AANAC'S PPS review: questions & answers from the American Association of Nurse Assessment Coordinators (AANAC).

Q: I have heard that with the new RUG 53 system, we won't be able to get paid at the RHX or RHL levels--only the RMX and RML levels. We should be getting paid for the highest number of minutes of therapy, as we always have, so how can this be true?

A: It is when a resident classifies into both an RH and an RM level within the Rehabilitation + Extensive Services category that it will be the medium level that is paid. This is because the software selects for payment the group with the highest payment rate based on the case-mix index. The following table illustrates how this works.</p> <pre> Table. The payment selection process for residents in RH and RM levels RUG-III

Nursing + Nursing + Non- Total Category Therapy CMI Therapy $$ Case Mix Rate RHX 1.42 + 0.94 195.38 + 97.42 70.22 363.02 RML 1.68 + 0.77 231.15 + 79.80 70.22 381.17 Nursing component: $137.59 per unit of CMI Therapy component: $103.64 per unit of CMI </pre> <p>Analyzing this information, you can see, first of all, that the nursing component pays a higher rate per unit of CMI than the therapy component pays.

As indicated on the table, the nursing component for RML is much higher than it is for the RHX category and, even though the therapy component is higher for RHX, since the nursing component pays much more per unit of CMI, the net outcome is that the total rate based on the CMI for RML is higher than it is for RHX. Therefore, even though RHX is higher in the hierarchy than RML, it is the high nursing component for RML compared with RHX, combined with the higher rate per unit of CMI for nursing, which pushes the CMI up to the point that the total rate is higher for RML than it is for RHX.

The bottom line is that even though RML is lower on the hierarchy, its rate is higher than RHX, and you get paid the higher rate when the resident classifies into both categories. If the resident classifies only into the high category, then that is the category that will be paid.

Q: A resident was admitted on Dec. 18. I did the 5-day assessment without combining it with the Admission assessment. Now therapy wants to use grace days for the 14-day assessment to be able to capture more minutes. If I use grace days, the Admission assessment will be late. Do I just do the Admission assessment alone and then do the 14-day assessment using grace days?

A: Option 1: If you haven't transmitted the PPS 5-day, you can dually code it to AA8a = 1, AA8b = 1. Remember, to do the RAPs, VB2 must be today, 12/01. Then you can do the PPS 14-day using ARD grace days between 12/02 to 12/06.

Option 2: If 5-day is transmitted or if you choose to leave the PPS 5-day as it is, do just an Admission assessment (AA8a = 1) with R2B and VB2 no later than today, 12/01. Do not combine this MDS with a PPS 14-day. Do a separate PPS 14-day (AA8a = 0, AA8b = 7) that uses grace days choosing ARD among 12/02 to 12/06 to capture the therapy days.

Q: The initial Medicare certification is dated the day of admission. The first recertification is on or before day 14. Can the first recertification be dated the day of admission, as well? If not, what is the best day to select for the first recertification date?

A: Yes, the initial cert and the first recert can be dated the same date. This is from the Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, available at http://new.cms.hhs.gov/manuals/downloads/ge101c04.pdf:</p> <pre> 40.4-Timing of Recertifications for Extended Care Services-

(Rev. 1, 09-11-02) The first recertification must be made no later than the 14th day of inpatient extended care services. A skilled nursing facility can, at its option, provide for the first recertification to be made earlier, or it can vary the timing of the first recertification within the 14-day period by diagnostic or clinical categories. Subsequent

recertifications must be made at intervals not exceeding 30 days. Such recertifications may be made at shorter intervals as established by the utilization review committee and the skilled nursing facility. </pre> <p>Q: If a patient who is in a Part A stay in a skilled unit needs to be transported to and from a physician visit in another town, I know we are responsible for paying transportation. Are we also responsible for the doctor appointment bill and any lab or x-rays that may have been done there?

A: Nonambulance transport is not a Medicare covered service, so it does not fall under the rules of Consolidated Billing and could be billed to the resident. Regarding the physician visit, although the professional services rendered would be billed to Medicare, any labs or x-rays would be billed to the facility because they do fall under the rules of Consolidated Billing.

Q: I have a resident who shares a room with her husband. She needs standby assistance for transfers and minimal assist with dressing and toileting. Her husband provides all of her ADL care. We only help with her weekly bath. How would you code this in the ADL section? The definitions in Section G refer to the amount of help the staff provides, but if I mark her as "0" this doesn't reflect the help the husband provides.

A: Although the instructions refer to "staff" assistance, CMS has clarified that assistance by anyone, including staff, visitors, volunteers, etc., should be taken into account when making the coding decisions. Most recently, this was clarified in a satellite broadcast/Webcast.

With thanks to Rena R. Shephard, MHA, RN, FACDONA, RAC-C, AANAC Chair, and President of RRS Healthcare Consulting Services, San Diego.