Prospective Payment System for Long Term Care

• Abstract & Objectives
• Prospective Payment for Long Term Care
• The Prospective Payment Process
• The Balanced Budget Act of 1997
• The Minimum Data Set (MDS)
• Ensuring the Accuracy of the MDS
• Conclusion
• References

Nurses in Skilled Nursing Facilities (SNFs) are now both the sources of care and the primary revenue determiners for facilities. Since 1987, the American Nurses Association has been advising the Health Care Financing Administration (HCFA) on the impact on nursing of a prospective payment system (PPS) for skilled nursing facilities. The system that is now law places considerable trust in the nursing profession. Registered Nurses' assessment of SNF residents is the basis for determining which residents are eligible for the Medicare Part A Skilled Nursing benefit and at which payment level the SNF will be paid for each resident's care. The purpose of this independent study module (ISM) is to assist nurses in gaining new knowledge to be able to explain the new prospective payment system for long term care, the implications for nurses and residents, and their responsibilities in the process.

Objectives

Upon successful completion of this module the learner will have the ability to:

• Detail relevant aspects of the PPS system.
• Explain the relationships between the minimum data set (MDS) and the Resource Utilization Group (RUG).
• Identify the MDS elements used to calculate the RUG-III category.
• Describe both opportunities and challenges for registered nurses under PPS.
• Discuss ways to increase the accuracy of the MDS.

Prospective Payment System for Long Term Care

The Prospective Payment System (PPS) mandated for nursing homes comes as no surprise. In addition to the new prospective payment system for Medicare Part A benefits, nurses are also now affected by the Final Rule for the Minimum Data Set (MDS). This rule defines several responsibilities of registered nurses in relation to the Resident Assessment Instrument, of which the Minimum Data Set is an integral part. Understanding the MDS Final rule is essential to the practice of nursing in skilled nursing facilities (SNFs). This paper will address the parts of the MDS rule that are relevant to the prospective payment system for SNFs. Nurses are urged to explore the other implications of the MDS Final Rule as it relates to their practice.

The PPS was designed to minimize the documentation burden on nurses by using the same MDS assessment instrument to determine payment level as is used for care planning and quality assessment. The nurse's primary responsibility is simply to perform and document an accurate assessment according to a specific schedule. Care planning and care delivery are not affected by the prospective payment changes. Nurses have the opportunity to insure residents receive quality care and at the same time directly determine the payment for that care. Now that money is involved, the importance of assessments will be obvious to administrators. Nurses, rather than accountants, are the central professional in the payment system.

The PPS sets a payment level based on the functional capability and needs for service of each resident through a system known as Resource Utilization Groups (RUG-III). The system actually places similar incentives to control costs as managed care organizations attempt to do. The facility receives a specific payment for each day a resident is at a RUG-III determined level of care. How the money is spent is up to the facility, as long as the resident receives all needed care.

The PPS system was designed to be self-balancing with care, quality, and payment based on the same tool. In some settings, there may be pressure to "enhance" assessment to qualify for payment above that actually due for the resident. Any such pressure must be rejected. Nurses must understand the process of both resident assessment and prospective payment to insure appropriate care, appropriate payment, and to avoid potential pitfalls. Professional practice is the only winning strategy.

The Prospective Payment Process

The actual procedures needed to implement the PPS are very simple - in fact, simpler than the old process of daily skill level determination. The primary process necessary is performing an accurate assessment!

The essential steps in PPS are:

1. Perform a preliminary assessment to determine initial qualification.
2. Schedule assessments according to the PPS rules (5, 14, 30, 60, 90 day)
3. Collect data and complete the assessments on time with clinical accuracy.
4. Encode the MDS data into MDS computer software, which calculates the RUG-III scores.
5. Pass the resident's RUG-III score, assessment reference date, and the MDS "reasons for assessment" to the business office.
6. The business office places a HIPPS code (which incorporates the RUG-III score and the
7. reason for assessment) onto the claim, with the days covered by the assessment(s).
8. The business office submits the claim to the Medicare fiscal intermediary.
9. The Medicare fiscal intermediary calculates the payment due and transfers the money to the nursing facility.

That really is all there is to it! The key points are the MDS schedule, and the accurate completion of the MDS.

What is the Balanced Budget Act of 1997?

The Balanced Budget Act of 1997 is a law passed by Congress in the summer of 1997. The Balanced Budget Act contains provisions affecting many parts of the economy, and helped put the United States in a positive budget position for the first time in 30 years.

The provisions directed at the skilled nursing facilities culminate over 20 years of work to determine a fair system to pay for skilled nursing care after acute hospital stays for Medicare beneficiaries. The law as applied to Skilled Nursing Facilities is implemented in the Department of Health and Human Services interim final rule 42 CFR Parts 409, 410, 411, 413, 424. There are additional provisions of the Act affecting Skilled Nursing Facilities. In addition to the Part A (inpatient) payment changes, other provisions include Consolidated Billing for Part B services, caps on part B therapy payments, and restrictions on early transfer from hospitals. This booklet will not address these changes.

The prospective payment system described in the Balanced Budget Act replaces the retrospective "reasonable cost" based system previously utilized by Medicare for payment of skilled nursing facility services under Part A of the Medicare program.

Provisions of the Balanced Budget Act.

The main provisions of the Balanced Budget Act are:

1. Requires implementation of a Medicare SNF prospective payment system (PPS) for cost
2. reporting periods beginning on or after July 1, 1998.
3. The single case-mix adjusted Per-Diem PPS payment for each resident will encompass all costs of furnishing covered skilled nursing services.
4. The formula to determine the federal prospective rates accounts for differences between urban and rural costs, and is to be adjusted by area wage differences. There is no difference between type of facilities: hospital based facilities will be paid the same federal rate as freestanding facilities.
5. There will be annual updates to rates.
6. Adjustments for "case-mix creep" are required. This provision allows adjusting payment levels if the costs to the Medicare program increase without an increase in the actual care needs of beneficiaries.
7. Medical review for appropriateness of services is mandated.
8. Swing bed hospitals are included (with a delayed start date to 2000).
9. Submission of resident assessments is mandated.
10. A few costs are excluded from the rates, such as physician⁽¹⁾, nurse practitioner, nurse midwife, and certain other costs related to dialysis services. (For the purposes of PPS, dentists and podiatrists are considered physicians. Medicine men are not.)
11. A three year transition period of blending of facility specific cost based payments with an increasing case mix adjusted federal payments applies to all facilities receiving Medicare Part A payments prior to October 1, 1995.

How is Prospective Payment for Skilled Nursing Facilities different from Prospective Payment for hospitals?

The Prospective Payment System for SNFs differs from the acute hospital PPS system in fundamental ways. The acute hospital is paid a single payment to treat a condition using a system call Diagnostic Related Groups (DRGs) which are in turn based on the principle diagnosis of the patient, with provisions for patients with unusually high cost, called outliers. There is a single payment for the episode of care, regardless of how long or short the stay. Care for outliers is reimbursed based on individual documentation. Payment levels for DRG are based on claims data.

In contrast, the PPS for SNFs is a per-diem payment (meaning daily) based on the functional capabilities of the resident, other resident characteristics, and the need for services such as rehabilitation therapy. The system adjusts for differences in residents' care needs, co-morbidities and differences in resident capacities through an analysis of the resident's Minimum Data Set assessment known as Resource Utilization Groups, version 3 (RUG-III.) There is no provision for outliers. Payment levels for RUG-III groups are based on actual staff time measurements of the care required by residents in the groups, and the other services and costs of care received by residents.

How does the Prospective Payment System Affect Nursing?

The prospective payment system has three primary impacts on nursing:

1. The MDS assessments must be completed accurately and on time.
2. The schedule of MDS assessments requires more frequent MDS assessments for PPS residents.
3. The facility receives a single case mix adjusted payment for each resident day. All costs of care must be paid by the nursing facility. As intended by the law, the costs of care must be analyzed and controlled, while giving good quality care to residents.

This translates to additional time requirements for registered nurses. More nurses will be needed to maintain the assessment schedule. The additional nursing time is included in the payment rates to facilities, but the decisions on how resources are to be allocated is up to the facility administration. Nursing administrators in each facility should evaluate their assessment function needs, and insure sufficient time is available for accurate, timely assessment.

The schedule of assessments must be followed explicitly. Late assessments can result in delayed or minimum payments. Since the MDS is primarily a clinical document, it cannot be backdated to cover a missed assessment period. Nursing, in cooperation with the business office, must establish and follow procedures to insure timely assessments.

In addition to the universal use of the MDS to direct care planning, the MDS assessment information is used to determine the RUG-III value for each resident. The RUG-III value determines the resident's eligibility for skilled care (the highest 26 RUG-III groups are "deemed" covered by Medicare) and the level of payment. The MDS is the only information used to determine the payment level during a Medicare Part A stay.

The costs of care must be paid from the single case mix adjusted payment. Nursing administration should periodically evaluate the procedures used to deliver care, and make necessary changes to minimize waste, so as to deliver care in the most cost effective way consistent with the needs of residents.

What other care providers and staff are affected by PPS?

A registered nurse is required to supervise the entire MDS process and act as the MDS coordinator. All other care givers are involved in the assessment process, from the licensed independent practitioner's certification of the need for skilled care, and medical orders, to the certified nursing assistants informing registered nurses of the level of functioning (activities of daily living - ADLs) of each resident over the observation period.

Rehabilitation therapists (occupational therapists, physical therapists, and speech/language pathologists) are key players for the rehabilitation RUG-III groups. The therapists need to be instructed in the specific MDS items for which they are responsible. For instance, section P has items requiring the days of service and actual minutes that the resident is receiving therapy in the last 7 days or since admission to the nursing facility. Section T has items to collect the days and minutes of therapy expected to be delivered in the first 14 [15] days since admission or re-admission. Therapists have previously documented only the time the therapist spent with the resident. While the time the therapist spends with the resident will still be needed for the UB-92 claim, the therapists will also need to document the actual or planned minutes of time the resident is receiving therapy. (Section T collects the days and minutes of therapy planned for the resident for the first 15 days of a stay, thus the "planned minutes" come from the therapists' plan of care.)

The business office is also vitally interested in the MDS completion. The source of all Medicare Part A claims is the MDS coordinated by the registered nurse. The business office can serve as a backup or reminder for MDS completion to insure that all Medicare MDSs are completed on time (or within the allowed grace periods.) (Grace periods are time frames beyond the stated MDS data collections periods that are still acceptable to HCFA for the Assessment Reference Date, and may be used without financial penalty.)

What is the Minimum Data Set Final Rule?

The Minimum Data Set (MDS) as a part of the Resident Assessment Instrument (RAI) was developed by the Health Care Financing Administration to assist Medicare/Medicaid certified nursing homes in developing a comprehensive care plan for each resident. The Institute of Medicine (IOM) report in 1986 identified uniform resident assessment as essential to improvement in the quality of care delivered to residents and reform of the survey process. When the Omnibus Budget Reconciliation Act of 1987 (OBRA 87) became law in 1987, HCFA began a process of public comment leading to a final rule implementing the law. The process was completed on December 22, 1997. The Final Rule on the MDS includes the requirement to electronically encode and transmit all MDSs to the State in which each facility is licensed.

How does the MDS Final Rule affect Nursing?

The Final Rule specifies the responsibilities of facilities and nurses to complete the Resident Assessment Instrument (RAI), to encode the MDS in electronic format, and to transmit all MDSs to their State. The Final Rule is primarily concerned with the clinical and quality aspects of the Resident Assessment Instrument (RAI) and resident care. It complements the PPS rule, but applies to all residents of nursing facilities, while the PPS rule only affects residents in Medicare Part A stays.

What is the Minimum Data Set?

The Minimum Data Set is a standardized assessment instrument specified by HCFA and optionally supplemented by States (with approval from HCFA) which collects administrative and clinical information about residents. The MDS is a very complete and well-designed assessment which, when used with the Resident Assessment Protocols and professional judgment, is a comprehensive assessment and care planning tool. The use of the MDS is specified in the Long Term Care Resident Assessment Instrument User's Manual, Version 2.0 (MDS Manual). This manual is an essential reference for all nurses in nursing facilities.

The MDS collects assessment information on each resident's characteristics, activities of daily living (ADLs), medical needs, mental status, therapy use, and other things involved in comprehensive planning for resident care.

How is the Minimum Data Set used within Skilled Nursing Facilities?

The MDS is used to assess every resident in Medicare or Medicaid licensed facilities on admission, with a quarterly review and annual re-assessment. Significant change in a resident's condition causes a new comprehensive MDS (including review of the care plan) to be completed to insure the resident receives appropriate care.

For residents in Medicare Part A stays, the MDS is also used to determine payment. It is completed on the 5^th, 14^th, 30^th, 60^th and 90^th days following admission to the Medicare stay (or re-admission). The most relevant date for Medicare PPS purposes is the Assessment Reference Date (item A3a on the MDS form) with the other completion dates following as specified in the Final Rule and HCFA's Questions and Answer documents on the HCFA website.

The MDS can serve as the primary clinical assessment tool for all residents within nursing facilities. Using the concept of triggers and RAPS makes the MDS a comprehensive assessment. The MDS (with additional triggered assessments) is sufficient for most care setting. Other assessment forms in use in facilities should be examined for overlap with the MDS and duplicative forms eliminated.

What are the penalties for intentionally falsifying the MDS?

The Final Rule for MDS provides sanctions for intentionally falsifying MDSs: fines of up to $1,000 for each MDS a nurse falsifies, and a fine of up to $5,000 for each MDS that someone causes to be falsified. (Clinical disagreement does not constitute fraud or falsifying - if it is a legitimate clinical issue.) Accurately portraying the resident is the goal. If reviews by other clinicians identify inaccuracies in an MDS, changing the MDS to reflect the resident accurately is expected. Changes made to secure a higher payment, which are not supported by the registered nurse's assessment, may lead to sanctions.

What are Resource Utilization Groups?

Resource Utilization Groups (RUG-III) is a case mix system which sets payment based of the resources expected to be used to care for a resident based on the functional support requirement and medical needs of each resident. There are 44 groups used in the Medicare PPS program. (There are several alternative RUG-III groupings used in State Medicaid programs and for research purposes. Skilled Nursing Facilities must use the current Medicare RUG-III index.)

Resources are what the system pays for. Resources paid for include:

Time

Nursing (RN, LPN, aide)

Rehab (OT, PT, SLP, assistant, aide)

Non-rehab ancillaries

Medical supplies

Medications

Lab

Respiratory therapy

Radiology

General Services

Building and grounds maintenance

Dietary

Laundry

Activities

Capital

Buildings

Equipment

Utilization is how much resource is used to care for residents.

Time was collected using Staff Time Measurement studies to actually associate the direct time staff spent with residents, time spent on behalf of residents, and other time associated with the operation of the nursing facility. Time was collected from good facilities in 12 states. ("Good" facilities had no deficiencies on their last survey, and were acceptable to their Fiscal Intermediary and the State licensing office.

Cost reports provided costs of labor and services.

Claims provided non-rehab ancillary costs,

Groups are the grouping determined through analysis to identify residents with similar characteristics using similar resources

An MDS 2.0 was completed on each resident during the study period.

Sophisticated grouping analysis and a final review by an external panel of experts determined the final groups.

What is the relationship between MDS and RUG-III?

The MDS collected during the Staff Time Studies was the basis of the groups, the independent variable in the analysis. The MDS on a resident is analyzed using grouper software to determine the RUG-III group to which the resident belongs. The RUG-III directly determines the payment for each day of the resident's stay.

The RUG-III grouper uses 108 MDS 2.0 items to calculate the RUG-III score.

Thus, the MDS is used to calculate the RUG-III group, but the MDS is a separate process from the RUG-III system.

How is RUG-III calculated?

Using the MDS, the grouper program first calculates an ADL score, a depression index, and a cognitive performance score. It then identifies each of the major groupings for which the resident is qualified. It then compares the payment level of each group, and reports the highest paying group.

While it is technically possible to calculate a RUG-III by hand, it is very time consuming, and very difficult to do accurately. Use a grouper!

The ADL index, depression index and cognitive performance scales are also very useful clinically! They can help identify residents with depression and help guide the care planning to help the resident cope or resolve the depression. The cognitive performance scale can assist during care planning to set realistic goals for residents, as well as to identify changes in cognition that could be reversed or treated.

What is the relationship between RUG-III and payment?

Each of the 44 RUG-III groups has a specific daily payment associated with it. The federal payment for each RUG-III group is the same for all facilities in a geographic area. The payment level will vary by geographic area.

What is the schedule of MDS for PPS?

The RUG-III level set by the MDS determines the payment for specific days of the resident's stay. The day of admission counts as day one for all MDS calculations. For Medicare Part A purposes, the assessment reference date (ARD, item A3a on the MDS form) is the key date used to identify assessments. The ARD is the date at which the assessment represents the resident's condition, including a common point to count back for items which refer to a number of days. The assessment reference date determines the coverage period of each assessment.

If the resident leaves the facility and is admitted to another facility, and returns, the schedule of assessments starts over. If the resident experiences a significant change in condition, a new comprehensive assessment is required, and will set a new payment level until the next scheduled assessment. Note that all scheduled assessments are scheduled from the admission date (or re-admission.) A special case is when all therapies are discontinued on a resident in a Rehab RUG-III group: a full assessment (or comprehensive if also a significant change in the resident's condition) is required with an assessment reference date from 8 to 10 days after the last day of any therapy.

What processes, policies and procedures should nurses put in place to support PPS?

Nurses should evaluate all resident assessment and care planning policies and procedures, and update them to prevent duplication of effort and to conform to the new requirements of PPS and the MDS final rule. Include other disciplines and staff groups to insure good communication to improve care and resident outcomes. Pre-admission screening needs to be reviewed, and the utilization review process of determining resident skill needs should be re-evaluated. The nurse, pharmacist, and medical director should coordinate a review of medical orders for new admissions to insure appropriateness of medications and treatment. Where other disciplines or staff groups are involved, including those groups in the planning will help insure good communication. Special attention should be paid to assessment procedures to insure timely and accurate assessments.

Ensuring the Accuracy of the MDS

The Minimum Data Set (MDS) as a part of the Resident Assessment Instrument (RAI) was developed by the Health Care Financing Administration to assist Medicare/Medicaid certified nursing homes in developing a comprehensive care plan for each resident. The Institute of Medicine report in 1986 identified uniform resident assessment as essential to improvement in the quality of care delivered to residents and reform of the survey process. Facilities have had varying success in using the RAI system to develop effective care plans. State surveyors use information found in the RAI and the care plan to evaluate a facility's compliance with Federal regulations. Unfortunately, staff of many facilities have viewed this requirement as "government paper work" and have not integrated the MDS process into the care systems in their facilities.

Beginning July 1, 1998, the Health Care Finance Administration started to use a prospective payment system (PPS) for Medicare beneficiaries in Skilled Nursing Facilities (SNF). The prospective payment system was developed using one hundred and eight items from the MDS to calculate a Resource Utilization Group (RUG) for each resident. The grouping calculated for each resident determines the reimbursement the facility will receive for the resident's Medicare stay.

This change in the reimbursement system for Skilled Nursing Facilities has significantly enhanced the role of the Registered Nurse (RN). Federal regulations require that a registered nurse "conduct or coordinate" the assessment. Registered nurses have a critical role in assuring that the facility receives the appropriate reimbursement for the care of each Medicare beneficiary as well as coordinating the care and services provided. This enhanced role will be a challenge. It is essential that registered nurses develop systems which ensure that each assessment is completed accurately and within the time frames required by the Medicare reimbursement system.

Development of a System to Manage the MDS Process

It is very important that all staff who are involved in the completion of the MDS use the operational definitions found in the Long Term Care Resident Assessment User's Manual Version 2.0. Failure to use the operational definitions may cause an incorrect calculation of the Resource Utilization Group for that resident. Errors could lead to underpayment or overpayment for the care delivered.

Using a systems approach can assist health care professionals responsible for completing the MDS in assuring accuracy of the data. Assuring accuracy is essential to ensure that appropriate care and services are provided to each resident as well as the receipt of appropriate reimbursement by the facility.

Each facility should develop a specific training and competency program which must be completed before a health care professional participates in a resident assessment. All health care professionals responsible for completing all or part of the MDS must read the user's manual. Opportunity should be provided for asking questions. If there are issues raised which are not addressed in the MDS Manual, the state RAI coordinator should be contacted. A list of state RAI coordinators with their phone numbers can be found in Appendix A of the RAI manual.

The next step in developing competency in completing the MDS should include the opportunity for new employees to assess a resident and compare that assessment with one completed in the same time frame by an experienced registered nurse. The findings from the two assessments should be compared. When there are differences in coding, there should be a discussion of the operational definitions found in the manual. Again, if there are unresolved issues, the state RAI coordinator can be contacted for further information. It is the responsibility of the facility to ensure that all health care professionals complete the assessments of residents accurately.

Training sessions for health care professionals are provided periodically by state survey agencies. Other training opportunities are provided by professional organizations and educational institutions. The Health Care Financing Administration provides updated information concerning the MDS and the Prospective Payment System on the Internet. The following websites are useful resources:

It is essential that the operational definitions found in the MDS Manual be used to code the MDS. Assessments have traditionally been based on one direct observation by the assessor. Many MDS items require the gathering of information over a 24 hour period for one or more days, dependent on the assessment period determined by the RAI coordinator. All staff who observe, care for, and interact with a resident can provide information critical to the accurate completion of the MDS.

The Registered Nurse responsible for performing or coordinating the assessment for a resident has the responsibility for identifying the time period in which the assessment information will be collected. This date is recorded at Section A3a. This date sets the last day staff can collect information for a specific assessment. Events or changes which occur after that date cannot be included in the assessment. The Medicare system provides a range of dates in which each assessment must be completed. The Registered Nurse must work in concert with the business office in ensuring that assessments required for the Medicare payment system are completed according to the Medicare schedule and at the same time ensure that all required clinical assessments are completed according the regulations found in the Code of Federal Regulations at 42 CFR 483.20. Some software vendors included a scheduling program in their software. Most facilities will use a tickler file or similar system to identify the dates Medicare and Clinical assessments are due.

Role of the Registered Nurse in Prospective Payment

Registered nurses have an important role in ensuring that residents in Skilled Nursing Facilities receive the maximum benefit from their Medicare stay. Registered nurses are responsible for assessment and reassessment of residents to ensure that appropriate care planning is performed and appropriate services are delivered to each resident. In addition to ensuring quality care for residents, registered nurses are responsible for ensuring that the resident's assessment reflects the resident's condition and the services provided so that the facility received the appropriate reimbursement for each resident whose stay was reimbursed by Medicare Part A.

PPS for Skilled Nursing Facilities has significantly enhanced the role of the RN. Federal regulations require that a registered nurse "conduct or coordinate" the assessment. This enhanced role will be a challenge. It is essential that registered nurses develop systems which ensure that each section of the assessment is completed accurately and within the time frames required by the Medicare reimbursement system.

Sections G, P and T

All sections of the MDS are important. However, there are four sections which appear to be problematic for many facilities: Section G1- Assessment of Activities of Daily Living; Section P1 - Special Treatments, Procedures and Programs; Section P3 - Nursing Rehabilitation/Restorative Care; and Section T1b, c, d - Ordered Therapies.

Section G - Physical Functioning and Structural Problems

The definitions in the RAI manual state that the resident is to be assessed over a 24 hour period. For the Medicare 5 day assessment and readmission assessment, the assessment reference period can be the first to eighth day of admission or readmission. For other Medicare assessments, the period will be within seven days of the assessment reference date. Residents who are very dependent in their ADL's can be assessed in a shorter time frame than those residents whose ADL performance varies from day to day or who are relatively independent. One important concept of the MDS coding system is that the resident is assessed at their most dependent. A resident who normally was able to propel a wheel chair without assistance asked staff to push them back to their room from the dining because she was short of breath. If this activity occurred only one time in the assessment period, the coding for locomotion off the unit for self performance would be G1f(A) = 0 - independent, but the coding for G1f(B) = 2 - one person physical assist. Staff on all three shifts should provide information to the Registered Nurse concerning the resident's functioning on their particular shift. Residents are often more dependent late in the day and during the night than during day time hours. Providing nurse aides with a simple form to complete each shift indicating the level of assistance the resident received during the assessment period would significantly improve the accurate coding of items in this section. Coding Section G accurately requires that the registered nurse understand the operational definitions and apply them correctly. The following is a review of the definitions used to complete Section G. Additional explanatory information is provided in italics and the use of bold print within the MDS definitions.

ADL Coding Definitions

ADL Self- Performance

Code for the resident's performance over all shifts during the assessment period-Not including setup.

Code 0 - Independent - No help or staff oversight - or - help/oversight provided only 1 or 2 times during the last 7 days.

To accurately assess that an individual met the definition for independent in an activity of daily living, the full assessment period may need to be utilized.NOTE: Medicare 5 day and Medicare Readmission assessments may not cover a 7 day period. The assessment period is between the day of admission and the assessment reference date set by the RAI Coordinator.

Code 1 - Supervision - Oversight, encouragement, or cuing provided 3 or more times during the last seven days -or-Supervision (3 or more times) plus physical assistance provided only 1 or 2 times during the last 7 days.

Again with more independent residents, it maybe advisable to assess over the full five to seven day assessment period to determine the actual amount of assistance they may need. Remember that residents perform activities of daily living multiple times over a 24 hour period.

Code 2 - limited Assistance - Resident highly involved in activity: required physical help in guided maneuvering of limbs, or other non-weight-bearing assistance 3+ times - or - more help provided only 1 or 2 times during the last 7 days.

Note that the term non-weight-bearing assistance is used. Residents may receive non-weight-bearing assistance one or two times in an assessment period to be coded as independent or needing supervision. Limited assistance introduces weight-bearing assistance. Nurse aides need to understand the difference between non-weight bearing support and weight-bearing support in order to provide accurate information to the registered nurse.

Code 3 - Extensive assistance - While the resident performed part of the activity over the assessment period, help of the following type(s) was provided 3 or more times:

Full staff performance means that staff performed all aspects of the activity for the resident. Activities of daily living include multiple tasks. Registered nurses need to carefully read the definition for the activity.

Code 4 - Total Dependence - Full staff performance of the activity during the entire assessment period.

Few residents are completely dependent on staff for performance of an activity. The resident must be incapable of participating in any aspect of the activity. If the resident performs one aspect of an activity one time during the assessment period, a coding of 4 -Total Dependence is inaccurate.

Code 8 - Activity did not occur during the entire assessment period.

A resident who is bedfast and did not leave the bed during the assessment period would be coded on the MDS as a 4 for self performance for transfer.

ADL Support

Code for most support provided over all shifts during the assessment period; code regardless of resident's self-performance classification.

Code 0 - No setup or physical help from staff

The resident was able to perform the activity completely independently without physical assistance or cuing by staff.

Code 1 - Setup help only.

A resident is able to ambulate and transfer if staff place a walker beside the resident's bed in a specific position. Resident is able to be independent in bed mobility if staff raise the siderails so the resident can use the rails to change their position in bed.

Code 2 - One-person physical assist.Code 3- Two or more persons physical assist.Code 8 - Activity did not occur during the entire 7-day period.

Sections P and T

The items in Section P record special treatments and procedures which the resident received both in and out of the facility. Part a of Section P is used to identify treatments and programs which the resident received in the previous 14 days. The assessment reference date determines the look back time frame. The items listed under treatments (P1a. Special Care - TREATMENTS) can occur in and out of the facility. Transfer information provided by a hospital or another inpatient facility is critical for accurate completion of this section for 5 day /readmission Medicare assessments, 14 day Medicare assessments and Initial Comprehensive Assessments. This section allows facilities to identify resource intensive services provided to residents while in the facility. Residents who received the specialized treatments listed in this section while in a hospital are often admitted to a SNF for continued monitoring of the clinical condition which precipitated the need for the treatments and the effect of the treatments. The 14 day look back allows facilities to identify treatments which require monitoring for a period of time. An example would be a resident who received chemotherapy while in the hospital and was transferred to a SNF for skilled observation and treatment of symptoms related to the resident's response to the chemotherapy. The programs listed under P1a Programs are limited to those programs provided within the facility. Therefore, only those programs offered from the day of admission are recorded in this section. Section P1b. Therapy assessment evaluations are often completed by the therapists providing the services. Time spent by the therapist performing the initial therapy evaluation cannot be included in the days and minutes recorded in this section. In some facilities a therapist will evaluate each resident admitted for Medicare Part A services for the need for therapy. In other facilities, this evaluation will be delegated to the registered nurse coordinating the resident's assessment. Timely evaluations and initiation of appropriate therapies must be coordinated so that therapies can be recorded during the Medicare assessment periods. If therapies are not initiated in a timely manner, another assessment may need to be conducted to capture the information needed to reflect the therapies being provided. In October 1998, the Health Care Financing Administration issued additional guidance for completing Sections P and T on their PPS website. Nursing Rehabilitation Services are included in the RUG-III calculation. Registered nurses should evaluate each resident for the need for nursing restorative care (rehabilitation). This care must be delivered by nursing staff (including nurse aides) and supervised by a registered nurse. This is an area which is often overlooked by registered nurses coordinating the MDS. The failure to include rehabilitation/restorative services may have a negative impact on the reimbursement received by the facility.

Sections T1b, T1c, and T1d are completed with 5 day Medicare Assessments and Medicare Readmission Assessments. This section includes the amount of therapy provided since admission or readmission and therapy expected to be provided during the resident's first 14 days of stay. Many facilities have the mistaken idea that there is an advantage to delay completion of the 5 day Medicare or Readmission Assessment until at least five full days of therapy have been delivered. The number of days of therapy and minutes of therapy recorded in this section includes the therapy recorded in Section P as well as the days and minutes of therapy expected to be delivered. Therefore, using grace days will not change the RUG-III calculation. Registered nurses must work in collaboration with therapists in identifying residents who could benefit from therapies. The resident's ability to tolerate therapy, should also be evaluated. Residents who are unable to tolerate therapies at admission may need to be re-evaluated later in their stay. As an advocate for residents, registered nurses should ensure that each resident receives appropriate therapies during their Medicare stay.

Conclusion

The Medicare Prospective Payment System has created opportunities for registered nurses and advanced practice nurses to change practice for the benefit of residents and the professions. The PPS system was designed to be self-balancing with care, quality, and payment based on the same tool. In some settings, there may be pressure to "enhance" assessment to qualify for payment above that actually due for the resident. Any such pressure must be rejected. Nurses must understand the process of both resident assessment and prospective payment to insure appropriate care, appropriate payment, and to avoid potential pitfalls. Registered nurses are the critical element in successful implementation of the Prospective Payment System. Nurses must be prepared for the challenge.

References

Committee on Nursing Home Regulation. (1986). Improving the quality of care in nursing homes. Washington DC: National Academy Press.

Hawes, C., Morris, J., Phillips, C., Mor, V., and Fries, B. (1995). Reliability estimates for the minimum data set for nursing facility resident assessment and care screening (MDS). Gerontologist. 35, 172-178.

Health Care Financing Administration. (1998). Medicare program; Prospective payment system and consolidated billing for skilled nursing facilities. Federal Register, 63(91), 26252-26316.

Morris, J., Hawes, C., et al. (1990). Designing the national resident assessment instrument for nursing homes. Journal of the Gerontological Society of America. 30, 293-302.

Morris, J., Murphy, D., and Nonemaker, S. (1995). Long term care resident assessment instrument user's manual version 2.0. Baltimore, MD: Health Care Financing Administration.

Footnotes

1.For the purposes of PPS, podiatrists, dentists, optometrists and chiropractors are considered "physicians".