Way to say it, Nathan. I agree 100%.
Brenda W. Chance, RN, RAC-C
MDS Coordinator
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-----Original Message-----
From: Orth, Ron A
[mailto:[EMAIL PROTECTED]
Sent: Wednesday, April 21, 2004
12:39 PM
To: '[EMAIL PROTECTED]'
Subject: RE: Selecting an ARD -
Long explanation
Wouldnt it have made more
sense to base the default rate on the R2b date? Such as anything
dated after 14 days from the last possible ARD would be a default?
I have to agree with Nathan on the points made below. I certainly do hope
that CMS considers what is outlined. Isnt this how other assessments are
determined to be completed timely R2b or VB2!!
-----Original
Message-----
From: Nathan Lake
[mailto:[EMAIL PROTECTED]
Sent: Wednesday, April 21, 2004
10:32 AM
To: [EMAIL PROTECTED]
Cc: [EMAIL PROTECTED]
Subject: Selecting an ARD - Long
explanation
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."
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.
---- 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?
----- 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
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