The last big puzzle piece for providers and stakeholders preparing for the transition to the Patient-Driven Payment Model has been put in place. 

The Centers for Medicare & Medicaid Services quietly released the final version of the MDS 3.0 RAI Manual (version 1.17.1) Wednesday, and providers eagerly scoured the changes Thursday. The 1,309-page document becomes effective in less than two weeks (Oct. 1).

The updates found favor in various ways with close observers, who also noted there were no unexpected bombshells. 

“Most of the changes were anticipated such as the stipulation that Group Therapy is defined for Part A as the treatment of two to six residents, regardless of payer source, who are performing the same or similar activities, and are supervised by a therapist or an assistant who is not supervising any other individuals,” Steven Littlehale, chief innovation officer of Zimmet Healthcare Services Group, told McKnight’s Long-Term Care News.

New changes clarify which assessments swing-bed providers must complete, the definition of “interruption window” for interrupted Part A-covered stays, coding of Item I0200B, and changes regarding group therapy policies, among other corrections.

Brief Interview for Mental Status (BIMS)

Littlehale said he was pleased to see that “in the case of PPS assessments, staff may complete the Staff Assessment for Mental Status for an interviewable resident when the resident is unexpectedly discharged from a Part A stay prior to the completion of the BIMS.” 

“The updated manual states that the assessor should enter ‘zero,’ ‘No’ in ‘C0100: Should Brief Interview for Mental Status Be Conducted?’ and proceed to the Staff Assessment for Mental Status,” he added. 

The change is “a definite win for facilities,” according to Jennifer Leatherbarrow, RN, BSN, RAC-CT, IPCO, QCP, CIC, manager of clinical consulting at Richter Healthcare Consultants.

The manual clarifies how facilities can handle the PDPM calculation if the BIMS is not completed by allowing facilities to answer “no,” indicating the BIMS should not be completed, Leatherbarrow said. 

“This will allow the staff to answer the staff assessment and generate a score to be used in the calculation of the speech component of PDPM. This is a definite win for the facilities,” she told McKnight’s. 

Robert Gross, OT Clinical Consultant at Zimmet Healthcare Services Group, explained that “previously upon unexpected discharge, we would have had to settle for the Default HIPPS Rate (ZZZZZ), secondary to no HIPPS rate would be created by the Medicare Grouper due to missing data.”

“But with this change, we may still be able to capture accurate clinical information, despite unexpected discharge, as well as be reimbursed at the correct case-mix grouper for the ST Component,” he told McKnight’s. 

Not so fast

Littlehale also encouraged providers to review the interrupted stay policy examples in the manual. 

“The Interrupted Stay Policy” examples are extremely helpful to review, though confusion will continue to exist well into the next fiscal year,” he said. “Key things to remember: interrupted stay is never more than three days, it always involves the same SNF and it could be a change from Medicare Part A to another payer source (hospice, Medicaid), then back to Medicare Part A. OBRA requirements remain unchanged.

Leatherbarrow added that she is excited additional information was added to Section I, regarding the facility determination of a primary diagnosis in the skilled nursing facility. 

“In the instance where a resident had a CVA, we will not use the CVA as the primary diagnosis. Instead, we would use something like hemiplegia/hemiparesis or another late effect diagnosis related to the CVA,” she said.

Leah Klusch, the executive director of the Alliance Training Center, praised the upgrading of swing-bed guidance.

“That was very deficient in the draft of the manual, so I’m glad they did that,” she told McKnight’s.

“Make sure you’re completely aware of the rules for the IPA,” she added. “There are no opportunities to combine an IPA with another assessment.”

Klusch also cautioned that “we have to be very careful to review [any changes].” 

“On the 25th of September [next Wednesday], we will be starting to collect data for our earliest IPAs. So any changes in assessment policy or definitions would have to be implemented by then. Those will be considered transitional assessments,” she warned. 

“This is not a big exhale,” she added about the final RAI Manual updates. “Now, we have the final set of language that we have to work with, and that’s good but there’s work to do. The transferring of the language to the interdisciplinary team is where it’s got to happen.”

The preliminary release of the manual was May 20.