Note: This article contains information based on the most current version of the CMS RAI Manual at the time the article was published. Providers are responsible for verifying any information below with the most current version of the CMS RAI Manual to maintain compliance with all federal regulations.
One frequent and hard to diagnose issue that we've seen can occur whenever a Start of Therapy OMRA assessment is submitted. If you are receiving the message "-3804: Inconsistent HIPPS code: If A0310C equals 1 or 3, then the first character of Z0100A calculated by the QIES ASAP System must equal R." on your Final Validation Report, this article might be able to help.
When most people see this error, the first thing they do is go and check Z0100A on their assessment to see if it begins with 'R'. If the RUG does not begin with R, you may want to check your assessment information and possibly your clinical system software vendor to ensure that your RUG values are calculating properly since CMS requires all SoT OMRA assessments to have a Z0100A RUG starting with 'R'.
If the RUG does begin with 'R', things are a little more complicated. CMS addresses this problem in the RAI Manual Chapter 6 in a special section labeled "Adjustment for Start of Therapy OMRA":
If an assessment is an SOT OMRA, indicated by MDS Item A0310C = 1 or 3, whether or not it is combined with other types of assessments, then the Medicare Index Maximized RUG-IV classification in item Z0100A must be a Rehabilitation Plus Extensive Services group or a Rehabilitation group. Lower classifications are not valid for Z0100A on an SOT OMRA.
If the Z0100A classification for any SOT OMRA (Item A0310C = 1 or 3) is not in a Rehabilitation Plus Extensive Services group or a Rehabilitation group, then the following adjustment should be made:
- The Medicare RUG-IV group reported in Item Z0100A should be adjusted to AAA (the default group), the assessment should marked as invalid, and the assessment should be barred from submission. The Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system will reject the assessment if submitted.