P3 · 3/16/2016 1 Understanding PPS for the New Long Term Care Compliance Officer and Those Who...

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Understanding PPS for the New Long Term Care Compliance

Officer and Those Who Want a Refresher

Shawn Halcsik DPT, MEd, RAC‐CT, CPC, CHC

VP of Compliance & Clinical Services

Renee Kinder M.S. CCC‐SLP, RAC‐CT

Clinical Specialist

Evergreen Rehabilitation

Health Care Reform Triple Aim

Improved Health

Improved Healthcare

Cost Containment

Medicare Enrollment Growth

54 Million

[VALUE] Million

0

10

20

30

40

50

60

70

80

90

2015 2030

Benes

Benes

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2

Share of Medicare FFS Benes with Chronic Conditions

58

45

3129 28

16 15 1412 11

8 8 75 4

0

10

20

30

40

50

60

70

MedPAC March 2015 Source: CMS 2012

Older benes more likely to have multiple chronic conditions, 2010

47

28

17

9

37

34

20

9

23

33

27

1817

29 29

0

5

10

15

20

25

30

35

40

45

50

0‐1 2‐3 4‐5 6+

less than 65 65‐74 75‐84 85+

MedPAC March 2015 Source: CMS 2012

Medicare Spending is Concentrated Among Beneficiaries with Multiple Chronic Conditions, 2010

14

4623

28

32

19

0

10

20

30

40

50

60

70

80

90

100

Beneficiaries Spending

6 + conditons 4 or 5 conditions 2 or 3 conditions

MedPAC March 2015 Report Source: CMS 2012

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42% of Medicare Benes Discharge to PAC

20

17

4 1

% Benes

SNF HH IRF LTCH

MedPAC March 2015 Report Source: CMS 2012

Source: PH Conway (CMS)

Post Acute Care Usage2014

Dollars # Beneficiaries

SNF 28.6B 1.7 M

HH 17.7B 3.4 M

IRF 7.0B 376 K

LTACH 5.4B 134 K

Total 58.7B

OUTCOMES??Setting Appropriate??

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• 2010 OIG Report

• 2012 OIG Report: $1.5 billion

1728

50

5.7 10.70

20

40

60

2006 2008 2013

20.3

2.52.1

75.1

upcoded downcoded coverage correct

30.3

16.8

6.5

4.7

Therapy Specialty Care ADLs Oral/Nutrit None

Copyright 2015 Shawn Halcsik

Did not determine the extent to which Medicare payments for specific SNF claims were appropriate, including whether services billed for were necessary

Level of Therapy % of RUGs in Which SNFs Provided the Minimum # of Required Therapy Minutes

FY 2011 FY 2012 FY 2013

Ultra High 21% 29% 34%

Very High 12% 18% 22%

High 10% 15% 18%

Medium 7% 9% 10%

Low 14% 13% 12%

Type of Billing Change

FY 2011 FY 2012 FY 2013 EstimatedIncreased Medicare Payments from Changes in Billing Since FY 2011

Ultra High 49% 53% 57% $879 Million

Source: OEI‐02‐13‐00610 The Medicare Payment System for Skilled Nursing Facilities Needs to be Reevaluated

2016 OIG Work Plan

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PPSUnderstanding PPS

Skilled Nursing Facility Prospective Payment System

Skilled Nursing Facility Prospective Payment System (SNF PPS) was established in 1998 during which time the Minimum Data Set (MDS) became the tool for determining reimbursement for nursing home residents under Medicare Part A.

A Resource Utilization Group (RUG) case‐mix classification system was established in order to predict resource use via the MDS.

Prospective Payment System (PPS) LingoPPS‐Method of reimbursement in which Medicare payment is made based on the classification system of that service (e.g., resource utilization groups, RUGs, for skilled nursing facilities).

Assessment Reference Date (ARD) ‐ a key concept for all MDS assessments; drives payment by establishing the time period for capturing care and services on the MDS and, as such, it determines the RUG‐IV category for the particular assessment.

Resource Utilization Group (RUG)‐ case‐mix classification system developed to predict resource use via the MDS.

Minimal Data Set (MDS)‐ step one of the Resident Assessment Index (RAI) process, houses data for reimbursement purposes

Omnibus Budget Reconciliation Act (OBRA) of 1987‐dramatically changed the way Skilled Nursing Facilities (SNFs) approached resident care, radically modifying nursing home regulations and the survey process. The federal government established a requirement for comprehensive assessment as the foundation for planning and delivering care to nursing home residents.

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Admission Requirements

• Must have been an inpatient of a hospital for a medically necessary stay of at least 3 consecutive days

• Must admit to the SNF within 30 days of discharge from the hospital

• Must require SNF care for a condition that was treated during the qualifying hospital stay, or for a condition that arose while in the SNF for treatment of a condition for which the beneficiary was previously treated in the hospital.

SNF Level of Care

• All four factors must be met:• The patient requires skilled nursing services or skilled rehab services; are ordered by a physician and the services are rendered for a condition for which the patient received inpatient hospital services or for a condition that arose while receiving care in the SNF for a condition for which he received inpatient hospital services

• The patient requires these skilled services on a daily basis

• As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF

• The services delivered are reasonable and necessary for the treatment of a patient’s illness or injury. The services must also be reasonable in terms of duration and quantity

Skilled Service

• If the inherent complexity of a service prescribed for a patient is such that it can be performed safely and/or effectively only by or under the general supervision of a qualified therapist, the service is a skilled service

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Conditions

• Services must be directly and specifically related to an active written treatment plan that is based on an initial evaluation performed by a qualified therapist after admit to the SNF that is approved by the physician after any needed consultation with the qualified therapist

• Services must be of a level of complexity and sophistication, or the condition of the patient must be of a nature that requires the judgment, knowledge, and skills of a qualified therapist

Conditions

• The services must be provided with the expectation, based on the assessment made by the physician of the patient’s restoration potential, that the condition of the patient will improve materially in a reasonable and generally predictable period of time; or, the services must be necessary for the establishment of a safe and effective maintenance program; or, the services must require the skills of a qualified therapist for the performance of a safe and effective maintenance program

Conditions

• The services must be considered under accepted standards of medical practice to be specific and effective treatment for the patient’s condition

• The services must be reasonable and necessary for the treatment of the patient’s condition; this includes the requirement that the amount, frequency and duration of the services must be reasonable

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Certification RequirementsPub. 100‐01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, “Physician Certification and Recertification of Services,” §§40 ‐ 40.4.6.

• Certifications must be obtained at the time of admission, or as soon thereafter as is reasonable and practicable.

• The routine admission order established by a physician is not a certification of the necessity for post‐hospital extended care services for purposes of the program.

• There must be a separate signed statement indicating that the patient will require on a daily basis SNF covered care.

• A certification or recertification statement must be signed by the attending physician or a physician on the staff of the skilled nursing facility who has knowledge of the case, or by a physician extender (that is, a nurse practitioner, a clinical nurse specialist or, effective with items and services furnished on or after January 1, 2011, a physician assistant) who does not have a direct or indirect employment relationship with the facility, but who is working in collaboration with the physician.

• The recertification statement must contain an adequate written record of the reasons for the continued need for extended care services, the estimated period of time required for the patient to remain in the facility, and any plans, where appropriate, for home care. The recertification statement made by the physician does not have to include this entire statement if, for example, all of the required information is in fact included in progress.

Certification Requirements

• The first recertification must be made no later than the l4th 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 l4‐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.

Step by Step: Moving Thru the MDS

STEP ONE: An individual meets criteria for SNF Med A Level of Care.

STEP TWO: PPS Assessment Process is Completed• MDS Clinical Data Obtained• Assessment Reference Date (ARD) selected• Section O will include skilled rehab level of care minutes

STEP THREE: RUG Level is assigned based on anticipated costs of care

STEP FOUR: Assessments continue at regular intervals, as often as every 7 days, impacting reimbursement of services based on level of care

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Resident Assessment Index Process

I. The Minimum Data Set (MDS), a screening tool that provides information about the resident’s functional status.

II. Care Area Assessments (CAAs) are a set of 20 different assessments that are further, in‐depth evaluations of specific functional areas. A CAA must be completed for each care area that is identified as a possible problem, or triggered, as a result of the MDS assessment. After completing the CAA, a clinical decision is made based on the results as to whether the possible problem is in fact a real problem. When a problem is identified, the next step is to determine the root causes and contributing factors, risk factors for the resident related to the problem, and the need for referrals to other disciplines.

III. Care Plan, the working action plan that is developed based on the findings that result from the CAAs. The development of an individualized, interdisciplinary care plan designed to address the resident’s specific problems, strengths, preferences, risk factors, and complications is the primary purpose of the RAI process.

MDS Sections

• SECTION A. Identification Information

• SECTION B. Hearing, Speech and Vision

• SECTION C. Cognitive Patterns

• SECTION D. Mood

• SECTION E. Behavior

• SECTION F. Preferences for Customary Routine and Activities

• SECTION G. Functional Status

• SECTION H. Bladder and Bowel

• SECTION I. Active Diagnoses

SECTION J. Health Conditions

SECTION K. Swallowing/Nutritional Status

SECTION L. Oral/Dental Status

SECTION M. Skin Conditions

SECTION N. Medication

SECTION O. Special Treatment, Procedures, and Programs

SECTION P. Restraints

SECTION Q. Participation in Assessment and Goal Setting

SECTION V. Care Area Assessment (CAA) Summary

Resource Utilization Groups (RUG) Levels

Under the RUG‐IV system, Medicare Part A residents are classified into 66 categories according to the amount and type of resources they use.

Specific MDS 3.0 items reflecting a resident’s acuity, such as functional status, and certain treatments, conditions, and diagnoses, are used to help quantify the cost of care and services for reimbursement.

Categories are based on the projected cost of their care not diagnosis.

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PPS Assessments‐MDS Section A0310

OBRA Assessments

PPS Planned Assessments

PPS Other Medicare Required (OMRA) Assessments

Scheduled PPS Assessment Date Window

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1 2 3 4 5 65‐day Grace Day

75‐day Grace Day

85‐day Grace day

9 10 11 12 13 14

1514‐day Grace day

1614‐day Graceday

1714‐day Graceday

1814‐day Graceday

19 20 21

22 23 24 25 26 27 28

5 day assessment ARD DAY 1‐5

5 day assessment PAYS DAY 1‐14

14 day assessment ARD DAY 13‐14




1

Ms. Smith is admitted to Happy Valley Skilled Nursing Facility following a CVA. She meets all criteria for a Med A Stay.

She is tired and requests therapy starts the next day

2

Physical, occupational and speech therapy evaluate and determine she needs an RU level of care (720 minutes minimum in ARD lookback) to return to prior functional statusDay 2105 minutes of rehab

3

Feeling stronger, think I can tolerate a little more today

Day 3 150 minutes of rehab= 255 total

4

Let’s keep this ball rolling

Day 4150 minutes of rehab= 405 total

5

ANOTHER GREAT DAY!

Day 5200 minutes total rehab=605

6

Day 6200 minutes total rehab=805

7

8 9 10 11 12 13 14

Rehab and Nursing

Select Day 6 as the 5 day ARD

RU RUG MET


Other Medicare Required Assessments

• Start of Therapy OMRA

• End of Therapy OMRA

• Change of Therapy OMRA

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Start of Therapy (SOT) OMRA

• Optional• May be completed to calculate a Rehab RUG for a resident in a non‐Rehab RUG

• Rehab services are initiated between scheduled assessments, or• Rehab services started within a regular assessment window in a situation in which not enough therapy was delivered for a Rehabilitation RUG to be calculated.

• ARD• Set for day five, six, or seven• The first day of therapy counts as day one (date of first therapy evaluation, whether or not treatment is provided).

• Payment rate is set starting on the earliest start‐of‐therapy date (date of earliest therapy evaluation).

Start of Therapy SOT Sample

1Residents first day of Medicare

2No therapy

3No therapy

4No therapy

5Physical Therapy Eval

Day 1

6

Day 2

7MDS 5‐day PPS Assessment

Day 3

8

Day 4

9 10 11 12 13 14

DAY 5,6,7 SOT Window

Tips for Utilizing the SOT

• Why would rehab not start day 1?• Clinically complicated• Refusals

• SOT Myth• If Rehab does not start on day 1 an SOT is required• Fact‐ If enough therapy minutes are obtained in the lookback by 5 day ARD then reimbursement begins day one.

• Usually NOT best to combine SOT with a 5‐day PPS• 5‐day PPS begins payment on day 1 with RUG• SOT begins Rehab RUG payment on first day of first therapy discipline.• Best when resident covered with Nursing RUG and begins therapy later in Medicare stay

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End of Therapy (EOT) OMRA

Unscheduled SNF PPS assessment which is required when the resident was classified in a RUG‐IV Rehabilitation Plus Extensive Services or Rehabilitation group and continues to need Part A SNF‐level services after the planned or unplanned discontinuation of all rehabilitation therapies for three or more consecutive days.

Required EOT‐ Planned Rehab DC• Therapy Is Discontinued, Part A Continues (planned discontinuation of therapy)

• ALWAYS REQUIRED‐ The Medicare beneficiary is in a therapy RUG, and all therapy is being discontinued, and the resident will continue on Part A for skilled nursing care for at least three days.

• Purpose is to calculate a non‐therapy RUG (displayed in MDS item Z0150A) to bill for the daily skilled nursing services that continue after therapy ends.

• The non‐therapy RUG starts paying on the first non‐therapy day.

• ARD that is 1 to 3 days after the last day therapy services were provided.

• EOT OMRA is expected to be completed for missed therapy days regardless of whether therapy is missed on a weekday, weekend, or holiday

EOT SAMPLE

62

Physical Therapydischarge

63

Speech Therapy & Occupational Therapydischarge

REHAB LAST COVERED

DAY

64 65 66 67 68

Skilled Nursing Care continued for Wound Care

EOT ARD WINDOW

Remember: 60 day ARD pays days 61‐90 60 day ARD for this patient was on day 57Planned rehab dc day 63

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EOT Not Required‐ Planned Rehab DC

• The EOT OMRA is NOT required if skilled nursing continues for only one or two days after the last day of therapy.

• In that case, the therapy RUG continues to be billed for those days.

Monday Tuesday Wednesday Thursday Friday

Physical TherapyDischarge

Occupational Therapy Discharge

LAST COVERED DAY

Resident goes home

REHAB RUG PAYMENT CONTINUES

EOT Auditing

In cases where the last day of the Medicare Part A benefit, that is the date used to code A2400C on the MDS, is prior to the third consecutive day of missed therapy services, then no EOT OMRA is required. If the date listed in A2400C is on or after the third consecutive day of missed therapy services, then an EOT OMRA would be required.

End of Therapy with Resumption (EOT‐R)

• May be used when the resident will resume at the same therapy level as prior to the discontinuation of therapy.

• Resumption of therapy must occur no more than five days after the last day of therapy provided.

• In cases when an EOT‐R is used, the facility should bill the non‐therapy RUG given on the EOT OMRA beginning the day after the patient’s last therapy session. The facility would then begin billing the therapy RUG that was in effect prior to the EOT OMRA beginning on the day that therapy resumed (O0450B).

• Providers are not required to consider possible ADL changes when determining if a resumption of therapy will occur.

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EOT‐R Sample

15Therapy was going great, but now I have a respiratory infection and they will have to discharge my care.

LAST DAY OT/PT at Rehab High RUG

16Started my Antibiotic treatment hoping to feel better soon

17One day at a time

18Feeling better

19Just took my first deep breath in a week!

19Chest x‐ray reveals I am clear! Labs show no infection. Somebody call the therapy team

RESUMPTION OF THERAPY AT Rehab High RUG

20

Remember 14 day assessment pays day 15‐3014 day ARD set for day 13, patient becomes ill on day 14.

Change of Therapy (COT) OMRA: Background

Effective for all assessments with an ARD on or after October 1, 2011, a COT OMRA is required if the therapy received during the COT observation period does not reflect the RUG‐IV classification level on the patient’s most recent PPS assessment used for payment.

COT Observation Period: A successive 7‐day window beginning the day following the ARD of the resident’s last PPS assessment used for payment.

May be used to classify a patient into a HIGHER or LOWER RUG category

Change of Therapy (COT): When Required

• Required when intensity of therapy increases or decreases from RUG of most recent PPS assessment.

• Required even for assessments with Nursing RUG if receiving therapy.

• Changes in ADLs or other nursing services DO NOT require COTs.

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Change of Therapy (COT) Observation Window

COT Observation Period:

Rolling 7‐day window beginning:

• On the day following ARD of most recent assessment, or

• On the day therapy resumes with EOT‐R OMRA

Ending every 7 calendar days thereafter or

• On the ARD of next scheduled assessment

1 2 3 4 5 6 75 day ARD 325mins= RH RUG

8 9 10 11 12 13 14COT Check Point and 14 day assessment 500 mins=RV

15 16 17 18 19 20 21COT CheckPoint Remains RV

22 23 Speech Therapydischarge

24 25 26 27 30 day ARD325 mins= RH RUG

28

29 30 31 PAYMENT STARTS for 30 day

32 33 34NEW COT CHECK POINT

35

REIMBURSEMENT PAID AT RH

REIMBURSEMENT PAID AT RV



REIMBURSEMENT PAID AT RV REIMBURSEMENT PAID AT RH

COT OMRA Considerations

• In order to determine if a COT OMRA is required, providers should perform an informal change of therapy evaluation that considers the intensity of the therapy the patient received during the COT observation period.

• But what must a facility actually consider?

• Total Reimbursable Therapy Minutes (RTM)

• Number of Therapy Days

• Number of Therapy Disciplines

• Restorative Nursing (for patients in a Rehab Low category)

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COT Example: Increased RUG8Mr. Adams regains weight bearing status from Ortho following hip surgeryDAY 8 is 5 day ARD, RUG=RV 500 minutes

9

PT/OT increaseminutes from 50/50 minutes to 75/70

10 11 12 13 14

15‐ COT Check Point Day

RUG achieved is RU=720 minutes, effective day 9

17 18 19 20 21 22

COT LOOKBACK DAYs 9‐15

Combining Assessments

Combining Scheduled and Unscheduled PPS Assessments

• If the ARD for an unscheduled PPS assessment falls within the ARD window (including grace days) of a scheduled PPS assessment, and the ARD for the scheduled assessment would be set for a day after that of the unscheduled assessment, then the assessments must be combined.

• For example, if the ARD for an EOT OMRA is Day 14 of a resident’s stay and the 14‐day scheduled PPS assessment is not set for prior to Day 14, then the assessments must be combined.

Q and A Combining Assessments

Q‐What Item Set do I use for the combined assessment?

A‐ The Item Set for the scheduled assessment should be used.

Q‐What do I use for the ARD of the combined assessment?

A‐ The ARD for the combined assessment is what would have been used for the ARD of the unscheduled assessment.

Q‐What if I mistakenly set the ARD of the scheduled assessment for a day that is after the ARD set for the unscheduled assessment?

A‐ The scheduled assessment is deemed invalid and payment is set as if the assessments had been combined properly.

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Early COT

• If the ARD for a COT OMRA is set for prior to Day 7 of the COT observation period, the facility must bill the default rate for the total number of days that the assessment is out of compliance, ie the number of days by which the assessment is early

• The default rate begins on Day 1 of the COT observation period

• The early COT resets the COT calendar

Early COT Example28 29 30

30‐day ARD is Day 30

31

Retrospective COT payment begins

32

33 34 35

COT ARD set for Day 35 (2 days early)

36 37

AppropriateCOT Checkpoint is Day

37

Bill Default Day 29‐30, 2 days as COT was 2 days early

Bill RUG level from COT beginning on Day 31 and continue until the next scheduled or unscheduled assessment used for payment

Late Unscheduled Assessment

• Failure to set the ARD for an unscheduled PPS assessment within the defined ARD window for that assessment, and the resident is still on Part A, the ARD cannot be set for any earlier than the day the omission was identified

• The number of days out of compliance, including the late ARD, must be billed at default

• Default days last until the point of an intervening assessment

• The late assessment resets the COT calendar

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Missed Unscheduled PPS Assessments

• Failure to set the ARD for an unscheduled PPS assessment within the defined ARD window for that assessment, and the resident is discharged from Part A, the assessment is considered missed and cannot be completed

• All days that would have been paid by the missed assessment (had it been completed timely) are provider‐liable

• Provider liable lasts until the point of an intervening assessment

• Exceptions Chapter 6

Missed Assessment Example

• 30 Day ARD is Day 30

• COT Checkpoint is Day 37

• The COT is missed

• EOT completed with ARD Day 42 (Last Day of Therapy Day 39)

• Discharged from Part A on Day 45

• Bill• Days 31‐39 are Provider Liable

• Days 40‐45 billed with RUG from EOT OMRA

30

30 Day ARD is Day 30

31 32 33 34 35 36

37

COT Checkpoint is

Day 37

The COT is missed

38 39

Last Day of Therapy Day

39

40 41 42

EOT completed

with ARD Day 42

43

DAY 31‐39 Provider Liable

DAY 31‐39 Provider Liable Days 40‐45 billed with RUG from EOT OMRA

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ADL

• Bed Mobility‐how resident moves to and from lying position, turns side or side, and positions body while in bed or alternate sleep furniture

• Transfer‐how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet)

• Toilet Use‐how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts clothes. Do not include emptying bed pan, urinal, bedside commode, catheter bag or ostomy bag

• Eating‐how resident eats and drinks, regardless of skill. Do not include eating/drinking during medication pass. Includes intake of nourishment by other means (eg tube feeding, TPN, IV fluids admininstered for nutrition or hydration)

ADL Score Calculation

• Consider all episodes of the activity that occur over a 24 hour period during each day of the 7 day look back

• Score self performance and support• Self Performance‐

• Measures how much of the ADL activity the resident can do for self

• Rule of three

• Support‐• Measures how much facility staff support is needed for the resident to complete the ADL

60

Code Level of Self Performance

0

1

2

3

4

7

8

Code

0

1

2

3

8

Setup Help Only

One Person Physical Assist

Two+ Person Physical Assist

ADL Activity Itself Did Not

Occur During the Entire Period

Level of Support

Resident is provided with materials or devices necessary to perform the ADL independently.

This can include giving or holding out an item that the resident takes from the caregiver

Resident was assisted by one staff person

Resident was assisted by two or more staff persons

The activity did not occur or family and/or non‐facility staff provided care 100% of the time

for that activity over the entire seven day look‐back period

Definition

Resident completed activity with no help or over‐sight every time during the seven day look‐

back period

Oversight, encouragement, or cueing was provided three or more times during the seven

day look‐back period

Resident was highly involved in activity and received physical help in guided maneuvering

of limb(s) or other non‐weight bearing assistance on three or more times during the seven


Resident performed part of the activity over the seven day look‐back period, help of the

following type(s) was provided three or more times: Weight‐bearing support provided three

or more times. Full staff performance of activity during part but not all of the seven day look‐

back period

There was full staff performance of an activity with no participation by resident for any

aspect of the ADL activity. The resident must be unwilling or unable to perform any part of

the activity over the entire seven day look‐back period

The activity occurred but not three or more times



Coding Instructions for ADL Self Performance

Coding Instructions for ADL Support

Definition

Code for the most support provided over all shifts; code regardless of resident's self‐performance classification

Resident completed activity with no help or oversightNo Setup or Physical Assist

Activity Did Not Occur

Independent

Supervision

Limited Assistance

Extensive Assistance

Total Dependence

Activity Occurred Only Once

or Twice

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Section G: G0110 (1) Coding

0‐Independent

No help or staff oversight at any time and the activity occurred at least 3 times

1‐ Supervision

Oversight, encouragement, or cueing (no hands on assistance) was provided three or more times

2‐ Limited Assistance

Resident highly involved in the activity, staff provided guided maneuvering of limbs or other non weight bearing assistance 3 or more times

Section G: G0110 (1) Coding

3‐ Extensive Assistance

Resident performed part of the activity and staff provided weight‐bearing support OR provided full staff performance of activity 3 or more times during part of the 7 day look back

4‐ Total Dependence

Full staff performance of the activity during entire 7‐day look‐back. Complete non‐participation by the resident in all aspects of the ADL task

Rule of Three Exceptions

• Code 0, Independent‐Coded only if the resident completed the ADL activity with no help of oversight EVERY TIME the ADL activity occurred during the 7 day look back period and the activity occurred at least 3 times

• Code 4, Total Dependence‐Coded only if the resident required FULL STAFF PERFORMANCE of the ADL activity EVERY TIME the ADL activity occurred during the 7 day look back period and the activity occurred three or more times

• Code 7, Activity occurred only once or twice‐Coded if the ADL activity occurred fewer than three times in the 7 day look back period

• Code 8, Activity did not occur—Coded only if the ADL activity did not occur or family and/or non‐facility staff provided care 100% of the time for that activity over the entire 7 day look back period

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Rule of Three

• When an activity occurs three or more times at any one level code that level• When an activity occurs three or more times at multiple levels, code the most dependent level that occurred three or more times

• When an activity occurs three or more times and at multiple levels, but not three times at anyone level, apply the following:

• (a)Convert episodes of full staff performance to weight‐bearing assistance, as long as did not occur every time.

• Weight bearing episodes that occur three or more times or full staff performance that is provided three or more times but not all are included in the ADL self performance coding level for extensive assist

• (b)When there is a combination of full staff performance and weight bearing assistance that total three or more times, code extensive assist

• (c)When there is a combination of full staff performance/weight bearing assist and/or non weight bearing assist that total three or more times, code limited assist (does not apply if (b) applies)

• If none of the above are met, code supervision

CMS RAI MANUAL Page G‐8

Section G: “Rule of Three” Steps

Note: STOP and choose level when criteria is met.

Step One: Activity occurs 3 or more times at any level. CODE THAT LEVEL.

Step Two: Activity occurs 3 or more times at multiple levels, CODE‐most dependent level

Step Three: Activity occurs 3 or more times, however not at 3 times for any one level, convert based on:

staff performance

weight bearing assistance/and non‐weight bearing assistance

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Step One Example

Step One: Activity occurs 3 or more times at any level. CODE THAT LEVEL

Example:

No assistance x2 (0‐Independent)

Supervision x3 (1‐Supervision)

Non‐weight‐bearing assistance x2 (2‐Limited Assist)

Code‐ 1‐ Supervision

Step 2 Example

Step Two: Activity occurs 3 or more times at multiple levels, CODE‐most dependent level.

Example:

Supervision x6 (1‐Supervision)

Non weight bearing assistance x5 (2‐Limited Assist)

Weight bearing assistance x2 (3‐Extensive Assist)

Code: 2‐ Limited Assist

Step 3: 3 occurrences at different levels

A. Convert episodes of full staff performance (4‐TD) to weight bearing assistance (3‐EA) , unless full staff performance occurred every time the ADL was performed in 7‐day look back period (4‐TD).

B. When there is a combination of full staff performance and weight‐bearing assistance that total 3 or more times‐ CODE‐ 3 Extensive Assist

C. When there is a combination of full staff performance, weight bearing assistance and/or non‐weight bearing assistance that total three or more times‐ CODE‐ 2 Limited Assist

If none of above. CODE 1‐Supervision

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Step Three A Example

Step Three: Activity occurs 3 or more times, however not at 3 times for any one level, convert based on staff performance/weight bearing assistance/and non‐weight bearing assistance.

A. Convert episodes of full staff performance to weight bearing assistance, unless full staff performance occurred every time the ADL was performed in 7‐day look back period.

Example:

Non‐weight bearing assist (limited assist) x2

Weight‐bearing assist (extensive assist) x2 2 + 1 =3

Full staff performance (total dependence)x1

Answer Code: 3‐ Extensive Assist

Step Three B Example

B. When there is a combination of full staff performance and weight‐bearing assistance that total 3 or more times‐ CODE‐ 3 Extensive Assist.

Example:

Weight bearing assistance (extensive assist) x2

Full staff performance (total dependence) x2

Answer Code‐ 3 Extensive Assist

Step Three C Example

C. When there is a combination of full staff performance, weight bearing assistance and/or non‐weight bearing assistance that total three or more times‐ CODE‐ 2 Limited Assist

Example:

Non weight bearing assist (limited assist) x1

Weight bearing assist (extensive assist) x1

Full staff performance (total dependence) x1

Answer Code 3‐ Limited Assist

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Bed Mobility Case Study

Ms. Adams was admitted from home and has severe osteoporosis of her cervical spine. As a result she is able to sit on the bed (0) and lie down independently (0) however requires weight bearing support of her lower back to sit up (EA‐3) and verbal cues (LA‐2) to turn side to side.

During morning routine her CNAs provided verbal cues to turn her on 4 occasions; PT provided weight bearing support to help resident sit up in bed 2x; and she sat independently on the edge of the bed during oral care and was able to lay down for a quick nap before lunch.

Coding? 2,2,2,2; 3,3; 0,0Coding= 2 Limited Assist per step one of algorithm

Transfers Case Study

Mr. Smith was admitted s/p acute care stay secondary to TBI. He is noted to require:

• Verbal cues for safety when transferring from bed to w/c secondary to reduced visual field and impulsivity (Supervision‐1)

• Need for UE guided movements during sit to stand transfer to rolling walker (Limited assist‐2 )

• Weight bearing assist for trunk for stand to sit transfer into dining room chairs (Extensive assist‐3)

How will gaps in daily coding affect accuracy?

Considerations for auditing ADLs

Watch For

Recording only resident’s abilities (i.e. tasks they can complete with minimal assistance or independently). Ask rehab or other staff if unsure how to assist with more challenging tasks

Recording the type and level of assist the resident “should” receive

Copycat charting

Assess For

Account/document for variances across shifts and assess for reasons (meds, fatigue, mood)

Documentation should paint a picture of resident needs

Code all portions and areas of each ADL task

Every time you answer a call light‐ CODE ADLs

Include all IDT members

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Bed Mobility, Transfers, & Toilet

Self Performance "‐", 0, 1, 7, or 8 2 3 4 3 or 4

Support any number any number "‐", 0, 1, or 2 "‐", 0, 1, or 2 3

ADL Score 0 1 2 3 4

Eating

Self Performance"‐", 0, 1, 2, 7, or

8 "‐", 0, 1, 2, 7, or 8 3 or 4 3 4

Support "‐", 0, 1, or 8 2 or 3 "‐", 0, or 1 2 or 3 2 or 3

ADL Score 0 1 2 3 4

Section O

Section O: Distinct Calendar Days

With the October 1, 2013, addition of coding item O0420, the RUG‐IV filter in the payment grouper using the sum of O0410A4, O0400B4, and O0400C4 (number of days of therapy) is no longer used. Instead, the grouper will select the number of calendar days(O0420). CMS (2013b) states:

For Medium Rehabilitation, the requirement of 5 or more therapy days across the three disciplines (sum of O0410A4, O0400B4, and O0400C4) is being replaced by 5 or more distinct calendar days of therapy (O0420).

For Low Rehabilitation, the requirement of 3 or more therapy days across the three disciplines (sum of O0410A4, O0400B4, and O0400C4) is being replaced by 3 or more distinct calendar days of therapy (O0420).

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Mode

• Individual—direct one on one care

• Concurrent‐Treatment of two patients at the same time when the patients are performing different activities, regardless of payer source, in the line of sight of the treating therapist.

• Group‐Planned treatment for four patients performing same/similar activity

Individual Therapy

• Individual Therapy• Therapy provided on an individual basis

• “One on one”

Individual Therapy Example

• Mr. Weary is receiving SLP services for dysphagia. He received one on one treatment time of 30 minutes.

• MDS Record:• Individual Therapy= 30 minutes

• All 30 minutes are counted toward MDS

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Concurrent Therapy

• Concurrent Therapy• Treatment of 2 residents at the same time, when the residents are notperforming the same or similar activities, regardless of payer source, both ofwhom must be in line‐of‐sight of the treating therapist for Part A.

• When a Part A resident receives therapy that meets this definition, it isdefined as concurrent therapy for the Part A resident, regardless of the payersource of the second resident.

Concurrent Therapy Example

• Tammy Therapist is treating two Part A patients. She assists Mr. A with Therapeutic Exercises in order to improve Lower Extremity strength due to knee buckling during gait. She also performs interventions with Ms. B for balance activities. She goes back and forth between the two patients. Total treatment time is 20 minutes.

• MDS Record: • Concurrent for each patient is 20 minutes.

• 10 minutes is counted toward RUG.

Group Therapy

• For Part A as the treatment of 4 residents, regardless of payer source, who are performing the same or similar activities.

• For Part B: treatment of two patients or more, regardless of payer source, at the same time.

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Group Therapy Example

• Ollie, OT, is performing a Group activity with 4 patients for cooking. While in the activity, the patients work on fine motor skills for chopping and measuring, balance activities by reaching in cabinets and cognition by ability to follow directions. The treatment for all 4 patients lasts one hour.

• MDS Record: • Group Therapy: 60 minutes for all four patients

• 15 minutes are counted toward RUG score

Co‐treat

• When two clinicians, each from a different discipline, treat one resident at the same time (with different treatments), both disciplines may code the treatment session in full.

• Therapists should only provide co‐treatment if the purpose for such treatment is to enhance the quality of care the patient receives.

• Practitioners should never co‐treat simply because it is logistically more convenient to do so.

• If the therapists believe co‐treatment is the best way to help the patient progress toward his or her goals, they must clearly document that rationale within each daily note.

Co‐Treatment

Part A

• When two clinicians, each from a different discipline, treat one resident at the same time with different treatments, both disciplines may code the treatment session in full.

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Co Treatment Example: ST/OT

• Speech and Occupational Therapy may provide co treatment to an individual during meal time in order to yield greater meal time functional outcomes for an individual with dysphagia in addition to self feeding deficits.

Co Treatment Example PT/ST

• Physical and Speech Therapy may provide co‐treatment for an individual who presents with gait disturbance in addition to cognitive impairments affecting their abilities to negotiate obstacles in facility in order to yield greater functional outcomes for ability to ambulate throughout environment

PPSRUG Level Criteria

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RUG Categories

• Rehabilitation Plus Extensive Services• RUX, RUL, RVX, RVL, RHX, RHL, RMX, RML, RLX

• Rehabilitation• RUA, RUB, RUC, RVA, RVB, RVC, RHA, RHB, RHC, RMA, RMB, RMC, RLA, RLB

• Extensive Services• ES3, ES2, ES1

• Special Care High• HE2, HE1, HD2, HD1, HC2, HC1, HB2, HB1

RUG Categories

• Special Care Low• LE2, LE1, LD2, LD1, LC2, LC1, LB2, LB1

• Clinically Complex• CE2, CE1, CD2, CD1, CC2, CC1, CB2, CB1, CA2, CA1

• Behavioral Symptoms and Cognitive Performance• BB2, BB1, BA2, BA1

• Reduced Physical Function• PE2, PE1, PD2, PD1, PC2, PC1, PB2, PB1, PA2, PA1

Rehabilitation Plus Extensive ServicesRUX, RUL, RVX, RVL, RHX, RHL, RMX, RML, RLX

• Residents satisfying all of the following three conditions:• Having a minimum activity of daily living (ADL) dependency score of 2 or more.

• While a resident, receiving complex clinical care and have needs involving tracheostomy care (O0100E2), ventilator/respirator (O100F2), and/or infection isolation (O100M2).

ADL SCOREC= 11‐16B = 6‐10A = 0‐5

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Rehabilitation Plus Extensive ServicesRUX, RUL, RVX, RVL, RHX, RHL, RMX, RML, RLX

RUG ADL Rehab Group Extensive Service

RUX 11‐16 Ultra High YES

RUL 2‐10 Ultra High YES

RVX 11‐16 Very High YES

RVL 2‐10 Very High YES

RHX 11‐16 High YES

RHL 2‐10 High YES

RMX 11‐16 Medium YES

RML 2‐10 Medium YES

RLX 2‐16 Low YES

RehabilitationRUA, RUB, RUC, RVA, RVB, RVC, RHA, RHB, RHC, RMA, RMB, RMC, RLA, RLB

• Residents receiving physical therapy, occupational therapy, and/or speech‐language pathology services while a resident.

ADL SCORE• C= 11‐16

• B = 6‐10

• A = 0‐5

RUG

Level

Minutes Number

Disciplines

Frequency

Discipline #1

Frequency

Discipline #2

Ultra

High

720+ At least 2 At least 5 days At least 3 days

Very High 500‐719 At least 1 At least 5 days NA

High 325‐499 At least 1 At least 5 days NA

Medium 150‐324 Any or all 3 At least 5 days NA

Low 45‐149 Any or all 3 At least 3

days*

NA

Extensive ServicesES3, ES2, ES1

• Residents satisfying the following two conditions:• Having a minimum ADL dependency score of 2 or more.

• While a resident, receiving complex clinical care and have needs involving: • tracheostomy care (O100E2)

• ventilator/respirator (O100F2)

• infection isolation (O100M2)

RUG ADL Score Extensive Service

ES3 2‐16 Tracheostomy AND Vent/Resp

ES2 2‐16 Tracheostomy OR Vent/Resp

ES1 2‐16 Infection Isolation

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Special Care HighHE2, HE1, HD2, HD1, HC2, HC1, HB2, HB1• Residents satisfying the following two conditions:

• Having a minimum ADL dependency score of 2 or more.• Receiving complex clinical care or have serious medical conditions involving any one of the following: comatose (B0100), septicemia (I2100), diabetes (I2900) with insulin injections (N0350A) and insulin order changes (N0350B), quadriplegia (I5100) with a higher minimum ADL dependence criterion (ADL score of 5 or more), chronic obstructive pulmonary disease (COPD) with shortness of breath when lying flat (I6200, J1100C), fever (J1550A) with pneumonia (I2000), vomiting (J1550B), weight loss (K0300), or tube feeding meeting intake requirement (K0510B1 or K0510B2), parenteral/IV feeding (K01510A1 or K0510A2), or respiratory therapy for 7 days (O0400D2).

• Depression End Splits• D0300 Resident Mood Interview 10‐98• D0600 Staff Resident Mood 10 or greater

• ADL Score

Special Care HighHE2, HE1, HD2, HD1, HC2, HC1, HB2, HB1RUG ADL Score Depressed

HE2 15‐16 Yes

HE1 15‐16 No

HD2 11‐14 Yes

HD1 11‐14 No

HC2 6‐10 Yes

HC1 6‐10 No

HB2 2‐5 Yes

HB1 2‐5 No

Special Care LowLE2, LE1, LD2, LD1, LC2, LC1, LB2, LB1

• Residents satisfying the following two conditions:• Having a minimum ADL dependency score of 2 or more.• Receiving complex clinical care or have serious medical conditions involving any of the following: cerebral palsy (I4400) with ADL dependency score of 5 or more, multiple sclerosis (I5200) with ADL dependency score of 5 or more, Parkinson’s disease (I5300) with ADL dependency score of 5 or more, respiratory failure and oxygen therapy while a resident (I6300, O01100C2), tube feeding (K0510B1 or K0510B2) meeting intake requirement, ulcer treatment with two or more ulcers including venous ulcers, arterial ulcers or Stage II pressure ulcers, ulcer treatment with any Stage III or IV pressure ulcer, foot infections or wounds with application of dressing (M0300, M1030), radiation therapy while a resident (O0100B2), or dialysis while a resident (O100J2)

• Depression End Splits• Resident Mood Interview 10‐98• Staff Resident Mood 10 or greater

• ADL Score

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Special Care LowLE2, LE1, LD2, LD1, LC2, LC1, LB2, LB1

RUG ADL Score Depressed

LE2 15‐16 Yes

LE1 15‐16 No

LD2 11‐14 Yes

LD1 11‐14 No

LC2 6‐10 Yes

LC1 6‐10 No

LB2 2‐5 Yes

LB1 2‐5 No

Clinically ComplexCE2, CE1, CD2, CD1, CC2, CC1, CB2, CB1, CA2, CA1

• Residents receiving complex clinical care or have conditions requiring skilled nursing management, interventions or treatments involving any of the following: pneumonia (I2000), hemiplegia (I4900) with ADL dependency score of 5 or more, surgical wounds or open lesions with treatment (M1040D, E with M1200 F, G or H), burns (M1040F), chemotherapy (O0100A2) while a resident, oxygen therapy (O100C2) while a resident, IV medications (O100H2) while a resident, or transfusions while a resident (O100I2).

• Extensive Services or Special Care with ADL of 0 or 1• Depression End Splits

• Resident Mood Interview 10‐98• Staff Resident Mood 10 or greater

• ADL Score



CE2 15‐16 Yes

CE1 15‐16 No

CD2 11‐14 Yes

CD1 11‐14 No

CC2 6‐10 Yes

CC1 6‐10 No

CB2 2‐5 Yes

CB1 2‐5 No

CA2 0‐1 Yes

CA1 0‐1 No

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Behavioral Symptoms and Cognitive PerformanceBB2, BB1, BA2, BA1

• Residents satisfying the following two conditions:• Having a maximum ADL dependency score of 5 or less.

• Having behavioral or cognitive performance symptoms, involving any of the following: difficulty in repeating words, temporal orientation, or recall (score on the Brief Interview for Mental Status <=9), difficulty in making self understood, short term memory, or decision making (score on the Cognitive Performance Scale >=3), hallucinations, delusions, physical behavioral symptoms toward others, verbal behavioral symptoms toward others, other behavioral symptoms, rejection of care, or wandering.

• Restorative Nursing End Splits

Behavioral Symptoms and Cognitive PerformanceBB2, BB1, BA2, BA1

RUG ADL Score Restorative Nursing

BB2 2‐5 2 or more

BB1 2‐5 0 or 1

BA2 0‐1 2 or more

BA1 0‐1 0 or 1

Reduced Physical FunctionPE2, PE1, PD2, PD1, PC2, PC1, PB2, PB1, PA2, PA1

• Residents whose needs are primarily for support with activities of daily living and general supervision.

• Do not meet criteria for other categories

• Meet criteria for Behavioral and Cognitive Category but ADL score is greater than 5

• Restorative Nursing End Splits

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Reduced Physical FunctionPE2, PE1, PD2, PD1, PC2, PC1, PB2, PB1, PA2, PA1

RUG ADL Score Restorative Nursing

PE2 15‐16 2 or more

PE1 15‐16 0 or 1

PD2 11‐14 2 or more

PD1 11‐14 0 or 1

PC2 6‐10 2 or more

PC1 6‐10 0 or 1

PB2 2‐5 2 or more

PB1 2‐5 0 or 1

PA2 0‐1 2 or more

PA1 0‐1 0 or 1

Let’s Audit

SNF PEPPER Target Areas


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SNF PEPPER Target Areas, cont.

Therapy



National Data RUG %

RUG Code RUG DescriptionNumber of RUG

Days Billed% of RUG Days

to Total Days

RUB Rehabilitation Ultra High with ADL 6 - 10 15,952,506 24.54%RUC Rehabilitation Ultra High with ADL 11 - 16 11,710,600 18.01%RUA Rehabilitation Ultra High with ADL 0 - 5 8,113,151 12.48%RVB Rehabilitation Very High with ADL 6 - 10 5,729,059 8.81%RVC Rehabilitation Very High with ADL 11 - 16 5,360,794 8.25%RVA Rehabilitation Very High with ADL 0 - 5 4,204,466 6.47%RHC Rehabilitation High with ADL 11 - 16 2,063,077 3.17%RHB Rehabilitation High with ADL 6 - 10 1,724,937 2.65%RHA Rehabilitation High with ADL 0 - 5 1,434,049 2.21%RMC Rehabilitation Medium with ADL 11 - 16 1,060,134 1.63%RMB Rehabilitation Medium with ADL 6 - 10 720,779 1.11%RMA Rehabilitation Medium with ADL 0 - 5 598,144 0.92%LD1 Special Care Low with No Depression and ADL 11 - 14 465,642 0.72%LE1 Special Care Low with No Depression and ADL 15 - 16 387,359 0.60%RUX Rehabilitation Ultra High And Extensive Services with ADL 11 - 16 380,051 0.58%LC1 Special Care Low with No Depression and ADL 6 - 10 337,551 0.52%CA1 Clinically Complex with No Depression and ADL 0 - 1 317,080 0.49%CC1 Clinically Complex with No Depression and ADL 6 - 10 292,478 0.45%RUL Rehabilitation Ultra High And Extensive Services with ADL 2 - 10 276,547 0.43%PC1 Physical Function with <=1 Restorative Nursing and ADL 6 - 10 242,303 0.37%Top 20 RUGs Nationwide 61,370,707 94.41%

All RUGs Nationwide 65,015,306 100%

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Audit Areas

• Orders• Certification• ADL Score• Section O• Static Trends• Modality

• Co‐Treat• Claim Accuracy

• Medical Necessity

Audit: Orders and Certifications

• Orders• Admission to PPS Stay• Therapy• Support for RUG billed

• Certifications• Complete

• reasons for the need/continued need for skilled care services• the estimated period of time

• Signed• Dated• Timely

• First recertification must be made no later than the l4th day of inpatient extended care services. Subsequent recertifications must be made at intervals not exceeding 30 days.

Audit: ADL Score

• Bed Mobility‐how resident moves to and from lying position, turns side or side, and positions body while in bed or alternate sleep furniture

• Transfer‐how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet)

• Toilet Use‐how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts clothes. Do not include emptying bed pan, urinal, bedside commode, catheter bag or ostomy bag

• Eating‐how resident eats and drinks, regardless of skill. Do not include eating/drinking during medication pass. Includes intake of nourishment by other means (eg tube feeding, TPN, IV fluids admininstered for nutrition or hydration)

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Audit: ADL Score

• Consider all episodes of the activity that occur over a 24 hour period during each day of the 7 day look back

• Score self performance and support• Self Performance‐

• Measures how much of the ADL activity the resident can do for self

• Rule of three

• Support‐• Measures how much facility staff support is needed for the resident to complete the ADL

116

Code Level of Self Performance

0

1

2

3

4

7

8

Code

0

1

2

3

8

Setup Help Only

One Person Physical Assist

Two+ Person Physical Assist

ADL Activity Itself Did Not

Occur During the Entire Period

Level of Support

Resident is provided with materials or devices necessary to perform the ADL independently.

This can include giving or holding out an item that the resident takes from the caregiver

Resident was assisted by one staff person

Resident was assisted by two or more staff persons



Definition

Resident completed activity with no help or over‐sight every time during the seven day look‐

back period

Oversight, encouragement, or cueing was provided three or more times during the seven


Resident was highly involved in activity and received physical help in guided maneuvering

of limb(s) or other non‐weight bearing assistance on three or more times during the seven


Resident performed part of the activity over the seven day look‐back period, help of the

following type(s) was provided three or more times: Weight‐bearing support provided three

or more times. Full staff performance of activity during part but not all of the seven day look‐

back period

There was full staff performance of an activity with no participation by resident for any

aspect of the ADL activity. The resident must be unwilling or unable to perform any part of

the activity over the entire seven day look‐back period

The activity occurred but not three or more times



Coding Instructions for ADL Self Performance

Coding Instructions for ADL Support

Definition

Code for the most support provided over all shifts; code regardless of resident's self‐performance classification

Resident completed activity with no help or oversightNo Setup or Physical Assist

Activity Did Not Occur

Independent

Supervision

Limited Assistance

Extensive Assistance

Total Dependence

Activity Occurred Only Once

or Twice

Rule of Three Exceptions

• Code 0, Independent‐Coded only if the resident completed the ADL activity with no help of oversight EVERY TIME the ADL activity occurred during the 7 day look back period and the activity occurred at least 3 times

• Code 4, Total Dependence‐Coded only if the resident required FULL STAFF PERFORMANCE of the ADL activity EVERY TIME the ADL activity occurred during the 7 day look back period and the activity occurred three or more times

• Code 7, Activity occurred only once or twice‐Coded if the ADL activity occurred fewer than three times in the 7 day look back period

• Code 8, Activity did not occur—Coded only if the ADL activity did not occur or family and/or non‐facility staff provided care 100% of the time for that activity over the entire 7 day look back period

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Rule of Three

• When an activity occurs three or more times at any one level code that level• When an activity occurs three or more times at multiple levels, code the most dependent level that occurred three or more times

• When an activity occurs three or more times and at multiple levels, but not three times at anyone level, apply the following:

• (a)Convert episodes of full staff performance to weight‐bearing assistance, as long as did not occur every time.

• Weight bearing episodes that occur three or more times or full staff performance that is provided three or more times but not all are included in the ADL self performance coding level for extensive assist

• (b)When there is a combination of full staff performance and weight bearing assistance that total three or more times, code extensive assist

• (c)When there is a combination of full staff performance/weight bearing assist and/or non weight bearing assist that total three or more times, code limited assist (does not apply if (b) applies)

• If none of the above are met, code supervision

CMS RAI MANUAL Page G‐8

120

Patient Name

ARD

Bed Mobility

Self Performance 0 1 2 3 4 7 8

Support 0 1 2 3 8

4Transfer


Support 0 1 2 3 8

Toilet


Support 0 1 2 3 8

Eating


Support 0 1 2 3 8

Self Performance "‐", 0, 1, 7, or 8

Support any number

ADL Score 0

Self Performance "‐", 0, 1, 2, 7, or 8

Support "‐", 0, 1, or 8

ADL Score 0


Eating

3 or 4

3

4

"‐", 0, 1, 2, 7, or 8 3 or 4 3 4

2

any number

1

3

"‐", 0, 1, or 2

2

4

"‐", 0, 1, or 2

3

2 or 3 "‐", 0, or 1 2 or 3 2 or 3

1 2 3 4

Total ADL Score (A = 0‐5; B = 6‐10; C = 11‐16)

ADL Score Worksheet

Bed Mobility ADL Score

Transfer ADL Score

Toilet ADL Score

Eating ADL Score

STEP 1: Determine Self Performance ScoreSTEP 2: Determine Support Score

Step 3: Calculate ADL Score for each category

STEP 4: Enter Scorefor Each of the Four Categories

STEP 5: Add up the scores for bed mobility, transfer, Toilet, and eating to Get ADL Score

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121

ARD

RUG

billed

ADL audit

score match = X

ADL SCORE AUDIT TOOL

Patient Name

Total Audited

Total Match

% Match

Example #1

• Toileting and Transfers• Self Performance

• Limited assist X 7

• Extensive assist X 2

• Total Dependence X 6

• Support• One Person Physical Assist

• Independent with Bed Mobility and Eating

• ADL Billed = B (6‐10)

Example #1

• Bed Mobility = 0

• Eating = 0

• Toileting = • Self Performance = 3

• Did not require full staff performance every time• Convert Total Dependence to Extensive Assist

• Support = 2

• Transfers = • Self Performance = 3

• Did not require full staff performance every time• Convert Total Dependence to ExtensiveAssist

• Support = 2

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Bed Mobility


Support 0 1 2 3 8

0

Transfer


Support 0 1 2 3 8

2

Toilet


Support 0 1 2 3 8

2

Eating


Support 0 1 2 3 8

0

4 = A


Support any number

ADL Score 0


Support "‐", 0, 1, or 8

ADL Score 0

2 or 3 "‐", 0, or 1 2 or 3 2 or 3

1 2 3 4

1 2 3 4

Eating

"‐", 0, 1, 2, 7, or 8 3 or 4 3 4

2 3 4 3 or 4

any number "‐", 0, 1, or 2 "‐", 0, 1, or 2 3

Toilet ADL Score

Eating ADL Score




Transfer ADL ScoreBed Mobility = 0Eating = 0Toileting = 2Transfers = 2 Total Score = 4ADL Billed = B (6‐10)Correct ADL = A (0‐5)

Example #2

• Toileting and Transfers and Bed Mobility• Self Performance

• Supervision x 5

• Limited x 2

• Extensive x 2

• Support• Set up help only

• Independent with Eating

• ADL Billed = A (0‐5)

Example #2

• Bed Mobility • Self Performance = 1• Support = 1

• Toileting • Self Performance = 1• Support = 1

• Transfers • Self Performance = 1• Support 2= 1

• Eating = 0

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Example #2

• Bed Mobility = 0

• Transfer = 0

• Toileting = 0

• Eating = 0

• Total Score = 0


• Correct ADL = A (0‐5)

Bed Mobility


Support 0 1 2 3 8

0

Transfer


Support 0 1 2 3 8

0

Toilet


Support 0 1 2 3 8

0

Eating


Support 0 1 2 3 8

0

0 = A


Support any number

ADL Score 0


Support "‐", 0, 1, or 8

ADL Score 0

2 or 3 "‐", 0, or 1 2 or 3 2 or 3

1 2 3 4

1 2 3 4

Eating

"‐", 0, 1, 2, 7, or 8 3 or 4 3 4

2 3 4 3 or 4

any number "‐", 0, 1, or 2 "‐", 0, 1, or 2 3

Toilet ADL Score

Eating ADL Score




Transfer ADL Score

Example #3

• All ADLs Self Performance• Limited assist X 3

• Extensive assist X 1

• Total Dependence X 3

• All ADLs Support• One Person Physical Assist


Example #3

• Bed Mobility • Self Performance = 3• Support = 2

• Toileting • Self Performance = 3• Support = 2

• Transfers • Self Performance = 3• Support = 2

• Eating • Self Performance = 3• Support = 2

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Example #3

• Bed Mobility = 3/2

• Transfer = 3/2

• Toileting = 3/2

• Eating = 3/2

• Total Score = 8


• Correct ADL = B (6‐10)

Bed Mobility


Support 0 1 2 3 8

2

Transfer


Support 0 1 2 3 8

2

Toilet


Support 0 1 2 3 8

2

Eating


Support 0 1 2 3 8

3

9 = B


Support any number

ADL Score 0


Support "‐", 0, 1, or 8

ADL Score 0

2 or 3 "‐", 0, or 1 2 or 3 2 or 3

1 2 3 4

1 2 3 4

Eating

"‐", 0, 1, 2, 7, or 8 3 or 4 3 4

2 3 4 3 or 4

any number "‐", 0, 1, or 2 "‐", 0, 1, or 2 3

Toilet ADL Score

Eating ADL Score




Transfer ADL Score

Audit: Section O

• Mode• Individual—direct one on one care

• Concurrent‐Treatment of two patients at the same time when the patients are performing different activities, regardless of payer source, in the line of sight of the treating therapist.

• Group‐Planned treatment for four patients performing same/similar activity

• Distinct Days

Example #1

PPS Day 1 2 3 4 5 6 7 8

Calenday Day 14‐Feb 15‐Feb 16‐Feb 17‐Feb 18‐Feb 19‐Feb 20‐Feb 21‐Feb

Day of Week Sunday Monday Tuesday Wednesday Thursday Friday Saturday Sunday

PT Individual 52 75 75 78 80

PT Concurrent

PT Group

OT Individual 75 78 80 52 75

OT Concurrent

OT Group

ST Individual

ST Concurrent

ST Group

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Example #2

PPS Day 1 2 3 4 5 6 7 8




PT Concurrent 30 30 30 30

PT Group


OT Concurrent

OT Group

ST Individual

ST Concurrent

ST Group

Example #3

PPS Day 1 2 3 4 5 6 7 8




PT Concurrent

PT Group


OT Concurrent 20 20 20 20 20

OT Group

ST Individual 20 20 20 20 20

ST Concurrent

ST Group

Example #4

PPS Day 1 2 3 4 5 6 7 8




PT Concurrent 30

PT Group 20 20


OT Concurrent 30

OT Group 20 20

ST Individual

ST Concurrent

ST Group

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Example #5

PPS Day 1 2 3 4 5 6 7 8




PT Concurrent 20 20 20 20 20

PT Group


OT Concurrent 20 20 20 20 20

OT Group

ST Individual

ST Concurrent

ST Group

Example #6

PPS Day 1 2 3 4 5 6 7 8




PT Concurrent

PT Group


OT Concurrent 35 35

OT Group

ST Individual 50 50 50 50 50

ST Concurrent

ST Group

Total

minutes RUG Billed Audit RUGBill Error

Patient Id'r Individ Conc Grp Days Individ Conc Grp Days Individ Conc Grp Days

MDS 360 5 360 5 720

Doc'n 360 5 360 5 720

MDS 300 60 5 360 5 690

Doc'n 300 120 5 360 5 720

MDS 360 5 200 5 200 5 760

Doc'n 360 5 100 100 5 100 5 610

MDS 300 15 10 5 300 15 10 5 620

Doc'n 300 30 40 5 300 30 40 5 650

MDS 150 100 5 150 100 5 5 400

Doc'n 150 100 5 150 100 5 400

MDS 250 5 250 5 250 5 750

Doc'n 250 5 180 70 5 250 5 715 x

xx

2

3

4

5

6

1

Section O Audit Tool

Physical Therapy Occupational Therapy Speech Therapy

RU RU

RH RH

RU RV

RV RU

RU RV

RV RV

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Audit: Static Trends

• Evaluation Time

• Frequency

• Duration

• RUG Level

• Intensity

Modality

• RAI manual Page O‐25 states “Only skilled therapy time (i.e., requires the skills, knowledge and judgment of a qualified therapist and all the requirements for skilled therapy are met) shall be recorded on the MDS. In some instances, the time during which a resident received a treatment modality includes partially skilled and partly unskilled time; only time that is skilled may be recorded on the MDS. For example, a resident is receiving TENS for pain management. The portion of the treatment that is skilled, such as proper electrode placement, establishing proper pulse frequency and duration, and determining appropriate stimulation mode, shall be recorded on the MDS. “

Cotreat

• When two clinicians, each from a different discipline, treat one resident at the same time (with different treatments), both disciplines may code the treatment session in full.

• Therapists should only provide co‐treatment if the purpose for such treatment is to enhance the quality of care the patient receives.

• Practitioners should never co‐treat simply because it is logistically more convenient to do so.

• If the therapists believe co‐treatment is the best way to help the patient progress toward his or her goals, they must clearly document that rationale within each daily note.

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Triple Check Part A Claim

• HIPPS (RUG) codes match

• ARD match

• Days correct each HIPPS

• Revenue Codes correct

• Units correct

• Section O matches therapy logs

• ADL Score supported

• MD certification present

• Orders present

• IDT members signed Z0400

• MDS signed Z0500

• Validation MDS Accepted by State

• Ancillaries/Pharm/Etc. correct

Triple Check: Claim Verification

• Type of Bill• Dates (from/through)• Name• Address• DOB• Sex• Admit Date• Type of Admission• Source of Admission• Status

• Condition Codes (if applic)• Occurrence Codes• Hospital Stay Dates• Value Codes• Total Charges• Payer Source• Provider #• NPI#• Beneficiary Name• Beneficiary Medicare #

Claim Information• Revenue Codes

• 0022 = HIPPS 025X = Pharmacy• 01xx = Room and Board 026X = IV • 018x = Leave of Absence 027X = Medical Supplies• 0420 = PT 030X = Lab• 0430 = OT 032X = Radiology (diagnostic)• 0440 = ST 047X = Audiology• 0410 = RT 054X = Ambulance

• HIPPS Code• Five Digit Code

• First Three Digits = Three Digit RUG• Last Two Digits = Two Digit Modifier to indicate assessment indicator (AI) code• Default = AAA00

• Units must equal the number of days for each HIPPS code billed

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Assessment Indicator Codes

Scheduled Assessment Unscheduled Assessment

10 = 5 day 01 = Significant Change

20 = 14 day 02 = SOT

30 = 30 day 04 = EOT

40 = 60 day 0A = EOT‐R

50 = 90 day 0D = COT

Combined Assessment = 4th Digit is scheduled and 5th Digit is unscheduled5 day and COT Combined AssessmentScheduled 10 + Unscheduled 0D = 1D

Claim Example

Rev Code Description HIPPS Service Date Units

0022 HIPPS RVB10 10415 8

HIPPS:First Three Digits = RVB = RUG

Fourth Digit = 1 = 5 dayFifth Digit = 0 = no unsched

ARD

Example 11 2 3 4 5 6 7 8 9 10 11 12

Date 28‐Dec 29‐Dec 30‐Dec 31‐Dec 1‐Jan 2‐Jan 3‐Jan 4‐Jan 5‐Jan 6‐Jan 7‐Jan 8‐Jan

PT Minutes 45 E;50 55 58 42 32 45 15 58 50

OT Minutes 46 E;50 55 45 48 31 45 60 40 55

ST Minutes 40E; 45 15 59 50 55 30

Total Assess Min 506

Assessment Billed 5 day

Audit RUG

Billed RUG RV RV RV RV RV RV RV RV RU RU RU RU

13 14 15 16 17 18 19 20 21 22 23 24

Date 9‐Jan 10‐Jan 11‐Jan 12‐Jan 13‐Jan 14‐Jan 15‐Jan 16‐Jan 17‐Jan 18‐Jan 19‐Jan 20‐Jan

PT Minutes 66 54 35 46 45 69 47 47

OT Minutes 55 46 45 45 55 45 45 45

ST Minutes 55 55 50 55 50 50 50 45


Assessment Billed 14/COT

Audit RUG

Billed RUG RU RU RU RU RU RU RU RU RU RU RU RU

25 26 27 28 29 30 31 32 33 34 35 36

Date 21‐Jan 22‐Jan 23‐Jan 24‐Jan 25‐Jan 26‐Jan 27‐Jan 28‐Jan 29‐Jan 30‐Jan 31‐Jan 1‐Feb

PT Minutes 45 45 45 45 32 33 30 66

OT Minutes 45 45 50 46

ST Minutes 50 50 50 50 45 45 30 35

Total Assess Min 723 501

Assessment Billed 30 day COT

Audit RUG

Billed RUG RU RU RU RV RV RV RV RV RV RV RH RH

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Example 1 PPS Calendar

ARD Date Total Minutes Assessment Billed RUG Dates Paid

1.4.16 5 Day

1.11.16 14 Day/COT

1.23.16 30 Day

1.30.16 COT

2.6.16 COT

1 2 3 4 5 6 7 8506 Min 5 Day RV_

9 10 11 12

13 14 15 738 Min14/COT RU_

16 17 18 19 20 21 22 745 Min

23 24

25 26 27 723 Min 30 Day RU_

28 29 30 31 32 33 34 501 Min COT RV_

35 36

37 38 39 40 41 328 Min COT RH_

42 43 44 45 46

5 Day Pays Days 1‐8 at RV

COT Pays for Days 28‐34 at RV

14 Day/COT Pays Days 9‐27 at RU

COT Pays for Days 35‐46 at RH

Example 1 PPS Calendar

ARD Date Total Minutes Assessment Billed RUG Dates Paid

1.4.16 506 5 Day RV 12/28‐1/4

1.11.16 738 14 Day/COT RU 1/5‐1/23

1.23.16 723 30 Day RU Not used for payment

1.30.16 501 COT RV 1/24‐1/30

2.6.16 328 COT RH 1/31‐2/11

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Example 1 Claim


0022 HIPPS

0022 HIPPS

0022 HIPPS

0022 HIPPS

Example 1 Claim


0022 HIPPS RV_10 1/4/2016 8

0022 HIPPS RU_2D 1/11/2016 19

0022 HIPPS RV_0D 1/30/2016 7

0022 HIPPS RH_0D 2/6/2016 12

Example 2 Claim


0022 HIPPS RV_10 1/4/2016 8

0022 HIPPS RU_2D 1/11/2016 19

0022 HIPPS RV_0D 1/30/2016 7

0022 HIPPS RH_0D 2/6/2016 12

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Example 2

• COT checkpoint on 1/30/2016 (day 34) showed a COT was required but therapy and MDS did not communicate until 2/2/2016. The COT ARD was completed three days late on 2/2/2016 (day 37)

• Next COT checkpoint was set correctly on 2/9/2016

What should be on the claim?

Example 21 2 3 4 5 6 7 8 9 10 11 12


PT Minutes 45 E;50 55 58 42 32 45 15 58 50

OT Minutes 46 E;50 55 45 48 31 45 60 40 55

ST Minutes 40E; 45 15 59 50 55 30



Audit RUG


13 14 15 16 17 18 19 20 21 22 23 24


PT Minutes 66 54 35 46 45 69 47 47

OT Minutes 55 46 45 45 55 45 45 45

ST Minutes 55 55 50 55 50 50 50 45



Audit RUG


25 26 27 28 29 30 31 32 33 34 35 36


PT Minutes 45 45 45 45 32 33 30 66


ST Minutes 50 50 50 50 45 45 30 35



Audit RUG

Billed RUG RU RU RU

37 38 39 40 41 42 43 44 45 46 47 48

Date 2‐Feb 3‐Feb 4‐Feb 5‐Feb 6‐Feb 7‐Feb 8‐Feb 9‐Feb 10‐Feb 11‐Feb

PT Minutes 37 30 30 25 48 38 30 24

OT Minutes

ST Minutes 30 30 30 15


Assessment Billed COT COT

Audit RUG

Billed RUG

1 2 3 4 5 6 7 8506 Min 5 Day RV_

9 10 11 12

13 14 15 738 Min14/COT RU_

16 17 18 19 20 21 22 745 Min

23 24

25 26 27 723 Min 30 Day RU_

28 29 30 31 32 33 34 501 Min COT RV_

35 36

37 38 39 40 41 328 Min COT RH_

42 43 44 45 46


COT Pays for Days 28‐34 at RV


COT Pays for Days 35‐46 at RH

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1 2 3 4 5 6 7 8506 Min 5 Day RV_

9 10 11 12

13 14 15 738 Min14/COT RU_

16 17 18 19 20 21 22 745 Min

23 24

25 26 27 723 Min 30 Day RU_

28 29 30 31 32 33 34 501 Min COT RV_

35 36

37 383 MinCOT RH

38 39 40 41 42 43 44 246 Min COT RM_

45 46



COT Pays for Days 38‐46 at RM

COT Pays for Days 31‐37 at RHDEFAULT

ORIGINAL CORRECTED

ARD Date TotalMinutes

Assessment

Billed RUG ARD Date TotalMinutes

Assess Type

Audit RUG

1.4.16 506 5 Day RV 1.4.16 506 5 Day RV

1.11.16 738 14 Day/COT

RU 1.11.16 738 14 Day/COT

RU

1.23.16 723 30 Day RU 1.23.16 723 30 Day RU

1/24/16‐1/26/2016

AAA

1.30.16 501 COT RV 2.2.16 383 COT RH

2.6.16 328 COT RH 2.9.16 246 COT RM

Example 2 Correct Claim


0022 HIPPS RV_10 1/4/2016 8

0022 HIPPS RU_2D 1/11/2016 19

0022 HIPPS AAA00 3

0022 HIPPS RH_0D 2/2/2016 7

0022 HIPPS RM_0D 2/9/2016 9

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Example 3 Claim


0022 HIPPS RV_10 1/4/2016 8

0022 HIPPS RU_2D 1/11/2016 22

0022 HIPPS RV_30 1/23/2016 16

Example 3‐‐COT Checkpoints1 2 3 4 5 6 7 8 9 10 11 12


PT Minutes 45 E;50 55 58 42 32 45 15 58 50

OT Minutes 46 E;50 55 45 48 31 45 60 40 55

ST Minutes 40E; 45 15 59 50 55 30



Audit RUG


13 14 15 16 17 18 19 20 21 22 23 24


PT Minutes 66 54 35 46 45 69 47 47

OT Minutes 55 46 45 45 55 45 45 45

ST Minutes 55 55 50 55 50 50 50 45



Audit RUG


25 26 27 28 29 30 31 32 33 34 35 36


PT Minutes 45 45 45 45 32 33 30 66


ST Minutes 50 50 50 50 45 45 30 35



Audit RUG


37 38 39 40 41 42 43 44 45 46 47 48

Date 2‐Feb 3‐Feb 4‐Feb 5‐Feb 6‐Feb 7‐Feb 8‐Feb 9‐Feb 10‐Feb 11‐Feb

PT Minutes 37 30 30 25 48 38 30 24

OT Minutes

ST Minutes 30 30 30 15

Total Assess Min

Assessment Billed

Audit RUG

Billed RUG RU RU RU RU RU RU RU RU RU RU

Example 3

• Missed COT 1/30/2016

• Missed COT 2/6/2016

• Missed COT assessments discovered after discharge

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1 2 3 4 5 6 7 8506 Min 5 Day RV_

9 10 11 12

13 14 15 738 Min14/COT RU_

16 17 18 19 20 21 22 745 Min

23 24

25 26 27 723 Min 30 Day RU_

28 29 30 31 32 33 34 501 Min COT RV_

35 36

37 38 39 40 41 328 Min COT RH_

42 43 44 45 46



MISSED

Example 3 Correct Claim


0022 HIPPS RV_10 1/4/2016 8

0022 HIPPS RU_2D 1/11/2016 19

Overpayment for dates of service 1/24/16 to discharge due to provider liable for

missed assessment

Audit: Medical Necessity

• Documentation Review‐‐Medical Necessity • Nursing Medical Necessity & Daily Skill

• Nursing services are considered skilled when they are so inherently complex that they can be safely and effectively performed only by, or under the supervision of, a registered nurse or, when provided by regulation, a licensed practical (vocational) nurse.

• ADL score consistent with Therapy RUG

• Therapy Medical Necessity & Daily Skill• Therapy services are considered skilled when they are so inherently complex that they can be safely and effectively performed only by, or under the supervision of, a qualified therapist.

• Therapy Plans of Care are individual, pt. centered, and match patient clinical presentation

• RUG Level (treatment intensity) and LOS (treatment duration)


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MDS Areas

• Extensive Services• ES3, ES2, ES1

• Special Care High• HE2, HE1, HD2, HD1, HC2, HC1, HB2, HB1

• Special Care Low• LE2, LE1, LD2, LD1, LC2, LC1, LB2, LB1

• Clinically Complex• CE2, CE1, CD2, CD1, CC2, CC1, CB2, CB1, CA2, CA1

• Behavioral Symptoms and Cognitive Performance• BB2, BB1, BA2, BA1

• Reduced Physical Function• PE2, PE1, PD2, PD1, PC2, PC1, PB2, PB1, PA2, PA1


• Residents receiving complex clinical care or have conditions requiring skilled nursing management, interventions or treatments involving any of the following: pneumonia, hemiplegia with ADL dependency score of 5 or more, surgical wounds or open lesions with treatment, burns, chemotherapy while a resident, oxygen therapy while a resident, IV medications while a resident, or transfusions while a resident.

• Extensive Services or Special Care with ADL of 0 or 1• Depression End Splits

• D0300 Resident Mood Interview 10‐98• D0600 Staff Resident Mood 10 or greater

Example: Clinically Complex

• Step 1• I2000 Pneumonia• I4900 & ADL Score Hemiplegia/Hemiparesis with ADL Score >= 5• M1040D, E Surgical wounds or open lesions with any selected skin

treatment (M1200F, M1200G, M1200H)• M1040F Burns• O0100A2 Chemo while a resident• O0100C2 Oxygen therapy while a resident• O0100H2 IV Meds while a resident• O0100I2 Transfusions while a resident

• Step 2• D0200A ‐> I are used to calculate D0300• D0500A ‐> J are used to calculate D0600

• Step 3 • ADL Score

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CE2 15‐16 Yes

CE1 15‐16 No

CD2 11‐14 Yes

CD1 11‐14 No

CC2 6‐10 Yes

CC1 6‐10 No

CB2 2‐5 Yes

CB1 2‐5 No

CA2 0‐1 Yes

CA1 0‐1 No

PPSFuture Audit Areas

Improving Medicare Post‐Acute Care Transformation (IMPACT) Act of 2014• Bi‐partisan bill signed into law October 6, 2014• Requires MedPAC to evaluate the feasibility of a unified payment system for PAC.

• Requires Secretary to collect common patient assessment data beginning in 2018 and after two years of data collection report to Congress recommending an approach for a unified PAC PPS

• Requires Standardized Patient Assessment Data for:• Assessment and Quality Measures• Quality care and improved outcomes • Discharge Planning• Interoperability• Care coordination

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IMPACT Act

• Purposes• Improvement of Medicare beneficiary outcomes

• Provider access to longitudinal information to facilitate coordinated care

• Enable comparable data and quality across PAC settings

• Improve hospital discharge planning

• Research

Impact Act‐Why?

SNF

MDS

4 Point Scale

IRF

IRF‐PAI

FIM (7 point scale)

HH

OASIS

Scale varies depending on task

LTCH

LTCH care

Care

Requirements for Standardized Assessment Data • IMPACT Act added new section 1899(B) to Title XVIII of the Social Security Act (SSA)

• Post‐Acute Care (PAC) providers must report:• Standardized assessment data• Data on quality measures• Data on resource use and other measures

• The data must be standardized and interoperable to allow for the:• Exchange of data using common standards and definitions• Facilitation of care coordination• Improvement of Medicare beneficiary outcomes

• PAC assessment instruments must be modified to:• Enable the submission of standardized data• Compare data across all applicable providers

• Financial Penalties for failure to submit data will result in 2% reduction to annual payment update

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Functional status, cognitive function, and changes in functional and cognitive

function

•SNF: October 1, 2016

• IRF: October 1, 2016

• LTCH: October 1, 2018

•HHA: January 1, 2019

Skin integrity and changes in skin integrity

• SNF: October 1, 2016




Medication Reconciliation





Incidence of major falls





Communicating the existence of and providing for the

transfer of health information and care preferences





Resource use and other measures





Standardized Patient Assessment Data

• Requirements for reporting assessment data:• Providers must submit standardized assessment data through PAC assessment instruments under applicable reporting provisions

• SNF: October 1, 2018• IRF: October 1, 2018• LTCH: October 1, 2018• HHA: January 1, 2019

• The data must be submitted with respect to admission and discharge for each patient, or more frequently as required

• Data categories:• Functional status• Cognitive function and mental status• Special services, treatments, and interventions• Medical conditions and co‐morbidities• Impairments• Other categories

Standardized Data

CMS MLN Connect October 2015

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MDS Section GG0130: Self Care

MDS Section GG0170: Mobility

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Don’t Forget Cognition

• NOMS??

• BIMS??

• CAM??

Shawn Halcsik

[email protected]

Renee Kinder

[email protected]

Questions?

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