CMS Final Rules Changes on 10/1/2011: Impact on Therapy RUG’s Levels
The final CMS rules changes will have a profound affect on therapy minutes included in a patient’s RUG’s level, therapy staffing requirements, per diem reimbursements received, and will require sophisticated therapy software systems with efficient and accurate treatment planning and staff scheduling tools.
Summary: Impact on Therapy RUG’s Levels & Operations
- New limitations on the inclusion of Group treatments in the calculation of RUG’s levels will require more total therapy time in order to achieve the same RUG’s levels as in the past.
- The new MDS 3.0 Assessment Schedule reduces therapists’ flexibility in selecting RUG’s levels by eliminating grace days and the ability to use treatment minutes provided in multiple assessment periods.
- Seven day therapy staff coverage may be required at most SNF’s to ensure consistent patterns of therapy treatment and to avoid “breaks” in treatment that may result in reduced per diem reimbursements.
- Efficient and accurate treatment planning and staff scheduling tools will be required. Therapists must provide treatment minutes daily consistent with the RUG’s level per diem reimbursement. Failure to do so may result in reduced per diem reimbursements.
Directives for Group Therapy
Group treatment is defined as 4 patients. A Group treatment session should always be scheduled to include 4 patients. If a scheduled patient is not present in the Group, then the total Group minutes for the remaining 3 patients will still be divided by 4 patients for the purposes of calculating RUG’s levels.
The total “unallocated” Group minutes will be entered on the MDS 3.0 Form. The facility’s MDS software will divide by 4 patients regardless of the number of patients in the Group. The 25% maximum limit on Group minutes included in a patient’s RUG’s level still applies, after dividing total Group minutes by 4 patients. Therapists must document the reason for using Group treatments in the Daily Note or Progress Report.
In CarePoint, total Group minutes will be entered on the Daily Treatment Record for each patient in the Group. The number of patients in the Group is identified with the Session button for payroll purposes only. Total “unallocated” Group minutes divided by 4 patients are used when calculating RUG’s levels for each patient subject to the 25% maximum limit when compared to total minutes. Total “unallocated” Group minutes are used in the MDS 3.0 Form for each patient regardless of the number of patients in the group.
For example, the plan is for 4 patients to be treated in a Group for 60 minutes. Only 3 patients attend. The therapist records 60 minutes for payroll purposes. The RUG’s level calculations include 15 minutes (60 minutes divided by 4 patients) for each patient or a total of 45 minutes subject to the 25% maximum limit. The MDS 3.0 Forms include 60 minutes for each patient or a total of 180 minutes.
MDS 3.0 Assessment Schedule: Grace Days & Assessment Reference Date Changes
The schedule remains the same as posted originally in the proposed rules. Specifically, there are fewer grace days and shorter reporting periods. Therapists’ ability to use the same treatment minutes provided on a specific day in more than one assessment period is reduced. See attached schedule.
MDS Assessment Changes
Re-statement is required on the EOT OMRA which must be completed if there are 3 missed days with no therapy from any discipline. For the EOT OMRA, the 3 missed days should be billed at the NC RUG’s level. A SOT OMRA can be completed after the 3 or more missed days but a new therapy evaluation is required. For the SOT OMRA, the RUG’s level calendar resumes on the date of the SOT OMRA.
For example, the patient was discharge on day 50 because no treatments were provided on days 50, 51, or 52. Treatments resume on day 53. The 5 day look back period is day 57 and the 7 day look back period is day 59. This assessment is used to calculate the per diem reimbursements for the first days after the SOT OMRA (like a 5 day assessment) or for days 53 to 60. Also, this assessment can be combined with the 60 day assessment which would then calculate the per diem reimbursements for days 53 through 90.
EOT-R OMRA: End of Therapy Resumption
EOT-R’s may be used when therapy has been missed for at least 3 consecutive calendar days and is expected to resume within 5 calendar days following the last day of therapy AND the therapy RUG’s level remains the same. In this case, a new evaluation would not be necessary. The 3 to 5 days with no therapy would have a RUG’s NC level or possibly no per diem reimbursement. When therapy resumes, you can continue at the same RUG’s level.
COT OMRA: Change of Therapy
SNF’s are required to complete a COT OMRA whenever the intensity of therapy (total reimbursable therapy minutes) changes to such a degree that it would no longer reflect the RUG level and per diem reimbursement for a patient based on the most recent assessment. "The COT observation period is a successive 7 day window beginning on the day following the ARD set for the most recent assessment (or beginning the day therapy resumes with an EOT-R) and ending every 7 calendar days thereafter."
For example, if a patient is at an RV RUG’s level with an ARD on day 18, then the observation date for this patient is day 25. If they have 499 minutes in that observation period, then you must perform a new assessment and possibly select an RH RUG’s level from the beginning of the observation period forward. Conversely, if they have 720 minutes in the observation period, then you may be able to skill the patient up to an RU RUG’s level from the beginning of the observation period forward.
CarePoint clients can use our Schedule Patients and Part A Planner tools to plan and control therapy minutes provided which enables them to maintain the RUG’s levels achieved in the assessment period. These tools prevent a decline in therapy minutes below the level necessary to maintain the per diem reimbursements achieved or highlight a possible increase in RUG’s levels on the observation date where medically appropriate.