Guest Columns

The value of attending national Open Door Forum calls

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Steven Littlehale
Steven Littlehale

I often describe the monthly CMS Open Door Forum call as a monthly staff meeting; if you miss the meeting you better read the minutes to see what projects were assigned to you!

Recently, Centers for Medicare & Medicaid Services officials confirmed that the policy discussed on page 2-51 of the RAI User's Manual for the MDS 3.0 that holds that a change of-therapy Other Medicare Required Assessment (COT OMRA) “may not be used as the first assessment to establish a resident's current RUG-IV therapy group.” 

This RAI manual change issued in October 2013 may not have caught the eye of all providers. The Change of Therapy OMRA is required when the resident was receiving a sufficient level of rehabilitation therapy to qualify for a Rehabilitation category. This means enough total reimbursable therapy minutes (RTM) delivered, and number of therapy days and disciplines providing therapy.

Furthermore, officials stressed that a COT OMRA may only be completed for a resident when “the most recent assessment used for PPS, excluding an end-of-therapy OMRA, has a sufficient level of rehabilitation therapy to qualify for an Ultra High, Very High, High, Medium, or Low Rehabilitation category.”  Meaning that if the assessment PRIOR did not have a sufficient level of therapy to be assigned, a REHAB RUG by policy providers cannot do a COT and get “into” that RUG a week later.

So just how big is the “issue”?  We took a look at all MDS 3.0 COT assessments submitted to PointRight database in CY 2013 and found that of the 167,000 COT assessments, 3.5% were preceded by a non-rehabilitation RUG.

The issue with this policy is that providers are delivering rehabilitation services, and if the model of delivery is not sufficient to qualify for a RUG-IV therapy group, the provider must wait until the next scheduled or non-COT unscheduled assessment before an assessment can be completed to assign that resident into another RUG.

The needs of the resident must be met, so providers might find themselves with costs for rehabilitation services that are much higher than revenue generated from the non-rehabilitation RUG.

CMS officials understand the issue that has been raised, and they stated their commitment to examining the breadth of impact of this issue, as well as exploring potential courses of action that may be determined necessary.

In the meantime, the Open Door Forum meeting suggests it's time to look at your model of therapy delivery. Providing only individual treatment sessions, with few to no groups and concurrent sessions, could work against you.

Can rethinking this offer ways to reduce the risk of falling short of five days of unique treatment? What about the many benefits to both resident and program of an upper-body strengthening group? Now take the strategy of having Medicare beneficiaries attend that group a couple times a week.

Meeting the skilled needs of the resident is a compliance requirement so this is not a one size fits all approach. But it's hard to argue against the benefits from improved upper or lower body strength. Actually, we might all benefit from this group!

Steven Littlehale is a gerontological clinical nurse specialist, and EVP and chief clinical officer at PointRight Inc. 

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Guest Columns

Guest columns are written by long-term care industry experts, ranging from academics and thought leaders to administrators and CEOs.

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