Case Mix Review

Contact Info
Case Mix Review
651-201-4200
health.fpc-cmr@state.mn.us

Contact Info

Case Mix Review
651-201-4200
health.fpc-cmr@state.mn.us

Case Mix Review
Frequently-Asked Questions

This page includes answers to frequently-asked questions about how to complete the Minimum Data Set (MDS) 3.0, the Optional State Assessment (OSA), Section S of the Omnibus Budget Reconciliation Act (OBRA) assessment, and other requirements.

Providers are encouraged to use the information provided in the Minnesota Case Mix Review Manual and the answers below to complete their coding. If you have questions or need additional assistance, please contact Case Mix Review staff at Health.MDS@state.mn.us.

Reconsiderations

Should the resident, or their representative, complete and submit the Request for Reconsideration form, or are facilities expected to complete this form and submit the reconsideration?

The facility staff should complete and submit the Request for Reconsideration form to the Case Mix Review Program on behalf of the resident or their representative. For more information, please see the section titled Request for Reconsideration of a Resident's Case Mix Classification and the Request for Reconsideration Form in the Minnesota Case Mix Review Manual.

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Admission Assessment Requirements

No. If the facility elected to complete an Admission Assessment for all admissions regardless of payer source and length of stay, the Admission Assessment and a corresponding OSA with the same ARD is required.

Yes. For MDS coding purposes this would be considered two days. The Admission Assessment is not required when the admission and discharge occur on the same calendar day.

No, facilities that have elected to accept the short stay rate for all admissions who stay 14 days or less do not have to complete an Admission Assessment until the resident remains in the facility for more than 14 days.

If the resident is in a Medicare or Medicaid certified bed and the facility elected to complete an Admission Assessment for all admissions, an Admission Assessment is required even for respite stays of 14 days or less, except when the resident is admitted and discharged on the same day.

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General Questions about the OSA

The OSA is required for most admissions to nursing facilities that are Medicare and Medicaid certified regardless of who the payer is. The OSA is required:

  • Each time an OBRA comprehensive, quarterly, or Significant Correction to prior Quarterly Assessment (SCQA) assessment is completed, and
  • When all therapy and isolation services end, if the most recent assessment (either an OBRA assessment with an ARD on or before 9/30/2023 or an OSA with an ARD on or after 10/1/2023) resulted in a rehabilitation or isolation RUG-IV classification in Z0200A.

The OSA is NOT required when completing a stand-alone Discharge or Prospective Payment System (PPS) Assessment or Tracking Record.

The following facilities are NOT required to complete the OSA:

  • Facilities that do not accept Medicaid
  • Swing Beds
  • VA Facilities
  • Any facility that has elected the Short Stay option AND the resident’s stay is 14 days or less.

If the resident’s stay is more than 14 days, the admission assessment and OSA are required.

Currently, Minnesota Statutes indicate a SCSA must be completed when all therapy and isolation services end. We are looking at getting the statutory language changed in the next legislative session. Effective 10/1/2023, Minnesota Case Mix assessment processing staff will be looking for an Optional State Assessment (OSA) with A0300B coded a “5” when all therapies and isolation services end. The ARD requirements for End of Therapy (day 8) and End of Isolation (day 15) OSA do not change.

The OSA will generate a new classification notice for State Medicaid Billing purposes. If the OSA is missing or the ARD of the OSA is not set timely, a penalty will be applied to the assessment.

No, Case Mix staff will be auditing specific MDS items found in both the OSA and OBRA assessments.

The Minnesota Department of Human Services (DHS) continues to evaluate their payment system options for Medicaid and private payers. It is not known what payment system option will replace RUG-IV at this time. CMS plans to retire the OSA on September 30, 2025.

CMS does not allow the OSA to be combined with any other assessment type. The OSA is a stand-alone assessment for State payment purposes only.

Yes, the OSA data elements can be copied from an OBRA assessment with the same ARD. Both, the OSA and OBRA, assessments should be submitted to the Centers for Medicare and Medicaid Services (CMS) preferably in the same batch.

The managed care provider determines what assessment(s) the facility is required to complete. You would need to contact the managed care provider for this information.

A facility would need to contact the payer to determine what assessments they will require the facility to complete for payment purposes.

Yes, anytime one of the Federally required OBRA assessments listed in A0310A on the MDS is completed, a OSA with the same ARD, must also be completed. The OSA does not replace the Federal assessment. Both assessments must be completed. The ARDs of the Federal assessment and OSA must match.

Yes, the penalty rate (AAA) is in effect from the time the assessment was due until the first of the month, following submission and acceptance of the assessment into the Internet Quality Improvement Evaluation System (iQIEs).

No, Minnesota does not use the OBRA or PPS assessments for payment. The requirement to complete an OSA when all therapy services end applies if the resident’s classification on their most recent assessment, either an OBRA assessment with ARD on or before 9/30/2023, or an OSA with ARD 10/1/2023, or later is a Rehabilitation classification.

Yes, the resident’s payer source is not a factor in determining whether the OSA is required. The requirement for an OSA applies to all facilities that participate in the State Medicaid Program, regardless of the resident’s payer source.

If the facility does not participate in the Medicaid program e.g., Veterans Administration facilities, this requirement does not apply.

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Completing the OSA

Several items necessary to calculate a RUG-IV classification were removed from the OBRA assessments and RAI Manual but remain on the OSA. These items are: A0300, D0200, D0300, G0110, K0510, O0100, O0450, O0600, O0700, and X0570. Instructions for completing these items are included in the OSA Manual.

The OSA Manual can be downloaded from the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual (cms.gov) website. Scroll down to the Download section. Instructions for completing the remaining items on the OSA can be found in the respective sections of Chapter 3 of the RAI Manual. The guidance in the OSA Manual should only be applied when completing an OSA.

Yes, O0600, and O0700 can be dashed as these items are not needed to determine a RUG-IV classification.

No. In Minnesota, we do not use the following OSA options:

  • Start of Therapy,
  • End of Therapy, 
  • Both Start and End of Therapy, or
  • Change of Therapy.

If the facility chooses to complete an assessment to capture the addition of rehab or isolation services, one of the appropriate Federal OBRA assessment options in item A0310A must be completed.

The Federal OBRA assessments use section GG to calculate the PDPM classification for Medicare beneficiaries. The OSA uses the late loss Activities of Daily Living (ADLs) in section G to calculate the RUG-IV classification used for all private pay and Medicaid stays in Minnesota. Both, Section G and GG must be completed.

The entire PHQ-9 Resident Mood Interview must be completed, during the look back period of the assessment, on the OSA. Follow the instructions in the OSA Manual when completing the PHQ-9 interview. The instructions for completing the PHQ-2 to 9 Resident Mood Interview in the Minimum Data Set (MDS) Resident Assessment Instrument (RAI) 3.0 User’s Manual are very different and are not applicable to the PHQ-9 Resident Mood Interview.

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OSA When Therapy Services End

No, the OSA is required when all therapy services end if the resident has a State Medicaid (Z0200) Rehab RUG classification RAA, RAB, RAC, RAD, or RAE on their most recent assessment, either an OBRA assessment with ARD on or before 9/30/2023, or an OSA with ARD 10/1/2023, or later.

No, if therapy treatment was not provided, the OSA is not required.

No, the OSA is only required when all therapy ends if the most recent assessment, either an OBRA assessment with ARD on or before 9/30/2023, or an OSA with ARD 10/1/2023 or later, resulted in a State Medicaid (Z0200) Rehab RUG classification of RAA, RAB, RAC, RAD, RAE.

Yes, an OSA is required, regardless of the number of disciplines providing service. If the State Medicaid RUG classification (Z0200) on the most recent assessment, either an OBRA assessment with ARD on or before 9/30/2023, or an OSA with ARD 10/1/2023 or later, is a Rehab RUG classification, the OSA is required.

Yes; if the resident is receiving “skilled” therapy services outside of the facility during the look-back period of an assessment, the therapy services would be coded on the Minimum Data Set (MDS). If the resident received enough therapy to qualify for a Rehabilitation Resource Utilization Group (RUG) classification on their most recent assessment, either an OBRA assessment with ARD on or before 9/30/2023, or an OSA with ARD 10/1/2023 or later, an OSA is required when therapy services end, regardless of where the services were provided.

If the resident has a State Medicaid (Z0200) Rehab RUG classification RAA, RAB, RAC, RAD, RAE, the OSA is required when all therapy services end. Starting or continuing a RNP is not a consideration when determining if the OSA is required.

If the resident dies or is Discharged Return Not Anticipated (DRNA) on or prior to day eight, the OSA is not required. If the resident is Discharged Return Anticipated (DRA) on or prior to day eight and their most recent assessment, either an OBRA assessment with ARD on or before 9/30/2023, or an OSA with ARD 10/1/2023 or later, resulted in a State Medicaid (Z0200) Rehab RUG classification RAA, RAB, RAC, RAD, RAE, the OSA is required. The Assessment Reference Date (ARD) of the OSA must be set on day eight after reentry to the facility. The day of reentry to the facility is considered day one when determining the ARD.

If the resident will continue to qualify for a State Medicaid Rehab RUG classification, the OSA is not required. However, if therapy services resume prior to or on day eight and the therapy services change to such a degree that the resident will no longer qualify for a State Medicaid Rehab RUG classification by day eight, the OSA is required.

If the resident is discharged after the ARD of the End of Therapy OSA, but prior to the completion deadline of the assessment (day 14 after the ARD), the OSA is still required.

If therapy resumes prior to day eight after reentry and the resident will again qualify for a State Medicaid Rehab RUG classification, the OSA is not required until all therapy services are discontinued.

The resident’s payer source is not considered when determining whether an OSA must be completed. A change in payer source does not require an OSA. If there is no break in therapy services when the resident’s payer source changes, the OSA is not required until all therapy services have ended. If all therapy services are discontinued and then resumed on or prior to day eight and the resident continues to qualify for a State Medicaid Rehab RUG classification, the OSA is not required until all therapies are again discontinued. However, if therapy resumes on or prior to day eight and the resident no longer qualifies for a State Medicaid Rehab classification, the OSA is required.

Yes, the ARD of this assessment must be set on day eight after all therapy services have ended. The last day therapy was provided is considered day (zero) 0, the first day with no therapy is day (one) 1 when determining the ARD of the assessment. Assessments with late ARDs will receive a penalty. The penalty will be in effect from the time the assessment was due until the first of the month following submission and acceptance of the assessment into the iQIES system.

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OSA When Isolation Services End

No, if isolation was not coded on the most recent assessment, either an OBRA assessment with ARD on or before 9/30/2023, or an OSA with ARD 10/1/2023 or later, the OSA is not required. If the State Medicaid Billing (Z0200) classification is an ES1, isolation was coded on the MDS. There are times when isolation is coded on the MDS and the classification is not an ES1. If the resident had an ADL Score of 0-1 and isolation was coded on the MDS, the classification assigned will be either a CA1 or CA2, not a ES1.

If the resident dies or is DRNA prior to or on day 15, the OSA is not required.

However, if the resident is DRA on or prior to day 15, and if isolation was coded on their most recent assessment, either an OBRA assessment with ARD on or before 9/30/2023, or an OSA with ARD 10/1/2023 or later, and the assessment resulted in a State Medicaid RUG classification of ES1, CA1, or CA2, the OSA is required when isolation services end. The ARD of the OSA must be set on day 15 after reentry to the facility. The day of reentry is considered day one when determining the ARD.

Yes, the ARD of this assessment must be set on day 15 after all isolation services have ended. The last day the resident was in isolation is considered day (zero) 0, the first day out of isolation is considered day (one) 1 when determining the ARD of the assessment. Assessments with late ARDs will receive a penalty. The penalty will be in effect from the time the assessment was due until the first of the month following submission and acceptance of the assessment into the iQIES system.

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Completing Section S of the OBRA

The instructions for completing Section S are found in Appendix D of the Minnesota Case Mix Review Manual (PDF).

The addition of Section S on the Federal OBRA assessments does not eliminate the need to complete an assessment when all isolation services end.

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Troubleshooting

We ask that the OSA and OBRA assessments be submitted in the same batch to minimize validation errors and prevent assessment processing delays. Submitting these assessments on the same day would also prevent these issues. We recognize that one of the assessments may be rejected which may prevent submitting the assessments on the same day. In this situation, the rejected assessment should be corrected and submitted as soon as possible. We do not apply a penalty if the OSA and OBRA assessments are not submitted in the same batch or on the same day.

There is nothing further you need to do. Sometimes when the OSA and OBRA assessments are submitted in the same submission batch you may get a warning that it is late. The warning is caused by the order in which the assessments were processed by CMS. This is just a warning, the assessment was accepted, and you can ignore the warning. CMS is working on resolving this warning issue.

While the data specs for A2400B/C do allow one to skip these items, the data specs for A0300B indicate if the item is coded a “2” the Start and End Dates of the Medicare stay cannot be dashed or blank. Going forward, A0300B should be coded a “5” on all OSA assessments. This will prevent submission problems and eliminate the need to look up the Start and End dates of the Medicare Part A stay when the assessment is completed.

Most often this occurs when there are discrepancies between what is coded on the OBRA assessment and the OSA. When the OBRA assessment and OSA have the same ARD, if an item appears on both the OBRA assessment and the OSA, the responses must match. Double-check the entries on both assessment and make the necessary corrections.

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Last Updated: 02/20/2024