Minnesota Case Mix Review Program

This information is intended for Long Term Care Facility Administrators, Directors of Nursing, Minimum Data Set (MDS) Coordinators, and staff who work with the MDS.

Admission Assessment Issue

Summary of the Issue

An Admission assessment processing issue has been identified when a resident is admitted in September and the Admission assessment ARD (Assessment Reference Date) is set on 10/1/2025, or later. The Centers for Medicare and Medicaid Services (CMS) will reject all Optional State Assessments (OSAs) with an ARD of 10/1/2025, or later.

Implications

As a result of this CMS restriction, facilities are unable to obtain the necessary Resource Utilization Group (RUG-IV) classification for September billing when the ARD of the Admission assessment falls on 10/1/2025, or later. This directly affects reimbursement and may create challenges in revenue cycle management for residents admitted in late September.

Admission Assessment Recommendations

If possible, for residents admitted in late September, ensure the ARD of the Admission/OSA assessment is set no later than 9/30/2025. Admission/OSA assessments with an ARD of 9/30/2025, or earlier, will yield both a RUG-IV and PDPM (Patient Driven Payment Model) classification.

For residents admitted in late September 2025 and the Admission ARD is set on October 1 or later, the facility is required to complete both an Admission assessment and an OSA with the same ARD.  Completing the OSA along with the Admission assessment ensures that the facility will receive a RUG-IV Case Mix classification for billing the September days of service and a PDPM classification for billing on Oct. 1 and later.

The OSA should NOT be submitted to the Internet Quality Improvement and Evaluation System (iQIES) the Centers for Medicare & Medicaid Services (CMS). However, the OSA must be faxed to the Minnesota Department of Health at 1-800-348-0191 by Oct. 31. Failure to meet this requirement will result in a penalty for all days of service provided in September 2025.

The Case Mix Review Program staff will review these Admission/OSA assessments during the facility's scheduled pool audit to ensure compliance and accuracy.

Billing Consideration for Discharge Return Anticipated Residents

If a resident is Discharged Return Anticipated in September 2025 AND returns to the facility within 30 days of their discharge date AND their reentry date is on or after 10/1/2025, the facility would bill the PDPM classification on their most recent OBRA assessment completed prior to the resident’s discharge.

Contact Information

If you have any questions, please contact Case Mix Review by email at health.mds@state.mn.us.  

This information is intended for Long Term Care Facility Administrators, Directors of Nursing, Minimum Data Set (MDS) Coordinators, and staff who work with the MDS.

Admission Assessment Issue

Summary of the Issue

An Admission assessment processing issue has been identified when a resident is admitted in September and the Admission assessment ARD (Assessment Reference Date) is set on 10/1/2025, or later. The Centers for Medicare and Medicaid Services (CMS) will reject all Optional State Assessments (OSAs) with an ARD of 10/1/2025, or later.

Implications

As a result of this CMS restriction, facilities are unable to obtain the necessary RUG-IV classification for September billing when the ARD of the Admission assessment falls on 10/1/2025, or later. This directly affects reimbursement and may create challenges in revenue cycle management for residents admitted in late September.

Admission Assessment Recommendations

When possible, for residents admitted in late September, ensure the ARD of the Admission/OSA assessment is set no later than 9/30/2025. Admission/OSA assessments with an ARD of 9/30/2025, or earlier, will yield both a RUG-IV and PDPM (Patient Driven Payment Model) classification. When possible, avoid setting the ARD of the Admission assessment on or after 10/1/2025, as this will impede billing for the services provided in September.

Collaborative Resolution Efforts

We are actively engaging with CMS and the Minnesota Department of Human Services to address this assessment processing and billing concern. Additional guidance will be provided as the information becomes available.

Other Updates

The PDPM FAQ Updates

The PDPM Frequently Asked Questions document on the Case Mix Review Program Information for providers page has been updated to include new examples.

Case Mix Review Update
August 2025

This information is intended for Long Term Care Facility Administrators, Directors of Nursing, Minimum Data Set (MDS) Coordinators, and staff who work with the MDS.

Frequently asked Questions

• The Frequently Asked Questions and Transcript from the Provider Webinar are now posted on the Minnesota Case Mix Review Website Provider page.

Consumer Fact Sheets

• Patient Driven Payment Model (PDPM) Consumer Fact Sheets are now posted on the Minnesota Case Mix Review Website Consumer page. The RUG-IV Consumer Fact Sheets will remain on the website until Jan. 1, 2026.

MDS Supporting Documentation

• Supporting documentation used to complete the Minimum Data Set (MDS) must be documented in the medical record on or prior to the Assessment Reference Date (ARD). MDS coding must be consistent with the clinical assessments documented in the medical record and must be validated for accuracy by the staff completing the assessment. If there is no documentation to support the MDS coding during the look back period, a late entry note referencing the observation period will not be accepted.
• When discrepancies between the medical record documentation and the MDS coding exist, a clarification note must be written to explain: the rationale for the coding decision, how the information was obtained, and who provided it. Clarification notes can be written after the assessment ARD but must be documented prior to the MDS completion date. A clarification note is not used for a lack of documentation in the observation period. Late Entry clarification notes written after the MDS completion date will not be used to validate the MDS coding.

Internet Quality Improvement and Evaluation System (iQIES)

• The iQIES User Interface Tool will no longer receive updates after Oct. 1. Facilities who use the iQIES User Interface for manual completion and submission of their MDS’ will need to transition to vendor, third-party, or company software to complete MDS records within the next six weeks. All assessments with a target date of Oct. 1 and later must be submitted in XML format.

Contact information

If you have any questions, please contact Case Mix Review by email at health.fpc-cmr@state.mn.us or call 651-201-4200.

Provider Webinar July 16

This information is intended for Long Term Care Facility Administrators, Directors of Nursing, Minimum Data Set (MDS) Coordinators, and staff who work with the MDS.

Assessment Notice change

In July, the Assessment Notice located in the Case Mix Review (CMR) Portal will display the Resource Utilization Group (RUG)-IV classification along with the Patient Driven Payment Model (PDPM) Nursing Component classification. The RUG-IV classification will be effective as listed and the PDPM Nursing Component will be effective on October 1, 2025.

Minimum Data Assessment (MDS) requirement for October 1

• Effective October 1, the Optional State Assessment (OSA) will no longer be required as a standalone assessment after all therapy or isolation is completed or with any Omnibus Budget Reconciliation Act (OBRA) assessment.
• If the most recent assessment completed prior to October 1 is a standalone OSA, an OBRA assessment will need to be completed, submitted and accepted into the Centers for Medicare and Medicaid Services (CMS) data base on or before September 30 to calculate a PDPM Nursing Component classification effective October 1.
• Effective October 1, a Significant Change in Status assessment will need to be completed on day 15, after isolation services have ended.

MDS supporting documentation

• Case Mix Review staff will be looking for Functional Abilities supporting documentation on all three shifts during the observation period.
• The resident’s self-care and mobility performance is based on direct observation, incorporating resident self-reports, reports from qualified clinicians, care staff/nursing assistants, and family documented in the medical record during the observation period.
• Documentation to complete the MDS must be obtained and documented in the medical record on or prior to the Assessment Reference Date (ARD). MDS coding must be consistent with the clinical assessments documented in the medical record.

Internet Quality Improvement and Evaluation System (iQIES)

• The iQIES User Interface Tool will no longer receive updates after October 1. Facilities who use the iQIES User Interface for manual completion and submission of their MDS’ will need to transition to vendor, third-party, or company software to complete MDS records. All assessments with a target date of October 1 and later must be submitted in XML format.

Training opportunities

The Case Mix Review (CMR) Program at the Minnesota Department of Health is offering training regarding changes to assessments effective October 1. The training will be presented by the State RAI Coordinator, Nadine Olness, RN RAC-CTA and Robin Lewis, RN Minnesota Case Mix Review Program Supervisor.

Contact information

For questions, please reach out to the Case Mix Review team at Health.MDS@state.mn.us.

This information is intended for Long Term Care Facility Administrators, Directors of Nursing, Minimum Data Set (MDS) Coordinators, and staff who work with the MDS.

New data elements added to Quarterly Assessments

Effective 10/1/24, I0100 (Cancer), I3700 (Arthritis) and I6500 (Cataracts, Glaucoma and Macular Degeneration) are required on all quarterly assessments. These items do not appear on the Optional State Assessment (OSA) as they do not impact payment. Contact your software vendor if these items do not appear on your quarterly assessments.

Prevent delays in processing payments

• Staff must ensure that the Therapy and Isolation Start and End Dates are correctly entered on all Omnibus Budget Reconciliation Act (OBRA) comprehensive assessments, OBRA non-comprehensive assessments and OSA, when appropriate. When these dates are not on the assessment, this assessment will not be immediately processed, requiring a call from the Case Mix Review staff for further information.
• Staff must ensure the OBRA assessment and the corresponding OSA are submitted in the same batch.

When to complete an 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 not required with Perspective Payment System (PPS) assessments, Discharge Assessments and Tracking Records. 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 OSA resulted in a rehabilitation RUG-IV classification in Z0200A or isolation was coded on the assessment.
• The OSA should not be used as a standalone assessment to capture a higher RUG classification. When completing a Significant Change in Status Assessment (SCSA) staff must ensure the criteria on pages 2-24 to 2-29 of the current RAI manual is met. A SCSA is not required when all therapy or isolation services end.
• The OSA for the end of therapy and the end of isolation cannot have the same ARD as an OBRA assessment. When a OSA has the same ARD as a Quarterly or Comprehensive assessment, the effective date of the OSA is the first of the month following the ARD. The standalone OSA completed when therapy or isolation ends is effective on the ARD of the OSA.

Contact information

If you have any questions, please contact Case Mix Review by email at health.fpc-cmr@state.mn.us or call 651-201-4200.