Ask the payment expert: Why are there so many lower RUG levels in residents receiving therapy?

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Ask the payment expert
Ask the payment expert
Q: Why do we see days in the lower Resource Utilization Group levels when a resident is receiving therapy?

A: The RUG-IV system no longer estimates minutes for therapy services. Therefore, it is essential that your resident receive five days of therapy during the initial “look back” period.

This can become a challenge if the resident refuses therapy and the facility is not monitoring the number of days. As an example, you may want to set an ARD on Day 8 and therapy starts on Day 2. You have a 5d/wk program and you perform therapy with the resident on Friday - Day 2, Monday - Day 5, Tuesday - Day 6 and then the resident refuses on Wednesday - Day 7.

You have to set the ARD by Thursday - Day 8 and you may not then have 5 days of therapy. Let us say you rendered over 500 minutes of therapy but with only four days of therapy, you would still not have a Rehab RUG. So your resident might fall to a PA1 instead of an RVA. For an Urban facility that is approximately $195 per day or $2730 for the first 14 days of the resident's stay.

Nursing and therapy must work together. You need to be looking at the days and minutes of therapy on a daily basis and discuss any problems.

If a resident refuses therapy or misses a day, you need to recalculate minutes and days of therapy and adjust your plan. I suggest you not plan Day 8 for each resident to complete five days of therapy.

In December 2010, the Office of the Inspector General (OIG) published a report called Questionable Billing By Skilled Nursing Facilities.” It discusses that CMS states Grace Days “should be used sparingly.” It is strongly suggested that use of grace days vary.

Finally, you need to explain to the resident that if they refuse therapy, it could jeopardize their Medicare coverage.

Please send your payment-related questions to Patricia Boyer at ltcnews@mcknights.com

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