AANAC's PPS review.

Questions and Answers from the American Association of Nurse Assessment Coordinators (AANAC)

Editor's Note: Record keeping for the Medicare Prospective Payment System (PPS) is a daunting prospect. The assessment and documentation for 44 Resource Utilization Groupings (RUGs) and the rules governing this are complicated and demand study and attention to detail. The penalties for mistakes are severe: at best, reimbursement at a "default rate" leading, in time, to red ink and possible bankruptcy; at worst, prosecution for Medicare fraud or abuse. Rescue does seem to be on the way, however, in the form of an organization founded just last year: The American Association of Nurse Assessment Coordinators (AANAC).

Consisting of nurses who have been designated as the PPS point persons in their facilities, AANAC is dedicated to helping facilities achieve accurate and timely resident assessment and appropriate Medicare reimbursement. One of AANAC's principal features is an online chat group for members to exchange observations, questions and answers about PPS-related problems. AANAC experts review all questions and peer-review the answers to ensure that members receive accurate information. Here, and published quarterly in subsequent issues of Nursing Homes/Long Term Care Management, is a sampling of common questions submitted to AANAC and their answers.

Source: Sheri Kennedy, RN, MS, Ed, Executive Clinical Editor

Q: I was told if a Medicare Part A resident was put on rehab, say, day 16, I would fill out an OMRA (Other Medicare Required Assessment) 8 to 10 days later to capture the new RUG and upgraded payment. Is this correct?

A: The regulations only allow for an OMRA when all therapy services have been discontinued. If therapy is started between assessments, most facilities will do a SCSA (Significant Change in Status Assessment). An OMRA, by definition, would need to be void of rehab minutes in Section P on the MDS.

[Source Document: Transmittal 405 -- "An OMRA is completed only when a beneficiary discontinues all occupational, physical and speech therapy. An SCSA is completed when triggered by the guidelines in the current version of the Long Term Care Resident Assessment Instrument Users Manual."] Editorial Comment: No assessment has been identified to specifically change the payment rate when therapy commences midcycle in the assessment schedule.

Q: Are we required to do RAPs with either the 5-day or the 14-day assessment?

A: Although the Interim Final Rule did contain a statement to this effect, HCFA clarified it in the Final Rule as follows: "There are no PPS requirements for comprehensive assessments (that is, those including Resident Assessment Protocols [RAPs]). Comprehensive assessments are only required for clinical reasons, as they have been since implementation of the nursing home reform requirements enacted in the Omnibus Budget Reconciliation Act of 1987."

RAPs are required on Admission assessments, not 5-day or 14-day PPS assessments. Since many nurses call the Admission assessment a "14-day assessment," I believe this contributes to the confusion. Finally, either the 5-day or the 14-day Medicare PPS assessment can be dually coded with the OBRA-required Primary Admission assessment. You do see RAPs on this dually coded assessment, but the RAPs belong to the Admission primary "reason for assessment," not the PPS "reason."

Q: Excuse me, I am new to all of this: What's an ARD?

A: Assessment Reference Date (A3a on the MDS).

[Source Document: RAI Manual, which describes the ARD as the "Last day of the MDS observation period. This date refers to a specific endpoint in the MDS assessment process. Almost all MDS items refer to the resident's status over a designated time period, most frequently the seven-day period ending on this date. The date sets the designated endpoint of the common observation period, and all MDS items refer back in time from this point. Some cover the 14 days ending on this day, some the 30 days ending on this date, and so forth."]

Q: We have an MDS-related question for the following scenario: Resident admitted late afternoon 4/12 and then sent to hospital a.m. of 4/13. Was Medicare certified upon admission 4/12? Do we need to complete an MDS for the short time he was in our facility?

A: You can either complete an MDS, or bill for one default day with HIPPS code AAA00. The Interim Final Rule states that if the facility chooses not to complete the MDS, it will have to bill the default day. I had heard that some FIs are stating "no MDS = no payment." However, that is not so. The SNF can bill using the default HIPPS code AAA00.