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MDS 3.0's challenging PPS assessments

March 1, 2011
by Carol Maher, RN-BC, RAC-CT
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MDS 3.0 and RUGs-IV hit long-term care with a wave of change on October 1, 2010. Universally, most MDS coordinators struggled with the new assessment tool-facing software problems and transmission roadblocks on top of learning the new interview protocols-and the RUGs-IV transition process. With that rough beginning behind us, it is clear that new rules for the optional Start of Therapy OMRAs (SOTs), the End of Therapy OMRAs (EOTs), and the Short Stay Assessments are causing the most confusion.

For those unfamiliar with the MDS Coordinator specialization, follow this acronym glossary.

ARD: Assessment Reference Date

EOT: End of Therapy

MDS: Minimum Data Set

OMRA: Other Medicare Required Assessment

PPS: Prospective Payment System

RUG: Resource Utilization Group

SOT: Start of Therapy


SOTs can be used to begin Rehab RUG payment when therapy starts while the resident is presently covered under a nursing RUG score. This optional assessment is widely misunderstood. Many MDS coordinators erroneously believe that an SOT must be used when therapy did not evaluate and treat a Medicare resident on day one of his/her Medicare stay. This is causing facilities to lose Medicare reimbursement. The 5-day PPS assessment begins payment on day one of the resident's Medicare stay just as it did with MDS 2.0. If facility staff provides enough therapy to obtain a Rehab RUG by the assessment reference date (ARD) of the 5-day PPS assessment, that Rehab RUG begins payment on day one of the resident's stay even if therapy did not begin until a few days after the beginning of the resident's Medicare stay. As a general rule, it is best to never combine the SOT with the 5-day scheduled PPS assessment unless it is being completed as a Short Stay Assessment.

The American Association of Nurse Assessment Coordination (AANAC) is a nonprofit professional association representing nurse executives working in the long-term care profession. AANAC is operated by nurses for nurses and is dedicated to providing members with the resources, tools, and support they need in their specialized role of leaders and managers in long-term care. For more information, visit or call (800) 768-1880.

For SOTs other than Short Stay Assessments, the ARD must be day five, six, or seven from the earliest date of the first therapy (PT, OT, or SLP) to evaluate the resident as recorded in MDS items O0400A5, B5, or C5. The rules for setting ARDs on the MDS form would apply to the SOT as well as scheduled assessments. This means that facility staff must input the ARD onto the MDS form/item set either on a hard copy or the computerized form/item set on day five, six, or seven from the earliest therapy start date. The SOT can be combined with any scheduled PPS assessment or it can stand alone. The best use of this new assessment is when therapy begins while the resident is presently being covered by a skilled nursing RUG. Again, do not combine the SOT with the 5-day assessment unless doing a Short Stay Assessment.


The EOT is not a new concept to the MDS process, but it brings more restrictive and confusing instructions for setting ARDs as well as earlier payment changes than were previously required. The EOT is not optional. This assessment is required for a resident when all skilled therapy ends, the resident is presently covered by a Rehab RUG, and the resident remains covered on Medicare Part A by skilled nursing services. This EOT is required if there is even one skilled payment day after the end of all therapy services, since the payment to the nursing RUG obtained from this EOT assessment begins on the first day after the latest therapy end date as recorded in O0400A6, B6, or C6.

Carol maher, rn-bc, rac-ct
Carol Maher, RN-BC, RAC-CT

The ARD for this must be day one, two, or three after the last day on which therapy was provided for at least 15 minutes. The date to set the ARD is not dependent upon the actual date of the physician's order to discontinue therapy but upon the actual last day that skilled therapy was provided. Setting this ARD has been made more confusing because the Centers for Medicare & Medicaid Services (CMS) has determined that day one, two, or three would include days that therapy would have normally been scheduled. The last day on which therapy treatment was furnished is considered day zero when determining the ARD for the EOT. Day one is the first day after the last therapy treatment was provided. Day one would correspond to the first day on which therapy services would normally be provided after the last day therapy was provided. For example:

  • When a facility provides rehabilitation therapies Monday through Friday and the resident's last day of therapy was on Tuesday, day one is Wednesday.

  • If the resident's last day of therapy was Friday at the same facility, day one would be Monday.

  • If a facility provides therapy six days a week (for example, OT is provided Sunday through Friday, PT is provided Monday through Friday, and SLP is provided Tuesday through Friday), day one would be Sunday, regardless of the type of therapy the resident received.

To further confuse this process, CMS has taught that if the facility has ever provided therapy on a Saturday and/or a Sunday, those days must be included in the days that therapy would normally be provided when determining when to set the ARD.