The Centers for Medicare & Medicaid Services (CMS) recently published the Skilled Nursing Facility (SNF) Prospective Payment System (PPS) and Consolidated Billing for Skilled Nursing Facilities Proposed Rule for fiscal year (FY) 2012. In the proposed rule, which was published in the Federal Register on May 6, 2011, CMS attempts to address concerns that SNF providers have expressed regarding the CMS Assessment Reference Date (ARD) policy.

In the proposed rule, CMS clarifies the policy set forth in its FY 2010 SNF PPS final rule that the ARD for an end-of-therapy (EOT) Other Medicare-Required Assessment (OMRA) must be set 1 to three days after discontinuation of all therapies. CMS recognizes that many SNF providers have been confused and expressed concern over the meaning of the phrase “discontinuation of therapy services” in that CMS did not distinguish between planned and temporary unplanned discontinuation of therapy (as in illness, patient refusal, physician office visit) in the FY 2010 final rule. CMS clarifies that providers must complete an EOT OMRA for a patient classified in a Resource Utilization Group, Version IV (RUG-IV) therapy group if the patient goes without therapy for three consecutive days, regardless of the reason for the discontinuation. By completing the EOT OMRA, the SNF will be paid the appropriate non-therapy RUG-IV rate. If therapy resumes, a start-of-therapy (SOT) OMRA can be completed to reclassify the patient into a therapy RUG-IV group at any time during the Part A stay. CMS is asking for comment on the proposed assessment window and grace day changes, as well as the clarification of the ARD for EOT OMRA.

In the proposed rule, CMS also proposes to eliminate the distinction between five-day and seven-day facilities for purposes of setting the ARD for the EOT OMRA. In the FY 2010 final rule, CMS stated that “when a facility only provides therapy five days a week […] the weekend days would not be counted toward the establishment of the ARD for the EOT OMRA.” CMS recognizes that this policy has caused significant confusion for SNF providers who might use weekends to make up for therapy that was not provided during the week or who might only provide therapy on weekend days when a holiday falls on a weekday, as it has been unclear to providers whether they would be considered a five-day facility or a seven-day facility. CMS proposes that an EOT OMRA must be completed once therapy services cease for three consecutive days, regardless of the reason, whether planned or temporarily due to illness, patient refusal, doctor office visits, etc., and regardless of whether the SNF offers therapy services five days per week or seven days per week. By completing the EOT OMRA, the SNF will be paid the appropriate nontherapy RUG-IV rate. CMS notes, however, that while the ARD for the EOT OMRA would be required to be set by the third consecutive calendar day after discontinuation of therapy services, the SNF also has the option of setting the ARD for the EOT OMRA on day one or day two after therapy services have been discontinued. Therefore, if a facility (regardless of whether it is a five-day or seven-day facility) discontinues therapy on a Friday, the ARD for the EOT OMRA would be required to be set for the immediately following Saturday, Sunday or Monday, if the patient has been provided therapy services in the interim.  

CMS also proposes to establish a new end-of-therapy resumption (EOT-R) OMRA. The EOT-R OMRA could be used in place of a SOT OMRA in cases where therapy stopped, an EOT OMRA was completed, and therapy subsequently resumes within five consecutive calendar days and at the same RUG-IV classification level that had been in effect prior to the EOT OMRA. For coding the resumption of therapy, two new items will be added to the Section O of the MDS. In cases where therapy resumes more than five consecutive days from the discontinuation of therapy, the SNF can either complete a SOT OMRA to classify the patient into a RUG-IV therapy group or wait until the next PPS assessment to classify the patient. Further, CMS proposes to establish a new change-of-therapy (COT) OMRA. The COT OMRA would be completed for patients classified into a RUG-IV therapy group whenever the intensity of therapy 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 agency is accepting comments on the Proposed Rule until June 27, 2011. A copy of the proposed rule is available here.1