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Target Audience: Medicare Fee-For-Service Program (also known as Original Medicare)
The Hyperlink Table, at the end of this document, provides the complete URL for each hyperlink.
Learn about these Medicare-required Skilled Nursing Facility Prospective Payment System (SNF PPS) assessments topics:
- Minimum Data Set (MDS) 3.0 background
- Assessments overview
- Factors affecting the assessment schedule
- Assessment results reporting
When “you” is used in this publication, we are referring to SNF providers.
Medicare Part A covers skilled care in a Medicare-certified Skilled Nursing Facility (SNF). Skilled care is nursing or other rehabilitative services, furnished pursuant to physician orders, that:
- Require the skills of qualified technical or professional health personnel
- Are provided directly by, or under the general supervision of, these skilled nursing or skilled rehabilitation personnel to assure the safety of the patient and to achieve the medically desired result
You must assess the clinical condition of SNF residents by completing the required MDS 3.0 assessments for each Medicare resident receiving Part A SNF-level care for reimbursement under the SNF PPS in a covered Part A stay.
The date an individual enters the facility and admits as a resident.*
- Assessment Indicator (AI)
A code used to indicate the type of assessment billed on a Medicare claim.
- Assessment Reference Date (ARD)
The last day of the observation period the assessment covers.
- ARD Window
The defined days when you must set the ARD. This does not include grace days.
- Grace Days
The date range when you may set the ARD or add additional days without penalty. Grace days apply only for scheduled assessments.
- Assessment Window
The defined days when you may set the ARD. This includes grace days as applicable.
The date a resident leaves the facility or the date the resident’s Medicare Part A stay ends, but the resident remains in the facility.*
*A day begins at 12:00 am and ends at 11:59 pm.
MDS 3.0 Background
The MDS 3.0 is a core set of elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. The screening, clinical, and functional status items in the MDS 3.0 standardize communication about resident problems and conditions. The MDS 3.0 contains items that reflect the acuteness of the resident’s condition, including diagnoses, treatments, and functional status. MDS 3.0 assessment data is personal information SNFs must collect and keep confidential by Federal law.
State Assessment Requirements
Check your State requirements to ensure you meet them, and contact your State RAI coordinator if you have any questions.
The MDS 3.0 is one of three components of the Resident Assessment Instrument (RAI). The other two components are:
- Care Area Assessment (CAA) Process, which assists with systematic interpretations of the completed MDS 3.0
- RAI Utilization Guidelines, which provide guidance on when and how to use the RAI
The complete RAI yields information about a resident’s functional status, strengths, weaknesses, and preferences, and it offers guidance on further assessment once you identify problems.
All SNF claims must include Health Insurance Prospective Payment System (HIPPS) codes, which is a 5-digit code consisting of a 3-digit RUG-IV code and a 2-digit AI, for the assessments billed on the claim.
The MDS 3.0 classifies residents into a Resource Utilization Group Version IV (RUG-IV) based on the average resources needed to care for someone with similar care needs. RUG-IV classifications help Medicare determine the Part A SNF PPS payment. The RUG-IV classification system includes eight major classification categories:
- Rehabilitation Plus Extensive Services
- Extensive Services
- Special Care High
- Special Care Low
- Clinically Complex
- Behavioral Symptoms and Cognitive Performance Problems
- Reduced Physical Function
To find resources and more information on the MDS 3.0 RAI and RUG-IV categories, refer to Chapter 6 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual on the MDS 3.0 RAI Manual webpage.
The SNF PPS establishes a Medicare-required PPS assessment schedule. Each required assessment supports reimbursement for a range of days of a Part A covered stay. The schedule includes assessments performed around Days 5, 14, 30, 60, and 90 of the stay. Additional unscheduled assessments are required under specific circumstances.
Conducting the Assessment
Each assessment must include all of these:
- Accurately reflect the resident’s status.
- Be conducted or coordinated by a registered nurse with the appropriate participation of other health care professionals.
- Include direct observation as well as communication with the resident and direct care staff on all shifts.
- Cover the Observation (Look Back) Period, which is the time period when the resident’s condition is captured by the MDS assessment. Do not code anything on the MDS that did not occur during the Observation Period.
The Medicare-required PPS assessment schedule includes 5-day, 14-day, 30-day, 60-day, and 90-day scheduled assessments. Except for the first assessment (5-day assessment), each assessment is scheduled according to the resident’s length of stay in Medicare-covered Part A care.
Complete the Medicare-required 5-Day Assessment when any of these occur:
- The Part A resident admits to the SNF
- The Part A resident readmits following a discharge assessment when return was not anticipated
- The Part A resident returns more than 30 days after a discharge assessment when return was anticipated
- The resident leaves a Medicare Advantage (MA) Plan and becomes covered by Medicare Part A (the Medicare PPS schedule starts over as the resident now begins a Medicare Part A stay)
You must complete scheduled assessments according to the information in Table 1. Scheduled Assessments.
REMEMBER: Assessment Window = ARD Window + Grace Days
|Assessment Type||AI||ARD Window||Grace Days||Medicare Payment Period|
|5-day||10||Days 1–5||Days 6–8||Days 1–14|
|14-day||20||Days 13–14||Days 15–18||Days 15–30|
|30-day||30||Days 27–29||Days 30–33||Days 31–60|
|60-day||40||Days 57–59||Days 60–63||Days 61–90|
|90-day||50||Days 87–89||Days 90–93||Days 91–100|
Scheduled Assessment Calendar
Using the Scheduled Assessment Calendar, enter the first day of Part A care in the field. Dates when you can and cannot set the ARD populate for you. The calendar is organized according to the Medicare payment period.
In some situations, you must complete assessments outside of scheduled Medicare-required assessments, known as unscheduled assessments. Expand each unscheduled assessment to learn more.
Significant Change in Status Assessment
Called the Swing Bed Clinical Change Assessment for swing bed providers
Complete when the SNF interdisciplinary team determines a resident meets the significant change guidelines for either decline or improvement.
A significant change is a major decline or improvement in a resident’s status that meets all of these requirements:
- It will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, and the decline is not considered “self-limiting”
- It impacts more than one area of the resident’s health status
- It requires interdisciplinary review and/or revision of the care plan
A significant change may require referral for a Pre-admission Screening and Resident Review evaluation if a mental illness, intellectual disability, or related condition is present or suspected.
Significant Correction to Prior Comprehensive Assessment
Complete when a significant error was made in the prior comprehensive assessment.
A significant error is an error in an assessment where both of the following are true:
- The resident’s overall clinical status is not accurately represented (that is, miscoded) on the erroneous assessment
- The error was not corrected via submission of a more recent assessment
A significant change differs from a significant error because it reflects an actual significant change in the resident’s health status and is not due to incorrect coding of the MDS 3.0.
Start of Therapy-Other Medicare Required Assessment
Complete only to classify a resident into a RUG-IV Rehabilitation Plus Extensive Services or Rehabilitation group. If the RUG-IV classification is not a Rehabilitation Plus Extensive Services or a Rehabilitation group, the Centers for Medicare & Medicaid Services (CMS) will not accept the assessment, and you may not use it for Medicare billing.
This is an optional assessment.
End of Therapy-Other Medicare Required Assessment
Complete when all of these are true:
- The resident was in a RUG-IV Rehabilitation Plus Extensive Services or Rehabilitation group
- The resident does not receive any therapy services for 3 or more consecutive calendar days
- The resident continues to require Part A SNF-level services
EOT-OMRA with Resumption
Complete when all of these are true:
- Therapy resumes after the EOT-OMRA
- Therapy resumes within 5 days after the last day of therapy
- Therapy resumes at the same RUG-IV classification level with the same therapy plan of care
Change of Therapy-Other Medicare Required Assessment
Generally, complete when both of these are true:
- The resident received a level of rehabilitation therapy to qualify for an Ultra High, Very High, High, Medium, or Low Rehabilitation RUG-IV category
- The intensity of therapy, as indicated by the total reimbursable therapy minutes delivered and other therapy qualifiers, such as the number of therapy days and disciplines providing therapy, changes to such a degree that it would no longer reflect the RUG-IV classification and payment assigned based on the most recent assessment used for Medicare payment
Complete for a resident who is not currently classified into a RUG-IV therapy group in rare cases where both of these are true:
- The resident had qualified for a RUG-IV therapy group on a prior assessment during the resident’s current Medicare Part A stay
- No discontinuation of therapy services occurred between Day 1 of the COT observation period for the COT-OMRA that classified the resident into the current non-therapy RUG-IV group and the ARD of the COT-OMRA that reclassified the resident into a RUG-IV therapy group
NOTE: The COT observation periods are successive 7-day windows. The first observation period begins on the day following the ARD set for the most recent scheduled or unscheduled assessment.* For example, if the ARD for a patient’s Medicare-required 30-Day Assessment is set for Day 30 and there are no intervening assessments, the COT observation period ends on Day 37.**
* Does not apply when the most recent assessment was an EOT-R. For more information, refer to Chapter 2 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual.
** Payment for a COT-OMRA continues to the end of the standard payment window, assuming no intervening assessment occurred.
You must complete unscheduled assessments according to the requirements, described in Table 2. Unscheduled Assessments, and the Assessment Tool. Unlike the defined payment days for scheduled assessments, Medicare payment days for unscheduled assessments vary by situation.
REMEMBER: Unscheduled assessments do not have grace days.
|Assessment Type||AI||ARD Window||Medicare Payment Period: Start||Medicare Payment Period: End|
|SCSA or SCPA||01||No later than 14 days after significant change/error identified||Payment begins on the ARD||End of standard payment period|
|SOT-OMRA||02||5–7 days after the start of therapy||Date of the first therapy evaluation||End of standard payment period|
|EOT-OMRA||04||1–3 days after all therapy discontinued||The day after all therapy discontinued||End of standard payment period|
|EOT-R||0A||1–3 days after all therapy discontinued||The day after the last day of therapy||The day before therapy resumes|
|COT-OMRA||0D||Day 7 (last day) of the COT observation period and then every 7th day until the next scheduled assessment||The first day of the COT observation period||End of standard payment period or until interrupted by the next COT-OMRA|
For detailed information on scheduled and unscheduled assessments, refer to Section 2.8 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual.
In addition to the two Omnibus Budget Reconciliation Act (OBRA)-required discharge assessments (OBRA Discharge assessment-return anticipated and OBRA Discharge assessment-return not anticipated), you must complete a Medicare-Required Part A PPS Discharge Assessment when the resident’s Medicare Part A stay ends, but the resident remains in the facility (is not physically discharged from the facility). This Medicare-required (as compared to OBRA-required discharge assessment) was added to the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual in 2016 (policy adopted in the Fiscal Year 2016 SNF PPS Final Rule). Standalone Medicare-Required Discharge Assessments do not impact payment and are intended to collect the standardized data to calculate quality measures (see the Report to Quality Improvement and Evaluation System [QIES] Assessment Submission and Processing [ASAP] System Section for more information).
Part A PPS Discharge Assessment
Generally completed when one of these is true:
- Medicare Part A stay ends, but the resident remains in the facility
- The resident is physically discharged on the same day or within one day of the end of the Medicare Part A stay
You must complete the OBRA Discharge Assessment and the Part A PPS Discharge Assessment, and you may combine them.
A Part A PPS Discharge Assessment is not required if the resident dies on the same day as the end date of the most recent Medicare stay.
- Equal to the end date of the most recent Medicare stay (A2400C) or
- If the End Date of the Most Recent Medicare Stay (A2400C) occurs on the day of or one day before the Discharge Date (A2000), you must complete the OBRA Discharge Assessment and the Part A PPS Discharge Assessment, and you may combine them
When the OBRA and Part A PPS Discharge Assessments are combined, the ARD (A2300) must be equal to the Discharge Date (A2000).
OBRA-Required vs. Medicare-Required Assessments
- OBRA standards: Designated by the reason selected in Item A0310A, Federal OBRA Reason for Assessment, and Item A0130F, Entry/Discharge Reporting and are required for all residents.
- Medicare standards: Designated by the reason selected in Item A0310B, PPS Assessment; Item A0310C, PPS Other Medicare Required Assessment – OMRA; and Item A0310H, Is this a SNF Part A PPS Discharge Assessment?, and are required for residents whose stay is covered by Medicare Part A.
A Medicare unscheduled assessment that falls within a scheduled Medicare-required assessment window cannot be followed by the scheduled assessment later in that window. You must combine the two assessments with an ARD appropriate to the unscheduled assessment. If you completed a scheduled assessment and an unscheduled assessment falls in that assessment window, the unscheduled assessment may supersede the scheduled assessment, and the payment may be modified until the next unscheduled or scheduled assessment. When the requirements for all assessments are met, you may combine the Part A PPS Discharge Assessment with most PPS and OBRA-required assessments. The Assessment Tool provides guidance about combining assessments, including setting the ARD.
The Assessment Tool does not cover every potential situation, though it does cover the most common situations. For more information, refer to the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual or contact your Medicare Administrative Contractor.
NOTE: You should not combine two Medicare-required scheduled assessments.
Factors Affecting the Assessment Schedule
Noncompliance with the Assessment Schedule
The default rate takes the place of the otherwise applicable Federal rate. It equals the rate paid for the RUG-IV group reflecting the lowest acuity level and is generally lower than the Medicare rate payable if the SNF submitted a timely assessment.
Medicare will pay the default rate for an assessment with an ARD outside the prescribed assessment window for the number of days the ARD is out of compliance. Frequent early or late assessment scheduling practices may result in review.
If you conduct an assessment earlier than the schedule indicates (that is, the ARD is not in the assessment window), you will receive the default rate for the number of days the assessment was out of compliance.
If you fail to set the ARD within the assessment window and the resident is still in a Part A covered stay, you must complete a late assessment.
For more detailed information and examples on early and late assessments, refer to Chapter 2, Section 2.13 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual.
REMEMBER: A late assessment cannot replace a different Medicare-required assessment.
If you set the ARD of the late assessment prior to the end of the period during which the late assessment would have controlled the payment (had the ARD been set timely) and no intervening assessments occurred, Medicare will pay the default rate for the number of days the assessment is out of compliance.
In this example, if there are no other assessments until the Medicare-required 60-day assessment, bill the remaining 22 days (Days 39–60) using the HIPPS code on the late assessment.
If you set the ARD of the late assessment after the end of the period when the late assessment would have controlled payment (had the assessment been completed timely) or an intervening assessment occurred and the resident is still in a Part A covered stay, you must still complete the assessment. Bill all covered days when the late assessment would have controlled payment (had the ARD been set timely) at the default rate.
In this example, you must complete the 30-day Medicare-required assessment within Days 27–33, which includes grace days, because a late assessment cannot replace a different Medicare-required assessment. The 30-day assessment covers Days 31–60 as long as the beneficiary has SNF days remaining and is in a Part A covered stay.
If you do not set the ARD prior to the end of the last day of the assessment window and the resident is no longer in a Part A covered stay, you may not bill for those days. Medicare will not pay for these days because no Medicare-required assessment exists in the Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system for the payment period.
You may bill at the default rate for a Medicare-required assessment not in QIES only in these situations:
- The stay is less than 8 days within a spell of illness
- The SNF is notified on an untimely basis of, or is unaware of, a Medicare Secondary Payer denial
- The SNF is notified on an untimely basis of a beneficiary’s enrollment in Medicare Part A
- The SNF is notified on an untimely basis of the revocation of a payment ban
- The beneficiary requests a demand bill
- The SNF is notified on an untimely basis of, or is unaware of, a beneficiary’s disenrollment from an MA Plan
For instructions on billing when one of these exceptions applies, refer to Chapter 6, Section 6.8 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual.
Other Factors Impacting the Assessment Schedule
These events may require adjustment of the assessment schedule:
- The resident dies on or before Day 8 of the SNF stay
- The resident transfers or discharges on or before Day 8 of the SNF stay
- The resident has a Short Stay (described below)
- The resident admits to an acute care facility and returns
- The resident goes to an acute care facility over a midnight and for less than 24 hours (without being admitted)
- The resident goes on a Leave of Absence (LOA) from the SNF
- The resident discharges from Part A skilled services, remains in the facility, and then returns to SNF Part A skilled level services
- There is a delay before the resident requires and receives skilled services
For instructions on how to bill when one of these situations applies, refer to Chapter 2, Section 2.13 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual.
The short stay policy may apply if the resident dies, discharges from the SNF, or discharges from a Part A covered stay on or before Day 8 of a Part A covered SNF stay. It allows assignment into a Rehabilitation Plus Extensive Services or Rehabilitation category when a resident received rehabilitation therapy and was not able to receive 5 days of therapy due to discharge from Medicare Part A.
For more information on the requirements for a short stay, refer to Chapter 6 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual.
Assessment Results Reporting
Report to QIES ASAP System
You must transmit MDS 3.0 data to a Federal data repository, the QIES ASAP system. You must submit MDS 3.0 assessments and tracking records mandated under the OBRA and the SNF PPS. Do not submit assessments completed for purposes other than OBRA and SNF PPS requirements (for example, private insurance, including MA Plans). For more information on transmitting MDS 3.0 data to the QIES ASAP system, visit the MDS 3.0 Technical Information webpage and refer to Chapter 5 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual.
The Medicare claim should include both of these codes:
- Appropriate HIPPS codes, in the order in which the beneficiary received that level of care, with revenue code 0022
- Occurrence code 50 with the ARD for each assessment period represented on the claim (except for the default HIPPS code AAAxx)
NOTE: Do not submit a Medicare Part A SNF claim until the QIES ASAP system accepts the corresponding assessment and you receive a Final Validation Report indicating the State accepted the assessment.
Correcting an Assessment
When a MDS 3.0 assessment is completed, edited, and accepted into the QIES ASAP system, you may not change it as the resident’s status changes during the course of the stay. The MDS must be accurate as of the ARD. You should note minor status changes in the resident’s record. A significant change in the resident’s status warrants a new comprehensive assessment.
The electronic record you submit to and is accepted into the QIES ASAP system is the legal assessment. Medicare does not recognize corrections made to the electronic record after acceptance or to the paper copy maintained in the medical record as proper corrections. Submit any corrections to the QIES ASAP system as described in Chapter 5, Section 5.5 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual.
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