May 19, 2011 |

CMS proposes the Change of Therapy OMRA

The long-term care industry has wide eyes and an ear to the ground following the initial publishing of the Centers for Medicare & Medicaid Services Proposed Rule for SNF PPS FY 2012 (PDF format). Many aspects of the Resident Assessment Instrument process are discussed and some major adjustments to how the SNF team manages each patient are presented.

One of the newly proposed items to implement will be a Change of Therapy other Medicare required assessment (COT OMRA). This new assessment is defined by CMS as being required when “a patient’s RTM [reimbursable therapy minutes] changes to the extent that the patient’s RUG classification, based on their last PPS assessment, is no longer an accurate representation of their current clinical condition.” (For the sake of definition: ‘‘‘[R]eimbursable therapy minutes’ are those minutes used to classify a patient for therapy purposes. For each of the RUG-IV categories, it is the number of reimbursable therapy minutes that is used to classify a given patient into a therapy RUG-IV group.”)

Click here for a review of MDS 3.0’s EOT OMRA, SOT OMRA and Short Stay Assessment from the March 2011 MDS Monitor column.

CMS believes that instituting a requirement to monitor the levels of care provided by therapy—via a rolling Assessment Reference Date, or ARD—would allow the agency to track changes in the patient’s condition and in the provision of therapy services more accurately. The desired result is improved accuracy of reimbursement for therapy services, which theoretically enhances the SNF’s ability to provide quality care to SNF residents.

The daily management and oversight of minutes is an intensive process. This is something that should currently be in place within the rehab department. Software capabilities with the onset of MDS 3.0 have improved and expanded significantly. A quick view of daily minutes provided to all patients yields valuable information for managing caseloads, streamlines department efficiency and facilitates communication with the interdisciplinary team.

The following excerpt is taken directly from the CMS Proposed Rule:

[W]e have found some cases where therapy services recorded on a given PPS assessment did not provide an accurate account of the therapy provided to a given resident outside the observation window used for the most recent assessment. We believe that when service levels change, whether inside or outside the observation period, such changes should be based on medical evidence […]We propose that, effective for services provided on or after October 1, 2011, SNFs would be required to complete a Change of Therapy (COT) OMRA, for patients classified into a RUG-IV therapy group, whenever the intensity of therapy (that is, the total RTM delivered) changes to such a degree that it would no longer reflect the RUG-IV classification and payment assigned for a given SNF resident based on the most recent assessment used for Medicare payment. The COT OMRA would be a new type of required PPS assessment, which would use the same item set as the current EOT OMRA. The ARD for the COT OMRA would be set for Day 7 of a COT observation period, which is a rolling 7-day window beginning on the day following the ARD set for the most recent scheduled or unscheduled PPS assessment (or beginning the day therapy resumes in cases where an EOT-R OMRA is completed[…]) and ending every 7 calendar days thereafter […] We want to stress that SNFs would be required to complete a COT OMRA only if a patient’s total RTM changes to such an extent that the patient’s RUG classification, based on their last PPS assessment, is no longer an accurate representation of their current clinical condition. However, an evaluation of the necessity for a COT OMRA (that is, an evaluation of the patient’s total RTM) must be completed every seven calendar days starting from the day following the ARD set for the most recent scheduled or unscheduled PPS assessment.

The expectation by CMS that the payment level/RUG classification be representative of the daily service delivery is a fair and reasonable expectation. Does this new system continue to emulate a prospective system? It appears not to when reading this Proposed Rule. It will however behoove the SNF staff to assure a solid system is in place at this time for monitoring levels of care on a weekly basis. Communication between the MDS Coordinator and Rehab is and will continue to be of utmost urgency to assure target RUG levels are met and reimbursement is not jeopardized. The rolling ARD, every seven days between assessment periods, will be a challenge for some facilities, but protects patients and the integrity of the Medicare program. Elisa Bovee, MS OTR/L, is the Vice President of Operations for Harmony Healthcare International. She has worked in the LTC industry for more than 19 years practicing and providing consulting services related to therapy and Medicare regulations and guidelines. Bovee began working for Harmony Healthcare as a regional consultant before becoming Director of Education and Training for Harmony University, an approved provider of educational hours and credits for NAB, MARN, AOTA and ASHA. Bovee is available for private audiences to discuss facility challenges between seminar dates.

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