Chapter 21 Federal Regulations TABLE 21.3 Scheduled Medicare Prospective Payment System Assessments

The Medicare-required standard assessment schedule includes 5-day, 14-day, 30-day, 60-day, and 90-day scheduled assessments, each with a predetermined time period for setting the assesment reference date (ARD) for that assessment. The skilled nursing facility (SNF) provider must complete the Medicare-required assessments according to the following schedule to ensure compliance with the SNF PPS requirements.

Medicare MDS Scheduled Assessment Type

5-day

14-day 30-day 60-day 90-day

Reason for Assessment (A0310B code)

01 02 02 04 05

Assessment Reference Date

Days 1–5

Days 13–14 Days 27–29 Days 57–59 Days 87–89

aGrace days: a specific number of days that can be added to the ARD window without penalty. bApplicable Standard Medicare Payment Days may vary when assessment types are combined. For example, when a provider combines an

unscheduled assessment, such as a Significant Change in Status Assessment (SCSA), with a scheduled assessment, such as a 30-day Medicare-required assessment, the new resource utilization group (RUG) would take effect on the ARD of the assessment. If the ARD of this assessment was day 28, the new RUG would take effect on day 28 of the stay. The exception would be if the ARD fell within the grace days. In that case, the new RUG would be effective on the first day of the regular payment period. For example, if the ARD of an unsched- uled assessment combined with the 60-day assessment was day 62, the new RUG would take effect on day 61.

Source: Centers for Medicare & Medicaid Services. MDS 3.0 RAI Manual v1.13:2-41. www.cms.gov/Medicare/Quality-Initiatives- Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html. Accessed October 14, 2015.

Assessment Reference Date, Grace Daysa

6–8

15–18 30–33 60–63 90–93

Applicable Stand- ard Medicare Payment Daysb

1–14

14–30 31–60 61–90 91–100

305

BOX 21.1 Unscheduled Medicare Prospective Payment System Assessments ●

There are situations when an SNF provider must complete an assessment outside of the standard scheduled Medicare-required assessments. These are known as unscheduled assessments. When indi- cated, a provider must complete the following un- scheduled assessments:

●

Significant Change in Status Assessment (for swing bed providers, this unscheduled assess- ment is called the Swing Bed Clinical Change Assessment)

● ● ●

Significant Correction to Prior Comprehensive Assessment

Start of Therapy, Other Medicare Required Assessment (SOT-OMRA)

End of Therapy, Other Medicare Required Assessment (EOT-OMRA)

Source: Centers for Medicare & Medicaid Services. MDS 3.0 RAI Manual v1.13:2-42. www.cms.gov/Medicare/Quality-Initiatives- Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html. Accessed October 14, 2015.

Change of Therapy, Other Medicare Required Assessment (COT-OMRA)

A Medicare unscheduled assessment in a scheduled as- sessment window cannot be followed by the scheduled assessment later in that window—the two assessments must be combined with an ARD appropriate to the un- scheduled assessment. If a scheduled assessment has been completed and an unscheduled assessment falls in that assessment window, the unscheduled assess- ment may supersede the scheduled assessment and the payment may be modified until the next unscheduled or scheduled assessment. See Chapter 6 (Section 6.4) and Chapter 2 (Section 2.10 of the MDS 3.0 RAI Man- ual) for complete details.