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 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, and at worst, prosecution for Medicare fraud or abuse. Rescue does seem to be on the way, however, in the form of an organization founded in 1999: 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 accu rate 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. Here, published quarterly in Nursing Homes/Long Term Care Management, is a sampling of common questions submitted to AANAC and their answers.

Q: Our facility admitted a patient last week to a skilled bed. She came from the hospital with a diagnosis of stroke. Rehab was only able to work with her for 3 days when she took a turn for the worse. Now she is comatose, and we moved her out of the Medicare bed into a regular bed on our heavy-care unit. Her 5-day assessment has been done. I know I need to do a significant change on her, but I am unsure when to do it. How do I set the dates for her significant change if she dies after only a few days out of skilled? Our business office is saying we have to do a significant change assessment on this woman even if she dies before the assessment is due in order for us to get paid, since she is no longer in a Medicare bed. Is this true?

A: There are many issues involved in this question. First, we need to know whether a comprehensive admission assessment, with RAPs, was completed.

If no admission assessment has been completed, Then no significant change assessment is required.

Logic: A baseline comprehensive admission assessment is required before a "change" can be noted.

Since the resident is no longer being covered under Medicare, no further Medicare assessments are required.

The next required OBRA assessment is the admission assessment. It must be completed by day 14 of her stay. This includes the RAPs. If the resident expires before day 14 of the stay, and this assessment was not completed, you are not out of compliance with any regulations; your payment would not be in jeopardy.

If an admission assessment has been completed, Then a significant change assessment might be required.

Logic: A significant change of status assessment must be completed within 14 days of identifying a significant change. However, if a resident expires before this 14-day window, there is no requirement to have completed said assessment. Your payment would not be in jeopardy if this assessment were not completed.

Again, since the resident is no longer being covered under Medicare, no further Medicare assessments are required.

Sheri Kennedy, RN, BA, MSEd

Q: I need help with this scenario: Resident was admitted 7/24 with Medicare coverage for IV antibiotics (lasted 10 days) and rehab therapy (spinal injury). Last skilled coverage (D/C from therapy) was 9/10. Resident was started on IV again 9/22.

Can I resume coverage for Medicare now that he was put back on IV? The resident was not transferred out to hospital.

A: Since you are within 30 days of D/C from Medicare A, you can restart coverage without another qualifying hospital stay.

Jan Cacek, RN

Q: I have a 30-day that was to be replaced by a OMRA. Resident finished all rehab 8 days ago. The charge nurse now informs me that there is a significant change in status. I can code this as a significant change in status assessment and it will replace both the OMRA and the 30 day, correct?

A: That is correct. The assessment can be coded as a significant change in status at AA8a, and as an OMRA at AA8b. As the ARD will be in the range for the 30-day assessment, this assessment will meet the requirements for all three assessments. HIPPS code = 28.

Sheri Kennedy, RN, BA, MSEd

Q: I have a question about therapy days/minutes. On a 14-day MDS (done with reference on day 11) if the look-back includes day/minutes from day 5 and the 5-day MDS (done on day 5) also used the day/minutes on day 5, can this be included again on the 14-day MDS? It was my under-standing that this was okay, but our therapist is disagreeing, saying that once minutes are counted on an MDS, they cannot be counted again. I'm sure I'll need a reference if anyone knows where I can find it.

A: It is absolutely okay to use those days and minutes for both assessments. You are using the allowed reference dates for your assessments.

Tammy Gola, RN, BSN, CRNAC

Q: If someone is out of the building at midnight, let's say in the ER, and returns early the next a.m. (resident is PPS), I realize you will not be paid for the day he/she was out at midnight, but am I correct that you do not have to start the PPS schedule over again, but merely skip the day and continue on?

A: That is correct. Absences from the facility that span midnight, but are not 24 or more hours in length, do not require a restart of the PPS schedule unless the resident had been admitted as an inpatient during that time. The accept able window for (future) PPS ARDs is delayed by 1 day.

Nathan Lake, RN, MSHA