The purpose of this article is to review the guidelines for the completion of an Omnibus Budget Reconciliation Act of 1987 (OBRA) Significant Change in Status Assessment (SCSA) and the Skilled Nursing Facility Prospective Payment System (SNF PPS) Interim Payment Assessment (IPA). Because there are both similarities and differences between these two assessments, it is important to understand when each assessment should be completed. The instructions for the SCSA and IPA assessments can be found in Chapter Two of the RAI Manual.
The SCSA is a comprehensive OBRA assessment that must be completed when the interdisciplinary team (IDT) determines that a resident meets the significant change criteria either for a major improvement or decline. This assessment is completed on any resident regardless of payor source. A significant change is defined as a major decline or improvement in a resident’s status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered to be self-limiting; impacts more than one area of the resident’s health condition; and requires interdisciplinary review and/or revision of the care plan. A condition is “self-limiting” when the issue will normally resolve itself without further intervention or by staff implementing standard disease-related clinical interventions within two weeks. Thus, providers have up to 14 days to determine if a resident meets the criteria for a Significant Change in Status Assessment.
An SCSA may be appropriate if there are either two or more areas of decline or two or more areas of improvement in the resident’s health status. However, staff may still decide that a resident would benefit from an SCSA even if there is only one change. Some examples of areas of a decline or improvement may include decision-making ability, mood changes, behavioral symptoms, activities of daily living (ADLs), continence patterns, weight loss, and pressure ulcers. This is not an exhaustive list of conditions that may or may not be present when a significant change is deemed necessary by the IDT. It is also important to mention that an SCSA must be completed when a resident enrolls in hospice, changes hospice providers, or revokes hospice services.
The Interim Payment Assessment is an optional assessment that can be completed any time after the PPS 5-day assessment for Medicare A beneficiaries. This assessment sets the payment for the remainder of the Part A stay beginning on the assessment reference date (ARD). The IPA may not be combined with any other assessment. When providers decide that there has been a change in a resident’s clinical or functional status that differs from their initial Patient Driven Payment Model (PDPM) classification, an IPA may be completed.
The RAI Manual does not specify criteria in which an IPA should be completed. Instead, the Centers for Medicare and Medicaid Services (CMS) leaves this decision up to the facilities. Therefore, it is necessary for providers to continuously monitor the condition of each resident in order to determine when a resident has undergone a clinical change that would give consideration to a new PPS assessment. The IPA is an assessment that facilities can utilize to carry out the ongoing monitoring of each resident and is not strictly limited to payment alone. Each facility should have strong processes to promptly identify clinical changes that may impact PDPM case-mix group classifications, as well as a policy and procedure outlining when an Interim Payment Assessment is to be completed.
To better understand both assessments, we will look at some examples as to when each should be completed. A scenario for when a Significant Change in Status Assessment should be performed: Mr. S. previously required supervision with setup help for his ADLs. He had a fall which resulted in a fractured hip. He now requires extensive assistance with all ADLs. Rehabilitation has started and staff is hopeful that he will return to his prior level of function in four to six weeks. An example of when an Interim Payment Assessment should be conducted: Mrs. E. is a Part A beneficiary in your facility for rehabilitation following a hip fracture. Her initial PDPM nursing category was Reduced Physical Function with no Non-Therapy Ancillary (NTA) services. During her stay, she develops pneumonia with a fever, and intravenous (IV) antibiotics are started. She has also become more dependent with her ADLs. Because of the combination of pneumonia with a fever, she now qualifies for the Special Care High nursing category. The administration of IV antibiotics has also increased her NTA comorbidity score by five points. Completing an IPA for this resident would increase the facility’s per diem rate due to the increase in both the Nursing and Non-Therapy Ancillary components.
Both the SCSA and the IPA are assessments that are to be completed when a resident has undergone a clinical change in status. The SCSA is an OBRA required assessment and may be completed for any resident regardless of payor source when the facility concludes that a resident has met the criteria for a Significant Change. The Interim Payment Assessment is optional and is to be completed only for Medicare Part A beneficiaries when the facility determines that the resident has experienced a clinical change that warrants a new PPS assessment. A resident may qualify for both assessments; however, these assessments must be completed separately.