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CMS pulls the “RUGs” out from under Providers Potential Effects of SNF PPS Final Rule
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To Receive CPE Credit
• Participate in entire webinar • Answer polls when they are provided
• If viewing this webinar in group o Complete group attendance form with
Title & date of live webinar Your company name Your printed name, signature & email address
o All group attendance sheets must be submitted to [email protected] within 24 hours of live webinar
o Answer polls when they are provided
• If all eligibility requirements are met, each participant will be emailed their CPE certificates within 15 business days of live webinar
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SNF PPS Final Rule FY2012
• Published in August 8, 2011, Federal Register o http://www.gpo.gov/fdsys/pkg/FR-2011-08-08/pdf/2011-19544.pdf
• Effective October 1, 2011
• Applies to SNFs, hospital-based SNUs, & swing beds (except in CAHs)
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Polling Question
• Are you affiliated with free-standing SNF or hospital-based?
o SNF
o Hospital-based SNU or swing bed
o Neither
o Unsure
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SNF PPS Final Rule FY2012
• Rates are decreasing by an average of 11.1%
o “Parity” or “recalibration” adjustment – 12.6% decrease
o Market basket 2.7%, less 1.0% productivity adjustment = 1.7% net increase
• Cuts only apply to therapy categories
• Non-therapy rates actually went up slightly by net market basket increase
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Rehab Rates Comparison (Urban, not wage adjusted)
Category FY 2011 Urban rates FY 2012 Urban rates Decrease
RUX $ 869.42 $ 737.08 (132.34)
RUL 847.33 721.01 (126.32)
RVX 786.66 656.06 (130.60)
RVL 698.28 588.60 (109.68)
RHX 722.91 594.39 (128.52)
RHL 637.69 530.14 (107.55)
RMX 668.30 545.24 (123.06)
RML 611.49 500.27 (111.22)
RLX 593.60 478.85 (114.75)
RUC 634.27 558.79 (75.48)
RUB 634.27 558.79 (75.48)
RUA 512.75 467.23 (45.52)
RVC 551.51 479.38 (72.13)
RVB 467.86 415.13 (52.73)
RVA 466.28 413.52 (52.76)
RHC 487.76 417.71 (70.05)
RHB 434.10 375.95 (58.15)
RHA 375.71 330.97 (44.74)
RMC 434.73 366.95 (67.78)
RMB 403.17 344.47 (58.70)
RMA 324.26 283.43 (40.83)
RLB 431.05 356.78 (74.27)
RLA 263.76 229.89 (33.87)
Clinical Rates Comparison (Urban, not wage adjusted)
Category FY 2011 Urban rates FY 2012 Urban rates Increase
ES3 $ 661.20 $ 672.93 11.73
ES2 517.58 526.77 9.19
ES1 462.34 470.55 8.21
HE2 446.56 454.49 7.93
HE1 370.81 377.39 6.58
HD2 418.15 425.57 7.42
HD1 348.71 354.90 6.19
HC2 394.48 401.48 7.00
HC1 329.77 335.63 5.86
HB2 389.75 396.66 6.91
HB1 326.62 332.42 5.80
LE2 405.53 412.73 7.20
LE1 339.24 345.26 6.02
LD2 389.75 396.66 6.91
LD1 326.62 332.42 5.80
LC2 342.40 348.48 6.08
LC1 288.74 293.87 5.13
LB2 325.04 330.81 5.77
LB1 276.11 281.02 4.91
CE2 361.34 367.75 6.41
CE1 332.93 338.84 5.91
CD2 342.40 348.48 6.08
CD1 313.99 319.57 5.58
CC2 299.79 305.11 5.32
CC1 277.69 282.62 4.93
CB2 277.69 282.62 4.93
CB1 257.18 261.74 4.56
CA2 235.08 239.26 4.18
CA1 219.30 223.19 3.89
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Parity Adjustment
• Transition from RUG III to RUG IV in FY2011 was intended to be budget neutral
• Payments to providers for SNF days October 2010 through April 2011 were higher than CMS projected
• Payment increases largely attributable to o Higher than anticipated therapy utilization
o Increased utilization of ultra high & very high rehab RUG categories
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Expected vs. Actual RUG Distribution
RUG Category Groups
FY2009 actual RUGs III
distribution
CMS projected RUGs IV
redistribution
Actual distribution October 2010 to
April 2011
Rehab + Extensive Services
39% 4% 3%
Rehab Only 51% 79% 89%
Total Rehab 90% 83% 92% Ultra High & Very High 62% 37% 73%
Clinical 10% 17% 8%
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Parity Adjustment
• No retrospective recovery of current overpayments
• Cuts for FY2012 intended only to decrease future payments, not recoup FY2011 overpayments
BUT…
• Potential impact on FY2012 rates of other provisions in final rule was not considered
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Objectives
• Understand impact of PPS changes
• Understand MDS form changes
• Understand new OMRAs
• Know changes to group therapy
• Understand changes to PPS assessment
• Learn how to improve MDS & claim accuracy through effective strategies
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2012 Final Rule Changes
• Effective October 1, 2011
o MDS/PPS assessment schedule
o New Other Medicare Required Assessment (OMRA)
o CMS clarifications
o Group therapy
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PPS Assessment Schedule
New PPS Assessment Schedule Effective October 1, 2011
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CURRENT SCHEDULE NEW SCHEDULE
Assessment Type
Code
Applicable Medicare
Payment Days
Assessment Reference Date
Grace Days Assessment
Reference Date Grace Days
5 day or Readmission
01, 06 1 - 14 Days 1 - 5 Days 6 - 8 Days 1 - 5 Days 6 – 8
14 day 02 15 - 30 Days 11 - 14 Days 15 - 19 Days 13 - 14 Days 15 – 18
30 day 03 31 - 60 Days 21 - 29 Days 30 - 34 Days 27 - 29 Days 30 – 33
60 day 04 61 - 90 Days 50 - 59 Days 60 - 64 Days 57 - 59 Days 60 – 63
90 day 05 91 - 100 Days 80 - 89 Days 90 - 94 Days 87 - 89 Days 90 – 93
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PPS Assessment Schedule
• Why change????
o Avoid overlapping & duplication of data Example
5-day assessment with ARD on Day 8 of stay & 14-day assessment with ARD on Day 11 have four overlapping days
o More accurately reflect resident status Example
Interview of 14-day assessment will better reflect that person during payment period
Transition for Implementation
• CMS Policy Summary:
In order to reduce overlap between assessment look-back periods, Effective for FY 2012 (beginning October 1, 2011), facilities will utilize the revised MDS assessment schedule in Table 10B in the FY 2012 SNF PPS proposed rule (76 FR 26389), which was finalized in the FY 2012 SNF PPS final rule (76 FR 48517)
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Polling Question
• Is your facility at greater risk for CMS medical review if grace days are used frequently?
o Yes
o No
o Unsure
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New PPS Assessments
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New PPS Assessments
• Other Medicare Required Assessments (OMRAs)
o End of Therapy (EOT) OMRA-clarification
o End of Therapy-Resumption (EOT-R) OMRA (Not considered NEW assessment)
o Change of Therapy (COT) OMRA
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EOT– Clarification • Providers are required to complete an EOT OMRA when
resident in Rehab RUG does not receive therapy services for 3 consecutive days, regardless of reason for discontinuation of therapy.
o Planned (discharged)
o Unplanned (refusals, appointments, illness of patient, illness of therapist, holidays)
• Setting of ARD for the EOT is unchanged. You still may set your ARD on Day 1, 2 or 3 after discontinuation of therapy services
• Recommend do not SUBMIT immediately because…
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ARD of EOT (Example)
Friday Saturday Sunday Monday Tuesday
Therapy
Tx Ends
EOT ARD
Day 1 Day 2 Day 3
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EOT– R (Resumption)
• If therapy resumes within 5 days & RUG level stays unchanged from previous assessment.
o Facility completes an EOT-R or modifies EOT to an EOT-R and submits
o New therapy order or evaluation is not required
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EOT-R OMRA
• Therapy services resume within five consecutive days after last day of therapy
• Resume at same rehab RUG category
• No new therapy evaluation or SOT OMRA required
• A0310C = 2 or 3
• Complete O0450A & O0450B (new)
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EOT-R OMRA
• Example
o Therapy ends Day 35 of stay
o Resumes at same level by Day 39 of stay
o Resumption date is reported on EOT OMRA, if EOT OMRA has not been submitted
o If submitted, complete modification to EOT OMRA
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Polling Question
• Does your facility submit your PPS assessments within the same week as completion?
o Yes
o No
o Unsure
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EOT Modified to EOT-R
• Patient received therapy Monday – Friday • Therapy not provided Saturday & Sunday • Monday, patient refused therapy • EOT OMRA now required • Tuesday therapy was missed due to appointment • Missed therapy did not result in change in clinical condition
that would make him tolerate less therapy & change his RUG-IV classification
• EOT OMRA completed with ARD of Monday • On Wednesday, EOT is modified into EOT-R by reporting
actual date of resumption, which was Wednesday
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EOT-R OMRA
• If therapy does not resume by 5th consecutive day, SNF may not complete EOT-R OMRA
• SOT OMRA with new therapy evaluation can be completed 5-7 days after first day therapy starts (optional)
CMS Transition Instructions
• Effective for all EOT-OMRA assessments with an ARD on or after October 1, 2011.
• Effective October 1, 2011, facilities will be considered 7-day facilities for the purposes of setting the ARD for an EOT OMRA.
• As October 1, 2011 is a Saturday, this day should be counted as a day of missed therapy if a patient does not receive any therapy services on that day.
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CMS – ABN clarification
• Inquiries as to issuing ABN weekly on Friday
• ABN should inform beneficiary of providers belief Medicare will no longer pay for SNF stay
• CMS expects unplanned discontinuation to be rare
• If unplanned discontinuation in services occur repeatedly, provider should evaluate if patient continues to meet Medicare coverage criteria
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Polling Question
• As providers, are you monitoring patients’ therapy minutes beyond look-back period for assessments?
o Yes
o No
o Unsure
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Change Of Therapy (COT) OMRA
• Required when
o Patient in RUG-IV Rehab therapy group has change in intensity of therapy services (total RTM* delivered) no longer reflect classification & payment assigned
o New type of PPS assessment Uses same item set as EOT OMRA
*RTM - Reimbursable therapy minutes
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COT OMRA
• ARD of COT OMRA set for Day 7 of COT observation period
o COT observation period is rolling 7-day window
o Beginning day following most recent PPS assessment (scheduled or unscheduled)
or
o Beginning day therapy resumes when an EOT-R OMRA is completed
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COT OMRA
• Example o ARD of 14-day assessment is Day 14 of stay
o Day 1 of COT observation is Day 15 of stay
o Facility required to review therapy minutes for week of Day 15-21 of stay
o ARD of COT OMRA would be set for Day 21 of stay, if total RTM changed RUG classification
o If no change in RTM – no COT OMRA required
o Next evaluation of patient’s total RTM for purposes of completing COT OMRA, would occur on Day 28 of stay (new COT observation period – Day 22-28)
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Therapy Issues
• Reimbursable Therapy Minutes (RTM)
o Therapy minutes necessary to reach or to classify patient into certain RUG-IV categories; given allocation of individual, concurrent & group therapy minutes
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Group Therapy
• Revised definition of group therapy
o Therapy provided simultaneously to 4 patients who are performing similar therapy activities
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Group Therapy
• Allocation of group therapy
o Full time spent by therapy with group therapy would be divided by 4 (by the software) to give RTM
o Example For 1 hour of group session, 60 minutes would be entered on MDS for each resident in group. Software would divide 60 minutes by 4 to get 15 RTMs, which count toward RUG-IV Rehab group
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Group Therapy
• Group therapy documentation will need to be more specific
o Type of group therapy (Plan of Care)
o Number of participants in group
o Number of total minutes
o Monitor RTMs during ARD window
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Therapy Issues
• Therapy student – clarification
o Therapy students working in an SNF would no longer be required to be in supervising therapist’s line of sight
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Strategies for PPS 2012
• Medicare meeting
• Triple check
• Scheduling calendar to monitor pertinent assessment dates
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Medicare Meeting
• Meet daily
o Brief update on all Medicare Part A patients
• Meet weekly
o Review Medicare Part A & B
o Review Progress-rehab & clinical
• Meet monthly
o Triple check
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PPS Assessment Dates
• Pertinent dates to monitor
o Entry
o Discharge
o Medicare start & end dates
o Therapy start & end dates
o COT 7-day rolling window
o Therapy resumption date
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Managing PPS Assessments
• Communication between Medicare coordinator & therapy
o Change in patient condition or status Rehab or clinical
o Refusal of any skilled services
o Appointments or LOAs
o Plan of action for Holidays
o Discharge plans
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Strategies for Success
• Evaluate financial impact of rate reductions on your organization
o Cuts based on national average overpayments
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Polling Question
• Have you estimated the impact of the final rule on your facility?
o Yes
o No
o Unsure
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Strategies for Success – ADLs
• Evaluate & monitor ADL scoring
RUG category ADL score National %
Rehab C 11 – 16 32%
Rehab B 6 – 10 37%
Rehab A 1 – 5 31%
Medically Complex E 15 – 16 23% Equivalent to “C” for Rehab Medically Complex D 11 – 14 29%
Medically Complex C 6 – 10 23% Equivalent to “B” for Rehab
Medically Complex B 2 – 5 15% Equivalent to “A” for Rehab Medically Complex A 0 – 1 10%
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Polling Question
• Is training for ADL capture part of your staff orientation program?
o Yes
o No
o Unsure
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Strategies for Success – ADLs
• ADL examples RUG category ADL score Urban rate per day Impact
RVC 11 – 16 $ 479 difference $ 64 per day
RVB 6 – 10 $ 415 $ 1,920 for 30 days
LD2 11 – 14 $ 397 difference $ 49 per day
LC2 6 – 10 $ 348 $ 1,470 for 30 days
CD1 11 – 14 $ 320 difference $ 37 per day
CC1 6 – 10 $ 283 $ 1,110 for 30 days
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Strategies for Success – Depression
• Mood interview results (clinical RUG categories only)
o National averages 13% with depression
87% without depression
• Examples of scoring depression
RUG category PHQ score Urban rate per day Impact
HE2 ≥ 10 $ 454 difference $ 77 per day
HE1 0 – 9 $ 377 $ 1,078 for 14 days
LE2 ≥ 10 $ 413 difference $ 68 per day
LE1 0 – 9 $ 345 $ 952 for 14 days
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Strategies for Success – Rates FY2012 Category Rate per day Rank
RUC $ 559 1
RUB 559 1
RVC 479 3
RUA 467 4
HE2 454 5
HD2 426 6
RHC 418 7
RVB 415 8
RVA 414 9
LE2 413 10
HC2 401 11
HB2 397 12
LD2 397 12
HE1 377 14
RHB 376 15
CE2 368 16
RMC 367 17
RLB 357 18
HD1 355 19
LC2 348 20
Strategies for Success – Rates 2012
Category Rate per day Assume PPD Therapy
Cost @ $1.05 / minute Net Rate per day Rank
HE2 $ 454 $ 454 1
RUC 559 $ (108) 451 2
RUB 559 (108) 451 2
HD2 426 426 4
LE2 413 413 5
RVC 479 (75) 404 6
HC2 401 401 7
HB2 397 397 8
LD2 397 397 8
HE1 377 377 10
RHC 418 (49) 369 11
CE2 368 368 12
RUA 467 (108) 359 13
HD1 355 355 14
RLB 357 (7) 350 15
LC2 348 348 16
CD2 348 348 16
LE1 345 345 18
RMC 367 (22) 345 19
RVB 415 (75) 340 20
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Strategies for Success
Week 1 Week 2 Week 3 Week 4 Week 5 Total
Assessment 5 - day 14 - day Dischg
Category RVC RVC RVB RVB Medicaid 28 MC days 7 MD days
Rate per day $ 551.51 $ 551.51 $ 467.86 $ 467.86 $ 150.00 $ 437.77 avg
Week total $ 3,861 $ 3,861 $ 3,275 $ 3,275 $ 1,050 $ 15,322
Therapy min 500 500 500 500 –
Therapy cost $ 525 $ 525 $ 525 $ 525 ($ 2,100)
Reimbursement, net of therapy cost $ 13,222
Current Care Model – Current Rates
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Strategies for Success
Week 1 Week 2 Week 3 Week 4 Week 5 Total
Assessment 5 - day 14 - day Dischg
Category RVC RVC RVB RVB Medicaid 28 MC days 7 MD days
Rate per day $ 479.38 $ 479.38 $ 415.13 $ 415.13 $ 150.00 $ 387.83 avg
Week total $ 3,356 $ 3,356 $ 2,906 $ 2,906 $ 1,050 $ 13,574
Therapy min 500 500 500 500 –
Therapy cost $ 525 $ 525 $ 525 $ 525 ($ 2,100)
Reimbursement, net of therapy cost $ 11,474
Change from FY2011 (13.2%) ($ 1,748)
Current Care Model – FY2012 Rates
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Strategies for Success
Week 1 Week 2 Week 3 Week 4 Week 5 Total
Assessment 5 - day 14 - day COT 30 - day, + COT
ARD Day 2 (no SOT) Day 14 (RHC) Day 21 Day 28
Category HE2 HE2 RUB RVB RVB 35 MC days
Rate per day $ 454.49 $ 454.49 $ 558.79 $ 415.13 $ 415.13 $ 459.60 avg
Week total $ 3,181 $ 3,181 $ 3,912 $ 2,906 $ 2,906 $ 16,086
Therapy min – 325 720 500 500
Therapy cost – $ 341 $ 756 $ 525 $ 525 ($ 2,147)
Reimbursement, net of therapy cost $ 13,939
Care Management Model – FY2012 Rates
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Strategies for Success
• Re-evaluate your care model o Resident’s clinical needs as important as therapy needs
o Monitor & train ADLs
o Capture depression for clinical RUG categories
o Understand hierarchy of all RUG rates
o Consider cost of therapy when selecting RUG category
• Manage delivery of care from admit to discharge o Work as an interdisciplinary team
o Do pre-assessment screening
o Evaluate all resident’s needs
o Compare ALL potential RUG categories
o Plan appropriate care
o Set ARDs for most benefit
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Strategies for Success
• Partner with your therapy provider
o Make sure they are “on board”
o Negotiate adequate payment for therapy services, even in non-rehab categories
• Manage expectations
o Staff
o Physicians
o Family
• Re-examine philosophy
• Influence behaviors
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Questions?
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Upcoming Webinar
• Issues in Unrelated Business Income for Health Care
o Thursday, September 8, 10:00-11:00 a.m. Central time
To register or for more information go to www.bkd.com/webinar/healthcare
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Continuing Professional Education (CPE) Credits
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CPE Credit
• Up to 1.5 CPE credits will be awarded upon verification of participant attendance; however, credits may vary depending on state guidelines
• For questions, complaints or comments regarding CPE credit, please email BKD Learning & Development Department at [email protected]
Lori Brunholtz
Director
918.584.2900
Suzy Harvey
Supervising Consultant
417.865.8701
