MDS Alert

Published on Tue Jan 27, 2004 PDF

An audit in time can save more than your bottom line.

They say a picture is worth a thousand words, and if the SNF's UB-92s don't provide an accurate snapshot of the resident's actual condition and care - you may have some explaining to do.
 
Yet some facilities have lightened up on itemized billing under the Medicare PPS, which pays an all-inclusive rate based on a resident's RUG. They logically ask: Why bill for every wound-care supply or pharmacy item, etc., if we get paid the same rate anyway?
 
The answer, of course, is that the facility's bottom line is at stake. Fiscal intermediaries may end up denying claims that don't include services/supplies that support the RUG level billed.
 
For example, say a Medicare resident is skilled at SE3 under the presumption of coverage based on a hospital IV, posits Rena Shephard, MHA, RN, FACDONA, RAC-C, president of RRS Healthcare Consulting Services in San Diego, and chair of the American Association of Nurse Assessment Coordinators. "Up until the assessment reference date (ARD) for the 5-day assessment, the medical record and the claim would not be expected to include IVs or other medical services provided in the hospital," Shephard notes. But if the facility continued to skill the resident after the ARD, the medical record must reflect that the resident received a skilled level of care. "The FI might question why the UB-92 doesn't reflect services that support the RUG level billed beyond the ARD once the presumption of coverage no longer applies," she cautions.
 
In addition to potential claims denials, "facilities that don't itemize their billing can definitely encounter compliance issues," cautions Joseph Lubarsky, CPA, with the Milwaukee office of BDO Seidman LLP. "The Medicare charges on the facility's cost report should coincide to what's billed to Medicare," Lubarsky says. "And FIs do, to some extent, match UB-92s to the facility's cost report."
 
Watch Out: "If the UB-92 claim form contains charges that are not reflected in the medical record, the question of billing for services not actually provided may arise," Shephard cautions.

Do Presubmission Billing Audits
 
Thus, at a minimum, the MDS coordinator or RNAC and the person compiling the billing should review the claims before they go out the door to make sure they capture the services/items provided, advises Diane Martinez, RN, NHA, health care consultant with Parente Randolph LLC in Pittsburgh, PA. "If you have a daily Medicare meeting, review products and supplies and service utilization at that time," she advises.
 
Don't Overlook: Also make sure the MDS and UB-92 include diagnoses to support the RUG and services billed to Medicare. "Double check the diagnoses on the MDS and coded on the UB-92 to make sure they support clinical services - for example, finger sticks for diabetics or wound supplies and care for pressure sores," advises Nancy Augustine, RN, MSN, director of quality improvement and risk management for LTCQ Inc. in Lexington, MA.
 
The more people eyeballing the MDSs and billing, the better, in Augustine's view. "The wound care nurse, for example, may know a resident is receiving certain supplies, and therapy will have a better idea of the minutes of therapy received by the resident." Rehab could thus catch an errant rehab RUG score.

Keep Your Cash Flowing
 
Of course, you don't want your UB-92 reviews to bog down your billing and bottleneck cash flow. "If you have to hold up billing to hunt down information to support billing, then your system needs to be fixed," Martinez emphasizes. "You should have systems in place to have some assurance that you are capturing the information for itemized billing on  a daily basis. The preferred method of capturing charges is an electronic system, such as a bar code system,  that records daily supplies and products used by each resident," she adds.
 
Some facilities agree presubmission UB-92 audits are a good idea but fear they will take too much staff time. That's not the case, though, if you put together a good method for gathering the backup information and have skilled people performing that function, says Carolyn Lehman, MSN, RN, NHA, a nurse consultant with Howard, Wershbale & Co. in Cleveland, OH. She's seen models work where the Medicare admissions nurse pulls the supportive documentation for billing, as an example.