MDS 3.0’s challenging PPS assessments

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

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.

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. For example, a facility occasionally provides skilled OT on Saturdays and skilled PT on Sundays. The resident, who is scheduled to receive therapy five days per week, ends all therapy on Friday but continues to receive skilled nursing services. The ARD for the EOT would need to be set on Saturday, Sunday, or Monday to meet the requirements or else default will be charged. If, on the other hand, the facility never provides therapy over the weekend, Monday, Tuesday, or Wednesday would be the days on which to set the ARD.

However, if the resident discharges earlier than a day when the ARD could be set, there is no penalty for setting the ARD of the EOT early. Let’s assume a resident-who is in a facility that never provides weekend therapy-ends therapy on Friday, receives a skilled nursing service on Saturday, and discharges home on Sunday. In this case the ARD for the EOT can be set to be Saturday or Sunday without penalty. Unlike with MDS 2.0, the payment changes the day after the last therapy treatment day regardless of which date the ARD is set. The dates for setting the ARD are given in order to get the resident interviews completed and allow the team to set the ARD while in the required window to prevent default.

CMS announced in 2010 that in addition to the requirement to complete the EOT when all therapies end, facility staff are required to complete EOTs anytime a resident misses three consecutive days of therapy due to illness, medical hold, staffing issues, refusals, etc. Like the rules for setting ARDs, the three days in a row would include weekend days if the facility ever provides weekend therapy. For example, in our facility that occasionally provides therapy on Saturday and Sunday, we have a resident who missed his scheduled therapy on Friday. The facility staff is obligated to try to provide that missed treatment on Saturday or Sunday. If the resident does not receive any therapy on Friday, Saturday, or Sunday, an EOT would be required, assuming the resident received another daily skilled service to justify billing Part A for those days. For Part A therapy services to resume, new therapy evaluations would be required. However, in our facility that never provides weekend therapy, a missed treatment day on Friday would be considered day one, and Monday would be considered day two. In this instance, if the resident missed therapy on Friday but accepted therapy on Monday, no EOT would be required.


In MDS 2.0, residents who discharged earlier than day eight could obtain a Rehab RUG in many cases using therapy estimations in Section T after therapy evaluations were completed and therapy was scheduled. There is no Section T in MDS 3.0. There is no guarantee of a Rehab RUG with short-stay residents. For residents in the facility eight days or fewer, a Rehab RUG may be obtained when fewer than five days of therapy were provided if the resident meets all eight requirements for the Short Stay Assessment.

The eight requirements are:

  1. The assessment must be a SOT OMRA (A0310C = 1 or 3).

  2. A PPS 5-day (A0310B = 01) or readmission/return assessment (A0310B = 06) has been completed. The PPS 5-day or readmission/return assessment may be completed alone or combined with the SOT OMRA.

  3. The ARD (A2300) of the SOT OMRA must be on or before the eighth day of the Medicare Part A stay.

  4. The ARD (A2300) of the SOT OMRA must be the last day of the Medicare Part A stay (A2400C). See instructions for item A2400C in Chapter 3 of the RAI User’s Manual for more detail.

  5. The ARD (A2300) of the SOT OMRA may not be more than three days after the start of therapy date (item O0400A5, O0400B5, or O0400C5, whichever is earliest). This is an exception to the rules for selecting the ARD for a SOT OMRA.

  6. Rehabilitation therapy (speech-language pathology services, occupational therapy, or physical therapy) started during the last four days of the Medicare Part A covered stay (including weekends).

  7. At least one therapy discipline continued through the last day of the Medicare Part A stay. At least one of the therapy disciplines must have a dash-filled end of therapy date (O0400A6, O0400B6, or O0400C6) indicating ongoing therapy or an end of therapy date equal to the end of covered Medicare stay date (A2400C).

  8. The RUG group assigned to the SOT OMRA must be Rehabilitation Plus Extensive Services or a Rehabilitation group (Z0100A). LTL

Carol Maher, RN-BC, RAC-CT, is a Certified Gerontological Registered Nurse with more than 30 years of long-term care experience. She has been working with the MDS for more than 15 years 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 March;60(3):26-32

Topics: Articles , MDS/RAI , Medicare/Medicaid