Learning Objectives
- Identify components of the MDS that impact SNF Part A payment and associated RUG categories.
- Identify CPT coding for therapy services and strategies for selecting the most appropriate code for skilled service.
- Identify the impact of ICD-10 on therapy services.
Medicare Part A Prospective Payment System (PPS)
Methodology of PPS
We know that the methodology of PPS reimburses a predetermined dollar amount based upon projected or planned care defined by projected or planned resources that we plan to use for the patient. That being said, I think the most important thing that we want to take away from this is that hopefully the facility and staff (OT, PT, and SLP) are working together to determine what the level is for reimbursement for the patient. Sometimes we get caught up in needing to have certain levels or following certain guidelines, but the reality is that it always needs to be based on patient need.
Key Terms/Glossary
- Minimum Data Set (MDS) 3.0
- Resident Assessment Instrument (RAI)
- Case Mix Index (CMI)
- Resource Utilization Group (RUG)
- Resource Utilization Grouper
- Assessment Reference Date (ARD)
- Look Back Period
- Care Area Triggers (CATs)
- Care Area Assessments (CAAs)
Minimum Data Set. We are currently using 3.0 in our facilities to guide the reimbursement and payment for SNF part A.
Resident Assessment Instrument. I want to also highlight the Resident Assessment Instrument, the RAI manual, which is a term you will hear thrown around a lot. I get many questions on a daily basis about how to code this or “I coded this and it is not coming up correctly. What do I do?” I will tell you that I always go back to my RAI manual. If you have never looked at it, I strongly urge you to go out to the CMS website, download it, and start looking through it. Pay close attention to Chapters 3, relating to Therapy Services (Section O), and 6 that refers to RUG categories. Many answers for common questions can come straight from the RAI manual.
Resource Utilization Group. You should be familiar with RUG (Resource Utilization Group) groups, and we will talk about those in a minute.
Assessment Reference Date. You have probably heard of the Assessment Reference Date, or the ARD. This is the last day of the observation period or the look back period for particular resident.
Care Area Triggers and Care Area Assessments. I want to look at the CATs (Care Area Triggers) and the CAAs (Care Area Assessments). Your nurses are going to identify specific areas that will need to be care planned and this is going to become important maybe for us as we look at grace days.
