SET EOT BEFORE your COT checkpoint!

I have searched the RAI manual for evidence to the contrary and found none, so PLEASE KEEP THIS IN MIND AS YOU SCHEDULE YOUR EOT’S AND COT’S.  Please set your EOT date on or before your COT checkpoint.

From page 6 in the attached webinar presentation

COT Side Note: Not a change in the RAI Manual

The discontinuation of therapy is not enough to end COT

assessments, some event must happen on or before the

COT date:

1.  An EOT is completed;  or

2.  The resident is discharged;  or

3.  The resident’s Medicare Part A stay ends.

Start of COT observation period after EOT-R

• In cases where the last PPS Assessment was an EOT-R, the end of the first COT observation period is Day 7 after the Resumption of Therapy date (O0450B) on the EOT- R, rather than the ARD. The resumption of therapy date is counted as day 1 when determining Day 7 of the COT observation period. For example:

— If the ARD for an EOT-R is set for day 35 and the resumption date is the equivalent of day 37, then the COT observation period ends on day 43

SNF Presumption- Conditions and care that result in required RUGs

SNF Presumption- Conditions and care that result in required RUGs

Special Care High

Comatose and completely ADL dependent or ADL did not occur

Septicemia

DM and insulin shots all 7 days and insulin order changes on 2 or more days during the look back

Quadriplegia with ADL score >=5 (Bed Mobility, Transfers, Toileting and Eating)

COPD and SOB when lying flat

Fever and pneumonia or vomiting or weight loss or feeding tube

Parenteral/IV feedings

Respiratory Therapy for all 7 days (we do not have this)

Special Care Low

Cerebral palsy, or Multiple sclerosis, or Parkinson’s with ADL score >=5

Respiratory failure and oxygen while a resident

Feeding tube

Two or more stage 2 pressure ulcers with two or more selected skin treatments

One stage 2 pressure ulcer and one venous/arterial ulcer with two or more selected skin treatments

Foot infection, DM foot ulcer or other open lesion of foot with application of dressings to feet

Radiation treatment while a resident (at cancer center)

Dialysis treatment while a resident (at hemodialysis unit)

Clinically Complex

Pneumonia (active diagnosis, still taking antibiotics)

Hemiplegia/hemiparesis with ADL score >=5

Surgical wounds or open lesions with any selected skin treatment (only one needed)

Burns

Chemo, or oxygen or IV medications or transfusion while a resident

Survey Tags that can be associated with the completion of an MDS assessment

The following are the Survey Tags that can be associated with the completion of an MDS assessment. F272: Facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident’s functional capacity. F273: When required, a facility must conduct a comprehensive assessment of a resident within 14 days of admission. F274: When required, a facility must conduct a comprehensive assessment of a resident within 14 days of determining a significant change in status has occurred. F275: A comprehensive assessment must be completed not less than once every 12 months (366 days). F276: A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months. F278: The assessment must accurately reflect the resident’s status. F279: A facility must use the results of the assessment to develop, review and revise the resident’s comprehensive plan of care. F280: The resident has the right to, unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State, participate in planning care and treatment or changes in care and treatment. F286: A facility must maintain all resident assessment completed within the previous 15 months in the resident’s active clinical record (centralized location). F287: MDS data must be submitted within CMS established time frames

BIMS: Rules for stopping the interview before it is complete

RAI Manual page 2-4 Rules for stopping the interview before it is complete: — Stop the interview after completing (C0300C) “Day of the Week” if: 1. all responses have been nonsensical (i.e., any response that is unrelated, incomprehensible, or incoherent; not informative with respect to the item being rated), OR 2. there has been no verbal or written response to any of the questions up to this point, OR 3. there has been no verbal or written response to some questions up to this point and for all others, the resident has given a nonsensical response. If the interview is stopped, do the following: 1. Code -, dash in C0400A, C0400B, and C0400C. 2. Code 99 in the summary score in C0500. 3. Code 1, yes in C0600 Should the Staff Assessment for Mental Status (C0700C1000) be Conducted? 4. Complete the Staff Assessment for Mental Status."

MDS Drug Class Index references

Hydroxyzine is not included as an antianxiety agent on the MDS Drug Class Index from the American Society of Consultant Pharmacists (published by Med-Pass). This is an authoritative resource, since the ASCP members are the consultant pharmacists in long term care. However, they are not the only authoritative resource out there. The best place to look is on the website of the Food & Drug Administration (FDA), since they are the ones who assign the classifications. But in the end, if you can show a surveyor you're using a generally accepted resource and you coded based on that resource, you should be just fine. (AANAC Rena Shepard 11/2015)

Therapy Cap update 4-2015

Therapy Caps

 

https://www.cms.gov/Medicare/Billing/TherapyServices/index.html?redirect=/TherapyServices

Latest Applicable Legislation/Law:  This section was last updated to include revisions to Medicare law for therapy caps, and related provisions, through Section 202 of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).  MACRA extended the therapy caps exceptions process through December 31, 2017 and modified the requirement for manual medical review for services over the $3,700 therapy thresholds.  MACRA also extended the application of the therapy caps, and related provisions, to outpatient hospitals until January 1, 2018.

Under Medicare Part B, the annual limitations on per beneficiary incurred expenses for outpatient therapy services are commonly referred to as “therapy caps.”  The therapy caps amounts are determined on a calendar year (CY) basis which means that all beneficiaries begin a new cap each year. For CY 2015, the limit on incurred expenses is $1,940 for physical therapy (PT) and speech-language pathology services (SLP) combined. There’s another limit of $1,940 for occupational therapy (OT) services. Deductible and coinsurance amounts paid by the beneficiary for therapy services count toward the amount applied to the limit.

With the passage of MACRA, an “exceptions process” to the therapy caps is currently in effect for the remainder of CY 2015 and for all of CY 2016 and CY 2017.  For services furnished during a calendar year that exceed the therapy caps, with an exceptions process in place, providers and practitioners may request an exception on a beneficiary’s behalf when those services are reasonable and necessary.  To indicate this medical necessity, the therapy provider or practitioner is required to add a KX modifier to the claim for each applicable service.  By using the KX modifier, the provider attests that the services are both (a) reasonable and necessary and (b) that there is documentation of medical necessity in the beneficiary’s medical record. Manual policies relevant to the exceptions process apply only when exceptions to the therapy caps are in effect.

The therapy caps exceptions process applies an annual manual medical review (MMR) requirement when a beneficiary’s incurred expenses reaches a threshold of $3,700.  Each beneficiary’s incurred expenses apply towards the MMR thresholds in the same manner as it applies to the therapy caps. There’s one threshold for PT and SLP services combined and another threshold for OT services.  Now, through MACRA, not all claims exceeding the thresholds are subject to MMR as they were before.  The MMR is currently in effect through December 31, 2017 for some claims over the $3,700 thresholds.  For a general overview of the medical review process, go to the Medical Review and Education website.  For more information on the MMR of therapy claims above the $3,700 thresholds, visit the Medical Review and Education website’s Therapy Cap section.

L0200B edentulous

Q: Should L0200B, edentulous, be coded if the resident has no teeth, but also has no mouth problems?
A: The RAI User's Manual instructions state that if the resident "lacks all natural teeth or parts of teeth," this must be coded on the MDS. The CAA will trigger and it will systematically be determined whether there is a problem for the resident related to this.

Combining a Combining a PPS 5 day/return readmission with a Sig Change assessment

Combining a Combining a PPS 5 day/return readmission with a Sig Change assessment
If you do choose to combine a SCSA with the 5 day, be aware that unless you set the ARD in grace days (ie, day 6,7, or 8) you will get default payment for the days prior to the ARD. To pay from day 1, you must set the ARD in grace days. Why?
Source: [LTC Network 3-17-12] Because of the way that the AI (Assessment indicator) definition is written, the payment for a Significant Change that is scheduled within the window of a scheduled assessment (outside of grace days) is effective on the ARD. There is no exception/distinction for a 5 day assessment. If the sig change is scheduled in grace days, then the payment is effective on the 1st day of the payment period.
5 day/Return-Readmission combined with Sig Change

Transition Spreadsheet

https://spreadsheets.google.com/ccc?key=0Aq8xd_a-8uTJdDI5STl4cE5udmN0bERGdVRvN09tdHc&hl=en&authkey=CO22vIQI

Summarized from information provided during the CMS August 24, 2010, RUG-IV national call. These explanations focus on the 5-day and 14-day assessments, but the same rules apply for all of the scheduled PPS assessment types.

The PowerPoint handout from the call is posted on https://www.cms.gov/SNFPPS/02_Spotlight.asp and contains the detail about the options. A second set of handouts from the call provides detailed information about the ARD windows permitted for each assessment for each option.

The transcript of the call as well as the audio recording are expected to be posted on the CMS website.

All of the options have their pros and cons. They are summarized in the PowerPoint document from the CMS call.

Option 1 - No Substitution
5-day assessment payment block (days 1-14) overlaps September to October

·Use MDS 2.0 5-day assessment to cover the days through Sept. 30 with RUG-III
·Use MDS 3.0 5-day assessment to cover the remainder of the days with RUG-IV
·Use MDS 3.0 14-day assessment to cover applicable days with RUG-IV if skilled coverage continues

Example
· Part A day 1 = 9/27/10
· 5-day assessment covers 9/27 to 10/10
· MDS 2.0 5-day pays for 9/27-9/30 (4 days)
· MDS 3.0 5-day pays for 10/1-10/10 (10 days)
· If resident remains skilled, MDS 3.0 14-day picks up on 10/11

14-day assessment payment block (days 15-30) overlaps September to October
· Use MDS 2.0 14-day assessment to cover the days through Sept. 30 with RUG-III
· Use MDS 3.0 14-day assessment to cover the remainder of the days with RUG-IV
· Use MDS 3.0 30-day assessment to cover applicable days (days 31-60) with RUG-IV if skilled coverage continues

Example
·Part A day 1 = 9/12/10
·14-day assessment covers 9/26-10/11
·MDS 2.0 14-day assessment covers 9/26 – 9/30 (5 days)
·MDS 3.0 14-day assessment covers 10/1 – 10/11 (11 days)
·If resident remains skilled, MDS 3.0 30-day assessment picks up on 10/12


Option 2 – MDS 3.0 for MDS 3.0
5-day assessment payment block (days 1-14) overlaps September to October
· Use MDS 2.0 5-day assessment to cover days through Sept. 30 with RUG-III
· Use MDS 3.0 14-day assessment to calculate RUG-IV group to cover
o Remaining days from 5-day payment block AND
o Payment block for 14-day assessment (as long as Part A coverage continues)

Example
·Part A day 1 = 9/27/10
·5-day assessment covers 9/27 to 10/10
·MDS 2.0 5-day pays for 9/27-9/30
·MDS 3.0 14-day assessment covers 10/1 – 10/26 (10 days from the 5-day payment block + the 16 days for the 14-day payment block) as long as Part A coverage continues

14-day assessment payment block (days 16-30) overlaps September to October
· Use MDS 2.0 14-day assessment to cover days through Sept. 30 with RUG-III
· Use MDS 3.0 30-day assessment to calculate RUG-IV group to cover
o Remaining days from 14-day payment block AND
o Payment block for 30-day assessment (as long as Part A coverage continues)

Example
·Part A day 1 = 9/12/10
·14-day assessment covers 9/26-10/11 (16 days)
·MDS 2.0 14-day assessment pays for 9/26-9/30 (5 days)
·MDS 3.0 30-day assessment pays for
o Remaining days in 14-day payment block,10/1 – 10/11 (11 days) AND
o Payment block for 30-day assessment (days 31-60, 30 days)


Option 3 – Substitute MDS 3.0 for MDS 2.0 (don’t do MDS 2.0 at all)
5-day assessment payment block (days 1-14) overlaps September to October
· Use MDS 3.0 5-day assessment to cover all 14 days
o Calculates RUG-III for days through September 30
o Calculates RUG-IV for days in October

· Use MDS 3.0 14-day assessment to calculate RUG-IV group to cover starting day 15 of Part A stay (as long as Part A coverage continues)

Example
· Part A day 1 = 9/27/2010
· MDS 3.0 5-day assessment covers all 14 days of the 5-day payment block (days 1-14)
o 9/27-9/30: RUG-III
o 10/1-10/10: RUG-IV

· MDS 3.0 14-day assessment covers regular 16-day payment block starting 10/11 (as long as Part A coverage continues)


14-day assessment payment block (days 15-30) overlaps September to October
· Use MDS 3.0 14-day assessment to cover all 16 days
o RUG-III for days through September 30
o RUG-IV for days in October

· Use MDS 3.0 30-day assessment to calculate RUG-IV group to cover starting day 31 of Part A stay (as long as Part A coverage continues)

Example
· Part A day 1 =9/12/10
· MDS 3.0 14-day assessment covers all 16 days of the 14-day assessment payment block (days 16 through 30)
o 9/26-9/30: RUG-III
o 10/1-10/11: RUG-IV

· MDS 3.0 30-day assessment covers regular payment block (days 31-60) as long as Part A coverage continues



Default Option (LOL - NOT an option)
· When the Part A stay ends 10/1/1- to 10/4/10, the facility may opt not to complete required PPS assessment and bill the default rate instead
· Discharge assessment still required under OBRA requirement (does not pertain to payment)

OBRA Schedule & Transition Planning

From one MDS 3.0 to the next 3.0 you will use the ARD.

For the Transitions from 2.0 to 3.0 you will use the following:

If the first assessment come Oct is a quarterly, schedule it so the ARD is not later than 92 days from the previous MDS 2.0 quarterly R2b date.

If the first assessment come Oct is a comprehensive (Annual), schedule is so the ARD is not later than 366 days from the Previous MDS 2.0 Comprehensive Vb2 date and not later than 92 days from the previous MDS 2.0 assessment R2b.

Once you complete your first MDS 3.0 you will schedule subsequent MDS 3.0 assessments from ARD to ARD.