No more Rehab Medium RUG defaults

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Shelly Mesure, MS, OTR/L
Shelly Mesure, MS, OTR/L

Well, Oct. 1 has passed, and we're all still hanging in. The biggest changes we saw to rehab were the addition of reporting co-treatment minutes on our billing logs and Section O on the MDS. And, the new question of “how many DISTINCT calendar days” were received between SLP, OT, and PT.

The issue with this new reporting requirement is not a significant problem for most rehab departments. In other words, most rehab departments are able to treat a patient for at least a combination of five separate calendar days over the seven-day assessment reference period between all discplines.

The definition of a therapy visit requires each discipline to provide a minimum of 15 minutes of billable treatment time within the calendar day. This may be a combination of several visits (for example, 10 minutes in the morning with another 5-minute afternoon session) within the same day.

However, there are 2 primary scenarios that may require special attention to ensure the five days of rehab are obtained.

1.     Dialysis patients or other patients that may have difficulty receiving therapy every day.

2.     The “frequent flyers” – in other words, patients who are admitted and discharged before a traditional five-day assessment can be performed.

Scenario #1 will require several approaches:

A.     Always attempt at least a minimal therapy treatment session (lasting 15 minutes or longer) on the days of dialysis treatment, as clinically appropriate. This might require creative scheduling from the therapy staff (someone is willing to work very early or stay until later) if you have a large volume of these types of patients.

B.     The other alternative is establishing two separate restorative nursing programs, RNP, that won't duplicate therapy services. However, the RNP programs MUST BE completed a minimum of six days per assessment period, in addition to three days of therapy sessions. Depending on how your RNP departments are running, this may be an option to capture the very early or very late scheduling issues.

With the second option, you will end up receiving the Rehab LOW RUG category, but it may be well-worth the extra effort, especially if you qualify for the RLB rates.

Scenario #2 requires completely different approaches:

A.     Ask your MDS coordinators if they are up-to-date on completing a short-stay MDS. It requires very specific criteria, and every criteria must be met to qualify:

1.     The assessment must be a Start of Therapy OMRA (A0310C = 1 or 3). This assessment may be completed alone or combined with any OBRA assessment or combined with a PPS 5-day or readmission/return assessment. The Start of Therapy OMRA may not be combined with a PPS 14-day, 30-day, 60-day, or 90-day assessment. The Start of Therapy OMRA should also be combined with a discharge assessment when the end of Part A stay is the result of discharge from the facility, but not combined with a discharge if the resident dies in the facility or is transferred to another payer source in the facility.

2.     A PPS 5-day (A0310B = 01) or readmission/return assessment (A0310B = 06) has been completed. The PPS 5-day or readmission/return assessment may be completed alone or combined with the Start of Therapy OMRA.

3.     The ARD (A2300) must be on or before the eighth day of the Part A Medicare covered stay. The ARD minus the start of Medicare stay date (A2400B) must be seven days or fewer.

4.     The ARD (A2300) of the Start of Therapy OMRA must be the last covered Medicare Part A day. The Start of Therapy OMRA ARD must equal the end of Medicare stay date (A2400C). The end of the Medicare stay date is the date Part A ended. See instructions for A2400C in Chapter 3 for more detail.

5.     Rehabilitation therapy (speech-language pathology services, occupational therapy or physical therapy) started during the last 4 days of the Medicare Part A covered stay (including weekends). The end of Medicare stay date (A2400C) minus the earliest start date for the three therapy disciplines (O0400A5, O0400B5, or O0400C5) must be 3 days or less.

6.     At least one therapy discipline continued through the last day of the Medicare Part A covered stay. At least one of the therapy disciplines must have a dash-filled end of therapy date (O0400A5, O0400B5, or O0400C5) indicating ongoing therapy or an end of therapy date equal to the end of covered Medicare stay date (A2400C).

B.     If all six of these conditions are met, then the assignment of the RUG-IV rehab therapy classification is calculated based on average daily minutes actually provided, and the resulting RUG-IV group is recorded in MDS item Z0100A (Medicare Part A HIPPS Code).

Please reference Chapter 6 of the RAI Manual v3.0 for more specific examples of utilizing the short stay requirements.

If none of these approaches for either scenario is utilized, then the patient will default to the most appropriate nursing RUG category for payment, regardless, if any therapy was provided. So, don't get too relaxed. These new “minor” changes can still result in “big” changes financially and to the impact of the rehab RUGs.

Shelly Mesure ("Measure"), MS, OTR/L, is the senior vice president of Orchestrall Rehab Solutions and owner of A Mesured Solution Inc., a rehabilitation management consultancy with clients nationwide. A former corporate and program director for major long-term care providers, she is a veteran speaker and writer on therapy and reimbursement issues.


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Rehab Realities is written by Renee Kinder, MS, CCC-SLP, RAC-CT.  She currently serves as Director of Clinical Education for Encore Rehabilitation and acts as editor of Perspectives on Gerontology, a publication of the American Speech Language Hearing Association.

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