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 -----
Sent: Wednesday, April 21, 2004 6:52
AM
Subject: Re: PPS Assessments and
Selecting an ARD
I have been following this and I feel the need to
throw my 2 cents in. The interpretation of the manual is that one
cannot wait until day 9 to set the ARD. How would the state or the
feds know when you chose the ARD? If it is day 9 and somehow the need
for the MDS was missed and you went ahead and set it for day 8, how would
anyone know that it is late and needs to paid at default rate?
Michelle
----- Original Message -----
Sent: Tuesday, April 20, 2004 3:46
PM
Subject: Re: PPS Assessments and
Selecting an ARD
We have guidance from CMS: >From
the RAI User's Manual, page 2-40:
<<QUOTE
Late or Missed
Assessment Criteria
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.
>>END QUOTE
Rena
Rena R.
Shephard, MHA, RN, FACDONA, RAC-C
Chair, American Association of Nurse
Assessment Coordinators
[EMAIL PROTECTED]
Subj: PPS Assessments and Selecting an ARD
Date:
4/20/04 1:38:23 PM Pacific Standard Time
From: [EMAIL PROTECTED]
Reply-to:
[EMAIL PROTECTED]
To: [EMAIL PROTECTED]
Sent from the
Internet
Do you remember a couple months ago we had
a discussion about the setting of
the ARD for PPS assessments? I made
the case that the ID team should be able
to make the ARD decision
after the window had closed (for example, waiting
until day 9 before
deciding which of the first 8 days works best for the
Medicare 5 day
ARD).
I learned today that, lacking guidance from CMS, at least
one State RAI
coordinator teaches this as an acceptable way of
setting the ARD. Amazing
isn't
it.
Nathan
