CMS Issues Proposed SNF PPS Rule for FY 2012
The Centers for Medicare & Medicaid Services (CMS) released its proposed Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities regulation for fiscal year (FY) 2012. CMS is proposing significant policy changes, including changes to student supervision, group therapy, therapy documentation, and assessment schedule requirements.
CMS is also considering two options for setting the 2012 Medicare payment rates for SNFs. The first option would provide a 1.5 percent increase ($530 million) and is derived from applying the 2012 market basket index of 2.7 percent reduced by 1.2 percentage points to account for greater efficiencies in the operation of nursing homes. The second option would adjust for an unexpected spike in nursing home payments during FY 2011. This option would restore overall payments to their intended levels on a prospective basis which would require reducing FY 2012 payments to Medicare SNFs by $3.94 billion, or 11.3 percent lower than payments for FY 2011. Comments on the proposed rule are due June 27, 2011.
Some highlights of the proposed rule that would impact occupational therapy practitioners are:
- CMS is proposing to remove the line-of-sight supervision requirement for students to make it consistent with other inpatient settings (i.e., no specific CMS requirements, it is up to state/local laws and the skilled nursing facility [SNF]).
- CMS is proposing to allocate group therapy minutes in the same manner that concurrent therapy minutes are allocated (for example, four patients receiving group therapy for 1 hour would be recorded as 15 minutes each). CMS also noted that it believes that the most appropriate group therapy size for the SNF setting is four patients.
- CMS is proposing to clarify documentation requirements to justify the use of individual, concurrent, or group therapy and include ongoing support based on the patient’s needs and goals.
- CMS is proposing to modify the current Medicare-required assessment schedule to incorporate new assessment windows and grace days, in order to avoid duplicative assessments and appropriately capture changes in the patient’s status.
- CMS is proposing to clarify the End-of-Therapy (EOT) Other Medicare-Required Assessment (OMRA) policy regarding the completion of an EOT OMRA.
- CMS is proposing to eliminate the distinction between 5-day and 7-day facilities for purposes of setting the Assessment Reference Date (ARD) for the EOT OMRA.
- CMS is proposing that when an EOT OMRA has been completed and therapy subsequently resumes, SNFs may complete an End-of-Therapy Resumption (EOT-R) OMRA, rather than a Start of Therapy (SOT) OMRA, in cases where therapy services have ceased for no more than 5 consecutive days and have resumed at the same RUG-IV classification level.
- CMS is proposing to require SNFs to complete a Change of Therapy (COT) OMRA for patients classified into a RUG-IV therapy group whenever the intensity of therapy (that is, the total RTM delivered) changes to such a degree that it would no longer reflect the RUG-IV classification and payment assigned for a given SNF resident based on the most recent assessment used for Medicare payment. The COT OMRA would be a new type of required PPS assessment, which would use the same item set as the current EOT OMRA.
AOTA is currently analyzing the implications of the SNF PPS proposed rule and will be drafting comments. Please e-mail us at rrpd@aota.org with your thoughts.
The following are excerpts taken directly from the proposed rule in the Federal Register. Please refer to the proposed rule for more information about specific changes.
Student Supervision
Because we consider it inequitable for SNFs to be subject to a more restrictive set of standards in this regard than the other inpatient settings, we believe that line-of-sight supervision should no longer be required in the SNF setting. Instead, as with other inpatient settings, each SNF would determine for itself the appropriate manner of supervision of therapy students, consistent with applicable State and local laws and practice standards. Accordingly, we are proposing to revise our current policy regarding supervision of therapy students, such that a therapy student working in an SNF would no longer be required to be in the supervising therapist’s line of sight. We invite comments on our proposed revision to the supervision requirements for therapy students working in SNFs, and note that we plan to continue monitoring the provision of therapy services in the SNF setting. We also note that we may revisit this issue in the future; however, consistent with the aim of promoting greater uniformity across inpatient settings on this point, we believe that such an analysis would most appropriately take place in the broader context of therapy standards that pertain to inpatient settings generally.
Group Therapy and Therapy Documentation
We believe that groups of fewer than four participants do not maximize the group therapy benefit for the participants…. We believe that in groups of 2 or 3 participants, the opportunities for patients in the group to interact and learn from each other are significantly diminished given the small size of the group… we believe that the most appropriate group therapy size for the SNF setting is four, which we believe is the size that permits the therapy participants to derive the maximum benefit from the group therapy setting…for purposes of payment under the Medicare SNF PPS, for the reasons discussed above, we are proposing to establish a standard that defines group therapy as therapy provided simultaneously to four patients who are performing similar therapy activities.
We believe that allocating group therapy minutes among the four group therapy participants best captures the resource utilization associated with providing a maximally beneficial group therapy intervention. For therapists treating patients in a group setting, the full time spent by the therapist with these patients would be divided by 4 (the number of patients that comprise a group). For example, if a therapist spends 1 hour with four residents in a group therapy session, regardless of payer source, then the time used to determine the appropriate RUG-IV classification for each Medicare beneficiary receiving SNF care benefits as part of a qualified Part A stay will be 15 minutes, or 60 minutes of total therapist time divided by four…
We believe it is important to clarify our expectations regarding the clinical documentation needed to support each patient’s plan of care, including the patient’s prescribed group therapy interventions, as further discussed below. Additionally, we specifically solicit comments on the types of patients for which group therapy may be appropriate, and the specific amounts of group therapy that may be beneficial for these types of patients. We anticipate using this information to assess the appropriate use of group therapy in SNFs and may revise standards of group therapy care in SNFs accordingly.
Under §409.23(c), Medicare pays for therapy services if they are furnished, among other things, in accordance with a plan that meets the requirements of §409.17(b) through (d). Section 409.17(c)(1) states that the plan must prescribe “the type, amount, frequency, and duration of the physical therapy, occupational therapy, or speech-language pathology services to be furnished to the individual.” As evidenced by the discussion of care planning and the qualifications for skilled therapy services in Chapter 3, Section O of the RAI manual in relation to item O0400, SNFs are expected to include supporting documentation in each patient’s medical record on an ongoing basis. We further believe that such medical record documentation is needed so that SNFs can verify that the plan of care is being followed…
It should be clear, based on the patient’s medical record, therapy notes, and/or other related documentation, how the prescribed skilled therapy services contribute to the patient’s anticipated progression toward the prescribed goals. Because group therapy is not appropriate for either all patients or all conditions, and in order to verify that group therapy is medically necessary and appropriate to the needs of each beneficiary, SNFs should include in the patient’s plan of care an explicit justification for the use of group, rather than individual or concurrent, therapy. This description should include, but need not be limited to, the specific benefits to that particular patient of including the documented type and amount of group therapy; that is, how the prescribed type and amount of group therapy will meet the patient’s needs and assist the patient in reaching the documented goals.
Should the actual utilization of therapy services deviate significantly from the patient’s plan of care, we expect the facility to update the plan of care to prescribe the new type, amount, frequency, and duration of physical therapy, occupational therapy, and speech-language pathology services. Furthermore, we believe that such changes to the mode and/or intensity of therapy must be justified by changes in the beneficiary’s underlying health condition; thus, in order to demonstrate that such changes are medically necessary, the provider should clearly describe in the plan of care the reasons for deviating from the original care plan. Consistent with §409.17(c), the revised care plan must outline the updated goals and the revised type (that is, mode), amount, frequency, and duration of physical therapy, occupational therapy, and speech-language pathology services to be furnished to the patient.
We expect that the data reported in these required assessments, both scheduled and unscheduled, provide an accurate representation of the skilled therapy and nursing needs of the patient. Thus, if providers find changes in clinical and therapy status which would affect the accuracy of a resident’s most recent assessment, then we would expect (as discussed above) that these changes would be recorded in the patient’s plan of care and medical record, as well as through the use of unscheduled assessments, to determine if a subsequent change in payment is necessary… we are proposing alternative solutions which would help capture perceived changes in resident status…
MDS 3.0 Assessment Schedule and Other Medicare-Required Assessments
After further review of the MDS 3.0 assessment schedule, we believe that the combination of the current grace period allowance and observation period could cause MDS assessments to be performed in such a way that some of the information coded on a subsequent assessment is duplicative of the previous assessment… The intended purpose of the Medicare assessment schedule was to capture the changes in the patient’s status, especially during the first few weeks of the Medicare stay. However, because the observation periods overlap so closely, changes in the patient’s status are not reflected as originally intended…we propose to modify the current Medicare-required assessment schedule (Table 10A) to incorporate new assessment windows and grace days, as indicated in Table 10B, with appropriate changes to be made in the RAI Manual.
We believe that these proposed changes to the Medicare-required assessment schedule will result in less duplication of information coded on subsequent assessments, and will better capture the patient’s change in status, as well as the change in services/treatments, over the course of the stay without creating undue burden on providers. We also believe that ensuring the passage of a greater amount of time between assessments would improve patient and provider satisfaction and care quality, as it would not be necessary to repeat interview questions and assessment items required on the MDS assessments within such a short period of time. We solicit comments regarding these proposed changes to the current MDS 3.0 assessment schedule.
We wish to clarify…the policy that the ARD for an End-of-Therapy (EOT) OMRA must be set 1 to 3 days after the discontinuation of all therapies (speech-language pathology services and occupational and physical therapies)… Thus, we are clarifying that…an EOT OMRA must be completed once such therapy services cease for three consecutive days, regardless of the reason.
We wish to clarify what is meant by the phrase “discontinuation of therapy services” as it applies to our policies governing completion of PPS assessments. We recognize that there may be two types of “discontinuation of therapy services.” A discontinuation in therapy services may be temporary;… Alternatively, a discontinuation of therapy services may be characterized as a “planned” discontinuation, that is, the discontinuation is consistent with the patient’s plan of care such as when the patient has reached the prescribed therapy goals… we are clarifying that providers must complete an EOT OMRA for a patient classified in a RUG-IV therapy group if that patient goes three consecutive days without being furnished any therapy services, regardless of the reason for the discontinuation of therapy…Accordingly, providers are required to complete an EOT OMRA in cases where a resident who is currently assigned to a therapy RUG-IV group has not received any therapy services for three consecutive days. By completing the EOT OMRA, SNFs will be paid at the appropriate non-therapy RUG-IV rate (starting the day following the last day that therapy services were furnished to the patient), depending on other relevant characteristics of the patient’s condition. If therapy resumes, the SNF may complete the optional Start-of-Therapy (SOT) OMRA, which can be used to reclassify the patient into a therapy RUG-IV group at any point during a resident’s Part A SNF stay until completion of the next regularly scheduled PPS assessment.
We propose to eliminate the distinction between 5-day and 7-day facilities for purposes of setting the ARD for the EOT OMRA. Accordingly, we propose that, effective October 1, 2011, an EOT OMRA for a patient classified in a RUG-IV therapy group would be required if that patient goes three consecutive calendar days without being furnished any therapy services, regardless of whether the facility is a 5-day or 7-day facility or the reason for the discontinuation in therapy services… We believe that this proposed policy of requiring all SNFs to set the ARD for the EOT OMRA by the third consecutive calendar day after a patient’s therapy services have been discontinued, appropriately reflects that the frail and vulnerable populations within SNFs require consistent therapy without significant breaks in services… We invite comments on this proposed change to our policy related to setting the assessment ARD for the EOT OMRA.
Some providers have suggested that the completion of an EOT OMRA and subsequent SOT OMRA may not be necessary for all patients, particularly in cases where therapy services resume at the same mode and intensity as the patient was receiving before the discontinuation of therapy service. We have considered this issue and we believe that, in some cases where an EOT OMRA has been completed and therapy resumes shortly thereafter, an SOT OMRA may not be necessary to establish the patient’s clinical condition, specifically where the RUG-IV classification level has not changed… we propose that, effective for services provided on or after October 1, 2011, when an EOT OMRA has been completed and therapy subsequently resumes, SNFs may complete an End-of-Therapy Resumption (EOT-R) OMRA, rather than an SOT OMRA, in cases where therapy services have ceased for a period of no more than 5 consecutive calendar days, and have resumed at the same RUG-IV classification level that had been in effect prior to the EOT OMRA… We solicit comments on our proposal to allow providers the option to complete an EOT-R OMRA...
It has been suggested by some providers that when a facility furnishes therapy only on weekdays, it should routinely issue an [Advance Beneficiary Notice] ABN every Friday afternoon in order to anticipate the possibility that a given resident might be unable or unwilling to undergo therapy on the following Monday, thereby triggering an EOT OMRA and potentially causing the patient to drop below a covered level of care in the SNF… under the current policy, a facility that provides therapy services 5 days per week would not count the weekend days in determining the ARD for the EOT OMRA and, thus, an EOT OMRA would not necessarily be triggered if the patient were to be unwilling or unable to undergo therapy on the following Monday. Nevertheless, we note that, as discussed above, we are proposing in this rule to eliminate the distinction between 5 and 7-day facilities for purposes of setting the ARD for the EOT OMRA. Even so, it is still important to bear in mind that, in this situation, the decision to issue an ABN is an individualized action, and should not be applied across the board to all patients. The ABN should not be provided merely because of the possibility that the patient might be unwilling or unable to participate in therapy the next day. There must be an actual discontinuation of therapy before the SNF can anticipate that the patient may enter into custodial care. In addition, it may not be the case for every patient that the continued SNF stay would become noncovered custodial care as a result of the cessation of therapy. Thus, it is not until that point has actually been reached that the issuance of an ABN would become appropriate.
We have found some cases where therapy services recorded on a given PPS assessment did not provide an accurate account of the therapy provided to a given resident outside the observation window used for the most recent assessment. We believe that when service levels change, whether inside or outside the observation period, such changes should be based on medical evidence… we propose that, effective for services provided on or after October 1, 2011, SNFs would be required to complete a Change of Therapy (COT) OMRA, for patients classified into a RUG-IV therapy group, whenever the intensity of therapy (that is, the total RTM delivered) changes to such a degree that it would no longer reflect the RUG-IV classification and payment assigned for a given SNF resident based on the most recent assessment used for Medicare payment. The COT OMRA would be a new type of required PPS assessment, which would use the same item set as the current EOT OMRA. The ARD for the COT OMRA would be set for Day 7 of a COT observation period, which is a rolling 7-day window beginning on the day following the ARD set for the most recent scheduled or unscheduled PPS assessment (or beginning the day therapy resumes in cases where an EOT-R OMRA is completed, as further discussed below), and ending every 7 calendar days thereafter…We want to stress that SNFs would be required to complete a COT OMRA only if a patient’s total RTM changes to such an extent that the patient’s RUG classification, based on their last PPS assessment, is no longer an accurate representation of their current clinical condition. However, an evaluation of the necessity for a COT OMRA (that is, an evaluation of the patient’s total RTM) must be completed every seven calendar days starting from the day following the ARD set for the most recent scheduled or unscheduled PPS assessment (or in the case of an EOT-R OMRA, starting the day that therapy resumes… It should be noted that this proposed policy regarding the COT observation period and setting the ARD for completion of the COT OMRA would be independent of the policy for setting the ARD for the EOT OMRA as described previously… We believe that the COT OMRA would allow us to track changes in the patient’s condition and in the provision of therapy services more accurately, resulting in improving the accuracy of reimbursement for therapy services and enhancing the SNF’s ability to provide quality care to SNF residents. We invite comments on this proposal to require a COT OMRA when the total RTM changes to such a degree as to affect RUG-IV classification and payment.
