Industry Insights

Revisions to Change of Therapy Assessment Policy Effective October 1

September 2014
Author:  Suzy Harvey

Suzy Harvey

Managing Consultant

Consulting

Health Care

910 E. St. Louis Street, Suite 200
P.O. Box 1190
Springfield, MO 65801-1190 (65806)

Springfield
417.865.8701

The fiscal year 2015 Federal Register brought revisions to the Change of Therapy (COT) policy related to when COT assessments can be completed. The Centers for Medicare & Medicaid Services (CMS) clarified the new policy on the Skilled Nursing Facility-Open Door Forum (SNF-ODF) on September 17, 2014. While the news is positive, one aspect of the policy might leave providers wondering if CMS has created more confusion.

In specific situations, providers are now allowed to complete COT assessments for residents not currently in a resource utilization group (RUG) IV therapy classification or those who weren’t receiving enough therapy to support a RUG-IV therapy classification on their prior COT assessment. The resident assessment instrument (RAI) manual states the COT may be completed only if the following conditions are met:

  • The resident has been classified into a RUG-IV therapy group on a prior assessment during the resident’s current Medicare Part A stay.
  • There has been no discontinuation of therapy services between Day 1 of the COT observation period for the COT that classified the resident into the current non-therapy group and the assessment reference date (ARD) of the COT that reclassified the resident into a RUG-IV therapy group. 

SNFs still will be able to complete a COT assessment following an assessment that index-maximized the resident into a non-therapy RUG-IV group. This assumes the resident was receiving sufficient therapy days and minutes to qualify for a RUG-IV therapy group, despite being index maximized into a clinical RUG group.

Here are several examples of the new COT policy:

Example 1:

  • Five-day assessment on Day 8 of stay = RVB
  • 14-day assessment on Day 15 of stay = RVB
  • COT completed on Day 22 of stay = CC1 due to only four distinct calendar days of therapy
  • COT allowed on Day 29 combined with a 30-day assessment to reclassify the resident into a RUG-IV therapy group

Example 2:

  • Five-day assessment on Day 8 of stay = RVB
  • 14-day assessment on Day 15 of stay = RVB
  • Therapy is missed on Days 16 - 18, requiring an end of therapy (EOT) assessment; therapy resumes on Day 19 of the stay, so the EOT is modified to an end of therapy resumption (EOT-R) assessment
  • COT is not allowed on Day 22 of stay due to completion of EOT-R
  • Day 1 of the COT observation period will start on Day 19, when therapy resumed

Example 3:

  • Five-day assessment on Day 8 of stay = CC1, due to only four distinct calendar days of therapy
  • COT may not be combined with the 14-day assessment, as a RUG-IV therapy group was not established for the five-day assessment
  • The 14-day assessment will need to be completed; if classified into a RUG-IV therapy group, the COT observation period will begin

While the ability to use the COT assessment to reclassify residents back into a RUG-IV therapy group is a welcome relief, there are some drawbacks to the policy, as the example below illustrates:

Example 4:

  • Five-day assessment on Day 8 of stay = RHC
  • 14-day assessment on Day 15 of stay = CC1, due to only four distinct calendar days of therapy
  • COT is not allowed to reclassify the resident into a RUG-IV therapy group, as the prior assessment was not a COT and did not classify the resident into a RUG-IV therapy group

In this example, the SNF would need to combine the 14-day assessment with a COT, which will retroactively decrease payment for Days 9 - 14 from an RHC to a CC1, or wait until the 30-day assessment to reclassify the resident into a RUG-IV therapy group.

Clarification from CMS appears to directly conflict with RAI COT policy, which allows the facility to choose to combine a scheduled assessment with a COT if it falls in the window of a scheduled assessment. It is unclear whether CMS intended this with the COT policy change or it was an oversight due to wording in the final rule.

This policy is effective beginning October 1, 2014. COT assessments completed to reclassify a resident into a RUG-IV therapy group must have an ARD on or after October 1, 2014. A question asked during the SNF-ODF clarified that if a COT was completed with an ARD of September 28, 2014, and classified a resident into a non-therapy group, a COT with an ARD of October 4 could be completed to reclassify a resident into a RUG-IV therapy group.

SNFs will need to be careful to accurately apply the new policy to prevent reimbursement issues.

If you are interested in an unbiased external review to determine the accuracy of your facility assessments, contact your BKD advisor.

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