The new PPS challenge: Change of Therapy OMRA

Carol Maher, RN-BC, RAC-CT

October 2011 came to pass with a whole host of challenges for the SNF Prospective Payment System (PPS). Along with lowered Resource Utilization Group (RUG) rates, shortened assessment windows and changes related to group therapy, additional PPS assessments are now required. The Change of Therapy (COT) Other Medicare Required Assessment (OMRA) and the End of Therapy with Resumption OMRA began to be used on October 1. Understanding the correct use of these OMRAs and developing processes for staff teams to manage them will be critical to the financial success of facilities. This article focuses on the COT OMRA.

The COT OMRA is not optional. It will use the familiar End of Therapy OMRA item set. MDS item A0310C will be enlarged to include a new choice: “4. Change of Therapy OMRA.” The COT OMRA will be effective for all PPS assessments with an assessment reference date (ARD) of October 1, 2011, or later.

SNFs are required to complete a COT OMRA when the RUG-IV level changes from the last PPS assessment due to an:

  • increase or decrease in the number of reimbursable therapy minutes;

  • increase or decrease in the number of therapy days; and/or

  • increase or decrease in the number of therapy disciplines.

The ARD of the COT OMRA must be

day 7 of the COT observation period, which is a rolling 7-day window beginning the

day after the ARD set for the most recent scheduled or unscheduled PPS assessment. The exception is when an End of Therapy with Resumption OMRA is completed. In this case, the first day of the COT observation window is the date that therapy resumed (O0450B). There is no grace period for COT OMRAs. This is important: The only date that can be used to set the ARD for this new assessment is day 7 of the observation window.

What does this look like? Here’s an example: The ARD for your 30-day PPS assessment is set for day 28. The COT observation window begins on day 29. The observation window is always 7 days. On day 35, the facility staff reviews: the reimbursable therapy minutes, the therapy days provided on days 29-35, and the number of therapy disciplines that were provided to that resident over the 7-day observation window to determine whether the resident remains in exactly the same Rehab RUG-IV group as obtained on the 30-day PPS assessment. If the therapy provided was not at the same RUG level, the COT must be completed using the ARD of day 35. If, however, the therapy provided in the 7-day look-back window on day 35 was at the same RUG level obtained on the 30-day PPS assessment, no COT would be completed. The COT observation window would begin again on day 36. The therapy provided between days 36-42 would be reviewed to determine whether the therapy provided in this 7-day assessment window is at the same RUG level as the RUG obtained on the 30-day assessment.

This COT observation review process is also required for residents who have been receiving therapy services but, due to index maximization, whose most recent PPS assessment obtained a nontherapy RUG. For these residents, the facility staff must review the therapy provided during the 7-day COT observation window to determine whether the therapy provided during that period has changed enough to change the RUG to a Rehab RUG. If the therapy provided was at a level high enough to change the RUG, the COT OMRA must be completed, using day 7 of the COT observation window as the ARD.


Your resident is receiving a Rehab High level of therapy and also meets the requirements for HE2 on the ARD of day 14. The Special Care High RUG would pay more than the Rehab High RUG. Therefore the resident’s RUG is HE2. The facility staff would review the therapy provided on days 15-21. The resident received less therapy during this observation window. The therapy provided was only at the Rehab Medium level.

Is a COT OMRA required?

No, it is not required because, with index maximization, the HE2 RUG would continue to pay despite this change in therapy provision. If, however, during the 7-day observation window ending on day 21, the resident received more than 500 minutes of therapy by a single therapy discipline, he or she would now qualify for a Rehab Very High RUG. Since the Rehab Very High RUG pays more than the HE2 RUG, the COT OMRA must be completed in order to place the resident into the correct Rehab RUG. COT OMRAs are not required when there are changes in nursing coverage.

Do not forget to complete the scheduled PPS assessments (5-, 14-, 30-, 60- and 90-day PPS). If the ARD for a scheduled PPS assessment has not yet been set and a COT OMRA is required within the window for the scheduled assessment, the assessments must be combined. If the ARD for the scheduled assessment has already been set and is before day 7 of the rolling COT observation window, complete the scheduled assessment. The COT observation window resets with the ARD of the scheduled assessment (beginning the day after the ARD of this new scheduled assessment). For example: The ARD of a 5-day PPS assessment is day 8. The seventh day of the COT observation window would be day 15. However, if day 13 is chosen by the facility staff and the ARD set on the MDS form on day 13, the COT observation window resets to begin on day 14.

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

Topics: Articles , MDS/RAI