Update of Minor changes

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Section

B.5.
Small
Entities

In the final rule CMS-1351-F, CMS 25% of the total
SNF number are non-profit. This equates to 3,597 nonprofit SNFs.

Change
SNFs are required to complete a COT OMRA when a
SNF resident was receiving a sufficient level of
rehabilitation therapy to qualify for an Ultra High,
Very High, High, Medium, or Low Rehabilitation
category and when the intensity of therapy (as
indicated by the total reimbursable therapy minutes
(RTM) 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 assessment used for Medicare payment.
In the proposed rule CMS-1622-P, CMS identified
25% of the total SNF number are non-profit. This
equates to 3,678 non-profit SNFs.

B.5.
Small
Entities

We estimate the average number of COT OMRAs to be
completed will equal 62 per year per facility and will be
the same across all respondents based on guidance
provided in CMS-1351-F.

Based on our analysis of assessments completed
during FY 2014, we estimate the average number of
COT OMRAs to be completed will equal 44 per year
per facility

Updated to reflect most recent
data.

B.6.
Collection
Frequency

We need to collect this information when there is a
change in the RTM as calculated over a seven-day span
based on the Assessment Reference Date (ARD).
Because providers currently are not required to report
the RTM that occur outside the observation window of
a given PPS assessment, we do not have the relevant
data to predict with certainty the number of COT
OMRAs that may be required per year. However, we
have attempted to use the administrative data currently
available as a reasonable proxy to determine estimates
of provider burden.

Based on our analysis of assessments completed
during FY 2014, we estimate the average number of
COT OMRAs to be completed will equal 44 per year
per facility. The number of stays for FY2014 FY
2014 was approximately 2.63 million.

When
estimates
were
originally made, we did not
have the relevant data to
predict the amount of COTs
which would be done yearly.
We were also unsure about
how
COTs
would
be
completed when therapy was
increased versus decreased.
We now have that data and
have determined that we do
not need to separate the data
on COTs completed when

A.
Background

Original
SNFs will be required to complete a COT OMRA only
when the intensity of therapy (i.e., the total count of
Reimbursable Therapy Minutes (RTM)) actually being
furnished 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 assessment used for Medicare payment.

The number of stays for 2009 was approximately 2.26

Rationale
Revised to match clarified
instructions in MDS3.0 RAI
Manual.

Updated to reflect most recent
data.

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million. Based on a 30-day average length of stay for
RUG-IV, we believe the average number of times that a
COT OMRA would need to be completed due to a
decrease in therapy is once per stay. Based on our
review of the first eight months of FY 2011 data, we
found that approximately 40 percent of the claims
resulted in assignment to a higher-than-projected
Rehabilitation RUG. A possible reason for the
difference between projected and actual FY 2011 RUGIV case-mix utilization could involve instances where
the intensity of therapy actually being furnished
changed (that is, decreased) within the payment period
to such a degree that it no longer reflected the RUG-IV
classification and payment assigned for a given SNF
resident based on the most recent assessment used for
Medicare payment. As discussed, previously, if such
changes or decreases in therapy utilization occur
outside the observation window of a given PPS
assessment, and the provider would continue to be
reimbursed under a higher-paying Rehabilitation RUG
until the next PPS assessment.
For FY 2012, providers will be required to complete a
COT OMRA in these situations. Although we believe
that only some of the 40 percent difference is likely
attributable to these instances, the 450 percent would
provide a quantifiable maximum burden estimate for
these cases. At this time, we are unable to determine
other quantifiable estimates for decreases in therapy
utilization necessitating a COT OMRA. Using the
percentage of claims resulting in a higher-thanprojected Rehabilitation RUG as a way to estimate the
maximum number of times that a therapy decrease
could result in the need for a COT OMRA, 40 percent
of 2.26 million, or 813,074 stays, could be affected.

Change

Rationale
therapy is increased versus
decreased.

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Original
The total number of estimated COT OMRAs per SNF
for FY 2011 would be 57.

Change

Rationale

Initially, when the COT was introduced, we
increased the MDS burden on skilled nursing
facilities by requiring the completion of the COT
OMRA when a SNF resident was receiving a
sufficient level of rehabilitation therapy to qualify for
an Ultra High, Very High, High, Medium, or Low
Rehabilitation category and when the intensity of

We decreased the burden
estimate based on the current
and updated data that was not
available when this was
originally proposed.

In addition, the COT OMRA can be used when
providers increase the amount of therapy provided. As
stated above, providers currently are not required to
report RTM that occur outside the observation window
of a given PPS assessment; therefore, we do not have
the relevant data to predict with certainty the number of
COT OMRAs that may be required per year due to an
increase in therapy. We have used the historical data
available at this time to quantify situations where an
increase in therapy occurs. The Start-Of-Therapy
(SOT) OMRA represents situations where therapy has
increased to a level significant enough to change the
RUG to a therapy RUG. The estimate for the possible
number of times that a CT OMRA would be required
due to an increase in therapy uses the number of SOT
OMRAs as a proxy. Using the number of SOT
OMRAs completed in the first eight months of FY
2011, projected for the entire year, we estimate that the
total COT OMRAs required due to an increase in
therapy would be 71, 330, or 5 times per facility per
year.
Therefore, the estimated total number of COT OMRAs
per facility per year is 62.
B.12.
Burden
Estimate
(Total Hour
and Wages)

We have increased the MDS burden on skilled nursing
facilities by requiring the completion of the COT
OMRA when there is a significant change in the RTM
provided, and the therapy delivered over a seven day
period no longer reflects the RUG-IV classification and
payment assigned for a given SNF resident based on the
most recent assessment used for Medicare payment.

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Original

B.12.a.
COT OMRA
Preparation,
Encoding
and
Transmission
Time

According to the On-Line Survey and Certification
System (OSCAR) there were approximately 14,266
skilled nursing facilities certified to participate in the
Medicare program during the FY 2011 year- to-date
projections. We anticipate the average number of COT
OMRAs requiring completion due to an increase in
therapy to be one for average 30-day SNF stays. For
CY 2009 there were approximately 5.7 million claims,
90 percent having a RUG-IV group containing
rehabilitation. The number of stays for CY 2009 was
roughly 2.26 million (2,258,539).
Therefore, 2,032,685 stays (2,258,539 stays * .90) are
estimated to be classified into a rehabilitation category.
In our FY 2011 year-to-date projection from the first
eight months of data, approximately 40 percent of the
claims resulted in a higher than projected rehab RUG.
Using this as a way to estimate the maximum number
of times that a therapy decrease could result in the need
for a COT OMRA, 40 percent or 813,074 stays could
be affected. The total number of annual estimated stays
per SNF for FY 2011would be 57. (813,074)/14,266
SNFs = 57 stays per facility with a decrease in therapy
per SNF per year.)

Change
therapy (as indicated by the total reimbursable
therapy minutes (RTM) 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 assessment used for
Medicare payment. However, with this current
reinstatement of the COT OMRA and updated data
for the current reporting period, we have decreased
the burden estimates to complete this assessment.
According to the On-Line Survey and Certification
System (OSCAR), there were approximately 15, 421
skilled nursing facilities in FY 2014. Based on our
analysis of assessments completed during FY 2014,
we anticipate the average number of COT OMRAs
requiring completion per facility per year to be 44.
We estimate that it will take 50 minutes (0.8333
hours) to collect the information necessary for coding
a COT OMRA, 10 minutes (0.1667 hours) to code
the responses, and 2 minutes (0.0333 hours) to
transmit the results, or a total of 62 minutes (1.0333
hours) to complete a single COT OMRA.
The total estimated hours for COT OMRA
preparation, coding and transmission are 701,119
hours/year (565,414 + 113,110 + 22,595). The
break-out for each component of this estimate is
shown below.

COT Preparation:
Average No. of

Completion

Total Annual

Rationale

Time Burden decreased based
on actual and current data
used as opposed to predicted
data.

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Although the estimate cited above represents a proxy
for times where a COT will be used to report decreases
in therapy, we anticipate this will be an overestimate in
total payment impact as providers will likely react by
supplying therapy needed to maintain the reported RUG
level.
In addition, the COT OMRA can be used when
providers increase the amount of therapy provided.
The Start of Therapy (SOT) OMRA represents
situations where therapy has increased to a level
significant enough to change the RUG. We provide
estimates for the possible number of times that a COT
would be required due to an increase in therapy based
on the number of SOT OMRAs as a proxy. Using the
first eight months of FY 2011 projected for the entire
year, we estimate the number of SOT OMRAs to be
approximately 5 per facility. Therefore, we believe the
estimate of 57 stays per SNF needing a COT OMRA
for decreased therapy levels and 5 COTs per facility per
year for increased therapy levels to be reasonable.
As stated above, the FY 2011 year-to-date projection
from the first eight months of data, indicates that
approximately 40 percent of the claims resulted in a
higher than projected rehab RUG. The case-mix for
the ultra-high and very high rehab categories was much
higher than expected and the case-mix utilization for
the high and medium rehab categories were lower than
expected. Using this information, we calculated an
estimated dollar impact based on the FY 2011 SNF PPS
rates in cases where a COT would be required due to a
decrease in therapy. We used a resource utilization shift
from an ultra-high level of rehab, RUC ($634.27), to a

Assessments
Reporting
44 Per
Respondent/year

Change
Time/COT

0.8333 hrs

Rationale
Hour Burden

565,414
hours/year

COT Coding:
Average No. of
Assessments
Reporting

Completion
Time/COT

Total Annual
Hour Burden

44 Per
Respondent/year

0.1667 hrs

113,110
hours/year

COT Transmission:
Average No. of
Assessments
Reporting

Completion
Time/COT

Total Annual
Hour Burden

44 Per
Respondent/year

0.0333 hrs

22,595
hours/year

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high level of rehab, RHC ($487.76), for urban providers
as a reasonable estimate to determine payment
differences after a required COT due to a decrease in
therapy. The payment difference between RUC and
RHC is $146.51 per day. With over 79 percent of stays
being 30 days or less, and assuming that half of the 30day stay (15 days) represented a decrease in therapy
levels (essentially one of the two assessments during
this time), there would be a $2,197.65 ($146.51 * 15)
difference per stay in payment after billing at the new
COT RUG level. With approximately 813,074 stays per
year involving a COT with decreased therapy, this
results in a possible savings of $1,786,852,164.
For those COTs completed for an increase in therapy,
we estimated possible increases in expenditures based
on a case-mix utilization shift from rehab medium
utilization, RMC ($434.73), to rehab very high
utilization, RVC ($551.51). Our projected utilization
anticipated 70 percent of all days to be in the RM, RH
or RV rehabilitation categories. Therefore, we believe
an estimate based on a shift from the lowest to highest
rehabilitation category in this range is reasonable. The
payment difference per day for a shift from RMC to
RVC is $116.78 per day. Again, half of a 30-day stay
would result in an increase payment of $1,751.70
($116.78*15) per stay. With an average of 5 stays for
14,266 facilities needing a COT OMRA for increases in
therapy, the increase in expenditures for all facilities for
one year is estimated to be $124,948,761.
Combining the anticipated savings from the COTs
involving decreased therapy ($1,786,852,164), with the
COTs involving increased therapy ($124,948,761), the
net savings is approximately $1,661,903,403.

Change

Rationale

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Change

We note that the estimate cited above generates savings
from situations where a COT will be used to report
decreases in therapy. We anticipate this will be a
significant overestimate in total payment impact as
providers will likely react by supplying therapy needed
to maintain the reported RUG level.
We estimate that, based on average burden associated
with the End-Of-Therapy (EOT) OMRA, which uses
the same basic item set as the COT OMRA, it will take
50 minutes (0.8333 hours) to collect the information
necessary for coding a COT OMRA, 10 minutes
(0.1667 hours) to code the responses, and 2 minutes
(0.0333 hours) to transmit the results, or a total of 62
minutes (1.0333 hours) to complete a single COT
OMRA.
The total estimated hours for COT OMRA preparation
for both decreased and increased therapy hours, coding
and transmission are 913,884 (677, 562+ 135,512+ 27,
102) + (59,442 + 11,888 + 2,378). The break-out is
shown below.

Average No. of
Assessments
Reporting

Completion
Time/COT

Total Annual
Hour Burden
[Hours per
response*813,074
(# of RUG-IV
stays subject to
COT for
decreased

Rationale

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Change
therapy)]

57 Per
Respondent/year

0.8333 hrs

677,552
hours/year

Average No. of
Assessments
Reporting

Completion
Time/COT

Total Annual
Hour Burden
[Hours per
response*71,330
(# of RUG-IV
stays subject to
COT for
increased
therapy)]

5 Per
Respondent/year

0.8333 hrs

59,442
hours/year

Average No. of
Assessments
Reporting

Completion
Time/COT

Total Annual
Hour Burden
[Stays subject
to COT for
increased
and
decreased
therapy)]

62 Per
Respondent/year

0.8333 hrs

737,003
hours/year

Rationale

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COT Coding: Increased and Decreased
Therapy
Average No. of
Assessments
Reporting

Completion
Time/COT

Total Completion
Time [Hours per
response*813,074
(# of RUG-IV
stays subject to
COT for
decreased
therapy)]

57 per
Respondent/year

0.1667 hrs

135,512
hours/year

Average No. of
Assessments
Reporting

Completion
Time/COT

Total Annual
Hour Burden
[Hours per
response*71,330
(# of RUG-IV
stays subject to
COT for
increased
therapy)]

5 Per
Respondent/year

0.1667 hrs

11,888
hours/year

Average No. of
Assessments

Completion
Time/COT

Total Annual
Hour Burden

Change

Rationale

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Reporting

62 Per
Respondent/year

Change
[Stays subject
to COT for
increased
and
decreased
therapy)]

0.1667 hrs

147,401
hours/year

COT Transmission: Increased and
Decreased Therapy
Average No. of
Assessments
Reporting

Completion
Time/MDS

Total Completion
Time [Hours per
response*813,074
(# of RUG-IV
stays subject to
COT for
decreased
therapy)]

57 per
Respondent/year

0.0333 hrs

27,102 hrs/year

Average No. of
Assessments
Reporting

Completion
Time/COT

Total Annual
Hour Burden
[Hours per
response*71,330

Rationale

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Change

Rationale

To calculate burden, we obtained hourly wage rates
for Registered Nurses (RNs) and data operators from
the Bureau of Labor Statistics. MDS preparation
costs were estimated using RN hourly wage rates of
$62,440 per year, $0.50/minute without consideration
of employee benefit cost and $0.65/minute after
application of a 30 percent increase to account for
employee benefit compensation cost. For coding

Updated to account for latest
salary data from the Bureau of
Labor and Statistics.

(# of RUG-IV
stays subject to
COT for
increased
therapy)]
5 Per
Respondent/year

B. 12. B.
Estimated
Costs
Associated
with COTOMRA

0.0333 hrs

2,378 hours/year

Average No. of
Assessments
Reporting

Completion
Time/COT

Total Annual
Hour Burden
[Stays subject
to COT for
increased
and
decreased
therapy)]

62 Per
Respondent/year

0.0333 hrs

29,480
hours/year

To calculate burden, we obtained hourly wage rates for
Registered Nurses (RNs) and data operators from the
Bureau of Labor Statistics. MDS preparation costs
were estimated using RN hourly wage rates of $56,060
per year, $0.45/minute without consideration of
employee benefit cost and $0.58/minute after
application of a 30 percent increase to account for
employee benefit compensation cost. For coding

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functions we used a blended rate of $41,090; this was
the average for RNs ($56,060/yr) and data operators
($26,120/year). The blended rate calculates to $0.33
per minute without consideration of employee benefit
cost and $0.43 after application of a 30 percent increase
to account for employee benefit compensation cost. The
blended rate of RN and data operator wages reflects the
fact that SNF providers have historically used both RN
and support staff for the data entry function. For
transmission personnel, we used data operator wages of
$26,120 per year, or $0.21 per minute without
consideration of employee benefit cost and $0.27 after
application of a 30 percent increase to account for
employee benefit compensation cost
MDS
Function

Total
Minutes
Per
Respondent

Per
Loaded $
Rate

Estimated
Cost Per
Respondent
Per COT

COT
Preparation
COT Coding
Cot
Transmission
Total

50

$0.58

$29.00

Annual Cost
Burden
[(Annual
Hour
Burden in
Minutes*
60) *
minute
rate)]
$25,647,717

10
2

$0.43
$0.27

$4.30
$0.54

$3,802,937
$477,578

62

$1.28

$33.84

$29,928,233

There were 14,266 skilled nursing facilities which
sought reimbursement under the year-to-date projected
SNF PPS during FY 2011. The cost per facility would
be $2,097.87 ($29,928,233/14,266 facilities), assuming
57 stays involving 1 COT of decreasing therapy per
stay per year per facility, and, 5 COTs involving
increasing therapy per facility per year.

Change
functions we used a blended rate of $48,275; this was
the average for RNs ($62,440/yr) and data operators
($34,110/year). The blended rate calculates to $0.39
per minute without consideration of employee benefit
cost and $0.51 after application of a 30 percent
increase to account for employee benefit
compensation cost. The blended rate of RN and data
operator wages reflects the fact that SNF providers
have historically used both RN and support staff for
the data entry function. For transmission personnel,
we used data operator wages of $34,110 per year, or
$0.27 per minute without consideration of employee
benefit cost and $0.35 after application of a 30
percent increase to account for employee benefit
compensation cost
MDS
Function

Total
Minutes
Per
Respondent

Per
Loaded
$ Rate

Estimated
Cost Per
Respondent
Per COT

Annual
Cost
Burden
[(Annual
Hour
Burden in
Minutes*
60) *
minute
rate)]

COT
Preparation

50

$0.65

$32.50

$22,052,030

COT Coding

10

$0.51

$5.10

$3,460,47

Cot
Transmission

2

$0.35

$0.70

$74,967

Total

62

$1.51

$38.30

$25,987,469

There were 15,421 skilled nursing facilities which
sought reimbursement under the year-to-date
projected SNF PPS during FY 2014 The cost per
facility would be $1,685.20 ($25,987,469/15,421

Rationale

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Change
facilities), assuming 44 COTs per facility per year.

Rationale