MDS Alert

Published on Sun May 01, 2011 PDF

Making this simple check can keep you from holding the bag for rehab services.

Your RUG payments may be more at risk than you think if you haven't included these three strategies in your compliance efforts.

1. Keep tabs on what auditors are targeting. Consultant Elisa Bovee, MS, OTR/L, is seeing automated reviews targeting ICD-9 coding -- for example, looking at having speech involved where there's an orthopedic diagnosis for therapy. "We are also seeing therapy targeted when it's provided within the 60-day payment window," adds Bovee, VP of operations at Harmony Healthcare International in Topsfield, Mass.

Atlanta consultant Darlene Greenhill is seeing audits where "the focus appears to be on medical necessity of ultra high and very high RUGs on the 60-day MDS assessment."

2. Make sure residents actually received five days of therapy in the seven-day lookback. Sherri Robbins, RN, BSN, reports seeing instances where facilities accidentally bill a rehab HIPPS for a resident who didn't really receive five days of therapy as required to meet the criteria for skilled rehab under Part A.

In such cases, "there are five days of therapy across the various disciplines," says Robbins, supervising consultant at BKD LLP in Springfield, Mo. But when you look at the logs, there aren't five different days of therapy provided in the lookback. That occurs because the facility's "software simply adds the number of days across disciplines," she explains.

"Usually what happens is the therapy manager just gives the MDS coordinator the days and the individual, concurrent, and group therapy minutes," Robbins explains. "But the MDS coordinator doesn't look closely at the therapy treatment logs." Robbins notes, however, that she's talked to some therapy program managers who didn't realize when looking at the logs that a resident hadn't received the requisite five days of therapy.

Key: "Someone needs to sit down with the logs and, starting with the assessment reference date, count backwards seven days and record the number of minutes per discipline per day," Robbins advises.

3. Get the team with the rehab program. Greenhill is encouraging nurses to become more involved in rehab therapy overall so they "know what's happening and why. The MDS coordinators, in particular, should know whether a resident is receiving individual, concurrent or group therapy" to ensure the coding is correct on the MDS. She notes, however, that, in some cases, therapists, especially in large facilities, may be treating a large number of residents in the therapy room. "And staff doesn't know if they are treating one or two or a group or what's happening."

Greenhill advocates discussing this issue more often in Medicare meeting and conducting self-audits. "The bottom line is that if something goes wrong -- the facility is responsible."

Tip: When the team doesn't discuss therapy residents in the Medicare meeting, you see conflicts in the medical record documentation, Greenhill observes. "We even had a claim that went to medical review where the staff found when compiling the paperwork and documentation that the patient had refused therapy for a couple of weeks," she says. "And the facility mistakenly kept billing Medicare."