In response to the FY 2015 Skilled Nursing Facility Prospective Payment System (SNF PPS) final rule, effective Oct. 1, the Centers for Medicare & Medicaid Services (CMS) has released clarifications regarding change of therapy (COT) assessments. To avoid billing errors and the scrutiny of an audit, SNF staff need to understand the SNF PPS changes that were included in the recent update to the RAI User’s Manual.
The COT unscheduled PPS Other Medicare Required Assessments (OMRAs) are mandatory. They are required when a Medicare Part A resident receiving rehabilitation therapy qualifies for an ultra high, very high, high, medium or low Rehabilitation Resource Utilization Group (RUG) and when the intensity of therapy service changes to the point that the current payment category (RUG) is no longer applicable.1
The COT has a “rolling” assessment reference date (ARD) window, with an ARD checkpoint every seven days. It is calculated from the ARD of the most recent PPS assessment used for payment, with the exception of an end of therapy with resumption (EOT-R) assessment. The rolling window is required as long as the resident qualifies for a therapy RUG, regardless of whether the therapy RUG is the paying RUG, as in situations where a non-therapy RUG pays at a higher rate due to case-mix index maximization. In circumstances where facility staff are completing an EOT-R, the COT rolling window is counted from the date of the therapy resumption, after a break in therapy of at least three days and with the treatment resuming within five days of the last therapy treatment date.
The sole purpose of the COT assessment rolling windows is to monitor the level of therapy services provided and to adjust the billable RUG as frequently as weekly so that the Medicare Part A claim accurately reflects the current services. Monitoring the reimbursable therapy minutes (RTMs) to detect payment level changes can be a monumental task for facility staff, especially if they are not clear on the requirements.
To determine whether a COT is needed, facility staff must track RTMs daily. RTMs include total therapy minutes provided, number of therapy days and number of disciplines providing therapy. Therapy minutes include all individual minutes, half of concurrent minutes and one-fourth of group minutes per each therapy discipline (physical therapy, occupational therapy and speech therapy). RTMs do not include items such as initial therapy evaluations and documentation time. If changes in therapy service affect the payment RUG, then a COT is required. Facility staff should begin tracking RTMs from the ARD of the most recent PPS assessment or from the therapy resumption date (indicated in MDS item O0450) if an EOT-R assessment was completed.
Because most Medicare therapy RUG groups require at least five days of therapy, a resident who misses enough therapy in a seven-day period will not qualify for a therapy RUG. To ensure accuracy of the therapy RUGs based on days of service, in 2013, CMS implemented a new coding item on the MDS (O0420), titled Distinct Calendar Days of Therapy. While this new item established a clear threshold that matched the requirements for Medicare Part A rehabilitation, it had an adverse impact on residents who were at the facility solely for therapy.
If a resident missed enough therapy (three out of seven days), and the missed days were not sequential, then he or she would not qualify for a therapy RUG or an EOT-R. In all likelihood, the qualifying RUG would be one of the lowest paying, and the facility would have no recourse for rectifying the situation until the next scheduled assessment was completed. When the COT window count stopped, the facility would get a reduced payment until the next scheduled PPS assessment, which could be as far as 30 days away. This could result in the facility’s losing hundreds of dollars a day in Medicare payment and thousands of dollars during the 30 days between scheduled assessments’ standard billing cycles.
Before the COT assessment process was established, facilities were more likely to get paid for a higher level of therapy than was actually provided. After the 2013 COT policy change, facilities were at risk of being underpaid for the services they were providing.
To correct this payment discrepancy, CMS implemented a welcome solution. They clarified that, effective Oct. 1, 2014, a COT OMRA can be completed only when a resident is currently classified into a RUG-IV therapy group (regardless of whether the resident is classified into that group for payment), based on the resident’s most recent assessment used for payment.1 When a resident no longer qualifies for a therapy RUG, the COT rolling windows stop. When a resident is no longer classified into a RUG-IV therapy group, however, a COT can be completed when the following two conditions are met: