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 assessments and documentation for 44 Resource Utilization Groupings (RUGs) and the rules governing them 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.

The American Association of Nurse Assessment Coordinators (AANAC) consists 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 who 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. This department (published quarterly) provides a sampling of common questions submitted to AANAC and their answers.

Source: Sheri Kennedy, RN, BA, MS, Ed, Executive Clinical Editor, NAC News

Q: I have a PPS assessment coming up for someone who went off therapy, and nursing kept her on for a while longer--long enough to require doing an OMRA. Her 60-day assessment/OMRA can be combined, but I'm not sure which assessment is primary since the new rate for the OMRA assessment is the Assessment Reference Date (ARD), and for the 60-day, which will come first, the new payment period occurs a few days before the ARD. The ARD will be the same regardless of which is primary in order to have a nontherapy RUGS level. I'm not going beyond the range of allowable dates for the 60-day assessment.

A: This example is addressed in Transmittal 405. Because you are using grace days, the payment will change on day 61, even though the ARD might be day 64. The question is, how much is your payment going to drop? Depending on the answer, it might not be financially advisable to combine these two assessments.

Theresa Lang, RN, BSN, PHN, MAPA, CDONA/LTC

Q: Our Total Knees have been going home on the 5th day. Now my problem is how to project. I thought that since they went home before the 6th day, I should put in 5 days and whatever minutes were done in spaces Tlc & d. Our therapists said that they projected from the resident's first day, and we should project as though they weren't discharged. I called the MDS coordinators and the Fiscal Intermediary, all of whom said "follow the guidelines." What does that mean? How can I project and discharge on the 5yh day? We won't get paid for the 5th day, and this drops our RUG scores from Very High to High. How are you handling this problem?

A: The following excerpt is from the HCFA Q & A, which can be found at:www.hcfa.gov/medicaid/mds20/res_man.htm. Despite a lot of disagreement on this subject as a result of some of the wording in the PPS Final Rule, HCFA's Q & A still offers the correct response. This is the only way the facility can be paid for the intensity of services provided. HCFA never intended for facilities to give away services or, on the other hand, to be incentivized to keep residents longer just so they can get paid.

[HCFA Q & A excerpt]:

Q: Should I estimate the days/minutes for the Medicare patient based on 15 days even if I expect him to be discharged earlier than that?

A: Yes. The RUGs-III group to which the patient is classified is based on the minutes already received (Section P) and those expected to be provided (Section T). To accurately group the patient, the form must be filled out according to the directions. If the patient is discharged before the end of two weeks, the facility will hill at the RUGs-III group to which he classified for only the days he stayed in the nursing home.

Rena R. Shephard, RN, BA, CDONA 

Q: I have an MDS coordinator who states that if a resident is on PPS, you do not need to do the federally mandated assessments, i.e., initial admission, quarterly, etc., but rather only the PPS assessments. I cannot convince her differently, so I need to know exactly where to find the documentation stating that federal assessments are still required along with the PPS assessments and that they maybe dually coded.

A: I can't think of a document dealing with the MDS that does not say this. In the PPS final rule, it talks for pages about combining the two scheduled assessments (OBRA and PPS). Specifically, page 26266 offers considerable information that applies to these questions, e.g.:

* Column two, para 2: "In order to be in compliance with the requirements of Medicare and Medicaid certifications, facilities must complete an Initial Admission assessment, including RAPs, within 14 days of the patient's admission to the facility. Within approximately the same time frame, the requirements for PPS specify that facilities must complete two assessments for each patient in a Medicare-covered Part A stay."

* Column two, para 4: "In order to be in compliance with the requirements for Medicare and Medicaid certification, facilities must perform the HCFA Standard Quarterly review for each resident in the facility at least every 92 days. The requirements for PPS specify that a Medicare 90-day assessment be completed for each patient whose stay is still covered under Medicare. To minimize burden on the facility staff, the Medicare 90-day assessment that is completed to meet PPS requirements may also be used to meet the clinical requirement at 483.20 for completion of a Quarterly Review assessment. In this case, the 'Reason for Assessment' item on the assessment would be coded as both 'Quarterly Review' assessment and as a Medicare 90-day assessment."

If you have any further doubts, look at 383.20. These requirements have not changed.

Nathan Lake, RN, MSHA