In the Skilled Nursing world, we are all far-too-familiar with one of the newest unscheduled PPS assessments: Change of Therapy Other Medicare Required Assessment (COT OMRA); frequently called a “COT Assessment”. This has caused many MDS coordinators and Rehab Directors more than a few sleepless nights. Basically, for all Part A patients in a Rehab RUG, the SNF is required to set a COT checkpoint every seven days and if the patient is no longer in the same RUG as the most recent assessment, the SNF is required to perform the COT assessment. This COT assessment resets the payment for the last seven days (and going forward until it is interrupted) to this new RUG.
The COT came in to being as part of the SNF PPS Final Rule for FY 2012 (October 2011). Since then, CMS has been tracking this assessment and, on average, 11% of the PPS assessments in the country for FY 2012 (the most recent published numbers from CMS) were COT assessments. In the recent PEPPER letter that you received, the COT assessment was one of the data points that were outlined for your review. For the purposes of the PEPPER letter, the COT assessment was considered an “outlier” if more than 17% of your assessments were COT assessments. If that is the case, then you may be at risk for review and the bigger question is, “Why are you having so many COT assessments which may be losing you revenue?”
Confusion Over the COT Assessment May Put Revenue at Risk
The SNF PPS Final Rule for FY 2014 (October 2013) has created some confusion surrounding the COT assessment that may also put your revenue at risk. In the current RAI manual, a patient must receive 5 unique days of therapy to qualify for a Rehab Medium or higher RUG. When a patient falls out of the Rehab RUG due to only four unique days of therapy then the COT count stops and the only way to get a patient back into a rehab RUG is to do a Significant Change assessment (if the patient needs warrant that) or wait for the next scheduled assessment. If the patient is index-maximized into a non-therapy RUG but still met the criteria for a rehab RUG (5 unique days of therapy and the minute criteria in the look-back period) then the COT count continues and at the next COT the patient may be classified back into a Rehab RUG. Doing this incorrectly and discovering it after the fact, could be putting hundreds of thousands of dollars at risk depending on your Medicare A census.
Additionally, the timeliness of opening COT’s in your software may be putting you at risk for penalties imposed by CMS. CMS has allowed for the COT to be opened in your software up to two days after the ARD of the COT. Opening the COT after the two day limit will result in either the provider being paid the default rate (AAA) or no payment at all (provider liable days). These penalty rates would be paid to you for the number of days that you are out of compliance for that COT. As you know, the difference between a Rehab RUG and the default rate could cost you three to four hundred dollars per day out of compliance.
Lastly, one of the few gifts of the COT assessment is the ability to combine it with a scheduled assessment at your discretion to allow for capturing the ramp-up period or not capture the ramp-down period of changing RUGs. By doing this effectively you can increase your revenue (or not decrease your revenue) by hundreds of dollars per day.
As you can see in this brief discussion about the COT assessment, there are many pitfalls and opportunities related to the Change of Therapy OMRA. Managing the COT effectively can garner you tens of thousands of dollars (if not hundreds of thousands of dollars) in earned revenue per year or cost you that amount (and more) of lost revenue and penalties per year. Allow us to take a look at your documentation to see where the risks are and the rewards might be… Let us hear from you.