There is a mandated schedule for PPS assessments. This schedule is driven by the need to periodically identify resource utilization to set payment accordingly. Unlike the OBRA-required assessment schedule, the PPS assessment schedule is based on the days of the Medicare stay. Medicare benefit days are not always the same as the days of stay in the facility. “…it is not the admission date per se that determines the start of the Medicare assessment schedule, but rather, the commencement of Medicare-covered care in the SNF.” (Federal Register/Vol. 64, No. 146/Friday, July 30, 1999/Rules and Regulations, pg. 41659). The first day of the Medicare-covered stay is counted as “Day 1.” PPS assessments, which are listed in MDS Item AA8b, are based on the schedule from the RAI Manual (CMS, 2002, p. 2-29).
All MDS items must be signed and dated as completed at R2a and R2b within 14 days of the ARD, and encoded on the computer within 7 days of completion. Finally, assessments must be electronically transmitted no later than 31 days after their completion date (R2b). In addition to completing the assessments required under OBRA and PPS, Discharge and Reentry Tracking Forms must also be completed and submitted as mandated to track any discharges and reentries to the facility.
For PPS payment purposes, an assessment is considered to be late if the ARD is not set according to the mandated time frames. These time frames are called assessment windows. As long as the assessment window is open, the ARD may be set for any day within that window. Once the window closes (the calendar date is outside the mandated time frame), the ARD may not be set back in time into the window. The assessment cannot be backdated. For example, a 5-day assessment ARD must be set on any Day 1 through Day 8 of the Medicare stay. On Day 9, if the ARD has not yet been set, the facility’s only option is to set the ARD for Day 9. Because the assessment was late (the ARD is outside the allowable assessment reference dates), the facility must bill the default rate from the beginning of the payment period to the ARD of the late assessment.
In this case, that would be Days 1 through 8. On Day 9, the accurate payment rate is billed by the facility. If an ARD is set early – before the assessment window opens (before the allowable assessment reference dates) – the default rate must be billed for the number of days the assessment was outside the assessment window. For example, for the 14-day PPS assessment, the window opens on Day 11 (first allowable date for the ARD). If the ARD is set on Day 9, the facility would have to bill the default rate for 2 days (CMS, 2002, p. 2-39-2-40). Then for the remainder of the payment period (in this case 14 of the 16 days) would be billed at the accurate payment rate based on RUG-III classification.
* reprinted with permission by The American Association of Nurse Assessment Coordinators (http://www.aanac.org)
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