MDS Alert

Published on Fri Jan 01, 2010 PDF

Address these 6 elements before they add up to big payment denials.

What's the best way to keep your payment and compliance record on track? Do a careful prepay review of claims to make sure they will fly with the MAC, RAC and other government auditors.

Pivotal: In performing a triple check of each claim, the operative word is "claim," says Victor Kintz, MBA, CHC, LNHA, RAC-CT, CCA, managing director of operations for the Polaris Group based in Tampa, Fla. You want nursing, therapy, and billing to compare the claim to the medical record and all supportive documentation, he says.

Kintz suggests taking a look at the following six items for Part A claims (for more items to check, see the Polaris Group's Part A audit checklist on the next page):

1. The RUG score(s) on the claim. Is the RUG score correct and are you using the proper HIPPS (Health Insurance PPS) codes for that MDS?

2. The "service dates." Do these match the MDS ARD (assessment  reference date)?

3. The admission date, dates of service, and three-day qualifying hospital stay dates. Make sure these are correct. Also note who validated the three-day inpatient hospital stay.

4. The therapy minutes and number of therapy days in Section P. Are these correct for the RUG level coded?

5. The diagnoses on the claim. Specifically, is the primary diagnosis correct for that coverage period? Kintz asks. Are there any diagnoses on the claim that should not be there? Kintz has reviewed claims that have had speech therapy treatment codes when no ST was being provided. The codes "had been carried forward from a previous benefit period" without being removed.

6. Physician certification/recertification. Is the cert/recert signed,  dated, and obtained timely? "If not, you should get a delayed cert/re-certbefore submitting the claim," says Kintz.

Good question: Should SNFs do the triple check on every claim? "We tell people if you are new to the process of the triple check, then do it on every claim," Kintz advises. Over time, however, providers who do the triple check adjust their systems to ensure they are gathering accurate  data and documentation to support their claims, he observes. Thus, "at some point, you can probably move to doing the check on a certain percentage of claims. It also depends on the SNF's volume of claims."

In performing audits, Kintz finds that nurses generally do a good job of documenting in a way that supports non-therapy RUG scores. But 80 percent of claims are therapy RUGs, he points out, "and that's where the lion's share of the money is too" -- a scenario Kintz doesn't foresee changing under RUG-IV. And "on many audits we have seen more harm come from nursing documentation than from therapy in terms of jeopardizing medical necessity and/or as a practical matter."

Example: "The therapy notes will talk about working with the person on ambulation," Kintz says. "Yet nursing notes will say the person is ambulating ad lib to and from the dining room." And that note indicates the person doesn't need physical  therapy for ambulation, Kintz points out. However, "when you look more closely, you may find that actually a nursing assistant is accompanying the person when they ambulate, and providing touch guard assistance. But that's not written in the medical record," he adds.

Management tip: If your facility doesn't have a solid pre-billing review process in place, take a look at why not. One reason may be that the facility administration doesn't see the need because the facility has never been audited, says Kintz. "But that will change," he cautions.

Another reason may be turn over in key positions, such as the MDS coordinator, rehab director, administrator, director of nursing, etc., so the review "falls through the cracks."