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The new PPS challenge: Change of Therapy OMRA

November 8, 2011
by Carol Maher, RN-BC, RAC-CT
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How does this impact payment?

The RUG from Z0100A of the COT OMRA begins payment on day 1 of the observation window. This will be problematic for end-of-the-month billing. For example: A resident is admitted October 20. The 5-day PPS assessment ARD is set for October 27 and a RUG of RUB is obtained, which should pay for all days in October since admission. The 7-day observation window ends on November 3. The resident missed a day of therapy, so was found to be in the RMB RUG. This RUG would begin payment October 28. Late COTs would require facility staff to bill at the default rate. Missed COTs could cause provider liability.


To stay on top of this complex process, facility PPS teams will need to meet daily to set ARDs of scheduled assessments as well as review therapy provisions in the COT observation windows. Software systems can be helpful with this review process; in the absence of software, PPS 100-day spreadsheets (calendars) for each Medicare resident are helpful. Highlight the seventh day of the next observation window as soon as an ARD is set.

Therapy directors and MDS coordinators must review all residents at the end of each COT observation window. Remember to adjust the COT windows when a new ARD has been set for each resident. If no COT is required for one assessment window, highlight the seventh day from the day after the end of the reviewed COT observation window. When a resident misses a day of therapy for any reason, attempt to provide the missed therapy on another day in the assessment window. Providing therapy on weekends may be required to keep from dropping RUG levels. Communication among IDT members, as always, is critical to the facility's success.

Carol Maher, RN-BC, RAC-CT, is a Certified Gerontological Registered Nurse. She has 15 years' experience with the MDS and serves on the AANAC Board of Directors. Maher was one of the Gold Standard Nurses for MDS 3.0 as well as a member of the AHRQ Technical Expert Panel for Care Planning and the RTI Technical Expert Panel for Quality Measures for MDS 3.0. Long-Term Living 2011 November;60(11):24-25