Transcript Resident Assessment Instrument

MDS 3.0
Layout of RAI Manual
 Chapter 1 – RAI
 Chapter 2 – Assessments
 Chapter 3 – Item-by-Item Guide
 Chapter 4 – Care Area Assessment (CAA) Process and
Care Planning
 Chapter 5 – Submission and Correction
 Chapter 6 – Skilled Prospective Payment System (PPS)
 You can access the manual at:
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/NursingHomeQualityInits/MDS30RAIManual.html
Chapters
 Chapter 1 contains important information about the
content and completion of the RAI and how it serves the
nursing facility staff in problem identification. There is also
information about protecting the privacy of the MDS
information, among other topics.
 Chapter 2 details scheduling, completion and submission
timeframes for OBRA and PPS purposes. There are lots of
definitions in this chapter and some very useful charts that
outline timeframes related to scheduling, completion and
submission.
 Chapter 3 contains directions for completing each and
every MDS item. It is a must that this information be used to
guide assessments; simply referring to the form (or item set) for
directions will lead to inaccurate coding.
Chapters cont.
 Chapter 4 is titled Care Area Assessment (CAA) Process
and Care Planning – here you will find information about the
RAI process and how the CAAs provide the critical link
between the MDS and the care plan.
 Chapter 5 details Submission and Correction of the MDS
Assessments.
 Chapter 6 outlines the Medicare Skilled Nursing Facility
Prospective Payment System (SNF PPS) – there is some
overview information about SNF PPS in this chapter as well as
very detailed information about the RUG-IV system.
Appendices
 Appendix A – Glossary and Common Acronyms
 Appendix B – SA & CMS RO RAI/MDS Contacts
 Appendix C – Care Area Assessment (CAA) Resources
 Appendix D – Interviewing to Increase Resident Voice
 Appendix E – PHQ-9 Scoring Rules & Instruction for BIMS
 Appendix F – Item Matrix
 Appendix G – References
 Appendix H – MDS 3.0 Item Sets
CHAPTER 3:
OVERVIEW OF THE
ITEM-BY-ITEM GUIDE
Chapter 3
 Provides Item-by Item coding instructions for all required
sections and items in the MDS version 3.0 item set.
 Goal is to facilitate the accurate coding of the resident
assessment and to provide assessors with the rationale and
resources to optimize resident care and outcomes.
 Becoming familiar with the MDS recommended approach
is essential for an accurate assessment.
Standard Coding Conventions
 With the exception of certain items, the look-back period
does not include the hospital stay or days prior to
admission.
 Skip patterns – Instructions direct the assessor to “skip”
items and go on to another. When there is a skip pattern,
leave the item blank and move to the next item as directed.
 Use a check mark for boxes when instructions state to
“check all that apply”; otherwise leave the box blank
 Almost all items allow a dash indicating and item was not
assessed.
 Resident should be primary source of information, when
possible.
 With measurements, if count or measurement greater than
number of boxes, place a 9 in each box, i.e. 999 for 1010.
Sections and Intent
 A - Identification Information - Obtain key information to
uniquely identify each resident, nursing home, type of record,
and reasons for assessment.
 B - Hearing, Speech, and Vision - Document the resident’s
ability to hear, understand, and communicate with others and
whether the resident experiences visual, hearing or speech
limitations and/or difficulties.
 C - Cognitive Patterns - Determine the resident’s attention,
orientation, and ability to register and recall information.
 D – Mood - Identify signs and symptoms of mood distress.
Sections (cont.)
 E – Behavior - Identify behavioral symptoms that may cause distress
or are potentially harmful to the resident, or may be distressing or
disruptive to facility residents, staff members or the environment.
 F - Preferences for Customary Routine and Activities - Obtain
information regarding the resident’s preferences for his or her daily
routine and activities.
 G - Functional Status - Assess the need for assistance with activities of
daily living (ADLs), altered gait and balance, and decreased range of
motion.
 H - Bladder and Bowel - Gather information on the use of bowel and
bladder appliances, the use of and response to urinary toileting
programs, urinary and bowel continence, bowel training programs,
and bowel patterns.
Sections (cont.)
 I - Active Disease Diagnosis - Code diseases that have a
relationship to the resident’s current functional, cognitive,
mood or behavior status, medical treatments, nursing
monitoring, or risk of death.
 J - Health Conditions - Document health conditions that
impact the resident’s functional status and quality of life.
 K - Swallowing/Nutritional Status - Assess conditions that
could affect the resident’s ability to maintain adequate
nutrition and hydration.
 L - Oral/Dental Status - Record any oral or dental
problems present.
Sections (cont.)
 M - Skin Conditions - Document the risk, presence,
appearance, and change of pressure ulcers as well as other skin
ulcers, wounds or lesions. Also includes treatment categories
related to skin injury or avoiding injury.
 N – Medications - Record the number of days that any type of
injection, insulin, and/or select medications was received by the
resident.
 O - Special Treatments and Procedures - Identify any special
treatments, procedures, and programs that the resident
received during the specified time periods.
 P – Restraints - Record the frequency that the resident was
restrained by any of the listed devices at any time during the day
or night.
Sections (cont.)
 Q - Participation in Assessment and Goal Setting - Record the
participation of the resident, family and/or significant others in
the assessment, and to understand the resident’s overall goals.
 V - Care Area Assessment (CAA) Summary - Document
triggered care areas, whether or not a care plan has been
developed for each triggered area, and the location of care area
assessment documentation.
 X - Correction Request - Request to modify or inactivate a
record already present in the QIES ASAP database.
 Z - Assessment Administration - Provide billing information
and signatures of persons completing the
Section A – Identification Info
 A0050 – A2400
Special Interest
 A0100 – A:XXXXXX, B:XXXXXX, C:XXXXXXX
 A0310 – A–G designate the type of assessment.
 A1600 – Entry Date
 A2300 – Assessment Reference Date (ARD)
Section B – Hearing, Speech, Vision
 B0100 – B1200
Special Interest
 B0100 – Comatose or persistent vegetative state
 B0200 – Hearing: Assess with resident using normal hearing
appliances.
 B0700 – Makes self understood: Assess using preferred
language.
 B1000 – Vision: Assess using customary visual appliance.
Section C – Cognitive Patterns
 C0100 – C1600
Special Interest
 C0100 – Should Brief Interview for Mental Status be
Conducted (BIMS) ? Should attempt with most residents.
Determine if resident rarely/never understood verbally or in
writing or if the resident needs or wants an interpreter.
 Ask the questions as written and follow the basic interview
instructions.
 Only record the first attempt.
 Follow the skip pattern and complete Staff Assessment as
directed.
Section D - Mood
 D0100 – D0650
Special Interest
 If resident rarely/never understood follow skip pattern and
complete Staff Assessment as indicated.
 The assessment simply records the presence or absence of
specific mood indicators. IT DOES NOT DIAGNOSE.
 Follow interviewing tips and techniques.
 Notify appropriate clinical staff or mental health provider as
indicated.
Section E - Behavior
 E0100 – E1100
Special Interest
 Identifies behavioral symptoms that may cause distress to the resident.
 Focuses on the resident’s actions, not the intent of the behavior.
 Code based on behaviors observed or thoughts expressed.
 Follow the coding tips and special populations.
 Do not assume refusal as rejection. Must know the resident’s preferences
and goals to assess rejection.
 Make sure the behavior occurred in the seven day look-back period.
Section F – Preferences / Activities
 F0300 – F0800
Special Interest
 Used to obtain information regarding the resident’s
preferences for use developing the individualized care plan.
 Interview the resident and interview family or significant
other only if resident cannot answer.
 Follow coding tips and special populations.
 These answers are not subject to a particular look-back
period due and may change over time related to changes in
the resident’s preferences.
Section G – Functional Status
 G0110 – G0900
Special Interest
 Assesses assistance needed for completion of ADLs, altered
gait and balance and decreased range of motion.
 Follow coding tips and special populations
 Code only assistance as given by Facility Staff as defined in
the instructions.
 Follow the “Rule of Three” when an activity occurs at varying
levels and assistance.
Section H – Bladder and Bowel
 H0100 – H0600
Special Interest
 Follow coding tips and special populations.
 Bladder and Bowel toileting programs must be:
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Individualized, resident-specific based on assessment
Communicated to staff and the resident (as appropriate)
Response documented and re-evaluated as needed
 Fecal Impaction is no longer tracked on the Quality
Measures.
Section I – Active Diagnoses
 I0100 – I8000
Special Interest
 Code diseases that have a direct relationship to the resident’s
current functional status, cognitive status, mood, or behavior
status, medical treatments, nursing monitoring, or risk of
death.
 Determine if the diagnosis is active or inactive.
 Must be physician (or NP, etc.) documented in the last 60
days.
 Follow coding tips.
Section J – Health Conditions
 J0100 – J1900
Special Interest
 Pain – 5 day look-back. Resident interview
 Current Tobacco use – Electronic cigarettes not coded.
 Prognosis – Life expectancy less than 6 months requires physician
documentation (If receiving hospice services can code ‘yes’.
 Falls- J1700 A, B and C have look-backs beyond date of admission.
 Fall is not result of external force. Intercepted fall is a fall.
 Follow coding tips and instructions.
Section K – Swallowing/Nutrition
 K0100 – K0700
Special Interest
 Assess conditions that affect residents’ ability to maintain
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adequate nutrition and hydration.
Use industry standards when recording height of bilateral
amputees.
Base weight on most recent measurement in last 30 days.
Planned weight loss can include physician prescribed
planned diuresis.
Therapeutic diet must be ordered by a health care
practitioner as part of a treatment for a disease or clinical
condition.
Follow coding tips and instructions.
Section L – Oral/Dental Status
 L0200
Special Interest
 To record any dental PROBLEMS during the look-back
period.
 Conduct exam of lips and oral cavity with dentures or partials
removed. Visually observe and feel oral surfaces.
 Follow coding tips and instructions.
Section M – Skin Conditions
 M0100 – M1200
Special Interest
 PU definitions used in the RAI Manual have been adapted from
recommendations of the National Pressure Ulcer Advisory
Panel 2007 (NPUAP).
 Code the MDS according to the instructions in the RAI Manual
not the NPUAP definitions.
 Section M documents surgical wounds, venous, arterial or other
diabetic ulcers and deep tissue injury as well as pressure ulcers.
 Scabs and eschar are physically and chemically different.
 Important to follow coding tips, instructions, examples and skip
patterns.
Section N - Medications
 N0300 – No410
Special Interest
 Injections – Record number of days during the look-back
period the resident received any type of medication, antigen,
vaccine, etc., by SQ, IM, or ID (intradermal) injection.
 Insulin – Two Parts
 N0350A – Number of days during the look-back insulin was
received.
 No350B – Number of days insulin orders were changed (does not
include giving different doses according to sliding scale. Only
count if the entire sliding scale order was changed).
 Medications Received – Record number of days resident
received any of the indicated medication categories. (Code
according to the medication classification, not necessarily the
reason it is given).
Section O – Tx/Procedures/Programs
 O0100
Special Interest
 Section O0100 has two parts – “While not a resident”
and While a resident”. Check coding tips for correct
coding.
 Isolation – code only when resident requires strict
isolation (according to CDC, not simply facility policy
or physician order) or transmission-based precautions
and single room isolation because of active infection
and cannot have a roommate. Do not code if the
precautions are standard precautions.
The manual gives reference sites for CDC guidelines.
Oo250 – Oo300
 These sections document Influenza and
Pneumococcal Vaccine information.
0o400 - Therapies
 Code only medically necessary therapies that occurred
after admission/readmission to the NH that were:
 Ordered by a physician or other qualified professional based
on a qualified therapist’s assessment and treatment plan.
 Documented in the medical record.
 Care planned and periodically evaluated to ensure the
therapy is effective.
 May occur either inside or outside the facility.
Coding for Therapy
 Individual Minutes
 Enter the total minutes of therapy provided on an individual
basis in the last 7 days.
 Concurrent Minutes
 Enter the total minutes of therapy that were provided on a
concurrent basis in the last 7 days. Concurrent therapy is the
treatment of 2 residents at the same time, when the residents
are not performing the same or similar activities and both
resident must be in the line of sight of the treating therapist
or assistant for Medicare Part A. Part B residents may not be
treated concurrently.
Coding (cont.)
 Group Minutes
 Enter the total minutes of therapy provided in the last 7 days.
Group therapy for Part A is the treatment of 4 residents
regardless of payor source, performing the same or similar
activities and are supervised by a therapist or assistant who is
not supervising other individuals. For Medicare Part B,
treatment of 2 or more regardless of payor source, at the
same time.
 Co-Treatment Minutes
 Enter the total minutes of therapy each discipline of therapy
administered to the resident in co-treatment sessions in the
last 7 days.
Coding (cont.)
 Days – Enter the number of days therapy services were provided
in the last 7 days. A “day” of therapy is defined as skilled
treatment for 15 minutes or more during the day. Use total
minutes of therapy provided (individual plus concurrent plus
group) without adjustment to determine if the day is counted.
 Therapy Start Date – Record the date the most recent therapy
regimen started. This is the date the initial therapy evaluation
is conducted regardless if treatment was rendered.
 Therapy End Date – Record the date the most recent therapy
regimen ended. This is the last date the resident received
skilled therapy treatment.
(See clarifications, definitions and examples)
0o420 Distinct Calendar Days
 To record the number of calendar days the
resident received each specific type of skilled
therapy services for at least 15 minutes in the
past 7 days.
O0450 Resumption of Therapy
 In cases where therapy resumes after the EOT OMRA is
performed and the resumption of therapy date is no more
that 5 consecutive calendar days after the last day of
therapy provided, AND the therapy services resumed at the
same RUG-IV classification level that was in effect prior to
the EOT OMRA, an EOT-R may be completed.
 Determine when therapy will resume and code item
O0450Bwith the date that therapy will resume
O0500 Restorative Nursing
 Refers to nursing interventions that promote the resident’s
ability to adapt and adjust to living as independently and
safely as possible.
 May be started on a restorative nursing program when the
resident is admitted to the facility with restorative needs,
but is not a candidate for formalized rehab, when
restorative needs arise during a longer stay or in
conjunction with formal rehab therapy.
Restorative (cont.)
 The following criteria must be met to code O0500:
 Measureable objective and interventions must be documented in
the care plan and in the medical record.
 Evidence of periodic evaluation by the licensed nurse must be
present in the medical record.
 Nursing assistants/aides must be trained in the techniques that
promote resident involvement in the activity.
 An RN or LPN must supervise the activities in a restorative
nursing program.
(The manual gives guidance, definitions and examples.)
O0600 Physician Examinations
 Physician Exams:
 Includes MDs, ODs, podiatrists, dentists, NPs, Clinical Nurse
Specialist (per State law).
 Exam can be completed in the facility or at the physician’s
office. Do not include exams conducted prior to
admission/re-admission, ER visits or hospital observation
stays.
 Physician Examination can include partial or complete exam
of the resident, monitoring for response to treatment, or
adjusting treatment as a result of exam.
O0700 Physician Orders
 Physician Orders
 Includes written, telephone, fax or consultation orders for
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new or altered treatment. Does not include standard
admission or re-admission orders, renewal orders, or
clarifying orders without changes.
Administering a different sliding scale dose from a sliding
scale order does not count as an order change.
PRN orders already on file is not counted when the PRN
dose is activated.
Recertifications are renewals and do not count.
Multiple physicians with orders on the same day is counted
as 1 physician visit and 1 day in which orders were changed.
Do not count orders written by a pharmacist.
Section P – Restraints (P0100)
Special Interest
 Definition/CMS: Any manual method or physical or mechanical
device, material or equipment attached or adjacent to the resident’s
body that the individual cannot remove easily, which restricts
freedom of movement or normal access to one’s body. (Any device
must be individually assessed for effect on each resident.)
 Federal regulations nor CMS guidelines prohibit the use of physical
restraints in nursing homes, except when they are imposed for
discipline or convenience and are not required to treat the resident’s
medical symptoms.
 Exclude from this section items that are typically used in the
provision of medical care, such as catheters, drainage tubes, casts,
traction, leg, arm, neck or back braces, abdominal binders, and
bandages that are serving in their usual capacity to meet medical
needs.
Section Q – Participation in
Assessment and Goal Setting
 Q0100 – Q0600
Special Interest
 Intent is to record the participation and expectations of the
resident, family members, or significant other in the assessment
and understand resident’s goals.
 Section Q insures all have the chance to learn about home and
community based services and the opportunity to receive LTC in
the least restrictive setting. Answers to certain items will trigger
a follow-up which gives the resident the chance to receive
information, but additional assessment by the physician and
LCA may be necessary to determine if discharge is appropriate.
 Q0490 - Is an option Not to continue to be asked on assessments
other than comprehensive assessments.
Section V – CAA Summary
 V0100 – V0200
Special Interest
 Item V0200A documents which triggered care areas require
further assessment, decision as to whether or not a
triggered care area is addressed in the resident care plan
AND the location and date of CAA documentation
(this is a “map” to the CAA decision making
documentation).
 V0200B1 – Signature of the RN coordinating the CAA
process.
 V0200B2 – Date RN coordinating the CAA process certifies
the CAAs have been completed.
Section X – Correction Request
 X0150 – X01050
Special Interest
The purpose of Section X is to identify an MDS record to be modified or
inactivated.
 Modification for:
 Transcription errors
 Data entry errors
 Software product errors
 Item coding errors
 Other errors requiring modification
 Inactivation used to move an existing record in the QIES ASAP database
from an active file to an archive file. Used when the event did not occur.
 Manual Deletion required only three reasons.
 Refer to Chapter 5 for additional information.
Section Z – Assessment
Administration
 Z0100 – Z0400
Special Interest
 Z 0100 – Z0300B values are used typically calculated by the
software data entry product.
 Tennessee is NOT a case-mix State and TennCare payments are
not based on MDS information so Z0200 and Z050 do not apply
for TN.
 Z0400 – All staff who completed any part of the MDS must enter
their signatures, titles, sections they completed and the date
completed. This is an attestation of accuracy of their sections of
the assessment.
 Z0500 – RN assessment coordinator signing to certify
completeness of the assessment.
CHAPTER 4:
CAA PROCESS
AND
CARE PLANNING
Overview of the RAI and CAAs
 The MDS assessment identifies actual or potential areas of
concern.
 The RAI process supports efforts to further assess triggered
areas of concern to determine if the findings require
intervention.
 These conclusions provide the basis for developing an
individualized care plan for each resident.
CAA Process
 Should help staff:
 Consider each resident as a whole.
 Identify areas of concern that need intervention.
 Develop interventions to help improve, stabilize, or prevent
decline according to the resident’s condition, choices and
preferences.
 Address the need and desire for other considerations, such as
advanced care planning and palliative care.
What are the CAAs?
 Triggered responses to items coded on the MDS specific to a resident’s
possible problems, needs or strengths. The CAAs reflect conditions,
symptoms, and other areas of concern that are common in nursing home
residents.
 Interpreting and addressing the care areas identified by the CATs (care area
triggers) is the basis of the CAA process, and can help provide additional
information for the development of an individualized care plan.
 CMS does not mandate the use of a specific tool for completing the
assessment of the triggered areas.
 Facilities must use tools that are current and grounded in current clinical
standards of practice, such as evidence-based or expert-endorsed research,
clinical practice guidelines and resources.
 Use of sound clinical problem solving and decision making skills is
imperative.
20 CAAs
1. Delirium
2. Cognitive Loss/Dementia
3. Visual Function
4. Communication
5. Activity of Daily Living (ADL)
Functional/Rehabilitation Potential
6. Urinary Incontinence and
Indwelling Catheter
7. Psychosocial Well-Being
8. Mood State
9. Behavioral Symptoms
10. Activities
11. Falls
12. Nutritional Status
13. Feeding Tubes
14. Dehydration/Fluid Maintenance
15. Dental Care
16. Pressure Ulcer
17. Psychotropic Medication Use
18. Physical Restraints
19. Pain
20. Return to Community Referral
CAA Requirement
 CAAs are not required for Medicare PPS assessments.
 Required only for OBRA comprehensive assessments.
 Must be completed when a Medicare PPS assessment
is combined with an OBRA comprehensive assessment
in order to meet the requirements for the OBRA
comprehensive assessment.
What does the CAA process involve?
 Identifying and clarifying areas of concern that are triggered by
the MDS.
 Evaluating the triggered care areas to determine the need for
care plan interventions.
 CATs (Care Area Triggers) identify conditions that need further
evaluation through the CAA process.
 Care area issues/conditions may result from a single underlying
cause or from a combination of multiple factors.
 Not all triggers identify deficits or problems. Some indicate areas
of resident strengths and can suggest possible approaches to
improve functioning and minimize decline.
 Recognizing the connection among these symptoms and
treating the underlying cause can help address complications
and improve outcomes.
Other Considerations
 Assigning responsibility for completion of MDS and CAAs.
 Assessment must be conducted or coordinated by an RN
with input of other health professionals.
 Facilities may assign MDS items or portions of items to
various disciplines.
 Some triggered areas may require input from more than one
discipline.
 Facility is responsible for obtaining the input needed for
clinical decision making consistent with relevant clinical
standards of practice.
CAA Documentation
 Helps explain the basis for the care plan and how the IDT
determined the causes, contributing factors and risk for a
particular resident related to the triggered care areas.
 Based on review of the comprehensive assessment, the IDT
and resident and/or resident representative determine the
areas that require care plan interventions and develop,
revise or continue the individualized care plan.
 In order to provide continuity of care for the resident and
good communication with all persons involved in the
resident’s care, information from the assessment that led
the team to their care planning decision should be clearly
documented.
Documentation (cont.)
 Written documentation of the CAA findings and decision
making process may appear anywhere in the resident’s record
and includes:
 Relevant documentation for each triggered CAA that describes
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causes and contributing factors;
Nature of issue or condition;
Complications affecting or caused by the care are for this resident;
Risk factors related to the presence of the condition that affects
staff decision to proceed to care planning;
Factors considered in developing care plan interventions;
Need for additional evaluation by the physician or other health
professionals; and
Resources or assessment tools used for decision making and
conclusions.
Completion of Section V
 Use the “Location and Date of CAA Documentation”
column on the CAA Summary (Section V of MDS 3.0) to
note where the CAA information and decision making
documentation can be found in the resident’s record.
 Indicate in the column “Care Planning Decision”
whether the triggered care area is addressed in the care
plan.
 This will assist Surveyors and others to find the
information related to decision making and care planning.
Limitations of the RAI
 Facilities are responsible for assessing and addressing all
care issues that are relevant to individual resident,
regardless of whether or not they are covered by the RAI.
 The process of completing the MDS and related portions of
the RAI does not constitute the entire assessment that may
be needed to address issues and manage the care of
individual residents.
Limitations (cont.)
 It can be misleading or problematic to care plan individual
MDS findings or CAAs without any additional thought or
investigation because:
 The MDS may not trigger every relevant issue.
 Not all triggers are clinically significant
 The MDS is not a diagnostic tool or treatment selection
guide.
 The MDS does not identify causation or history of problems
RAI and Care Planning
 The comprehensive care plan is an IDT communication tool.
Use the results of the assessments to develop, review and revise
the resident’s comprehensive plan of care.
 The care plan MUST:
 Include MEASURABLE objectives and time frames.
 Describe the services to be furnished to attain or maintain the
resident’s highest practicable physical, mental, and psychosocial
well-being.
 Be reviewed and revised periodically.
 The services provided must be consistent with each resident’s
written plan of care.
 A complete care plan is required no later than 7 days after the
RAI is completed.
Analysis of Triggered CAAs
 Review triggered CAAs by doing in-depth, resident specific
assessment of the triggered condition in terms of the need
for care plan interventions.
 Consider issues/conditions that contributed to the
triggered condition, including ones not captured on the
MDS.
 Review of the CAAs helps staff decide if care plan
interventions are needed and what types of interventions
are appropriate.
Analysis (cont.)
 Reviewing results of the assessment help the IDT and the
resident and/or resident’s representative to identify
concerns that:
 Warrant intervention
 Affect the resident’s capacity to improve or maintain
function.
 Can help minimize onset or progression of impairments.
 Can help address the need and desire for other specialized
services.
CHAPTER 5:
SUBMISSION AND CORRECTION
OF
MDS ASSESSMENTS
CHAPTER 6:
MEDICARE
SNF PPS
Prospective Payment System
 The current focus on developing State and Federal payment
systems for nursing home care is based on recognizing the
differences among residents. Some residents require total
assistance with their activities of daily living (ADLs) and have
complex nursing care needs. Other residents may require less
assistance but need rehab or restorative nursing services.
 Reimbursement levels differ based on the resource needs of the
residents.
 The amount of reimbursement to the nursing home is based on
the resource intensity of the resident measured by items on the
MDS.
Resource Utilization Groups (RUGs)
 The RUG system uses information from the MDS assessments
to classify SNF residents into a series of groups representing the
residents’ relative direct care resource requirements.
 CMS has developed the RUG-IV classification system that
incorporates the MDS 3.0 items and is used in payment systems
for Medicare SNFs and Medicaid NFs.
 The MDS assessment data is used to calculate the RUG-IV
classification necessary for payment. MDS information is used
to define RUG-IV groups that form a hierarchy from the greatest
to the least resources used. Caring for residents in higher RUG
classifications is more costly and reimbursed at a higher level.
Eight Major RUG-IV Classification







Rehabilitation Plus Extensive Services
Rehabilitation
Extensive Services
Special Care High
Special Care Low
Clinically Complex
Behavioral Symptoms and Cognitive Performance
Problems
 Reduces Physical Function
 The eight classifications are divided into 66 groups based
on resident needs. (see RAI manual pages 6-2 through 6-5 for category
characteristics)
Relationship of Assessment to Claim
 Each required Medicare assessment is used to support Medicare
PPS reimbursement.
 Scheduled PPS assessments: 5-day, 14-day, 30-day, 60-day and 90-
day of a Medicare Part A stay.
 Unscheduled assessments are performed under certain
circumstances when required. (see Chapter 2)
 Numerous situations exist that impact the relationship between
the assessment and the claim beyond the information provided
in the RAI manual. It is the responsibility of the provider to
ensure that claims submitted to Medicare are accurate and
meet all Medicare requirements.
SNF PPS Eligibility Criteria
 Technical Requirements:
 Enrolled in M/C Part A and has days available to use
 Three-day prior qualifying hospital stay (i.e. 3
midnights)
 Admission for SNF-level services is within 30 days of
discharge from an acute care stay or within 30 days
of discharge from a SNF level of care.
SNF Criteria (cont.)
 Clinical Requirements:
 Has a need for and receives medically necessary skilled
care on a daily basis provided by or under supervision of
skilled nursing or rehab professionals.
 These services can only be provided in a SNF.
 Services must be for a condition:


For which the resident was treated during the qualifying
hospital stay, or
That arose while the resident was in the SNF for treatment of
a condition for which he/she was previously treated for in a
hospital.
Physician Certification
 Attending physician, physician on staff of the SNF or other
qualified practitioner working with the physician must
certify and periodically re-certify the need for extended
care services in the SNF.
 Certification is required on admission or ASAP. Initial
certification:


Affirms that the resident meets the existing SNF level of care
definition.
Validates via written statement that the resident’s assignment to
one of the upper RUG-IV (Top 52) groups is correct.
 Re-certifications are used to document continued need for
skilled services:


First re-cert required no later than 14th day
Subsequent re-certs no later than 30 day intervals.
SNF PPS Policies
 Delay in Requiring and Receiving Skilled Services (30-Day
Transfer) – Requires and receives services within 30 days of
hospital discharge.
 Medical Appropriateness Exception (Deferred Treatment) –
Elapsed period more than 30 days when inappropriate to begin
active treatment immediately after qualifying stay.
 Resident Discharged from Part A Skilled Services and Returns
to SNF Part A Skilled Level Services – May be eligible for M/C
Part A SNF coverage if meets the six criteria listed pages 6-51
and 6-52 of RAI Manual
 For greater detail refer to the Medicare Benefit Policy Manual.
Non-Compliance with PPS Schedule
 To receive payment under the SNF PPS, the facility must
complete the scheduled and unscheduled assessments as
described in Chapter 2 of the RAI Manual.
 An assessment without an ARD within the prescribed ARD
window will be paid at the default rate for the number of days
the ARD is our of compliance.
 Frequent early or late assessment scheduling practices may
result in a review.
 The default rate (AAA) takes the place of the otherwise
applicable Federal rate. It is equal to the rate paid for the RUG
group reflecting the lowest acuity level.
Early Assessments
 If a scheduled Medicare-required
assessment or an OMRA is performed
earlier than the schedule indicates (ARD
not in the defined window), the provider
will be paid at the default rate for the
number of days the assessment was out of
compliance.
 See examples page 6-52
Late Assessments
 If the ARD is not set within the defined window, including grace
days, the SNF must complete a late assessment. The ARD can
be no earlier than the day the error was identified.
 If the ARD is set prior to the end of the period during which the
late assessment would have controlled payment, the SNF will
bill the default rate for the number of days that the assessment
is out of compliance. The SNF would bill the HIPPS code
established by the late assessment for the remaining period.
 If ARD set after the end of the period during which the late
assessment would have controlled payment, must complete an
assessment, but must bill all covered days at the default rate
regardless of HIPPS code generated. (examples pg. 6-53)
Missed Assessments
 If the SNF fails to set the ARD of a scheduled PPS
assessment prior to the end of the last day of the ARD
window, and the resident is no longer a SNF Part A
resident, and a Medicare-required assessment does not
exist in the QIES ASAP system for the payment period, the
provider may not usually bill for days when an assessment
does not exist in the QIES ASAP system. (Provider liable)
 If the resident was already discharged from Medicare Part
A when this is discovered, an assessment may not be
performed.
 See pg. 6-54 and 6-55 for exceptions and examples.
Missed Unscheduled Assessment
 If the SNF fails to set the ARD for an unscheduled PPS
assessment within the defined ARD window for that
assessment, and the resident has been discharged from
Part A, the assessment is missed and CANNOT be
completed.
 ALL DAYS that would have been paid by the missed
assessment are considered PROVIDER-LIABLE. The
provider liable period only lasts until the point when an
intervening assessment controls the payment.
ARD Outside M/C Part A Benefit
 A SNF may not use a date outside the SNF Part A M/C
benefit (100 days) as the ARD for a scheduled PPS
assessment.
 A SNF may use a date outside the SNF Part A M/C benefit
as the ARD for an unscheduled PPS assessment, but only in
the case where the ARD for the unscheduled assessment
falls on a day that is not counted among the beneficiary’s
100 days due to an LOA (see Chapt. 2, Section 2.4 and 2.13)
and the resident returns from the LOA on M/C Part A.
The information provided in
this presentation came from the
CMS “Long Term Care Facility
Resident Assessment
Instrument User’s Manual”,
MDS 3.0, October 2013.
Contact Information
Telephone: 615-741-8002
Fax: 615-253-4356
E-mail: [email protected]