MDS Alert

Understand when you now must do an SCSA for hospice residents.

With no new items and no deleted items in the updated MDS 3.0, you may think that you have nothing that warrants your attention. But think again — the bulk of the changes to the October 2015 RAI Manual are in Chapter 2.

In the updated RAI Manual and MDS 3.0 Item Sets v1.13.2, which are effective Oct. 1, 2015, the Centers for Medicare & Medicaid Services (CMS) made mostly grammatical changes and corrections to typographical errors (see “Look For Reformatted RAI Manual Pages & Revised QMs,” MDS Alert, Vol. 13, No. 9, p. 107). For instance, CMS changed the way it displays the effective date for each item set in the revised RAI Manual.

“In the past, CMS would only update the date at the bottom of the page when they actually changed something on that page,” noted Cheryl Shiffer, RN, BSN, RAC-CT, RAI Coordinator for the Texas Department of Aging and Disability Services, in a recent training session. “But now, every page in the RAI Manual is dated October 2015. This makes it really easy for staff to know that they have the most current copy, that they’re looking at the most current version of the Manual.”

But that’s not all. CMS also made important clarifications and revised certain language in the RAI Manual that will change your compliance practices and MDS coding.

1. New Facilities Can Do OBRA Assessments, But Not Transmit Them

First, CMS revised page 2-4 in its requirements for new facilities submitting Omnibus Reconciliation Act of 1987 (OBRA) assessments via the Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system. Under “New Facilities,” the RAI Manual states:

“Prior to certification, although the facility is conducting and completing OBRA assessments, these assessments are not technically OBRA required, but are required to demonstrate compliance with certification requirements.”

In the same bullet, CMS has added a new clarification that states:

“Since the data on these pre-certification assessments was collected and completed with an ARD/target date prior to the certification date of the facility, CMS does not have the authority to receive this into QIES ASAP. Therefore, these assessments cannot be submitted to the QIES ASAP system.”

So you cannot transmit these pre-certification assessments via the QIES ASAP system and send them to CMS, Shiffer explained. In the next bullet, the RAI Manual specifies that after a completed survey where the new nursing home is found in substantial compliance, “the facility will be certified effective the last day of the survey and can begin to submit OBRA and PPS required assessments to QIES ASAP.”

Keep in mind that you don’t need to restart the MDS process once you certify beds. Restarting the OBRA process is not necessary; all you need to do is submit the next scheduled assessment.

2. Change in Ownership? Get New QIES ASAP IDs

And on page 2-5, the RAI Manual revises requirements when dealing with a change in facility ownership where the new owner does not accept the previous owner’s liabilities. In this case, CMS would treat the change in ownership occurrence as the creation of a new facility. Therefore, the RAI Manual now clarifies that:

“Staff who worked for the previous owner cannot use their previous QIES user IDs to submit assessments for the new owner as this is now a new facility. They must register for new user IDs for the new facility.”

Remember: Under the new ownership, you should “discharge” all the residents in the QIES ASAP system, and then complete an Admission assessment and Entry tracking record for all residents, Shiffer explained. For each resident, code:

• A0310F — Entry/discharge reporting as 01 — Entry tracking record;
• A1600 — Entry Date as the date of ownership change;
• A1700 — Type of Entry as 1 — Admission; and
• A1800 — Entered From as 02 — Another nursing home or swing bed.

3. Pay Attention to Clarified Hospice SCSA Rules

And on page 2-21, CMS revised the language in the requirement for performing a Significant Change in Status Assessment (SCSA). The RAI Manual now states: “A SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home.”

Meaning: “CMS is defining a hospice program as a Medicare-certified or State-licensed hospice provider,” Shiffer noted. So you don’t only do an SCSA when a resident enrolls into a Medicare-certified or State-licensed hospice, but you would also do a SCSA if the resident decided to change their hospice providers during their hospice stay and they remain a resident at the nursing home.

4. When You Must Complete a COT OMRA

On page 2-52 under the instructions for an EOT OMRA, CMS clarified when you must complete a Change of Therapy (COT) Other Medicare Required Assessment (OMRA). In cases where the last day of the Medicare Part A benefit (the date you use to code A2400C — End date of most recent Medicare stay) is prior to the third consecutive day of missed therapy services, then you do not need to complete an End of Therapy (EOT) OMRA.

But if the date in A2400C is on or after the third consecutive day of missed therapy services, then you must complete an EOT OMRA.

In cases where the date you use to code A2400C is the same date you code in A2000 — Discharge Date (meaning, cases where the discharge from Medicare Part A is the same day as the discharge from the facility), and this date is on or prior to Day 7 of the COT observation, then you don’t need to complete a COT OMRA. You may choose to combine the COT OMRA with the Discharge assessment under the rules outlined in Chapter 2 of the RAI Manual.

Note: “This is not a new policy,” according to an Oct. 7 analysis by Washington, D.C.-based Leading Age. “This clarifies the fact that an EOT is not required unless the provider is going to bill at least three days to Medicare after the last therapy date.”

5. Follow Crucial COT OMRA Instructions

Another language change occurred in the COT OMRA instructions on page 2-51:

“Required when the resident was receiving a sufficient level of rehabilitation therapy to qualify for an Ultra High, Very High, High, Medium, or Low Rehabilitation category and when the intensity of therapy (as indicated by the total reimbursable therapy minutes (RTM) delivered, and other therapy qualifiers such as number of therapy days and disciplines providing therapy) changes to such a degree that it would no longer reflect the RUG-IV classification and payment assigned for a given SNF resident based on the most recent assessment used for Medicare payment.”

“This instruction is timely due to the new rules for calculating Rehab Medium,” Leading Age noted. “If a resident received less than five distinct calendar days of therapy, there will be no Rehab RUG, therefore the COT count will cease with the ARD of the assessment that does not earn a Rehab RUG.”

More: Also not a new policy, CMS clarified that “a COT count begins the day after an ARD in which a Rehab RUG is earned, whether or not it is assigned due to CMI,” according to Leading Age. “This clarification brings language into the manual from previous PPS clarification memos.”

6. Conduct Resident Interview after ARD in This Case

Another clarification that CMS added from previous PPS memos deals with conducting resident interviews. On page 2-55 under “Coding Tips and Special Populations,” the RAI Manual now states:

“Note: In limited circumstances, it may not be practicable to conduct the resident interview portion of the MDS (Sections C, D, F, J) on or prior to the ARD for a standalone unscheduled PPS assessment. In such cases where the resident interviews (and not the staff assessment) are to be completed and the assessment is a standalone unscheduled assessment, providers may conduct the resident interview portions of that assessment up to 2 calendar days after the ARD (Item A2300).”

Significance: CMS likely added this language because many providers stopped this practice after the May 2015 RAI Manual release which didn’t include this instruction at that time, Leading Age explained.

Resources: You can download the entire updated RAI Manual at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html. Scroll down to the “Downloads” section at the bottom of the page to find links to the October 2015 RAI Manual and MDS 3.0 Item Sets, as well as the Change Tables and Replacement Manual Pages.