Long-Term Care

2014 SNF PPS Final Rule Analysis: MDS item effective October 1, 2013

MDS 3.0 Insider, August 23, 2013

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According to the final rule, CMS will add MDS item O0420, Distinct Calendar Days of Therapy, to the MDS assessment form sets. This item will also be added to the RUG-IV grouper.

“The addition of the new MDS item, that reports the number of distinct therapy days, does not represent a change to the SNF PPS system, it just aligns the MDS and RUG process with existing coverage and level of care requirements,” Brown says. “It should help ensure compliance with the level of care requirements.”

Medicare Part A skilled coverage guidelines (IOM 100-02 MBPM, Ch. 8 ) require therapy to be delivered to a beneficiary on at least five days—if therapy is the only skilled service—in order to meet the daily skilled coverage requirement. However, a beneficiary can currently obtain a RUG score in the medium categories through the MDS without meeting the five-day requirement, as the MDS does not record distinct calendar days of therapy.

For example, a patient may receive three days of physical therapy, two days of occupational therapy, and one day of speech-language pathology services. The MDS records these services as six days of therapy, generating a RUG score in the medium category (provided that the other essential requirements are met).

On April 1, 2013, through Transmittal R161BP, CMS added clarifying regulatory language to the MBPM under §30.6 – Daily Skilled Services Defined:

The daily basis requirement can be met by furnishing a single type of skilled service every day, or by furnishing various types of skilled services on different days of the week that collectively add up to “daily” skilled services. However, arbitrarily staggering the timing of various therapy modalities though the week, merely in order to have some type of therapy session occur each day, would not satisfy the SNF coverage requirement for skilled care to be needed on a “daily basis.” To meet this requirement, the patient must actually need skilled rehabilitation services to be furnished on each of the days that the facility makes such services available.

It is not sufficient for the scheduling of therapy sessions to be arranged so that some therapy is furnished each day, unless the patient’s medical needs indicate that daily therapy is required. For example, if physical therapy is furnished on 3 days each week and occupational therapy is furnished on 2 other days each week, the “daily basis” requirement would be satisfied only if there is a valid medical reason why both cannot be furnished on the same day. 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.

This means that if different disciplines distribute therapy across five days, there must be documentation to indicate the clinical need for staggering the services. Without that documentation, medical reviewers will deny all or part of a claim. The issue here is not whether the services are needed, but when they are needed in order to satisfy a daily basis.

To read our continuing coverage of the SNF PPS Final Rule, visit our blog MDSCentral.

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