Therapy Day Requirements for a RUG’s Level Medium
CarePoint therapy management software strives for complete regulatory and compliance accuracy. Our system requires 5 calendar days of therapy in the last 7 days in order to achieve a RUG’s Level Medium (RM) in accordance with the PPS regulations of 1998. We understand all the discipline requirements for each RUG’s level.
Authored by Mary L. Gennerman, OTR/L, Director of Clinical Services
A Billing Manager in New York Writes …..
“The calculation of RUG’s Level Medium (RM) has caused us some concern. CarePoint requires 5 calendar days of therapy in the last 7 days to achieve a RM. If therapy is provided for 150 minutes on fewer than 5 calendar days, then a RUG's Level Low (RL) is recorded. The RAI Manual indicates that a total of 150 minutes or more and at least 5 days of any combination of 3 disciplines in the last 7 days are required for a RM. Our MDS system does not ask if therapy was provided on separate calendar days when entering the days of combined therapy from any 3 disciplines.
The daily skilled criteria could be met through other means such as wound care or GT feeding. If a resident receives daily skilled wound care for 7 days, then there should be no need for therapy on 5 calendar days in order to achieve a RM or to be in compliance with daily skilled care. Our concern is that we may bill CMS for per diem reimbursement at an RL when we could bill a RM.”
CarePoint’s Clinical Staff Posed the Following Question to CMS …..
If PT and OT were provided for 3 days and those therapy interventions occurred on the same calendar days, then therapy was provided on only 3 calendar days. Nursing skilled service would have been provided on the remaining days. In this scenario CarePoint would calculate a RL and not a RM because therapy was not provided on 5 calendar days. The 3 days of PT and OT provided on the same calendar days appear as 6 days of therapy in our client’s MDS system and a RM is recorded. Nursing skilled services are also recorded but a RM is often the RUG’s category achieved because of the days of therapy.
CMS Provided the Following Response …..
“We are very aware of this issue and in future iterations of the RUG’s grouper we hope to have this fixed. The policy for qualifying for a RM is that the patient must receive 5 distinct days of therapy in the 7 day period. We encourage facilities to provide therapy as intended with the policy. However, your client's MDS system reflects the methodology used by the CMS grouper which calculates a RM in the way you described. Facilities should use the RUG’s level that would be generated from the CMS grouper for billing purposes. It should be noted that regardless of the RUG’s group assigned by the grouper software, the resident’s care needs must be sufficiently intensive to meet all aspects of the SNF level care that are being provided.”
CarePoint’s Conclusion & Recommendation …..
CMS confirmed that CarePoint calculates a RM correctly by requiring 5 calendar days of therapy in the last 7 days. Therapy provided for 150 minutes on fewer than 5 calendar days should be recorded as a RL. However, many MDS systems and CMS's own Grouper software does not validate this 5 calendar day requirement. Therefore, CMS allows a RM category to be billed if 5 days of therapy are provided on fewer than 5 calendar days. It is CMS's stated intention to correct this problem and begin requiring 5 calendar days of therapy for a RM. We recommend that clients amend their policies and procedures in order to ensure that their therapists and MDS coordinators are informed of the statutory requirements for a RM.
