productivity and ethical/legal limits

[Guest guest]

Mark- Thank you for directing to sites where she can obtain the HCFA

regs- it is very helpful to have these in hand when discussing the issue with

your managers.

Regarding use of the grace periods, it is in the regs that while days 1-5 will

most often be used as the assessment reference date, it may be more

appropriate for some patients to use days 6-8 as a reference date. In our

verbal discussion with HCFA representatives, this was explained to us that the

majority of patients admitted to SNFs nationwide require skilled nursing

services but not all require skilled rehab services. Therefore, it is usually

more beneficial for nursing to use days 1-5 as the A3 date on the first MDS as

this allows them to capture information from the hospitalization period to

categorize the patient into a RUGS group. For the rehab patients however, the

MDS requires that you look back at a 7 day period but the BBA states that

rehab minutes from the hospitalization period may not be counted. Therefore if

you use days 1-5 as the A3 date, you limit the number of days available to

provide rehab minutes codeable to the MDS. Use of days 6-8 (really 7-8 to

allow 7 full assessment days for rehab minutes) allows therapy to provide the

needed services to categorize a patient into the appropriate rehab category.

Reference the Medicare Provider Reimbursement Manual, Part 1, Transmittal 405,

July 1998 for clarification of the timeliness rule. Briefly, it states

" Timeliness Rule 1. The 5-day assessment reference date must be set on any day

from day 1 through day 8 of the covered stay (i.e., the assessment window for

the 5 day assessment including the 3 day grace period). "

While some intermediaries have stated that consistent use of the grace period

will result in review, the use of the grace period to provide the most

appropriate clinical care needs to be determined on a patient specific basis.

First, the patient will probably not participate in a rehab eval at 9:00 pm as

fully as they might at 10:00 am the next day. Second, the intermediaries may

choose to review a facility for any reason they like- review does not mean

denials. If your documentation supports the need to use day 6-8 instead of day

1-5, the review should not result in denials. If you do receive denials that

appear to be arbitrarily based on dates of the assessment, you have strong

support in the HCFA manual as to the timeliness of your assessment period and

could appeal the intermediaries decision. While I understand the facility not

wanting to use assessment dates that may result in review, the needs of the

patient must determine the assessment period. If you categorize a patient in a

lower group than is appropriate because of fear of using certain dates, you do

a disservice to the patient.

I strongly encourage therapists to read the PPS regs and work with their

facilities to provide appropriate rehab care. Remember that the facility is

transitioning through this change as well and needs education regarding the

regulations. Too often, one speaker on PPS states an absolute statement like

" Use of days 6-8 will result in review " and the facility has a knee jerk

reaction, refusing to use those days ever. Not all SNF admits are rehab

candidates- the previous system encouraged rehab intervention for all Medicare

A patients, but therapists now need to dtermine who will truly benefit from

rehab services and who is appropriate for a restorative nursing program to

group them appropriately.

Again, good luck !

Anne Coffman, MS, PT, GCS

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