MDS Alert

Focus on the 5-day ARD only will leave your payment cup half full.

If you go the extra mile to set an ARD on the 5-day MDS to RUG a resident into rehab plus extensive services, you're off to a great start. But don't stop there or your SNF could end up with some payment shortfalls on your watch.

Remember: The resident who receives rehab therapy may continue to qualify for one of the new rehab plus extensive service RUGs on the 14-day MDS, which pays for day 15 through 30 of his SNF stay.

Run the numbers: There's a huge payment difference between the RMX (rehab medium plus extensive services high) and RMC (rehab medium) or the rehab high categories, says Christine Twombly, RN, consultant with Reingruber & Company in St. Petersburg, FL. "We're talking about almost a $100 per day difference between RMX and RHC," she adds. "So you would want to set the ARD so the resident goes into RMX, if he meets the criteria."

The challenge: SNFs can fairly easily capture even IV fluids (with its seven-day lookback) on the 5 day MDS. But capturing hospital services on the 14-day MDS gets tricky.

Example: You can use day 11 as an ARD for the 14-day MDS and still capture any one of the four out of five hospital services (IV meds, suctioning, ventilators and tracheostomy care) to qualify the resident for a rehab plus extensive services category, says Ron Orth, RN, NHA, RAC-C, president of Clinical Reimbursement in Milwaukee. "But if you set the ARD on day 14, you will have missed the 14-day lookback for capturing those services," he notes.

Nail Down the Hospital Dates

To set the ARD, you have to know the exact date when the hospital stopped the resident's IV fluids or IV medication--or weaned him from the ventilator, emphasized Maureen Wern, CEO of Wern and Associates in a presentation at the recent National Association of Subacute and Postacute Care conference in Washington, DC. "Pre- admission screening is the single most important focus" under the RUG-53 system, Wern added. But the reality is that you need someone to go to the hospital and get the data, she said.

Tip: Director of nursing  Konie Murray, RN, recommends that facilities work with their referring hospital to gain access to residents' electronic medical records. "That requires some effort under HIPAA in terms of meeting privacy compliance requirements," adds Murray, with Sunshine Terrace Rehabilitation Center in Logan, UT. "But it's worth doing, if possible, because the nursing home can access actual medical record documentation," Murray says.

Don't Let OBRA Box You In

From a Medicare viewpoint, you can use either the 5-day or 14-day required assessment for the initial OBRA assessment, says Marilyn Mines, RN, BC, director of clinical services for FR&R Healthcare Consulting in Deerfield, IL. If your facility always uses the latter, however, it can't take advantage of the grace days for the 14-day Medicare assessment, leading to loss of revenue, says Mines.

Example: If your facility provides IV therapy in-house, consider using the 5-day MDS as the OBRA-required assessment for care planning. That will allow you to use the grace days on the 14-day MDS (through day 19) for rehab residents who receive IVs. Then if the resident is unable to attend therapy a day or two, you can extend the ARD to capture enough therapy for the projected RUG, says Jan Zacny, RN, with BKD Southern Missouri in Springfield, MO.

Remember: To code IV fluids at K5a, you need documentation to show that the fluids were administered for nutrition or hydration, advises Rita Roedel, RN, with Extendicare Health Services Inc. in Milwaukee.