Providers still adjusting to new Medicare rules

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Providers still adjusting to new Medicare rules
Providers still adjusting to new Medicare rules
The switchover to MDS 3.0 and RUG-IV may have happened months ago, but long-term care and therapy providers say they are still honing their policies and practices to ensure that residents receive the best treatment possible, and that appropriate reimbursement is attained for the therapy provided.

Getting there hasn't been easy, particularly in the face of implementation — and interpretation — challenges that surfaced in the weeks leading up to and following the start date. That was Oct. 1, 2010, for the new resident assessment and classification systems.

Compounding issues further, the Centers for Medicare & Medicaid Services proposed new restrictive rules in April. The new measures would revise the definition of group therapy, require allocation of group therapy minutes in assigning RUG-IV payment groups and impose a new Medicare-required assessment to be completed by skilled nursing facilities when changes in therapy intensity occur.

CMS has proposed the changes because it determined in a preliminary assessment that therapy patients are being classified into one of the highest paying RUG-IV therapy groups more than 40% of the time, thereby triggering Medicare payments far in excess of original federal estimates.

In light of these changes, ongoing training, improved staffing and communication, creative scheduling and diligent documentation are taking on new importance. They can help providers iron out any remaining wrinkles, justify their therapy approaches and, in the process, maintain their RUG utilization, sources told McKnight's.

The American Health Care Association reported an uptick in member facilities hiring additional staff to meet the needs of increasingly sick residents.

“The acuity level of many residents is increasing and so care plans must be adjusted to reflect an increase in rehabilitation or intensive therapy,” said Greg Crist, vice president of public affairs for Washington-based AHCA. “Facilities have been hiring more staff — increasing the number of nurses, ward clerks, dietary staff, [and others], varying on the degree of resident need.” Many facilities also have hired reimbursement coordinators to focus on the rules supporting payment coding, Crist added.

“MDS 3.0 and RUG-IV present many changes — a new tool, new payment methods and new assessments,” he said. “When you put all those things together, you have the need for adaptation, change and development — all with the end goal of increased [resident care] quality.”

Schedule smarter
Among therapy's biggest challenges since the new systems have taken effect have been allocating minutes among the three types of therapies — individual, concurrent and group — and ensuring that therapists fully understand the differences between the multi-resident treatments.

Currently, CMS defines concurrent therapy as treatment that involves one therapist treating two residents at the same time while the residents are performing different activities. Providers have rarely if ever filed for it, officials said. Group therapy, on the other hand, is currently defined as treatment that involves multiple residents doing the same or similar activities for a therapist who is not supervising any other individuals — however, in the SNF PPS proposed rule for 2012, the agency suggests changing the definition of “group” to therapy that involves four patients doing the same or similar activities. At this point, there's also no clear CMS definition on what constitutes “similar” activities, which means therapy providers have had to establish a reasonable definition on their own.

Aegis Therapies said it addressed this gray area by focusing training around specific clinical scenarios. If multiple residents are doing upper body strengthening, for example, but one uses weights or pulleys and another uses a strengthening band, it could be reasonably determined that those residents are indeed performing similar activities.

“For us, we made the distinction that it wasn't necessarily about the machines or the methods, but about the treatment focus,” said Bill Goulding, Aegis Therapies' national director of outcomes and reimbursement. This creates a better therapy session schedule for those who benefit from multiple-resident treatment, he explained.

More than ever, providers are finding that ongoing communication with nursing and medical staff, coupled with more sophisticated scheduling tools, is critical for preventing therapy-related snags that could jeopardize both care and reimbursement. At Friedwald Center for Rehabilitation and Nursing in Rockland County, NY, flexible scheduling hinges on interdisciplinary communication.

“Constant communication between therapy and nursing is critical. Nursing and medical staff need to be aware of what's going on in therapy and [vice versa],” said Susan Heller, Friedwald's rehabilitation director. “We are also looking to enhance and streamline therapy management by incorporating a sophisticated electronic therapy module which would allow for efficient management of therapy scheduling and monitoring of key reimbursement indicators.”

Building stronger relationships between nursing and rehab also has been a strong focus for A Mesured Solution Inc., Philadelphia. The consultant also has promoted the development of a “clinician's treatment decision tree” that utilizes group treatment options and concurrent therapy in situations such as “dove-tailing.” (Dove-tailing refers to a therapy approach whereby two Medicare Part A residents have different start/stop times and are receiving different types of treatment; such an approach can help therapists use their time more effectively, while still addressing goal-oriented tasks for each resident.)

Scheduling tweaks
“By changing the operations of how rehab delivers treatment and structures their ‘typical' treatment day, 100% of our clients maintained or even continued to increase their RUG utilization,” said Shelly Mesure, MS, ORT/L, rehabilitation management consultant and owner of A Mesured Solution. She added that those reimbursement increases occurred despite the loss of some nursing extensive services.

Scheduling therapy and maximizing reimbursement under the new payment system also means therapy providers must more closely evaluate and define the department's actual hours of operation, especially for the five-day MDS assessment. Because the RUG-IV system does not estimate projected minutes for therapy services, residents must receive five days of therapy during the initial look-back period, unless the Start of Therapy OMRA (Other Medicare Required Assessment) option is utilized.

The End of Therapy OMRA also can have an impact on department scheduling. If a resident were scheduled Monday through Friday, for example, but becomes ill and misses the Friday treatment, that, of course, counts as a missed therapy day. But the bigger problem is if the patient receives no treatments on Saturday or Sunday, even if he or she had not been scheduled to be treated on those days.

According to CMS's clarification on the end-of-therapy OMRA, which appeared in the April 28 proposed rule, that scenario would result in the need for an EOT OMRA and subsequent transition from rehab because three calendar days have elapsed without any skilled rehabilitation. Because this clarification has only just appeared in a proposed rule, it may be altered in some way before it becomes a part of the final rule for implementation, as of Oct. 1, 2012.

Nevertheless, it gives an indication as to CMS's view of what “missed treatments” means. CMS seems to be implying that the reason for missed treatments is not the issue, nor is it pertinent whether a therapy department was even open on some of the days in question.

Staffing plans for a therapy department's hours and days of operation must be flexible enough to react to any kind of missed sessions, especially when they occur on a Friday or Monday in a typical five-days-per-week department.

“It's very important for people to be on a scheduled therapy regimen and if a patient is missing three or more days of therapy, it's not good for the patient's condition,” said Sheila Lambowitz, CMS Director, Division of Institutional Post Acute Care, at May's SNF/LTC Open Door Forum. 

Therefore, staggering therapy schedules and ensuring that all residents receive the right treatment at the right time requires providers to log extra hours, as needed, and work hand-in-hand daily with nursing, admissions and other departments to discuss any problems and changes that may impact therapy scheduling.

“We are starting early to do ADLs and staying late for late admissions,” said Lucinda Zuviv, rehab program manager at Edgewater Pointe Estates, an ACTS continuing care retirement community in Boca Raton, FL.

The therapy department works closely with admissions — a must for capturing evaluations on Day 1. A discharge planning group and available weekend coverage are also key, added Angela Holman, Edgewater's director of nursing.

“If an admission takes place after a therapist has left for the day, we have them on call. It doesn't happen [often], but therapists are available when needed,” she said.

Take good notes
Meticulous documentation is critical for averting MDS 3.0- or RUG-IV-related problems, and providers are getting savvier in their approach.

This is especially important in light of the proposed CMS rule that will add a Medicare-required assessment to be completed by skilled nursing facilities personnel when changes occur in therapy intensity.

Aegis implemented software tools and improved documentation techniques that allow therapists to print out planned resident rosters and input procedural codes from physician orders to identify the treatment focus for each resident. Such an approach helps demonstrate similarities between residents, while allowing therapists and other care providers to improve therapy planning and scheduling, according to Goulding.

Corporate-wide collection and sharing of best practices has also played a key role in Aegis' therapy approach.

“Our priority is to see patients individually, but some may benefit from a group environment. We want to group them by like activities, and we want to find the best approach to providing those activities,” he said.

At Edgewater Pointe Estates, Genesis Rehab Services — the community's rehabilitation provider — supplies devices such as iPod touches and iPads, which simplify documentation and allow staff to more easily tackle e-mail, billing and daily note-taking, and communicate with the interdisciplinary care team.

“In any organization, it's good to make the best use of technology available at the time. Documentation can be a laborious process, so we're also looking to take advantage of technology that allows electronic documentation of ADLs and crosses over into MDS automatically,” Holman said.

Still, some of the best approaches to MDS 3.0 and RUG-IV are less about sophisticated technology and more about basic operational tenets that foster a more productive, soothing care environment. With MDS 3.0, many facilities struggle with Section Q, according to AHCA's Crist, because residents aren't always comfortable being continuously asked to respond to return-to-community inquiries.
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