MDS Alert

Published on Wed Aug 23, 2006 PDF

These easy-to-spot inconsistencies signal potential payment woes.

UB-92s can give you a quick heads up that all is not well with your MDSs or service delivery for rehab residents.

For example, if the UB-92 shows that a resident received enough therapy to go into a rehab RUG, you should question why he's not in one.

In such a case, "there's probably an MDS error" or staff didn't set the assessment reference date "to capture all the therapy," says Marc Zimmet, MBA, of Zimmet Healthcare Services Group LLC in Morganville, NJ. The firm reviews about 20,000 UB-92s for its nursing home clients monthly, looking for obvious or sometimes subtle inconsistencies.

Examples: Say a patient missed one day of therapy on a Thursday. And the MDS team set the ARD so that they only captured four days of therapy in the seven-day lookback instead of the requisite five days.

But "if the team had selected a different ARD, the resident might have gone into a more appropriate, higher paying rehab RUG. Or the rehab therapist could have come in on Saturday or Sunday to make up the day of therapy," Zimmet says.

In an extreme example, a resident who received rehab and also had an IV in the lookback might miss going into an RMX due to the above scenario, cautions Zimmet. Instead, he might go into SE1, which is about $160 less a day than RMX (federal unadjusted urban rates), he says.

Differentiate between care pattern and care capture: Zimmet has done reports for facilities where a clinical person will say: "How dare you tell me this resident should have been rehab!"

In such cases, Zimmet explains to the person how care capture differs from a care pattern. "We'll say: You provided the rehab, but you didn't capture it."

When the Minutes Don't Jibe With the Rehab RUG

When Zimmet sees from the UB-92 that a resident in a medium rehab RUG averaged 600 minutes of therapy, he knows to look more closely. Either the team didn't plan the ARD appropriately to capture the rehab minutes--or someone made an error in entering the number of therapy minutes in Section P, he says.

Tip: If someone enters 105 instead of 150 minutes in Section P, a resident who should have gone into a rehab RUG may fall into a non-rehab RUG, says Zimmet.

Preempt inaccuracies: To prevent errors, designate someone to check the actual therapy records against what has been entered into the P1b section, suggests Pauline Franko, a physical therapist and principal of Encompass Consulting & Education LLC in Tamarac, FL. 
 
This ADL Decline Is Likely Due to Undercoding

Say a new Medicare admission receives ultra-high intensity therapy and goes into RUA on the 5-day assessment. Residents with ADL scores of 4-8 go into RUA.

Then on the 14-day MDS, the resident jumps up to RUB, which includes residents with ADL scores of 9-15. That change in RUGs "indicates that the person received a ton of therapy but his ADL score declined," explains Zimmet.

In such scenarios, "we find 99 percent of the time that the facility undercoded the resident's ADLs on the 5-day assessment," Zimmet points out.

The net effect: The resident appears to have declined from the 5-day to the 14-day assessment when that wasn't really the case, he says.

Diagnosis Codes Can Signal An Ailing Claim

The principal diagnosis code (field 67) should support the rehab RUG, says Zimmet.

Red flag example: A principal diagnosis of pneumonia for an extended program of ultra-high rehab could put the claim at risk for audit, says Zimmet. "There is often an appropriate diagnosis," he adds.

Double check this: Look at what you've recorded as the resident's birth date in the background information. A 100-year-old patient getting ultra high rehab for 90 days "might raise a concern," says Zimmet.