Eli's Rehab Report

Here is what the specialists have to say.

You have to recognize and document when a patient needs a change of treatment because of a change of status -- decline or improvement -- and when a Change of Therapy Other Medicare-Required Assessment (COT-OMRA) is necessary since this can impact payment. Check out what this Medicare official has to say to help you document better.

"It's important to recognize at what point a COT is necessary, which is really only when that second character in a rehab group changes, versus when a significant change assessment is warranted," John Kane, health insurance specialist with CMS' Division of Institutional Post Acute Care said in response to a question posed by a caller during the SNF Open Door Forum on May 24.

"I will say that for a lot of the questions I've gotten recently, a significant change assessment actually would have been appropriate in those cases. I think it's sort of a misunderstood or an often overlooked assessment in terms of its importance," Kane explained.

"The differences between a COT and an SCSA are really clear," notes Marilyn Mines, RN, RAC-CT, BC, senior manager of clinical services for FR&R Healthcare Consulting Inc. in Deerfield, Ill. "A COT-OMRA is only done when there is going to be a change in your rehab category reimbursement rate. An SCSA is not related to therapy," she explains.

According to the RAI Manual, a COT-OMRA should be completed "when the intensity of therapy, which includes the total reimbursable therapy minutes (RTM), and other therapy qualifiers such as number of therapy days and disciplines providing therapy, changes to such a degree that the beneficiary would classify into a different RUG-IV category than the RUG-IV category for which the resident is currently being billed for the 7-day COT observation period following the ARD of the most recent assessment used for Medicare payment."

"The requirement to complete a change of therapy is reevaluated with additional 7-day COT observation periods ending on the 14th, 21st, and 28th days after the most recent Medicare payment assessment ARD and a COT OMRA is to be completed if the RUG-IV category changes. If a new assessment used for Medicare payment has occurred, the COT observation period will restart beginning on the day following the ARD of the most recent assessment used for Medicare payment," the RAI Manual (pg. 2-41) states.

In contrast, an SCSA for a resident must be completed when the interdisciplinary team (IDT) has determined that a resident meets the significant change guidelines (see the "Significant Change" below)

The RAI Manual explains that a SCSA is appropriate if there are either two or more areas of decline or improvement that extend beyond two weeks. These areas are defined by the RAI manual as:

• Resident's decision-making changes;
• Presence of a resident mood item not previously reported by the resident or staff and/or increase in the symptom frequency (PHQ-9©), e.g., increase in the number of areas where behavioral symptoms are coded as being present and/or the frequency of a symptom increases for items in Section E (Behavior);
• Any decline in an ADL physical functioning area where a resident is newly coded as Extensive assistance, Total dependence, or Activity did not occur since last assessment;
• Resident's incontinence pattern changes or there was placement of an indwelling catheter;
• Emergence of unplanned weight loss problem (5% change in 30 days or 10% change in 180 days);
• Emergence of a new pressure ulcer at Stage II or higher or worsening in pressure ulcer status;
• Resident begins to use trunk restraint or a chair that prevents rising when it was not used before; and/or
• Overall deterioration of resident's condition.

According to the RAI Manual (pg. 2-22), an SCSA is not required for minor or temporary variations in resident status, i.e., cases in which the resident's condition is expected to return to baseline within two weeks.

"However, staff must note these transient changes in the resident's status in the resident's record and implement necessary assessment, care planning, and clinical interventions, even though an MDS assessment is not required," the manual notes.

"For example, a 5% weight loss for a resident with the flu would not normally meet the requirements for a SCSA. In general, a 5% weight loss may be an expected outcome for a resident with the flu who experienced nausea and diarrhea for a week. In this situation, staff should monitor the resident's status and attempt various interventions to rectify the immediate weight loss. If the resident did not become dehydrated and started to regain weight after the symptoms subsided, a comprehensive assessment would not be required," the RAI manual (pg. 2-22) explains.