MDS Alert

Learn from 3 examples how to handle COT and RUG classification.

The Centers for Medicare & Medicaid Services (CMS) recently made major clarifications regarding how you can report therapy services and how you can classify those therapy services into RUG groups. Make sure you have a solid handle on the new policy to prevent potentially disastrous reimbursement issues. 

Clear Up Confusion Over RUG-IV Therapy Changes

CMS recently revised the Change of Therapy Other Medicare Required Assessment (COT-OMRA) policy regarding when you can complete COT assessments. In certain situations, you may now complete COT assessments for residents not currently in a RUG-IV therapy classification or those who weren’t receiving enough therapy to support a RUG-IV classification on their prior COT assessment, said Springfield, Mo-based managing healthcare consultant Suzy Harvey in an October analysis for BKD, LLP.

According to Harvey, the RAI Manual states that you may complete the COT to place a resident back into a therapy RUG category only if the following conditions are met:

• The resident has been classified into a RUG-IV therapy group on a prior assessment during the resident’s current Part A stay; and
• There has been no discontinuation of therapy services between Day 1 of the COT observation period for the COT that classified the resident into the current non-therapy group and the assessment reference date (ARD) of the COT that reclassified the resident into a RUG-IV therapy group.

Break Down Your COT OMRA

A COT Other Medicare Required Assessment (OMRA) is required when the resident was receiving a sufficient level of rehabilitation therapy to qualify for an Ultra High, Very High, High, Medium, or Low Rehab category, and when the intensity of therapy changes to such a degree that it would no longer reflect the RUG-IV classification and payment assigned for a given resident based on the most recent assessment used for Medicare payment, according to MDS education coordinator Mary Mass in a recent presentation for the North Carolina Department of Health and Human Services, Division of Health Service Regulation. 

Per the RAI Manual, a COT is required when the resident receiving payment for an RU, RV, RH, RM, or RL therapy RUG category is no longer receiving the amount of therapy to justify the payment, says Marilyn Mines, RN, BC, RAC-CT, MDS Alert consulting editor and senior manager of clinical services for FR&R Healthcare Consulting Inc. in Deerfield, Ill. By monitoring the seven days following each ARD, you can determine whether a COT OMRA is required.

The change in intensity of therapy is indicated by the total reimbursable therapy minutes (RTM) delivered and other therapy qualifiers such as number of therapy days and disciplines providing therapy, Mass noted.

For the COT OMRA, you would set the ARD for Day 7 of a COT observation period, Mass instructed. The COT observation period is a successive seven-day window beginning the day following the ARD of the resident’s last PPS assessment used for payment. 

Caveat: In cases where the last assessment was an End of Therapy with Resumption (EOT-R), the COT observation period begins on the resumption date listed in O0450B — Date on which therapy regimen resumed.

To determine if a COT OMRA is required, you should perform an informal change of therapy evaluation every seven days, according to Mass. This evaluation should consider the intensity of the therapy the patient received during the COT observation period, as well as:

• Total reimbursable therapy minutes;
• Number of therapy days;
• Number of therapy disciplines; and
• Restorative nursing (for residents in a Rehab Low category).

This is one way of determining the need to do a COT OMRA, but it can be time-consuming, Mines notes. If you review the therapy minutes and days, in most cases this would be sufficient to determine the need for a COT OMRA without actually doing an evaluation.

Remember: “A COT OMRA is required in cases where the therapy received during the COT observation period would cause the patient to be classified into a different RUG category,” Mass said.

“SNFs still will be able to complete a COT assessment following an assessment that index-maximized the resident into a non-therapy RUG-IV group,” Harvey noted. “This assumes the resident was receiving sufficient therapy days and minutes to qualify for a RUG-IV therapy group, despite being index-maximized into a clinical RUG group.”

What the New COT Policy Means: 3 Examples

For many, the new COT policy is somewhat confusing. Harvey offers the following examples to illustrate how the new policy works:

Example 1: For the five-day assessment on Day 8 of the resident’s stay, you classify RUG category as RVB (Rehabilitation Very High). For the 14-day assessment on Day 15 of the stay, you also classify RVB. The resident missed therapy on Days 16 through 18, requiring an EOT assessment. Therapy resumes on Day 19 of the stay, so you modify the EOT to an EOT-R assessment.

Therefore, you’re not allowed to assess a COT on Day 22 of the resident’s stay due to your completion of the EOT-R. Day 1 of the COT observation period will instead start on Day 19, when therapy resumed.

Example 2: For the five-day assessment on Day 8 of the resident’s stay, you classify the RUG category as CC1 (Clinically Complex), because the resident had only four distinct calendar days of therapy. You cannot combine the COT with the 14-day assessment, because you did not establish a RUG-IV therapy group for the five-day assessment. 

You must complete the 14-day assessment — and if you classify the resident into a RUG-IV therapy group, the COT observation period will begin. Depending upon when the therapy started, you may not be able to enhance reimbursement by completing either a combination 14-day and Start of Therapy (SOT) OMRA, or two separate assessments if there is a therapy RUG.

Example 3: For the five-day assessment on Day 8 of the resident’s stay, you classify the RUG category as RHC (Rehab High). For the 14-day assessment on Day 15 of the stay, you classify the RUG category as CC1, because the resident had only four distinct calendar days of therapy. You cannot use a COT to reclassify the resident into a RUG-IV therapy group, because the prior assessment was not a COT and did not classify the resident into a RUG-IV therapy group.

Can You Combine Scheduled Assessment with COT?

“In this example, the SNF would need to combine the 14-day assessment with a COT, which will retroactively decrease payment for Days 9 through 14 from an RHC to a CC1,” Harvey explained. 

Based on the clarification memo, unless you take the resident off a therapy RUG by completing a COT OMRA, you cannot use another COT OMRA to put the resident back into a therapy RUG, Mines says. In the scenario above, if you completed a combination 14-day and COT, you could do another COT on Day 22 to place the resident back into the rehab RUG as long as therapy was not discontinued.

“While the ability to use the COT assessment to reclassify residents back into a RUG-IV therapy group is a welcome relief, there are some drawbacks to the policy,” which the above example illustrates, Harvey said.