MDS Alert

The Change of Therapy OMRA could rock the payment boat.

Beware: You could soon have some MDS and RUG retooling to do in the rehab arena.

For starters: The FY 2012 SNF PPS rule "proposes changes to group therapy minutes," which is "both a policy change and a RUG-IV change," says Peter Arbuthnot, regulatory analyst with American HealthTech in Jackson, Miss.

The way the RUG-IV system works now, observes Pauline Franko, PT, MCSP, a facility "can get in some pretty hefty group time" that counts toward RUG placement. For example, "if you have ultra high with two therapy disciplines," the facility can capture 180 minutes of group therapy in a week, she says. "In theory, you could do group for all three disciplines," adds Franko, principal of Encompass Consulting & Education in Tamarac, Fla.

If enacted on Oct. 1 as written, however, the proposed rule would require a group to include exactly four residents, says Arbuthnot. And "the full time spent by the therapist with these patients would be divided by 4 (the number of patients that comprise a group)," states the proposed rule. "For example, if a therapist spends 1 hour with four residents in a group therapy session, regardless of payer source, then the time used to determine the appropriate RUG"IV classification" for each Part A SNF patient will be 15 minutes. The 25 percent cap on therapyminutes isn't going away, according to the rule.

CMS also simplifies instructions for when to do an End- Of-Therapy (EOT) OMRA, says Arbuthnot. There are "no special weekend therapy delivery rules. If therapy stops for three days you do the assessment -- period."

SNFs could forego doing a Start of Therapy OMRA and instead use a new optional End of Therapy Resumption (EOT-R) OMRA when a patient who missed three or more days of therapy goes back on the same level of therapy within five days of the last therapy session, according to CMS' Sheila Lambowitz who discussed the proposed SNF PPS rule during the May 2011 SNF/LTC Open Door Forum.

How the payment would work: The SNF would be paid at the non-therapy RUG level while under the EOT OMRA, but return to the prior rehab RUG with the EOTR, explains Arbuthnot.

There's more: A proposed Change of Therapy (COT) OMRA that would require SNFs to start looking at therapy minutes on the seventh day after the ARD of any PPS assessment to see if the therapy minutes changed to the extent that the resident would go into a different rehab RUG, says Arbuthnot. If so, they'd have to do the COT OMRA, he adds.

The rule states: "An evaluation of the necessity for a COT OMRA (that is, an evaluation of the patient's total RTM [reimbursable therapy minutes]) must be completed every seven calendar days starting from the day following the ARD set for the most recent scheduled or unscheduled PPS assessment (or in the case of an EOTR OMRA, starting the day that therapy resumes ... "

"The change in therapy OMRA will be a big wake up call for therapy departments that have been taking advantage of the system with regards to maintaining minutes of treatment that meet the criteria for the RUG classification in the payment period," says Elisa Bovee, MS, OT R/L, VP of operations for Harmony Healthcare International in Topsfield, Mass. "Many of the facilities we work with, however, are very conscientious of the minutes they provide during the entire time therapy is involved with a patient."

Upside: "The COT assessment works both ways," saysFranko. "It also addresses situations where a patient needs another therapy discipline or more minutes for whatever reason," she points out. Currently, "a facility doesn't get paid for that, unless the patient requires a significant change assessment."

Audit danger: At this point, only medical review can detect instances where a SNF provides fewer therapy minutes after the MDS observation period, says Franko. "But CMS (MACs, RACs, etc.) are getting so sophisticated with data collection and mining that the auditors are really going to be looking at facilities that are outside the norm in terms of the levels of therapy provided," she warns. Franko, in fact, predicts that "very high or ultra high groups will be subject to medical review. And if the minutes drop down outside observation periods, the SNF will have to justify why," she says.

Could what CMS has proposed go away? "It could," says Franko, depending "on how many comments and what types of comments CMS receives about the proposals."

For example, Franko has concerns about CMS specifying that a group has to include four residents. She notes that facilities without a large patient census may not have four residents to participate in a group, as the residents have to be performing similar activities. "Yet, certain types of patients really benefit from the group setting," she says.