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 Therapy, ADLs Top RAI Manual Update List

The effective coordination of Medicare benefits for residents will require teamwork among nursing staff and therapy clinicians.


With the release of the Centers for Medicare & Medicaid Services (CMS) fall updates to the RAI User’s Manual, nursing home staff have regulatory guidance to help them navigate the mandated Oct. 1, 2013, skilled nursing facility Prospective Payment System (SNF PPS) final rule changes.
Noteworthy changes include new questions that have been added to the Minimum Data Set (MDS) forms, as well as clarification on some key coding items.
Topping the list of interesting changes are coding instructions on a few “hot-button” issues: capturing activities of daily living (ADLs) (section G), setting the Assessment Reference Date (ARD) for discharge assessments, and changes to therapy service coding and payment.
The Federal Privacy Act that was posted in the manual has a compliance effective date of June 6, 2013. The manual includes three pages of updated text on the authority of government agents to receive and collect MDS data.
Highlights from these added sections include the need for residents to provide information to facility staff in order for the MDS to be completed and the requirement that residents receive a copy of the Privacy Act Statement (CMS, 2013a, chap. 1, p. 1-18).
Recently, some industry confusion arose regarding how and when to set the ARD for a discharge assessment. The update to the manual includes a welcome clarification. It says: “For a discharge assessment, the ARD (Item A2300) is not set prospectively as with other assessments. The ARD (Item A2300) for a discharge assessment is always equal to the discharge date (Item A2000) and may be coded on the assessment any time during the discharge assessment completion period (that is, discharge date (A2000) + 14 calendar days).” (Chap. 2, p. 2-36.)

Clarification For Coding

The highlight of the update to item G0110, Activities of Daily Living Assistance, is clarification on how and when to use the ADL Self-Performance Algorithm. In this update, CMS makes it clear that the coding rules are to be followed in sequence and that once the resident’s self-performance matches the rule, then coders are to code that level.

According to step one of the Instructions for the Rule of 3: “When an activity occurs three or more times at any one level, code that level” (chap. 3, p. G-6). If step one applies, coders are to stop there and not use the algorithm. For example, if a resident is Supervision three times, Limited Assist two times, and Extensive Assist two times, the coding would be Supervision because it happened three times; step one applies.

Section K Clarifications

Effective Oct. 1, 2013, a new MDS item, K0710, Percent Intake by Artificial Route, was added to this section (CMS, 2013b, NC Comp, p. 24). The new questions in K0710 split the answer options into three items: 1.) while NOT a resident; 2.) while a resident; and 3.) during the entire seven days.

The Resource Utilization Group (RUG) grouper now filters Special Care High and Special Care Low if the resident either receives at least 51 percent of total calories through tube feeding or receives 26 percent to 50 percent of total calories through tube feeding and 501 cc/day or more of fluid intake via the tube (K0710A3, K0710B3) for all seven days in the look-back period (CMS, 2013a, chap. 6, pp. 6-38, 6-40). Prior to this change, G-tube feeding did not have to occur during the entire seven-day look-back period.

New Coding Items Added

Co-treatment occurs when two clinicians (therapists or therapy assistants), each from a different discipline, treat one resident at the same time with different treatments. When this happens, both disciplines may code the treatment session in full. This is captured in O0400, Therapies, in a new coding subitem, (3A) Co-treatment Minutes, that applies to O0400A, Speech-language Pathology and Audiology Services, O0400B, Occupational Therapy, and O0400C, Physical Therapy. This new subitem asks coders to “enter the total number of minutes each discipline of therapy was administered to the resident in co-treatment sessions in the last seven days” (chap. 3, p. O-17).

One critical element to be aware of when coding co-treatments in item O0400 is that the minutes will not be used to calculate the rehabilitation RUGs. At this time, the co-treatment item is being used for clinical information only. CMS has confirmed that coders are to place co-treatment minutes both in O04003A as well as in the previous RUG therapy minute categories as appropriate (that is, individual minutes, O0400A–C1) in order for those minutes to count for payment.

Distinct Calendar Days

Effective Oct. 1, 2013, item O0420, Distinct Calendar Days of Therapy, was added to the MDS. It is used to record the number of calendar days within the past seven days that the resident received at least 15 minutes of speech-language pathology and audiology services, occupational therapy, or physical therapy (p. O-32). This new item represents an important change to payment and calculation of the PPS RUGs for Medicare A.

The RUG-IV files indicate that with the addition of O0420, the previous filter in the RUG grouper using the sum of O0410(A4), O0400(B4), and O0400(C4) (number of days of therapy) will no longer be used. For RUGs in FY 2014, the grouper will select the number of calendar days (O0420) instead. When considering how this change impacts the way therapy is scheduled and delivered in the SNF, it is important to be aware of new regulatory language added to the Medicare Benefit Policy Manual (MBPM). Effective April 1, 2013, CMS included instructions about daily skilled service. It states that in order for skilled service to be considered provided on a “daily basis” (which for therapy services means five days a week), facility staff can’t simply stagger therapy over five days in the look-back period.

The MBPM states, “The basic issue here is not whether the services are needed, but when they are needed. Unless there is a legitimate medical need for scheduling a therapy session each day, the ‘daily basis’ requirement for SNF coverage would not be met.” (CMS, n.d., p. 33.) Therapy charting should include not only the modality being provided but the reason for the planned treatment schedule. Take note of these instructions in light of the potential for government fiscal integrity audits (Kulus, 2013).

Teamwork among nursing staff and therapy clinicians is essential for effective coordination of Medicare benefits for residents. ■

More details about these updates to the RAI manual can be found here.

Judi Kulus, NHA, RN, MAT, C-NE, RAC-MT, is vice president of curriculum development for the American Association of Nurse Assessment Coordination. She can be reached at (800) 768-1880.
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