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

Q: A resident on Medicare Part A services completed therapies, remained skilled for nursing, and now is on a nursing RUG. He has had a decline in function and is again appropriate for rehab services. Should an OMRA be done to place him back into a rehab RUG level?

A: No, an OMRA would not be appropriate. A rehab RUG could be captured if the resident's status meets the criteria for a Significant Change in Status Assessment. RAI User's Manual Chapter 2, Section 2.9, Factors Impacting the SNF Medicare Assessment Schedule, pages 2-38 and 2-39:

Resident in a Part A Stay Begins Therapy

Adding therapy services to the treatments furnished to a beneficiary in a Part A stay does not automatically require a new assessment. However, if the therapy was added because the beneficiary experienced a significant change, an SCSA must be completed. In this case, the primary reason for assessment would be a SCSA (A8a = 3). If the SCSA is done during a Medicare assessment window, the SCSA can be combined with a regularly scheduled Medicare assessment. If the SCSA is not within a Medicare assessment window, the Medicare reason for assessment should be coded as AA8a = 3 and AA8b = 8, Other Medicare Required assessment.

Q: I have already transmitted an assessment to the state, and it has been accepted. I found a few days later that the resident was receiving skilled rehab. Am I able to submit a correction MDS? And if I can, how far back can you correct the MDSs?

A: There is no problem with correcting the PPS assessment. The time frame issue is that the adjustment bill to correct the payment must be sent within 120 days of the service "through" date on the claim covered by the assessment. See transmittal A-02-121 at http://cms.hhs.gov/manuals/pm_trans/A02121.pdf. Download the MDS correction policy at http://www.qtso.com/mdsdownload.html. It applies to all types of MDS assessments.

Q: Is it appropriate for therapists to record their time with Part A residents in 15-minute increments?

A: No, it is not. The PPS final rule addressed this issue, mandating that exact minutes spent treating the resident are to be reflected on the MDS. For billing purposes, the 15-minute increments may be used on the UB-92 claim form, since the RUG score is calculated from the MDS and not from the bill.

Q: If during a 7-day observation period I have 4 episodes of a 4 (total dependence), 5 episodes of a 2 (limited assist), and 1 episode of a 3 (extensive assist), how would I code this and why?

A: The definition for extensive assistance is "full staff performance of the function for part (but not all) of the last 7 days." Since there were 4 days of total dependence, then extensive assistance is the correct code for self-performance. Total dependence would not be the correct code, because the resident would have to require full staff performance of the activity during the entire 7-day period, with no participation by the resident at all. Limited assistance would not be correct, even though there were 5 episodes at that level, because the coding rules require coding at the highest level of dependence that occurred 3 or more times during the observation period. Refer to the flow chart on page 3-90 of the RAI Manual.

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