Eli's Rehab Report

Be prepared for potential Additional Documentation Requests for the lower 14 RUG categories.

You must be doing all that is in your power to stay on top of the changes to SNF RUG categories and MDS therapy coding that came into effect on Oct. 1, 2013. Here are four expert tips to help you keep on the right track.

1. Optimize Your Section O Reporting

The Change in Therapy (COT) process for review “cannot begin until an MDS is completed with sufficient minutes to meet a Rehabilitation category,” noted Kris Mastrangelo in a recent Harmony Healthcare International blog posting. But you must weigh reporting in Section O — Special Treatments, Procedures, and Programs versus the paying RUG category.

Meaning: “An MDS may have sufficient minutes to meet a category, yet index maximize to a higher paying Nursing category,” Mastrangelo explained. “Conversely, a Nursing RUG with therapy involved may not necessarily have sufficient minutes and days of therapy.”

Make sure you look at the number of minutes, days per discipline, and distinct calendar days of therapy to ensure the COT process can begin, Mastrangelo reminded.

2. Don’t Confuse the MDS-Generated RUG with Skilled Coverage Criteria

Beware that the RUG generated by the MDS is not the same as the skilled coverage criteria, Mastrangelo warned. If rehabilitation is the primary reason for a skilled level of care, you must ensure that therapy is clinically indicated at least five days per week so the patient can meet Medicare skilled coverage criteria.

Example: If you provide physical therapy (PT) on three days each week and occupational therapy (OT) on two other days each week, you’ve met the “daily basis” criteria, Mastrangelo said. But keep in mind that you would satisfy the daily skilled requirement only if there’s a valid medical reason why both the PT and OT cannot be furnished on the same day.

But beware that you cannot arbitrarily stagger the timing of various therapy modalities through the weeks, simply to have some type of therapy session occur each day, warned Middleburg Heights, OH-based Therapy Partners in a recent blog posting. Doing so “would not necessarily satisfy the SNF coverage requirement for skilled care to be needed on a ‘daily basis.’”

“This means that if different disciplines distribute therapy across five days, there must be documentation to indicate the clinical need for staggering the services,” Therapy Partners cautioned. “Without that documentation, medical reviewers may deny all or part of a claim.”

Bottom line: “The frequency a service is performed does not, by itself, make it a skilled service,” Mastrangelo stressed. “The services must be reasonable and necessary for the treatment of the patient’s condition.”

So you must show that you need to schedule the medically necessary therapies from multiple disciplines on different days. For instance, the resident may not be able to tolerate two therapies five times per week, Mastrangelo explained. “Medical complexities may also include scheduled medical treatments like dialysis, radiation, or chemotherapy that impact toleration of therapy.”

3. Make Sure You’re Meeting All MDS Scheduling Requirements

By adding item O0420 — Distinct Calendar Days of Therapy to the Rehabilitation Medium RUG requirement, you will have to factor this in to the ARD selection and COT review requirements to ensure that you meet all MDS scheduling requirements, Mastrangelo stated.

To classify into the Medium Rehabilitation category, the resident must receive five distinct calendar days of therapy within a seven-day time period, according to the Pennsylvania Department of Health’s (PADOH’s) office of the RAI Coordinator. “This reflects the SNF Level of Care requirement that skilled services must be needed and received on a daily basis. Payment rates for these RUGs are based on staff time over the requisite number of distinct therapy days.”

A COT MDS is required “when either or both the days of therapy and minute requirements are not met within the COT observation period from the previously established RUG,” Mastrangelo said. “There is the potential for a greater occurrence of COT assessments.”

4. Be Prepared for Additional Documentation Requests

If you have residents with behavior or cognitive impairments, these are medical complexities — and these patients commonly require skilled therapy interventions and have challenges receiving medically necessary therapy, Mastrangelo pointed out. “Without Clinically Complex or Special Care High and Low RUG qualifiers, there is the potential for a lower 14 Nursing RUG classification to yield.”

“These patients may also be more likely to refuse a therapy session and require a COT assessment,” Mastrangelo noted. “Given the national trend of Government Medical Record reviews for the lower 14 RUG categories, facilities must be prepared for these potential Additional Documentation Requests.”