Patti Garibaldi, RN, BA, Director of Clinical Consulting

Question:  If therapy does not start right away on day of admit, am I required then to do a Start of Therapy PPS MDS?

Answer:  A Start of Therapy MDS (SOT) is an optional non-scheduled assessment.  MDS 3.0 no longer has section T in order to project a RUG into a therapy RUG category.  A Start of Therapy PPS MDS is only used to get a residents RUG score into a Rehabilitation Extensive Services or Rehabilitation RUG category.  It is optional.  If you are able to complete your 5 days of therapy within the time frame allowed (day 5 or up to day 8 utilizing grace days) then you would do a normal 5 day PPS MDS and your RUG will classify into a therapy RUG rate for all the reimbursement days.  If therapy is not provided for various reasons (resident refuses, resident is ill, for example), then you may want to consider doing a Start of Therapy PPS MDS.  You need to complete this assessment 5-7 days after the Start of Therapy date noted in Section O of the MDS.  Please remember that if this is done after the grace day period, you will also need to complete a 5 day PPS assessment that will place you into a non-therapy RUG classification.  Once a Start of Therapy PPS assessment is completed, the RUG reimbursement will start on the day that therapy began.  See RAI manual Chapter 2

Question:  We were always told to watch our grace days.  Can we still use them and is there a penalty?

Answer:   Grace days are to be utilized to maximize the benefit of services to the resident.  There are no penaltys to using grace days.  There may be situations when an assessment might be delayed (e.g., illness of RN assessor, a high volume of assessments due at appoximately the same time) or additional days are needed to more fully capture therapy or other treatments.  There has been no changes in the allowed grace days from MDS 2.0 to MDS 3.0.  Grace days, however, are not applied to unscheduled Medicare PPS Assessments (refer to RAI manual chapter 2 page 41)

Question:  Do I have to do a entry tracking record on every resident?

Answer:  Yes, you have to do entry reporting on each resident.  there are two types of entries that you may utilize: Admission and reentry. 
      1.  The Entry Tracking record is the first item set completed for all residents
      2.  Must be completed every time a resident is admitted (admission) or readmitted (reentry) into a
           nursing home
      3.  Must be completed for a respite resident every time the resident enters the facility.
      4.  Must be compelted with 7 days after the admission/reentry
      5.  Must be submitted no later than the 14th calendar day after the entry
      6.  Required in addition to the initial Admission Assessment or other OBRA or PPS assessments
           that might be required
      7.  Is a stand alone tracking document
      8. MAY NOT be combined with an assessment
See chapter 2 pages 32 and 33 of the RAI manual

Patti Garibaldi, RN, BA Director of Clinical Consulting

Question:  We are transmitting our 5 day MDS and we are getting a Nursing RUG for day 1 and therapy RUG for the other days. Why is this happening?
Answer:  It sounds like you are coding your MDS as a Start of Therapy MDS rather than a Medicare 5 day PPS assessment. If you code as a Start of Therapy, then the therapy RUG will start on the day that you code section O0400A,B or C question 5, which is the start of therapy date you placed on section O of the MDS

Meet the Experts

Tracy Fritts, PT Regional Vice President for Consonus Rehab

Tracy Fritts received her Master’s of Science in Physical Therapy from Pacific University.  She is licensed as a PT in Oregon and Washington and she has been an active member in APTA and OPTA since 1990. She represented the OPTA as a Oregon PT Licensing Board Liaison for 2 consecutive 2-year terms and served on the Rules Advisory Committee in 2005. 

Tracy joined Consonus in 1995 as a Rehab Director at Marquis Care at Vermont Hills. She was promoted to  Lead PT then Director of Peak Staffing (Consonus Staffing) and eventually to Area Director.  During this time, Tracy was primarily responsible for the development of operations in Washington State.   Tracy was promoted to the Regional Vice President of Operations position in 2008 and oversees the operation of 40 rehab programs in Oregon, Washington, and Wisconsin.  In September, Tracy will complete a fellowship with the Aging Services of Washington Leadership Institute. 

Tracy lives in Portland with her husband and their two noisy, rambunctious, and fun-loving boys.    

Patti Garibaldi, RN, BA, Director of Clinical Consulting for Consonus Healthcare

Patti Garibaldi, RN, BA, Director of Clinical Consulting has been passionately involved in Long Term Care for over 35 years. Her nursing career spans both Acute and Long Term Care. She has held roles from Nursing Assistant to Director of Clinical Services and currently, Director of Clinical Consulting for Consonus Healthcare. Patti has served on multiple committees to affect change in policy development in the Long Term Care industry and has a vast knowledge of regulations in Long Term Care and Assisted Living for multiple States and at the Federal level. She has assisted many facilities in program development and successful survey outcomes and is a certified Resident Assessment Coordinator. Patti is a member of the Oregon Healthcare Association, the Oregon Geriatric Society, the American Association of Nurse Executives, and the American Association of Nurse Assessment Coordinators, Washington Healthcare Association, California Healthcare Association

Discharge Assesments: Wound Progress

Q: How do I complete section M on the discharge assessment if the resident is no longer in the facility and I cannot measure the wound or know what the wound bed looks like?

A: Each facility usually has a system in place to document wound progress. Often this is found on “Skin Progress Sheets”. The facility should determine if their progress sheets are accurate documents. This would be the source for current measurements of the wound and description of the wound bed. A facility should be sure that all nurses completing wound or skin progress sheets are fully trained in accurate wound staging, measurement and wound base terminology that aligns with the MDS 3.0 fields.

Discharge Assesment Completion

Q: Who do I have to complete discharge assessments on and what happens if the resident leaves unexpectedly and I cannot complete the resident interviews?

A: Discharge assessments are now required on all discharges other than death in a facility. The assessment has clinical questions as well as resident interview questions. If the resident leaves, you must complete the discharge assessment to the best of your ability and in absence of resident interview, you would complete the staff interviews that do have look-back periods attached to them.

Interview Documentation

Q:  Where do I document all my results from the interviews I complete?

A:  The MDS 3.0 is now a source document.  If the resident is interviewable, the answers that they give are directly documented on the MDS tool for each interview completed.  The scores or answers may result in a CAT (Care Area Trigger) on specific types of MDS’s (OBRA Admission assessment, Significant Change in Status assessment, Annual Assessment or Significant Correction of a prior Comprehensive assessment) and a  CAA (Care Area Assessment) can  be completed to determine the cause of the triggered area. Also, your resident’s clinical record is a source document and you can site the location of information that may support the triggered area. 

MDS 3.0 Oct. 1 Preparation

MDS 3.0 is now here and many work flow processes must be reviewed and considered as facilities move forward to understand and complete all the assessments that are now either required. Education of staff who will be completing the MDS 3.0 fields is critical to accuracy and will impact resident quality of care as well as reimbursement management.

Q: What do you feel are the most important steps for my facility to take in order to prepare for October 1, 2010 and the MDS 3.0 process?

A: First of all, determine which individuals in your facility will be completing portions of the MDS 3.0 just as you did for MDS 2.0 and assure that they have received adequate education in these areas.
Assure that those individuals that are going to be completing the four interviews (Brief Interview for Mental Status (BIMS), Resident Mood Interview (PHQ-9), Preferences for Customary Routine and Activities, and Pain) have practiced these interviews on each other prior to completing the interviews on their residents. I would encourage that all of these individual watch the VIVE video from CMS so that the interviews run smoothly and accurate information is obtained. The Video can be ordered from CMS at the following website: productordering.cms.hhs.gov with CMS product number 11479-CD.
To assist in workflow as of October 1, 2010 and allow a little time to learn the process, I would encourage that each facility consider moving any quarterly and annual OBRA assessments forward over the next few weeks. You can always move these OBRA assessments forward, you just can’t be late. This will give the interdisciplinary team members a little more time to grasp the MDS 3.0 process in October.

Work to organize the interview process. Be sure to plan for the interviews. Anyone trained in the interview process can complete the resident interviews. Calendar the interviews and invite the resident to attend. Make sure facility staff knows when interviews are taking place to reduce or restrict interruptions. Make a placard for the door to the resident’s room or office that you are using that states “do not disturb, interview in process”. Since one of the interviews measures cognitive status, interruptions may lead to false scoring.

Review your resident’s current active diagnosis. Since almost everyone does a recapitulation once a month, and this is your last month prior to MDS 3.0 launch, this is a perfect opportunity to clean up your physician orders and help with accuracy in coding section I, disease process, on the MDS 3.0 document.

Time Coding

Q:  A therapy aide prepares a treatment space by gathering weights and adjusting equipment for 5 minutes, then spends 10 minutes transporting Mrs. Smith to the therapy area.  Mrs. Smith then receives 30 minutes of therapeutic exercise one on one from a physical therapist after which she joins a group of 3 other patients who all participate in an obstacle course together for 15 minutes.  How would these minutes be coded on the MDS?

A:  It would be coded as:

     35 minutes of individual PT
     15 minutes of group PT

The five minutes the aide spent setting up the treatment area for the individual treatment can be coded on the MDS.  Time the aide spent transporting the patient to and from the therapy area is not considered set up and cannot be counted (note- if the therapist did this and was able to complete some assessment of status, wc mobility or gait training along the way, it could be counted).  The exercise with the PT is considered individual treatment and the interaction with other patients in a shared activity is group.

Rehab RUG Determinations

Q:  If a Med A patient stays long enough for only 4 days of therapy, how can a Rehab RUG level be obtained since Section T projections have been eliminated from MDS 3.0?

A:  The Medicare Short Stay Assessment Indicator of a Start of Therapy (SOT) OMRA will average the provided therapy minutes to potentially determine a Rehab RUG level.   Six criteria must be met: 

1. SOT OMRA combined with any OBRA, PPS, SBCAA or discharge assessment
2. PPS 5-day or Readmission/Return has been completed/combined with SOT OMRA
3. ARD must be on or before Day 8
4. ARD must be on the last day of the Medicare Covered Stay
5. Rehab started (evaluation) within the last 4 days of the stay
6. At least one therapy discipline continued through the last covered day

If this criteria is met then the minutes of therapy provided is divided by the number of days from the therapy eval to the last covered day to obtain an average. Rehab RUG categories are assigned base on this average. Achieving varying RUG levels would require the following number of minutes per category:

• Ultra High= 144 minutes or above
• Very High= 100 to 143 minutes
• High= 65 to 99 minutes
• Med= 30 to 64 minutes
• Low= 15 to 29 minutes

Concurrent Therapy Considerations

Q:  How does CMS define “concurrent” therapy treatments and what is the impact of providing treatments with this mode? 


A:  For Medicare Part A, concurrent treatments occur when two patients are being treated at the same time by the same therapist/assistant yet they are not performing the same or similar activities.  Both patients must be in the line of site of the therapist/assistant.  Medicare Part B does not recognize concurrent therapy and anytime two patients are seen at the same time, the treatment must be billed and documented as a group treatment.  For Medicare Part A patients only ½ of the therapy minutes delivered concurrently will contribute for the total needed to achieve each Rehab Rug level.  Facilities with rehab programs utilizing a significant amount of concurrent therapy treatments may see lower RUG levels if additional treatment minutes are not provided by either individual or group therapy modes. An increased number of therapists or increased productivity of existing staff may need to be considered. 

MDS 3.0 Rehab-related Changes

MDS 3.0 brings many changes to our facility including some that specifically impact the rehab department and your financial viability.  Some key rehab related changes include:

• The elimination of Section T to project patients into the Medium or High Category even when the required minutes/days for those categories weren’t provided during the assessment reference period.
•  The treatment minutes delivered to a patient concurrently with another patient’s treatment are divided in half by the MDS 3.0 Grouper to determine the total for the RUG level.
•  An End of Therapy OMRA must be done 1-3 days after therapy discharge instead of 8-10 days.
•  A Start of Therapy OMRA can now be done to determine a Rehab RUG category before the next regularly scheduled assessment.
• A Medicare Short Stay Assessment may be done to capture a Rehab RUG level if the patient discharges on or before day 8.
• Treatment minutes completed by therapy aides or techs cannot be counted on the MDS but the time they spend setting up a treatment can.
• Treatment minutes completed by students can only be counted if done in direct line of site of a supervising therapist or assistant who is not treating another patient at the same time.