1. MDS 3.0 and RUG-IV FY 2012 Updates and Clarifications March 2012 1RAI and MDS Conference

2. Agenda FY 2012: What does it look like? Clarifications Assessment Combination Unscheduled Assessment ARD Compliance Inactivating Assessments New Policy, Effective April 1, 2012 Interviews on Unscheduled Assessments March 20122RAI and MDS Conference

3. FY 2012: What does it look like? By the Numbers Overall Patient Case Mix *First Quarter, FY 2012 March 20123RAI and MDS Conference FY 2011FY 2012* Rehabilitation Plus Extensive Services2.5%1.8% Rehabilitation87.9%88.7% Extensive Services0.6%0.7% Special Care4.6%4.8% Clinically Complex2.5%2.3% BS/CP0.4%0.3% Reduced Physical Function1.5%

4. By the Numbers Rehabilitation Patient Case Mix *First Quarter, FY 2012 March 20124RAI and MDS Conference FY 2011FY 2012* Ultra-High Rehabilitation44.9%46.3% Very-High Rehabilitation26.9%27.0% High Rehabilitation10.8%10.5% Medium Rehabilitation7.6%6.5% Low Rehabilitation0.1% FY 2012: What does it look like?

5. By the Numbers Mode of Therapy Provision *First Quarter, FY 2012 March 20125RAI and MDS Conference STRIVEFY 2011FY 2012* Individual74%91%99% Concurrent25%1% Group<1%8%0% FY 2012: What does it look like?

6. By the Numbers Distribution of MDS Assessment Types *First Quarter, FY 2012 March 20126RAI and MDS Conference FY 2011FY 2012* Scheduled PPS Assessment95%85% Start of Therapy (SOT) Assessment2% End of Therapy (EOT) Assessment3% Combined SOT/EOT0% End of Therapy with Resumption (EOT-R)N/A0% Combined SOT/EOT-RN/A0% Change of Therapy (COT) AssessmentN/A10% FY 2012: What does it look like?

7. Assessment Combination Combining Scheduled and Unscheduled PPS Assessments If the ARD for an unscheduled PPS assessment falls within the ARD window (including grace days) of a scheduled PPS assessment, and the ARD for the scheduled assessment would be set for a day after that of the unscheduled assessment, then the assessments must be combined. For example, if the ARD for an EOT OMRA is Day 14 of a resident’s stay and the 14-day scheduled PPS assessment is not set for prior to Day 14, then the assessments must be combined and facilities should use the appropriate AI code to indicate the combined assessment. March 20127RAI and MDS Conference

8. Assessment Combination Combining Scheduled and Unscheduled PPS Assessments What happens if I do not combine them as I should? If a scheduled assessment ARD is set for a day that is after the ARD set for an unscheduled assessment, and the ARD for the unscheduled assessment is set for a day within the scheduled assessment ARD window, then the scheduled assessment is not used for payment purposes. March 20128RAI and MDS Conference

9. Assessment Combination Combining Scheduled and Unscheduled PPS Assessments What happens if I do not combine them as I should? Example #1 EOT OMRA completed with ARD of Day 14. Resident last received therapy on Day 11. 14-day assessment ARD set for Day 15. The EOT OMRA would pay beginning on Day 12 through Day 15 and continue until the next scheduled or unscheduled assessment used for payment. March 20129RAI and MDS Conference

10. Assessment Combination Combining Scheduled and Unscheduled PPS Assessments What happens if I do not combine them as I should? Example #2 COT OMRA completed with ARD of Day 13. 14-day assessment ARD set for Day 15. The COT OMRA would pay beginning on Day 7 (Day 1 of the COT observation period) through Day 15 and continue until the next scheduled or unscheduled assessment used for payment. Next COT observation period end date: Day 20 March 201210RAI and MDS Conference

11. Assessment Combination The COT OMRA and Other Assessments If the ARD of a PPS assessment used for payment is set for on or prior to Day 7 of the COT observation period, then no COT OMRA would be required. Relevance of “used for payment” If an assessment has an ARD set for on or prior to Day 7 of the COT observation period, but this assessment is not used for payment, then completing this assessment does not impact on the COT ARD calendar and the COT OMRA would still be required. March 2012RAI and MDS Conference11

12. Assessment Combination The COT OMRA and Other Assessments If the ARD of a PPS assessment used for payment is set for on or prior to Day 7 of the COT observation period, then no COT OMRA would be required. Example: If the last day of the COT observation period is on May 4 and the ARD of the 30-day assessment is set for May 4, the SNF may choose not to complete the COT OMRA (assuming the resident is not discharged prior to Day 32 of the stay) and the COT observation period would begin on May 5. March 2012RAI and MDS Conference12

13. Assessment Combination The COT OMRA and Other Assessments If the ARD of a PPS assessment used for payment is set for on or prior to Day 7 of the COT observation period, then no COT OMRA would be required. Example: If the last day of the COT observation period is on May 4 and the ARD for an EOT OMRA is set for May 4, the SNF may choose not to complete the COT OMRA. If the ARD for the EOT OMRA were set for May 5, regardless of when therapy ended, then a COT OMRA would be required with an ARD of May 4. March 2012RAI and MDS Conference13

14. Assessment ARD Compliance Setting the ARD for a Unscheduled PPS Assessment Unscheduled Assessment ARD Grace Period Facilities are permitted to set the ARD on an unscheduled PPS assessment for a day within the allowable ARD window for that assessment no more than 2 days after the window has passed. Example: For a COT OMRA where Day 7 of the COT observation period is Day 37, the ARD may be set for Day 37 no later than Day 39. Beginning Day 40, the ARD may be set for no earlier than the day on which the ARD is set. March 2012RAI and MDS Conference14

15. Assessment ARD Compliance Early Unscheduled Assessment Policy – COT OMRA If the ARD for a COT OMRA is set for prior to Day 7 of the COT observation period, the facility must bill the default rate the total number of days the assessment is out of compliance (the number of days by which the assessment is early). The default rate is effective from Day 1 of the COT observation period and is billed for the number of days that the assessment is out of compliance. Facility may then bill the RUG from the early COT OMRA for the remainder of the COT observation period until the next scheduled or unscheduled assessment used for payment. March 2012RAI and MDS Conference15

16. Assessment ARD Compliance Early Unscheduled Assessment Policy – COT OMRA Example 30-day assessment ARD is Day 30. –Day 7 of the COT observation period is Day 37. COT ARD set for Day 35 (2 days out of compliance) Facility would bill the default rate for Days 29 and 30. Facility would then bill the RUG from the early COT beginning on Day 31 until the next scheduled or unscheduled assessment used for payment. Early COT resets COT ARD calendar. –Next COT check: Day 42 March 2012RAI and MDS Conference16

17. Assessment ARD Compliance Late Unscheduled Assessment Policy If the SNF fails to set the ARD for an unscheduled PPS assessment within the defined ARD window for that assessment, and the resident being assessed is still on Part A, the ARD cannot be set for any earlier than the day the omission was identified. The total number of days the assessment is out of compliance, including the late ARD, must be billed at default, beginning on the day that the assessment would have controlled payment. March 2012RAI and MDS Conference17

18. Assessment ARD Compliance Late Unscheduled Assessment Policy The total number of days the assessment is out of compliance, including the late ARD, must be billed at default, beginning on the day that the assessment would have controlled payment. Intervening Assessment The SNF must only bill default until the point when an intervening assessment would control the payment. (COT Example #2) March 2012RAI and MDS Conference18

19. Assessment ARD Compliance Late Unscheduled Assessment Policy – EOT OMRA Example Resident last received therapy on Day 33. EOT ARD set for Day 39. (3 days out of compliance) Facility would bill the default rate for Days 34 through 36. Facility would then bill RUG from late EOT from Day 37 until next scheduled or unscheduled assessment used for payment. March 2012RAI and MDS Conference19

20. Assessment ARD Compliance Late Unscheduled Assessment Policy – COT OMRA Example #1 30-day assessment ARD is Day 30. –Day 7 of the COT observation period is Day 37. COT ARD set for Day 39 (2 days out of compliance) Facility would bill the default rate for Days 31 and 32. Facility would then bill RUG from late COT from Day 33 until next scheduled or unscheduled assessment used for payment. Late COT resets COT ARD calendar. –Next COT check: Day 46 March 2012RAI and MDS Conference20

21. Assessment ARD Compliance Late Unscheduled Assessment Policy – COT OMRA Example #2 30-day assessment ARD is Day 30. –Day 7 of the COT observation period is Day 37. COT ARD set for Day 52 (15 days out of compliance). EOT OMRA completed timely with ARD set for Day 42. – Resident last received therapy on Day 39 Facility would bill the default rate for Days 31 through 39. Facility would then bill RUG from EOT OMRA from Day 40 until next scheduled or unscheduled assessment used for payment. March 2012RAI and MDS Conference21

22. Assessment ARD Compliance Missed Unscheduled Assessment Policy If the SNF fails to set the ARD for an unscheduled PPS assessment within the defined ARD window for that assessment, and the resident has been discharged from Part A, the assessment cannot be completed. All days which would have been paid by the missed assessment, had it been completed timely, are considered provider-liable. March 2012RAI and MDS Conference22

23. Assessment ARD Compliance Missed Unscheduled Assessment Policy All days which would have been paid by the missed assessment, had it been completed timely, are considered provider-liable. Intervening Assessment The SNF must take as provider-liable those days covered by the missed assessment until the point when an intervening assessment would control the payment. (Example #2) March 2012RAI and MDS Conference23

24. Assessment ARD Compliance Missed Unscheduled Assessment Policy – COT OMRA Example #1 30-day assessment ARD is Day 30. –Day 7 of the COT observation period is Day 37. COT OMRA is not completed. Resident is discharged from Part A on Day 40. Omission identified two weeks after Part A discharge. Days 31 – 40 are considered provider-liable. March 2012RAI and MDS Conference24

25. Assessment ARD Compliance Example #2 30-day assessment ARD is Day 30. –Day 7 of the COT observation period is Day 37. COT ARD is not completed. EOT OMRA completed timely with ARD set for Day 42. – Resident last received therapy on Day 39 Resident discharged from Part A on Day 45. Days 31 – 39 are considered provider-liable. Facility would then bill RUG from EOT OMRA beginning on Day 40 and continue until discharge. March 2012RAI and MDS Conference25

26. Assessment ARD Compliance Compounding Effects In each case of an early, late, or missed unscheduled assessment, SNFs must consider the degree to which this untimely assessments affect other assessment requirements. Example A COT OMRA is completed with an ARD set for Day 35, while Day 7 of the COT observation period was Day 37. The SNF then completes a subsequent COT OMRA with an ARD set for Day 44 (7 days from original COT ARD) while the subsequent COT ARD should have been Day 42 (7 days from early COT ARD). March 2012RAI and MDS Conference26

27. Inactivating Assessments General Policy Once completed, edited, and accepted into the QIES ASAP system, providers may not change a previously completed MDS assessment as the resident’s status changes during the course of the resident’s stay – the MDS must be accurate as of the date of the ARD established by the time of the assessment. Providers should have a process in place to ensure assessments are accurate prior to submission. Such monitoring and documentation is a part of the provider’s responsibility to provide necessary care and services. March 201227RAI and MDS Conference

28. Inactivating Assessments Inactivation Related to Event Date or Reason For Assessment When the provider determines that an event date (ARD of any clinical assessment, entry date, and discharge date) or item A0310 (type of assessment) is inaccurate the provider must inactivate the record in the QIES ASAP system, then complete and submit a new MDS 3.0 record with the correct event date or type of assessment, ensuring that the clinical information is accurate. (Long-Term Care Facility Resident Assessment Instrument User’s Manual, MDS 3.0, Page 5-12.) March 201228RAI and MDS Conference

29. Inactivating Assessments Inactivation Related to Event Date or Type of Assessment If the ARD or Type of Assessment is entered incorrectly, and the provider does not correct it within the encoding period, the provider must complete and submit a new MDS 3.0 record. In this instance a new ARD date must be established based on MDS requirements, which is the date the error is determined or later, but not earlier. The new MDS 3.0 record being submitted to replace the inactivated record must include new signatures and dates for all items based on the look-back period established by the new ARD and according to established MDS assessment completion requirements. March 201229RAI and MDS Conference

30. Inactivating Assessments Inactivation Related to Event Date or Reason For Assessment Example Issue: A SNF is coding a 30-day assessment. Item A2300 (Assessment Reference Date) is coded as 02-04-2012, but it was supposed to be coded as 01-04-2012. This error is discovered on February 20 th. Solution: The improperly coded assessment must be inactivated and a new MDS 3.0 record must be created and submitted to the QIES ASAP. The ARD on this assessment can be no earlier than February 20 th and all items and signatures must be reflective of this new ARD. March 201230RAI and MDS Conference

31. Inactivating Assessments Inactivation Related to Event Date or Reason For Assessment What Types of Items Prompt an Inactivation? Only a small subset of items on the MDS prompt the need for an inactivation. Most errors on the MDS may be corrected through the standard modification process outlined in Chapter 5 of the MDS 3.0 RAI manual, page 5-10. March 201231RAI and MDS Conference - Type of Provider (A0200) - Type of Assessment (A0310) - Entry Date (A1600) - Discharge Date (A2000) - Assessment Reference Date (A2300)

32. Unscheduled Assessment Interviews Effective April 1, 2012, when coding a standalone unscheduled PPS assessment (COT, EOT, SOT), the interview items may be coded using the responses provided by the resident on a previous assessment, if the interview responses from the previous assessment were obtained no more than 14 days prior to the date those responses will be used on a subsequent standalone unscheduled PPS assessment. This change does not change other assessment policies with regards to the frequency of resident interviews. March 2012RAI and MDS Conference32

33. Unscheduled Assessment Interviews Qualifications Applies only to standalone unscheduled PPS assessments. Does not apply in cases where the unscheduled PPS assessment is combined with a non-PPS assessment or scheduled PPS assessment. At the discretion of the provider, if a change is observed during the observation period for the unscheduled PPS assessment, then responses may not be carried forward. Only in cases where the resident interview was completed on prior assessment, not staff assessment. March 2012RAI and MDS Conference33

34. Additional Training Resources  SNF PPS Website (www.cms.gov/SNFPPS/)www.cms.gov/SNFPPS/ (Includes information from training calls and recent FY 2012 clarifications)  MDS 3.0 Website (https://www.cms.gov/NursingHomeQualityInits/)https://www.cms.gov/NursingHomeQualityInits/ (Includes the September 2011 version of the RAI Manual and an October 2011 RAI Manual errata document) March 201234RAI and MDS Conference