MDS Alert

Follow these decision-making pointers.

When a rehab resident's therapy treatment ends, the decision-making begins for whether to do an Other Medicare Required Assessment (OMRA)--and, if so, how to manage the assessment reference date.

You have eight to 10 days from the day a resident receives his last rehabilitation therapy (physical, occupational and/or speech therapy) to do an OMRA with an ARD of day eight, nine or 10. The first "non-therapy day" counts as the first day in the count toward day 10 for doing the OMRA.

Remember: You only have to do an OMRA for a resident in a rehab RUG or a rehab plus extensive services RUG--if the resident continues to require skilled nursing care eight to 10 days after his therapy ends, according to the RAI user's manual.

Think Through These 3 OMRA-Related Decisions

Carefully considering the answers to these three questions can help you avoid compliance and payment issues.

Decision No. 1: Do you have a reason to keep a resident on skilled care for a few days after all of his therapy stops? The rules allow you to keep a resident on Part A and collect the rehab RUG rate until an OMRA is due. But facilities that routinely do so are inviting a review by the fiscal intermediary--or worse. "Facilities can, however, occasionally wait for a couple of days to discharge the resident from Part A after therapy stops in order to make sure the person will remain stable," says Joan McCarthy, manager of healthcare for RSM McGladrey Inc. in Chicago. But you have to have solid documentation as to why, she adds. For example, a resident who develops a fever and isn't getting out of bed after his therapy ends may require a couple more days of monitoring and nursing care, she says.

Don't make this mistake: McCarthy says she "sees some facilities that are so afraid to keep someone on skilled care for a couple of days after all therapies stop that they discharge the person to an intermediate bed and continue to provide skilled [nursing] services."

Decision No. 2: Should you do an OMRA eight to 10 days after the resident's therapy ends? To make this determination, review the requirements for the clinically complex and special care categories to see if a resident will RUG into one of those categories eight to 10 days after his therapy ends. "Facilities sometimes miss RUG drivers" in general, comments Maureen Wern, of Wern and Associates in Warren, OH. (For a closer look at this issue, see the April 2006 MDS Alert.)

For example, a resident with a fever and vomiting or fever and pneumonia and the requisite ADL score would qualify for a special care RUG, and could be skilled on that basis if he required daily skilled nursing care.

Remember: In addition to rehabilitation therapy, Medicare Part A SNF coverage includes direct skilled nursing services; management and evaluation of a patient care plan; observation and assessment of a patient's condition; and teaching and training activities. Thus, even if the resident goes into one of the lower RUGs that aren't presumed to be skilled, the SNF can still skill the person for daily nursing observation and assessment, as an example, until he's clinically stable, say MDS and reimbursement experts.

Decision No. 3: If you're going to do an OMRA, how can you set the ARD in a way that doesn't penalize the facility financially? In most cases, the rehab RUG the resident is in before you do the OMRA will pay more than a clinical RUG. If so, you can wait until day 10 to set the ARD, says Ron Orth, president of Clinical Reimbursement Solutions in Milwaukee. That's because the new RUG rate kicks in as of the ARD for an off-cycle OMRA (one due outside the window for a regularly scheduled MDS) or one performed in combination with a regularly scheduled Medicare MDS, such as the 30-day Medicare MDS.

Know the exception: What if the ARD for a combined OMRA and regularly scheduled Medicare MDS falls on a grace day outside the payment cycle for the regularly scheduled assessment? The payment will change on the day it normally would for the regular Medicare assessment.

Ready, set the ARD: Say a resident's last therapy day occurs on day 19 of his stay, so the OMRA is due anywhere from day 27 to 29. If the resident is going from a rehab RUG to a lower paying clinical RUG, consider using day 29 for the combined OMRA and 30-day Medicare assessment, suggests Marilyn Mines, RN, BC, director of clinical services for FR&R Healthcare Consulting in Deerfield, IL. That way, the resident's higher paying rehab RUG would remain in effect until day 29, Mines notes.

But say therapy delivers the last rehab therapy treatment on day 24, which means the facility may choose day 32, 33, or 34 for the ARD of the OMRA, all of which are grace days for the 30-day assessment. Again, you will combine the OMRA with the 30-day Medicare assessment. In this case, you could choose any of the days (from 32 to 34) for the ARD, says Mines. That's because the change in payment for the new RUG will occur after the first day of the new payment cycle (day 31).

When the clinical RUG pays more: You may want to set the ARD for the eighth or ninth day after the resident's therapy stops if the OMRA will result in a higher paying RUG score, says Orth.