Inpatient Facility Coding & Compliance Alert

CMS wants clarity in therapy days vs. therapy visits.

Heads up: The Centers for Medicare & Medicaid Services zeroed in on therapy in the 2014 proposed skilled nursing facilities (SNF) prospective payment system (PPS) rule. The agency isn’t planning any big payment cuts, but it does want to ensure that SNFs aren’t classifying patients into a higher-than-necessary RUG category.

Key: CMS clarified that calendar days of therapy determine classification of a Rehab RUG, not the number of therapy visits.

Suppose a SNF patient receives PT on Monday, Wednesday, and Friday and OT on Monday and Wednesday in a single week. “The current [MDS software] system reads that as 3+2=5 … but it is only three distinct calendar days,” explains Ellen Strunk, PT, MS, GCS, CEEAA, owner of Rehab Resources & Consulting, Inc. in Birmingham, AL. “CMS, however, intended for patients to receive therapy five to seven days out of a calendar week [if they’ve been classified as Rehab Medium],” she explains.

To efficiently track this discrepancy, CMS proposes to add item 00420 (Calendar Days of Therapy) to the MDS, and starting on Oct. 1, 2013, SNFs would have to record the number of calendar days the patient received therapy (from all disciplines) over the 7-day look-back period.

Determine the Impact on Your Facility Now

Experts predict a low impact on therapy reimbursement for SNFs, especially since few patients fall under the RM RUG. However, simulating the change now to determine the actual impact is a wise idea.

“Providers who may have interpreted the [RM] category to require 5 distinct visits (versus days) may need to review how they are projecting anticipated RUGs in their care delivery,” notes Yolanda Pence, vice president of compliance & quality management for Integra Rehab in Dalton, GA.

Critical: More focus will need to be placed on scheduling to make sure the criterion is met, says Wendy Apgar, MS, OTR/L, clinical development specialist for Rehab Choice, Inc. in St. Louis, MO. The change would also “require setting up a process for reporting the information to the MDS coordinators.”

Get your systems in place before Oct. 1 to document distinct calendar days during the seven-day look-back period, stresses Steven Jones, CPA, with Moore, Stephens, Lovelace, PA, in Clearwater, FL. You can then determine the revenue impact and “adjust [your] protocols to mitigate the loss of revenue that would otherwise occur.”

Good idea: Lobby your software vendors to incorporate an analysis of calendar days versus visits, Jones adds. 

Potential pitfall: “While the rule itself may be fair, there does not appear to be any allowance to correct an inadvertent error in visit or minute count without significant financial penalty,” Pence points out. “An opportunity to identify and correct inadvertent errors would seem to be reasonable, without additional penalty.”

Many also agree that SNF PPS payment should be more patient-centered. “Quality care is more important than counting minutes,” Apgar says.

Outcomes should be a feature of the payment system, Strunk says. “High utilization of therapy in this setting can be more easily explained when there is a tangible benefit tied to it.”