MDS Alert

Published on Thu Apr 12, 2007 PDF

3 rules help you avoid payment and compliance pitfalls

Residents receiving chemo that's not excluded from consolidated billing can take a major toll on a SNF's bottom line. But your MDS know-how can help ensure the SNF receives every penny it deserves in caring for such residents -- and sidesteps payment recoupments to boot.

Rule No. 1: Know the coding low-down for chemo and radiation. Chemotherapy or radiation will put a resident into a clinical RUG. If they have the requisite ADL scores, residents receiving chemo go into Clinically Complex. Those who receive radiation will RUG into Special Care. So make sure you code these treatments in Section P1a if the resident received them during any part of the 14-day lookback, including the hospital stay.

Keep in mind, however, that in order to check chemotherapy (P1aa), it has to be used to treat cancer, says Cheryl Field, MSN, RN, a consultant with LTCQ Inc. in Lexington, MA.

Example: Say a resident is getting Megace, which is an antineoplastic agent, postulates Field. Check to see the reason for the medication. If it's to stimulate the person's appetite, even though he has cancer, you can't code it, she says.

Rule No. 2: Separate RUG placement from skilled care needs. Just because a resident RUGs into Clinically Complex based on chemo doesn't mean he needs daily skilled nursing care.

A resident with breast cancer might be receiving tamoxifen, a hormonal treatment, for example, says Field. And you'd code that as chemo in Section P and check a cancer diagnosis in Section I, she instructs.  "But whether or not the resident will be skilled for Medicare is not linked to what RUG group" she goes into, Field cautions. You'd have to make that decision based on whether the person meets the technical coverage requirements for Part A and requires daily skilled care.

Rule No. 3: Watch for conditions and Rx that could up the RUG. Nurse consultant Christine Twombly, RN, has seen facilities miss coding conditions for residents with cancer that would have put the resident in a higher clinical RUG.

For example, chemotherapy alone puts a resident into Clinically Complex. But if a resident receiving chemo has "dehydration plus fever -- or vomiting plus fever," he'd go into Special Care, says Twombly,  with Reingruber & Company in St. Petersburg, FL. Weight loss (K3a) plus fever will also RUG someone into Special Care.

Capture extra $$: A resident in Clinically Complex because he's getting chemo who also has three or more indicators of depression in E1 over the 30-day lookback will get the end split for depression, which means more money.

Check Section M: A resident receiving chemo who has two or more stage 2 pressure ulcers -- or one stage 3 or 4 ulcer -- and two treatments will go into Special Care.

An IV (K5a) or IV med (P1ac) puts a resident with an ADL of at least 7 into Extensive Services, which pays more than Special Care or Clinically Complex. But you can't code an IV or IV med given solely during chemotherapy, cautions Field. "If the resident comes back to the facility with an IV and/or IV meds for vomiting or dehydration, then you code that."

Remember: If the resident is receiving rehab therapy, an IV or IV med could put him into rehab plus Extensive Services if he has an ADL score of at least 7.

Also: "You can code IVs and IV meds for a cancer patient in the hospital lookback if the IVs and IV meds weren't part of chemotherapy treatments," Twombly adds. Also exclude IVs and IV meds that were solely part of surgery or a diagnostic procedure and the immediate post-operative or post-procedure recovery period, instructs the RAI manual.

Test yourself: A resident with an ADL score of 7 received chemotherapy for cancer during the lookback for P1a. He had IV fluids (K5a) in the hospital lookback to treat dehydration -- and IV medication (P1ac) for pain management. The staff assesses and codes him as cognitively impaired according to the RUG-III Cognitive Performance Scale. What RUG would he go into? (See the answer below.)