What is an OMRA?

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MRA is an acronym that stands for Other Medicare Required Assessment. We are all familiar with the 5-day, 14-day, 30-day, 60-day and 90-day Prospective Payment System (PPS) Medicare cycle; there are, however, three off-cycle types of the Minimum Data Set (MDS). They are Significant Change, Significant Correction, and the OMRA. Essentially, the OMRA MDS must be done when all therapy services are stopped and the resident still qualifies for Part A services by another skilled services provider. The sole purpose of an OMRA is to adjust the payment of a Medicare resident out of a “Rehabilitation” Resource Utilization Groups (RUG) category into a “Medical” RUG for a continued stay.
       When an OMRA is to be completed, remember to notify the care plan team and that Assessment Reference Date (ARD) can be no earlier than Day 8 and no later than Day 10. Also, count the first day without therapy as Day 1, and this 8–10 day time frame will give you the seven observation days look-back period to capture services being provided to the resident.
       Remember, too, that the R2b date is as many as 14 days from the ARD and that, when possible, you must align and OMRA ARD with an ARD date for a required MDS if a day no earlier than Day 8 and no later than Day 10 falls within the allowable time frames of a regular MDS, including grace days. Therefore, complete only one MDS when combined.

Q & A

       Q: What is meant by “combining or replacing the regular MDS with an OMRA MDS,” and when does the RUG category change?
       A: If the OMRA ARD date can align with an allowable ARD date, for example the 30-day MDS (days 21–34), and the 8–10 day period without therapy services will fall on Day 26, you would combine the OMRA and the regular 30-day MDS and chose Day 26 as your ARD. The RUG rate changes off-cycle on Day 26 forward until the next required MDS is completed or the resident comes off of Medicare Part A services.
       Q: If grace days are used to combine the OMRA with a regular MDS, when does the RUG category change?
       A: If any of the days 8, 9, or 10 ARD dates fall on a grace day, such as Day 34, the two MDS must be combined, and the RUG rate will change on Day 31, on cycle.
       Q: If the OMRA cannot be combined with a regular MDS, what happens?
       A: the ARD date of an OMRA falls on a day that is not allowable for a regular MDS (ie, Day 44), the RUG rate changes off-cycle on the ARD date (ie, Day 44) until the next required MDS is completed. An OMRA MDS is completed, and then another MDS is completed at the next regular cycle.
       Q: If therapy has been discontinued and the resident does not continue to qualify for any other Medicare Part A skilled services, is an OMRA necessary?
       A: No, an OMRA is required only when therapy has been stopped and the resident still qualifies for Medicare Part A skilled services. If therapy is stopped, nursing may initiate observation days as clinically appropriate, up to seven days from the date therapy is discontinued. At any time during the observation period, if the resident no longer qualifies for skilled level of care, then a denial letter is issued and the OMRA MDS is actually never completed because the resident is off of Medicare Part A services before the eighth day, which is the first possible ARD date of an OMRA.
       Q: If a required 30-day MDS was completed at the “Rehabilitation Very High” RUG category and the required 60-day MDS, when completed, is at the “Rehabilitation High” RUG category, and the minutes of therapy services are reduced to the Rehab High RUG level mid-cycle (for example, on Day 42), is an OMRA MDS required? And can the RUG level be changed mid-cycle by the fiscal intermediary (FI)?
       A: An OMRA MDS is not required to be completed because therapy services were not stopped. Also the 30-day MDS will provide payment to the facility from days 31–60. The facility will want to review the resident to see if a Significant Change MDS would be required; however, this must meet the CMS MDS 2.0 User’s Manual clinical change definitions. Below is a section of the Medicare Provider Reimbursement Manual, which gives the definition of when an OMRA is performed:
       “PRM1 2836. Skilled Nursing Facility Prospective Payment System (PPS). Payment Requirements and Adjustments. b. Payment Schedule When an Off-Cycle MDS is Performed by a Skilled Nursing Facility (SNF)—An off-cycle MDS will not always result in a change in the Health Insurance Prospective Payment System (HIPPS) rate code assigned to the beneficiary. There are two off-cycle assessments that a beneficiary may require: 1) an Other Medicare Required Assessment (OMRA) or 2) a Significant Change in Status Assessment (SCSA). The HIPPS rate code that is established by the assessment reference date on the OMRA or SCSA will determine at what HIPPS rate continued payment will be made. An OMRA is completed only when a beneficiary discontinues all occupational, physical, and speech therapy. An SCSA is completed when triggered by the guidelines in the current version of the Long-Term Care Resident Assessment Instrument (RAI) User’s Manual.”
       In other words, an OMRA MDS would not be required in this case. If a significant change in condition meeting the required definition does not take place, the Rehabilitation Very High RUG category will remain in effect until the completion of the required 60-day MDS and should not be changed by the FI upon review.
       Q: If a resident is receiving therapy minutes but payment is in a Medical RUG (eg, a resident receiving speech therapy but the grouper assigns “Special” as the RUG because it is a higher reimbursement), is an OMRA necessary when all therapy is discontinued?
       A: No, an OMRA is required to drop the payment out of a Rehabilitation RUG into a Medical RUG. The resident was already assigned a Medical RUG. This is the exception to completion of an OMRA when all therapy is discontinued.
       Q: What happens if therapy is discontinued, an OMRA is completed with an ARD of Day 10, then the resident goes on therapy again on Day 13?
       A: An OMRA must be completed per regulations. Therapy is reinstated; the facility either will have to wait until a regularly required Medicare MDS is completed to achieve a Rehabilitation RUG or complete a SCSA, assuming the resident meets the criteria. This is not an optimal scenario, but it is important to remember the facility received a Rehabilitation RUG for nine days during the OMRA observation period and did not provide therapy. This is the nature of the PPS.
       Editor's note: For the answer to a question on billing modifiers, click the image below.