in number of therapies – Change in days of therapy – Change in days of rehab nursing The key question is whether the COT evaluation produces a change in the payment RUG class If payment RUG class changes, COT OMRA is required

45. 45 Observation Periods for the COT OMRA General rule: The COT evaluation period starts the day after the most recent ARD and runs for seven days – Example: 14-day assessment with ARD on day 13 establishes therapy RUG. – COT evaluation period starts on day 14 and ends on day 20 – If RUG class changes, complete COT OMRA with new rate effective as of day 14 – If no change, no COT required and next evaluation period is days 21-27

46. 46 Special Considerations for the COT If the COT evaluation reveals that a different RUG class is appropriate, you may have to combine the COT with another assessment Remember, you must combine scheduled and unscheduled assessments if: 1. The ARD for the unscheduled assessment falls within the ARD window for the scheduled assessment, and 2. The scheduled assessment has not been completed

47. 47 Special Considerations for the COT There is an exception to the general rule regarding the first day of the COT evaluation period If you complete the EOT-R, the evaluation period begins the day therapies resume Example: – Last day of therapy is day 31 and EOT ARD is day 33 – Therapy resumes on day 35 – Evaluation period starts on day 35 and goes thru day 41

48. 48 The COT Evaluation The COT evaluation is an informal evaluation with no specific form required You need to consider the following factors: – The resident’s total “Reimbursable Therapy Minutes” (RTMs), which are the minutes after allocation – The number of therapy days – The number of therapy disciplines – Restorative nursing for residents in a Rehab Low class The rehab RUG classes have not changed

49. 49 Index Maximization and the COT OMRA Index maximization means that if the resident qualifies for more than one RUG class, the resident is “maximized” into the RUG with the highest payment rate If the COT therapy evaluation would change the therapy RUG class, you need to consider index maximization If your current RUG payment for a nursing RUG is higher than for the new therapy RUG, no COT is required If the payment for the new therapy RUG is higher than the existing RUG payment, you must complete the COT OMRA

50. 50 Examples of Index Maximization Resident qualifies for RMC but index maximizes into LE2. – During the COT observation period, resident receives only enough therapy to qualify for RLB. – COT OMRA not required because no change to the index maximized RUG Resident qualifies for RMC but index maximizes into LE2. – During the COT observation period, resident receives enough therapy to qualify for RUB. – COT OMRA is required because of change to the index maximized RUG

51. 51 If A COT OMRA Is Late... You must still submit it. You will be paid the default rate for all days not in compliance with the ARD requirement. The ARD of the late COT OMRA restarts the 7 day observation period for the next COT OMRA.

52. 52 The COT OMRA Can Help Me When … You increase therapies. An example: – Resident starts therapy on day 10 – 14-day assessment with ARD on day 14 establishes therapy RUG to pay for days 15-30. – You increase therapies significantly on day 16 – Evaluation period starts on day 15 and ends on day 21 – Assessments are not combined – COT OMRA gets you higher RUG rate as of day 15

53. 53 The COT OMRA Can Help Me When … You manage the ARD windows strategically. An example: – New resident, weak, starts therapy on day 4, and increases therapy on day 7 – You set ARD for initial PPS assessment to get resident into a low therapy RUG, setting stage for COT OMRA to follow – COT evaluation raises RUG, and the COT OMRA payment rate will be retro to the day after initial ARD – To use the COM OMRA, the resident must qualify for a therapy RUG on previous assessment, even if index maximization puts resident in another RUG

54. 54 Transition Billing Issues If your bill covers Sept. 30 and Oct. 1, you will need two RUG classes—one for Sept. 30 and earlier, and one for Oct. 1 and later CMS will upgrade its system on 9/18 to calculate the both RUGs for ARDs from 8/22 through 10/31 The validation reports will reflect both RUG groups. For Sept. 30 and earlier, the Oct. RUG class will be shown in Error Message #1059 For Oct. 1 and later, the Sept. RUG class will be shown in Error Message #1060

55. 55 The End Megan Hamilton mhamilton@preshomes.org Darrell Shreve dshreve@agingservicesmn.org