When do we do the COT OMRA – is it based on index maximization?
This question was answered by guest blogger Joel VanEaton, BSN, RN, RAC-CT, CPRA, reimbursement and RAI clinician for Care Centers Management Consulting, Inc., in Johnson City, TN. For more information about the author, please see our About page. Visit regularly for VanEaton’s answers to reader-submitted questions about the COT and EOT-R OMRAs!
Q: When do we do the COT OMRA – is it based on index maximization? What is index maximization? Is there a chart, tables, or any handouts on this that I can refer to?
A: The COT is a complex issue to be sure. As to the answer for the first part of your question, I would refer you to an article I wrote for the February issue of PPS Alert for Long-Term Care titled, “COT, Basics to Best”. The article compiles all of the rules governing when a COT should or should not be completed. From that article, “The COT is required when the resident is receiving any amount of skilled therapy services and when the intensity of therapy (as indicated by the total reimbursable therapy minutes delivered and other therapy qualifiers such as number of therapy days and disciplines providing therapy) changes to such a degree that it would no longer reflect the RUG-IV classification and payment assigned for a given SNF resident based on the most recent PPS assessment.” That being said, there are many complex situations that arise when considering the COT and a firm grasp of all the pertinent rules is necessary.
As to when a COT would occur related to Index Maximization, again, I refer to the article: “In some situations, a resident may simultaneously meet the qualifying criteria for both a therapy and a non-therapy RUG. For some of these cases the RUG-IV per diem payment rate for the non-therapy RUG will be higher; therefore, although the resident is receiving therapy services, the index-maximized RUG is a non-therapy RUG. A facility is required to complete a COT evaluation for all residents receiving any amount of skilled therapy services, including those who have index maximized into a non-therapy RUG.”
With regard to your question about Case Mix Index Maximization, please see Chapter 6 page 6-23 of the October 2011 revised RAI User’s Manual for a thorough discussion of Index Maximization. Basically, from that section, “Index maximizing classification is used in Medicare PPS (and most Medicaid payment systems) to select the RUG-IV group for payment. There is a designated Case Mix Index (CMI) that represents the relative resource utilization for each RUG-IV group. For index maximizing, first determine all of the RUG-IV groups for which the resident qualifies. Then, from the qualifying groups, choose the RUG-IV group that has the highest CMI. For Medicare PPS, the index maximizing method uses the CMIs effective for the appropriate Federal Fiscal Year.”
There are many resources available for you to determine the CMI of each RUG. Basically, this is the method used by most software venders. Therefore, sections ZO100A and ZO150A contain the RUG scores that have the highest case mix weight of all of the RUG scores that could have been generated by the software you use with the completed MDS. Generally, the RUG that displays in ZO100A is the RUG score with the highest case mix weight and would be the RUG score used for billing purposes. There are exceptions such as in the case of an EOT, which often uses the RUG score determined in ZO150A. The specific CMI is also based on whether your facility is classified as urban or a rural. Many vendors also have prepared tables that show the RUG scores and the CMI. We have one such tool available in an MDS 3.0 downloadable RAI User’s Manual and Toolbox at Extended Care Products. Visit www.extendedcareproducts.com for sample tables containing both the urban and rural unadjusted rates along with the CMI.
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Justin Veiga
Justin Veiga is an editor in the long-term care division of HCPro. He edits books, moderates audio conferences, and writes the monthly newsletter PPS Alert for Long-Term Care and the MDS 3.0 Update e-newsletter.
Justin has written 51 posts.
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