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Even under the current interpretation, CMS and
the States don't know when we choose the ARD. There is no requirement to do
anything to indicate that we have made a choice.
As for being late, how are we defining "late"? As
of day 9, there are no recorded events that should have occured? The
first true "event" is not until R2b. The burden of gathering data, and making
sure the data is accurate for the selected observation period, exists
regardless of how or when you choose the ARD.
There is no requirement to pay the default rate
unless the ARD falls outside of the allowable window. Even completing the
assessment late does warrant the default rate as long as the ARD falls within
that window.
I hate getting long winded, but let's look
carefully at the RAI Manual.
The first item that applies to this issue is on
p2-28 where it states, "Each of the Medicare scheduled assessments has
defined days when the Assessment Reference date may be set. For example, for the
Medicare 5-day assessment, days one through five hve been defined as optmal days
for setting the Assessment Reference Date." The word "set" has two possible
meanings and is the focal point of this discussion. It can mean the day
that is chosen as the ARD, or it can be interpreted as the day the
decision is made to select an ARD.
On p2-40, there are two relevant passages. Under
the paragraph titled, Default Rate, it states, "MDS assessments are
completed according to an assessment schedule specifically designed for Medicare
payment,and each assessment applies to specific days within a resident's SNF
stay to determine the appropriate reimbursement for the
resident."
The most commonly referenced section states on
p2-40, "A late or missed assessment may be completed as long as the window
for the allowable ARD (including grace days) has not passed. If a late/missed
assessment has an ARD within the allowable grace period, no financial penalty is
assessed. If the assessment has an ARD after the mandated grace period, payment
will be made at the default rate for covered services from the first day of the
coverage period to the ARD of the late assessment."
EVALUATION
I believe that the common interpretation of the
word "set", as used on p2-28, is the day the decision is made to select an ARD,
but this interpretation does not appear to be supported by any other statements
in the Manual. No place in the Manual is there a requirement to record or prove
the date the decision was made. What is required is that the ARD be "set" to
actually fall within a specific and verifiable range of days. The date that is
chosen to be the ARD is very important and therefore must be documented.
The required events for the MDS are completion
dates. The ARD, R2b, VB2, and VB4 all mark a definable point in time that
corresponds to the end of a process and defines the "timliness" of our work. At
no time are we required to document decision points.
As I have said before, the paragraph titled "Late
or Missed Assessment Criteria" seems to have some logical errors in the text.
There is no difinition of "late" that would apply to an assessment where the
allowable window (days 1-8 in the case of a Medicare 5-day) has not passed.
I believe this text is incorrect.
The easy response to all this would be that waiting
until day 9 to choose the ARD is fraudulent and therefore should not be done. If
we loosely define "fraudulent" as involving some type of deception in order to
gain an unearned advantage, I fail to see how this is fraudulent. There is no
deception since there is no requirment to record the date a decision is made.
The ARD is simply defined as the last day for which data gathered on the
resident can be used on the assessment. If that date is not selected until a
week later, there is no change in the data that will be entered into the
assessment and no change in the payment.
PROPOSED MANUAL CLARIFICATION
There is one simple change that can be
applied to the Manual that will clarify this point. On p2-40 the sentence that
currently states, "A late or missed assessment may be completed as long as
the window for the allowable ARD (including grace days) has not passed."
should be changed to read, "A late or missed assessment may be
completed as long as the ARD falls within the allowable window (including grace
days)." This wording, in addition to clarifying the issue, seems to better
support the next sentence which reads, "If a late/missed assessment has an
ARD within the allowable grace period, no financial penalty is assessed."
Now, an assessment is "late" under current defintion due to a late R2b and
payment is determined by the date selected for the ARD. The burden on the
facility to ensure the correct data is entered into the assessment does not
change.
This change does not impact any other date
decisions. In the case of the Medicare 5-day, day 8 is the last allowable day
for the ARD. Therefore, the last possible date for a timely R2b would fall
on day 22 (assuming day 8 is chosen for the ARD and 14 day are used to complete
the assessment). That means that day 22 is the absolute last day for making a
decision about the ARD without causing at least one day to be paid at the
default rate.
I encourage CMS to look closely at this issue and
consider the proposed manaul clarification I have given.
Nathan
---- Original Message -----
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- Re: PPS Assessments and Selecting an ARD Michelle Witges
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