MDS Alert

Make ARDs work for - rather than against - your facility.

There's more riding on your ARDs than you might think, such as your bottom line and compliance record.

But you can turn assessment windows into opportunities for fair payment rather than lost revenues or government audits. These five strategies will help you set the best ARD for each Medicare assessment.

1. Always strive to capture the resident at his worst. Set an ARD that captures the resident's "sickest" moment and highest resource utilization, advises Maureen Wern, president of Wern and Associates in Warren, OH.

Tip: Consider setting the ARD for critically ill short-stay patients on the day they die or go back to the hospital, which is usually one of the most expensive days of the stay, suggests Nemcy Cavite Duran, RN, BSN, CRNAC, director of MDS for a facility in Flushing, NY. "That's the day when you start increasing services, such as oxygen, IVs - and the physician is usually writing 'stat' orders," she notes. "The resident usually also requires increased ADL assistance due to his acute illness."

2. Make ARD setting a team effort with an expert at the helm. "Every facility should have someone on board (preferably more than one) who really understands how to use the ARD to capture the highest level of services provided," advises Leah Klusch, RN, BSN, executive director of Alliance Training Center in Alliance, OH. "Yet that person should also listen to input from other interdisciplinary team members about selecting the ARD," she advises.

To set an ARD that best captures the resident's rehab utilization and acuity, therapists at Morrow County Hospital Extended Care Facility work with nursing and also consider social worker input about the resident's discharge plans, reports Jessica Kellough, PT. For rehab patients, the team tries to select the best possible seven days of therapy within the assessment window. "Sometimes patients miss therapy when they are out of the building for orthopedic follow-up or other procedures."

3. Set the ARD before the assessment window closes. Some facilities believe they can set the ARD after the assessment window has closed - if they have collected MDS data "24/7" and have the documentation available to back up their coding. But the Centers for Medicare & Medicaid Services says no.

"The RAI manual states that you may complete a late or missed assessment as long as the window for the allowable ARD (including grace days) has not passed," notes Andrea Platt, RN, a consultant with Thomas Healthcare Consulting in Indianapolis. "If the assessment has an ARD after the mandated grace period, Medicare pays the default rate for the covered services from the first day of the coverage period to the ARD of the late assessment," Platt cautions.

Other industry experts question CMS' rationale for not allowing facilities to set the ARD after the last grace day - if staff have been collecting MDS data during that time.

"CMS treats the ARD as if something magical happens on that date," which it doesn't, says Nathan Lake, RN, an MDS expert in Seattle. Others question how a facility would know in some cases how to capture the resident's highest acuity or service utilization until the last day of the allowable assessment period.

Solution: Assign a case manager or Medicare MDS coordinator to look at the resident on the last ARD and make sure to assign an ARD by that last day, suggest some MDS experts.

Beware, however: Facilities that make the ARD too much of a moving target without the whole interdisciplinary team being on the same page can create problems with RUG accuracy, says Nancy Augustine, RN, MSN, a consultant with LTCQ Inc. in Lexington, MA. For example, people reporting assessments and services to the MDS coordinator or completing parts of the MDS can end up working off different ARDs," Augustine says. Effective case management systems should be able to map out a resident's services, she adds.

4. Consider the ARD-setting implications of using the 14-day Medicare as the OBRA-required admission assessment. The OBRA-required assessment for care planning must be completed by day 14 of the resident's stay.

Thus, you lose the flexibility of using grace days 15 through 19 to capture the highest level of services or acuity - including addition of another therapy discipline or more rehab minutes, says Theresa Lang, RN, a consultant with Specialized Medical Services in Milwaukee.

5. Avoid a pattern of setting the ARD on grace days. "Some facilities consistently use day 30, 60 or 90 as the ARDs for those assessments, but they don't realize that the regular assessment window for the 30-day assessment, for example, is days 21 to 29 and day 30 is a grace day," says Lang.

"You don't want to have all the ARDs in a facility falling on grace days, as this practice raises red flags with the FI and CMS," she adds.