MDS Alert

Published on Mon Jan 28, 2008 PDF

Don't wait: Detect, head this trend off at the gate.

In coding the MDS, the devil may be in the details, but in the compliance world, it's patterns that do a facility in -- especially if medical reviewers construe them as fraud and abuse.

Example: Make sure residents don't consistently receive less rehab therapy than dictated by the MDS-generated rehab RUG over the billing period, suggested Rena Shephard, RN, MHA, FACDONA, in a presentation on compliance at the fall 2007 American Association of Nurse Assessment Coordinators conference in Las Vegas.

On medical review, the FI will first look to see that the minutes provided during the MDS assessment reference period were medically necessary, says Pauline Franko, PT, president of Encompass Consulting and Education in Tamarac, FL. "Then they will look at the balance of the time to see what level of therapy the SNF provided." And if the FI detects "a pattern where the residents receive therapy at a high level during the assessment reference [period] that drops off afterward without explanation," the SNF could have a big problem, she cautions.

Watch out for nursing rehab too: "A pattern of a rash of services provided a week or 10 days right around the observation period is suspect," says Patty Padula, RN, a consultant for Myers & Stauffer in Indianapolis, which does Medicaid reviews of nursing homes. "We sometimes see restorative nursing coded and documented only during the lookback period, which appears as though the restorative program wasn't provided otherwise."

Another problem FIs can catch: A resident receives mostly one-on-one therapy during the lookback so that group therapy doesn't exceed more than 25 percent of the total minutes per discipline, Franko says. But then he switches to group therapy after that, exceeding the 25 percent threshold for a therapy discipline. By group therapy, Franko isn't referring to dovetailing where the therapist assistant or therapist gets the patient started with a therapy treatment and continues to supervise the patient as he treats someone else.

Strategy No. 1: On a case-by-case basis, document carefully why a resident didn't receive expected therapy after the MDS assessment. Just because a resident goes into a particular rehab RUG level during the lookback doesn't mean he will continue to receive that level of treatment throughout the days covered by the assessment, Franko notes. For example, "if the resident became sick or had problems over that period of time, the FI would not expect the person to necessarily receive the same level of therapy minutes," she says. But nursing and therapy documentation need to explain that.

Strategy No. 2: Quantify your overall therapy utilization in the building. To determine therapy utilization after the assessment window, you can create a therapy utilization report that shows each resident's total therapy, says Jane Belt, RN, MSN, consulting manager with Plante & Moran PLC in Columbus, OH (see the tool on p. 15). For each resident, the report should show the following information, says Belt:

• Any excess or deficit compared to the billed RUG.