RUG’s Level OMRA’s: Know the Rules & Maximize Revenue
New CMS rules for Other Medicare Required Assessments (OMRA’s) go into effect on 10/1/2011. These rules place an additional burden on therapists to monitor when “therapy is not provided” and to adjust ARD’s (assessment reference dates) and RUG’s levels based on the level and frequency of care provided rather than on the patient’s changing condition.
These new rules will affect the patient’s RUG’s levels, therapy staffing requirements; per diem reimbursements received, and will require sophisticated therapy software systems with efficient billing override and alert capabilities that warn therapists when potential OMRA situations exist.
Other Medically Required Assessments (“OMRA’s”) Defined
SOT OMRA – A Start of Therapy OMRA would require a change in the RUG’s level for selected days. If a new assessment and re-evaluation of the patient’s condition is required, then the RUG’s level may change as well. A SOT OMRA can be completed after 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 evaluation in the SOT OMRA.
COT OMRA – A Change of Therapy OMRA would require a change in the RUG’s level for selected days. Therapists must provide treatment minutes over a 7 day period consistent with the RUG’s level per diem reimbursement established previously. If they do not, then a change in the per diem reimbursement may be required.
EOT OMRA – An End of Therapy OMRA would require a change in the RUG’s level for selected days. An EOT OMRA is required if there are 3 missed days with no therapy from any discipline. For the EOT OMRA followed by a SOT OMRA, the 3 or more missed days should be billed at the NC RUG’s level.
EOT-R OMRA – An End of Therapy Resumption OMRA 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 an NC RUG’s level or possibly no per diem reimbursement. When therapy resumes, you can continue at the same RUG’s level.
SSA – A Short Stay Assessment (SSA) may require a change in the RUG’s level for selected days. Reimbursement for the days the patient was on caseload is at the therapy RUG’s level. Per diem reimbursement for days without therapy before the evaluation date is limited to the NC RUG’s level.
Tips to Maximize Revenue with OMRA’s
COT OMRA’s – Managing COT OMRA’s is critical. A decline in the minutes provided below those required for the RUG's level billed after the ARD will result in lost revenue immediately. Sophisticated systems are required to maintain the level of therapy provided in the assessment period throughout the COT observation period and beyond. The COT observation period is the 7 day period beginning after the ARD and continues for each successive 7 day period thereafter.
SOT & EOT OMRA’s – Therapists may be able to bill for therapy at the non-case mix (NC) RUG’s level for the days a patient is off therapy caseload but continues to use their Medicare Part A benefits for nursing services. The per diem reimbursement at the NC RUG’s level is modest but you have earned it. Make sure your system has the flexibility to monitor and bill for any therapy days at the NC RUG’s level.
SSA – The Medicare Part A SSA rules are similar to the OMRA rules and often require the same management capabilities. These rules allow for some flexibility in RUG’s level selection for patients that are discharged on Day 8 or earlier. Often, these conditions can be “managed” to achieve a higher RUG’s level than would have been achieved without proper application of the SSA rules. Proper planning of treatments, ARD selection, and the discharge date may result in higher reimbursements. Sophisticated therapy software systems are required to manage these complex rules effectively.