Eli's Rehab Report

Confusing clarifications in revised RAI Manual threaten reimbursement.

Having trouble trying to understand the recent changes to guidance on RUG classifications under the Change of Therapy (COT) Other Medicare Required Assessment (OMRA) rules? When the Centers for Medicare & Medicaid Services (CMS) updated RAI Manual v1.12, Chapter 2 was revised, adding a variety of instructions. Read on to learn how to benefit from these changes and how missed therapy dates can spell trouble for your facility.

Take a Peek at New COT OMRA Directions

The RAI Manual now has revised and added new bullet points under “Change of Therapy (COT) OMRA” on Section 2.9, pages 52 through 54:

• “The COT ARD may not precede the ARD of the first scheduled or unscheduled PPS assessment of the Medicare stay used to establish the patient’s initial RUG-IV therapy classification in a Medicare Part A SNF stay.”
• Except as described below, a COT OMRA may only be completed when a resident is currently classified into a RUG-IV therapy group (regardless of whether or not the resident is classified into this group for payment), based on the resident’s most recent assessment used for payment.
• The COT OMRA may be completed when a resident is not currently classified into a RUG-IV therapy group, but only if both of the following conditions are met:

1. Resident has been classified into a RUG-IV therapy group on a prior assessment during the resident’s current Medicare Part A stay, and

2. No discontinuation of therapy services (planned or unplanned discontinuation of all rehabilitation therapies for three or more consecutive days) occurred between Day 1 of the COT observation period for the COT OMRA that classified the resident into his/her current non-therapy RUG-IV group and the ARD of the COT OMRA that reclassified the resident into a RUG-IV therapy group.

The revised instructions go on to state:

Under these circumstances, completing the COT OMRA to reclassify the resident into a therapy group may be considered optional. Additionally, the COT OMRA which classifies a resident into a non-therapy group or the COT OMRA which reclassifies the resident into a therapy group may be combined with another assessment, per the rules for combining assessments discussed in Sections 2.10 through 2.12 of this manual.

Reclassify When No Discontinuation of Services Occurs

Example 1: Mr. T classified into the RUG group RUA on his 30-day assessment with an ARD set for Day 30 of his stay. On Day 37, you checked the amount of therapy provided to Mr. T and found that while he did receive the requisite number of therapy minutes to qualify for this RUG category, he received therapy only on four distinct calendar days. This means that he would not qualify for an Ultra-High Rehabilitation RUG group.

Moreover, due to a lack of both restorative nursing services and five distinct calendar days of therapy, Mr. T did not qualify for a therapy RUG group. You complete a COT OMRA for Mr. T with an ARD set for Day 37, on which he qualifies for LB1. 

From that point, Mr. T’s rehab regimen continues without any discontinuation of therapy or three consecutive days of missed therapy. On Day 44, you check the amount of therapy that Mr. T received during the previous seven days and find that he again qualifies for the RUG-IV therapy RUA.

How to code: You can complete a COT OMRA with an ARD of Day 44 to reclassify Mr. T back into the RUG-IV therapy group RUA, for two reasons:

• Mr. T had qualified into a RUG-IV therapy group on a prior assessment during his current Medicare Part A stay (the 30-day assessment); and 
• No discontinuation of therapy services (planned or unplanned) occurred between Day 1 of the COT observation period for the COT OMRA that classified him into his current non-therapy RUG-IV group (Day 31), and the ARD of the COT OMRA that reclassified him into a RUG-IV therapy group (Day 44).

Beware of Missed Therapy Days

Example 2: Mr. A classified into the RUG group RVA on his 30-day assessment with an ARD set for Day 30 of his stay. On Day 37, you checked the amount of therapy provided to Mr. A during the previous seven days and found that while he did receive the requisite number of therapy minutes to qualify for this RUG category, he received therapy only on four distinct calendar days. This means Mr. A would not qualify for a Very-High Rehab RUG group.

Moreover, due to a lack of both restorative nursing services and five distinct calendar days of therapy, Mr. A did not qualify for any RUG-IV therapy group. You complete a COT OMRA for Mr. A, with an ARD set for Day 37, upon which he qualifies for LB1. 

The therapist intends to continue Mr. A’s rehab regimen from that point, but Mr. A does not receive therapy on Days 36, 37 and 38. On Day 44, you check the amount of therapy provided to Mr. A during the previous seven days and find that he again qualifies for the RUG-IV therapy group RVA.

What to do: You cannot complete a COT OMRA with an ARD of Day 44 to reclassify Mr. A back into the RUG-IV therapy group RVA. 

Why? Although Mr. A had qualified into a RUG-IV therapy group on a prior assessment during his current Medicare Part A stay (the 30-day assessment), a discontinuation of therapy services occurred between Day 1 of the COT observation period for the COT OMRA that classified the resident into his current non-therapy RUG-IV group, and the ARD of the COT OMRA that reclassified him into a RUG-IV therapy group (missed therapy on Days 36, 37 and 38). 

Study the Previous COT OMRA for Proper Classification

CMS then adds the following bullet point on page 53 (Section 2.9):

A COT OMRA may be used to reclassify a resident into a RUG-IV therapy group only when the resident was classified into a RUG-IV non-therapy by a previous COT OMRA (which may have been combined with another assessment, per the rules for combining assessments discussed in Sections 2.10 through 2.12 of this manual).

Example 3: Mr. E classified into the RUG group RUA on his 14-day assessment with an ARD set for Day 15 of his stay. No unscheduled assessments were required or completed between Mr. E’s 14-day assessment and his 30-day assessment. 

On Day 29, you checked the amount of therapy that Mr. E received during the previous seven days and found that while he did receive the requisite number of therapy minutes to qualify for this RUG category, he received therapy only on four distinct calendar days. This means that he cannot qualify for an Ultra-High Rehab RUG group.

Moreover, due to the lack of restorative nursing services and five distinct calendar days of therapy, Mr. E did not qualify for any RUG-IV therapy group. You complete a 30-day assessment for Mr. E with an ARD set for Day 29, on which he qualifies for LB1. But you opt not to combine this 30-day assessment with a COT OMRA (as permitted under the COT rules outlined in Section 2.9 of the Manual).

Mr. E’s rehab regimen continues from that point, without any discontinuation of therapy or three consecutive days of missed therapy. On Day 36, you check the amount of therapy he received during the previous seven days and find that Mr. E again qualifies for the RUG-IV therapy group RUA.

Solution: You cannot complete a COT OMRA with an ARD of Day 36 to reclassify Mr. E back into the RUG-IV therapy group RUA.

Reason: Although Mr. E had qualified into a RUG-IV therapy group on a prior assessment during his current Medicare Part A stay (the 14-day assessment), the assessment that classified him into a RUG-IV non-therapy group was not a COT OMRA. 

How Break in Therapy Affects Your Billing

Also, keep in mind that if you classify a resident into a non-therapy RUG on a COT OMRA and you subsequently decide to discontinue therapy services for that resident, an EOT OMRA is not required for this resident.

In Chapter 6 of the RAI Manual, CMS added some guidance on this (page 12, Section 6.4):

7. In all cases where an EOT-R would be completed, the resident must resume therapy at the same RUG-IV therapy level as had been in effect prior to the break in therapy. However, it is possible that the ARD for an EOT OMRA reporting resumption may be set for the first grace day of the allowable grace days for a scheduled PPS assessment, while the ARD for the scheduled assessment was set for a day within the normal ARD window. In this limited subset of cases, the resumption of therapy should occur using the previous RUG-IV therapy level (which should be the same as the therapy level determined on the scheduled PPS assessment if the resumption is appropriate) but using the Activities of Daily Living (ADL) score from the most recent PPS assessment.

CMS then provides an example: Mr. P is admitted to the nursing facility on Oct. 1, 2011. You set the ARD of the five-day assessment for Mr. P for Oct. 7 (Day 7) and the RUG you assigned to him is RVB. You set the ARD of the 14-day assessment for Oct. 14 (Day 14) and assign to him the RUG again as RVB. Then, you set the ARD of the 30-day assessment for Oct. 28 (Day 28) and the RUG assigned to Mr. P is now RVA.

Due to an acute illness, Mr. P is unable to receive therapy services from Oct. 29 through Oct. 31, but the staff expects him to resume therapy on Nov. 2 under the same therapy regimen. You complete an EOT for Mr. P with an ARD of Oct. 31 and report that resumption of therapy will occur on Nov. 2. The EOT OMRA assigns Mr. P a non-therapy RUG of CE2. Mr. P is discharged from the facility on Nov. 12.

How to bill: Assuming no intervening assessments were necessary, the CMS says that you should bill:

• Days 1 through 14 under HIPPS code RVB10;
• Days 15 through 28 under HIPPS code RVB20;
• Days 29 through 32 under HIPPS code CE20A; and
• Days 33 through 41 under HIPPS code RVA0A.

Significance: “This represents the one and only occasion where the three character RUG-IV therapy RUG code may differ from that which was billed prior to the break in therapy,” CMS states. “And the difference may only be in the third character in the therapy RUG code related to the resident’s ADL score.”

Take away These Key Points

“These clarifications are quite confusing,” concedes Marilyn Mines, RN, BC, RAC-CT, senior manager of clinical services for FR&R Healthcare Consulting Inc. in Deerfield, IL. “Think of it this way: you can only do a COT OMRA to put a resident back into a therapy RUG category if 1) a COT was performed that changed the resident from a Rehab to a clinical RUG, and 2) therapy continued while the resident was at a clinical RUG category.”

“Be aware that when the COT is optional, and one is not done, you lose the opportunity to put the resident back on a therapy RUG by completing another COT,” Mines explains. “Decisions made concerning the completion of a COT may limit financial loss at the start, but threaten financial gains in the end.”