Nursing Documentation: Do Your Medical Records Support Skilled Care?

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“Documentation not supportive of the RUG-IV classification billed…” is cited as the reason for multiple post-payment medical record review denials. Accurate and concise documentation to support the RUG-IV classification billed is a critical element in gaining accurate reimbursement, and supporting that reimbursement level during a medical review. This presentation covers the technical and clinical requirements for Medicare coverage, and requirements of skilled nursing documentation. The presentation identifies areas of the MDS 3.0 that are vulnerable to error and critical to accurate RUG-IV classification and identify strategies for better supporting these areas in medical record documentation. The correlation between the MDS 3.0 assessment and publicly reported information for the Quality Measures and 5 Star Quality Reporting are discussed.

1. Learn to describe the technical and clinical requirements for Medicare coverage.

2. Understand the goal of supportive skilled nursing documentation.

3. Develop a clear understanding of accurate coding in Section M.

4. Learn to identify sections of the MDS 3.0 assessment that are vulnerable to error and articulate strategies to support these areas in medical record documentation.

5. Learn to identify the correlation between medical record documentation, the MDS 3.0, and publicly reported information for the Quality Measures and 5 Star Quality Rating.

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Nursing Documentation: Do Your Medical Records Support Skilled Care?

  1. 1. Nursing Documentation: Do Your Medical Records Support Skilled Care? HARMONY UNIVERSITY The Provider Unit of Harmony Healthcare International, Inc. (HHI) Presented by: Beckie Dow, RN, RAC-MT Director of MDS / Nursing Education & Training
  2. 2. Director of MDS/Nursing Education & Training for Harmony Healthcare, International, Inc. Over 20 Years Experience in Long-Term Care Clinical and Reimbursement Accuracy in Assessments Quality Assurance Activities Interrelation between MDS, Care Planning, QA, and Clinical Excellence at the Bedside AANAC Master Teacher Speaker Bio (Beckie Dow) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 2
  3. 3. Harmony Healthcare International, Inc. 3 Nursing Documentation: Do Your Medical Records Support Skilled Care? Disclosure: The planners and presenters of this education activity have no relationship with commercial entities or conflicts of interest to disclose Planners: Elisa Bovee, MS, OTR/L Diane Buckley, BSN, RN, RAC-CT Beckie Dow, RN, RAC-MT Keri Hart, MS CCC, SLP, RAC-CT Kristen Mastrangelo, OTR/L, MBA, NHA Christine Twombly, RNC, RAC-MT, LHRM Presenter: Beckie Dow, RN, RAC-MT Director of MDS / Nursing Education & Training Copyright © 2013 All Rights Reserved
  4. 4. Harmony Healthcare International, Inc. Nursing Documentation: Do Your Medical Records Support Skilled Care? Disclosure Speaker: Beckie Dow, RN, RAC-MT Director of MDS / Nursing Education & Training The speaker has no relevant financial relationships to disclose The speaker has no relevant nonfinancial relationships to disclose Copyright © 2013 All Rights Reserved 4
  5. 5. Harmony Healthcare International, Inc. Nursing Documentation: Do Your Medical Records Support Skilled Care? Criteria for Successful Completion Complete Sign-in and Sign-Out on Attendance Form Attendance for entire session Completion and submission of speaker evaluation form Copyright © 2013 All Rights Reserved 5
  6. 6. Harmony Healthcare International, Inc. 6 Program Objectives The learner will be able to describe the technical and clinical requirements for Medicare coverage The learner will be able to state the goal of supportive skilled nursing documentation The learner will be able to identify sections for the MDS 3.0 assessment that are vulnerable to error and articulate strategies to support these areas in medical record documentation The learner will be able to identify the correlation between medical record documentation, the MDS 3.0, and publicly reported information for the Quality Measures and 5 Star Quality rating Copyright © 2013 All Rights Reserved
  7. 7. Program Goals This program will enable Healthcare providers to provide quality healthcare through understanding the requirements of skilled Medicare documentation and provide examples of skilled nursing documentation that will support a skilled level of care. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 7
  8. 8. What is Medicare? Medicare is a federal health insurance program for people 65 or older and certain disabled people It is administered at the federal level by the Centers for Medicare and Medicaid Services (CMS) Two parts--Hospital insurance and medical insurance Medicare payments are handled by private insurance organizations under contract with the Government Organizations handling claims from hospitals, SNFs, and HHAs are called intermediaries Organizations handling claims from doctors, supplies for SNFs and other suppliers of services covered under the medical insurance part of Medicare are called carriers Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 8
  9. 9. Medicare Coverage In each benefit period Medicare Part A pays for all covered services in the first 20 days in the SNF. Daily co-insurance amount is assessed to the beneficiary from 21st to 100th day Medicare only covers skilled care Medicare does not cover custodial care Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 9
  10. 10. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 10 Medicare Part A Coverage Requirements
  11. 11. Technical Requirements Technical requirements are not eligible for appeal—if the patient does not meet technical requirements their stay will not be covered It is the responsibility of the facility to determine if technical eligibility requirements are met Best practice: The facility should have a process for determining technical eligibility prior to admission Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 11
  12. 12. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 12 Technical Requirements Beneficiary is enrolled in Medicare Part A and has available days Beneficiary had a three-day qualifying hospital stay Skilled care must begin within 30 days after discharge from a hospital or the last covered Medicare day of a SNF stay
  13. 13. Technical Requirements Three-day qualifying stay does not include nights spent in observation status or in an ER bed Can be in different hospitals, but nights must be consecutive The day of admission, but not the day of discharge, is counted in the three days Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 13
  14. 14. Technical Requirements Skilled care must begin within 30 days (unless the Medical Appropriateness Exception applies) Medical Appropriateness Exception- Physician determines that an immediate skilled stay would not be appropriate for the patient Skilled stay can be deferred longer than 30 days after hospitalization Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 14
  15. 15. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 15 Clinical (Level of Care) Requirements The patient requires physician-ordered skilled nursing or rehabilitation services that relate to the hospital stay or a condition that arose while receiving post- hospital care The services are daily As a practical matter, the services must be delivered in the SNF The services are reasonable and necessary for treatment of the illness/injury
  16. 16. Medicare Coverage/Skilled Care Provided on a “daily” basis: Rehabilitation (PT, OT and/or SLP) must be at least five days per week An isolated break of “a day or two” is allowable Skilled nursing (or combination of nursing and rehabilitation) must be seven days per week Restorative nursing Programs must be at least six days per week Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 16
  17. 17. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 17 What is Skilled Care? Nature of service requires the skills of a licensed person (e.g. technical or professional personnel) Skilled services are provided directly by or under general supervision of a licensed nurse or therapist to assure the safety of the patient and to achieve the medically desired result Diagnosis and prognosis do not determine what is skilled care – it is the care of the patient that is the deciding factor
  18. 18. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 18 “Practical Matter” Criterion “As a practical matter, considering economy and efficiency, the daily skilled services can only be provided in a skilled nursing facility”
  19. 19. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 19 “Practical Matter” Criterion 1. Outpatient services are not available in the area where the individual lives. 2.Outpatient services are available in the area where the individual lives, but transportation to the closest facility could cause an excessive physical hardship, be less economical, or less effective that placement in the skilled nursing facility.
  20. 20. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 20 “Practical Matter” Criterion 3. The availability at home of a capable and willing caregiver should be considered, but the care can be furnished only in the skilled nursing facility if home care would be ineffective because there would be insufficient assistance at home for the patient/patient to reside there safely. 4. If the use of alternative services would adversely affect the patient’s medical condition, then as a practical matter the daily skilled service(s) can only be provided on an inpatient basis.
  21. 21. Copyright © 2013 All Rights Reserved 21 Harmony Healthcare International, Inc. SNF Level of Care Criteria Leave of Absence “An SNF should not interpret the practical matter criteria so strictly that it results in the automatic denial of coverage for patients who have been meeting all of the SNF level of care requirements but who have occasion to be away from the SNF for a brief period of time.” Harmony Healthcare International, Inc.
  22. 22. Skilled Nursing Documentation Requirements Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 22
  23. 23. Basics of Documentation Medicare has no specific requirements related to documentation Daily skilled care is required and must be proven in the record Documentation should be precise and contain information supporting the skilled care given No specific format is required by Medicare Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 23
  24. 24. Basics of Documentation The person reading your note was likely not present during your observations; you need to paint a picture with your words for them Written entries must be in terms easily understood by anyone reading the notes Documenting occurrences during your shift is like writing a story with a beginning, a middle and an end (each needs to be accurately depicted in the record) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 24
  25. 25. Basics of Documentation The physician relies on documentation in order to make adjustments to the plan of care The record must reflect the physical and mental status of the patient upon admission and changes during the stay in the facility. This will help serve as a tool to identify the changing care needs of the patient. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 25
  26. 26. Basics of Documentation Keep the purpose of your entry in your mind Summary of general observations Identification of specific problems Follow-up of previously identified problems Don’t leave the next reader in suspense and wondering what happened. When you have identified a problem, follow-up later to include the status at the end of your shift. Be descriptive and concise Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 26
  27. 27. Basics of Documentation Your notes should be: Objective, not critical or subjective Clear, concise, and comprehensive Accurate, truthful and honest; documentation should not appear self-serving, especially if an incident or injury occurs Reflective of observations, not of unfounded conclusions Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 27
  28. 28. Copyright © 2013 All Rights Reserved 28Harmony Healthcare International, Inc. Medicare Nursing Documentation Goal: Skilled nursing documentation should clearly delineate the medical complexity of the patient and skilled nursing services provided
  29. 29. Copyright © 2013 All Rights Reserved 29 Medicare Documentation There are increased reviews nationally These are often focused on patients that do not reflect skilled levels of care (e.g., those in the lower 14 RUG-IV groups) There is an increase in the likelihood that someone will review your Medicare documentation Harmony Healthcare International, Inc.
  30. 30. Copyright © 2013 All Rights Reserved 30 Medicare Nursing Documentation The key to documenting skilled services is understanding the Medicare coverage requirements Key Point: Nursing Rules the World! Skilled Nursing Services anchor ALL Part A benefits Harmony Healthcare International, Inc.
  31. 31. Skilled Nursing Documentation 101 Skilled Nursing Documentation falls under the following categories: Direct Nursing Skills Skilled Observation and Assessment Management of a Care Plan Teaching and Training Activities Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 31
  32. 32. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 32 Skilled Nursing Documentation Some questions to answer in your notes: Why does the patient require 24 hour care in the SNF? What does the nurse do to ensure medical safety and promote recovery? What patient issues require licensed nurse intervention? Key Point: Nursing always anchors skilled care!
  33. 33. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 33 Skilled Nursing Documentation What To Consider Including: Patient is at high risk for … Skilled assessment of … Daily skilled monitoring of … Potential for recurrence of … Potential for the following complications… There is a likelihood of change related to… The medical regimen is not essentially stabilized as evidenced by…
  34. 34. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 34 Skilled Nursing Documentation What To Consider Including: Patient continues to require daily skilled rehab for … Observation and assessment for potential complications related to … Potential for medical complications related to the diagnosis of … Plan of care is being monitored to promote recovery and ensure medical safety related to … The patient requires daily skilled management and evaluation of the plan of care related to …
  35. 35. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 35 Skilled Nursing Documentation What To Consider Including: Skilled neurological assessment resulted in… Daily skilled monitoring for signs and symptoms of exacerbation of _____ secondary to _______. Patient is high risk for ______ secondary to _______. Medications adjusted to _____________, ongoing skilled assessment of regimen to promote recovery and ensure medical safety. Patient continues to require daily skilled nursing as his treatment regimen is not essentially stabilized and there is a potential for recurrence of ________.
  36. 36. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 36 Non-Supportive Nursing Documentation Plateau in progress Voiced no complaints Patient requires custodial care Patient requires intermittent care Patient is unable to follow directions Patient requires intermittent services Patient has poor rehabilitation potential Patients medical treatment is essentially stabilized Refuses to participate in therapy (instead give the reason the patient is unable) Condition stable Slept well/family into visit
  37. 37. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 37 Daily Nurses Note Describe a skilled observation, assessment and/or action This note can be episodic Describe pertinent skilled happenings of the day or shift
  38. 38. Copyright © 2013 All Rights Reserved 38 Nursing Documentation: Daily Narrative Documentation Should evidence the critical thinking, judgment decision making by skilled nurses Daily nursing notes should evidence assessment of the data recorded on flow sheets and treatment sheets etc. vs. re- stating the data Harmony Healthcare International, Inc.
  39. 39. Copyright © 2013 All Rights Reserved 39 Nursing Documentation: Daily Narrative Documentation Documentation must justify the clinical reasons and medical necessity for: Medicare Part A coverage The skilled services being delivered The on-going need for coverage Harmony Healthcare International, Inc.
  40. 40. Copyright © 2013 All Rights Reserved 40 Nursing Documentation: Daily Narrative Documentation Diagnosis Driven Diagnosis related to acute hospitalizations Those which arose at the SNF Chronic conditions that potentially complicate the patient’s clinical status, stability or level of care needed Harmony Healthcare International, Inc.
  41. 41. Copyright © 2013 All Rights Reserved 41 Nursing Documentation: Admission and Re-Admission Nursing Notes Admission Nursing Note: Follows the admission nursing assessment and is based on those findings Is done by the nurse admitting the patient Incorporates information in referral and assessment data This nurse knows more about the patient than any other nurse will for several days Harmony Healthcare International, Inc.
  42. 42. Copyright © 2013 All Rights Reserved 42 Nursing Documentation: Admission and Re-Admission Nursing Notes HHI suggests that the following information be included in all Admission Notes: Exact time and date of admission Room number Location prior to admission Age, primary diagnosis, other pertinent medical history Assist level and number of assist with transfers and bed mobility provided by staff (2 assist to transfer) List any identified skilled needs which have been identified Harmony Healthcare International, Inc.
  43. 43. Copyright © 2013 All Rights Reserved 43 Nursing Documentation: Admission and Re-Admission Nursing Notes HHI suggests that the following information be included in all Admission Notes (Cont.) Prior level of functioning and if possible, discharge destination List of all nursing assessments which relate to the primary diagnosis and related secondary diagnosis Detailed skin assessment and historic skin staging reported Most ADL care provided (Bed mobility, Eating, Transfer, Toilet use) during the shift Harmony Healthcare International, Inc.
  44. 44. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 44 The Bottom Line Will the documentation in the patient’s medical record support the care and/or services provided to the patient as well as the coding on the MDS (which resulted in the daily rate for the care of that patient)?
  45. 45. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 45 Review of a Few Key MDS 3.0 Sections
  46. 46. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 46 MDS 3.0 Section D: MOOD
  47. 47. Section D: Mood Intent: The items in this section address mood distress, a serious condition that is underdiagnosed and undertreated in the nursing home and is associated with significant morbidity It is particularly important to identify signs and symptoms of mood distress among nursing home residents because these signs and symptoms can be treatable Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 47
  48. 48. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 48 A Key Point from the RAI Manual …the presence of indicators in Section D does not automatically mean that the resident has a diagnosis of depression or other mood disorder. Assessors do not make or assign a diagnosis in Section D, they simply record the presence or absence of specific clinical mood indicators.
  49. 49. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 49 Section D – Key Points PHQ-9OV (staff assessment) should include information from all shifts and disciplines Follow the interview script Use the cue cards Use the interview techniques from Appendix D of the RAI Users Manual Competency checks for interviewing staff
  50. 50. Section D – Key Points Section D has a potential impact on Percent of Residents Who Have Depressive Symptoms (Long Stay) Total Severity Score 10+, and Little interest or pleasure in doing things OR feeling or appearing down, depressed, or hopeless half or more of the days in the last two weeks (2, 3) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 50
  51. 51. Section D – Key Points For Nurses Documentation of follow up with patient to talk about areas that are responded to positively and are increased from last assessment Care planning for mood items Daily/weekly documentation about symptom prevalence and the efficacy of medications Gradual Dose Reduction, when appropriate Documentation of nursing support in relation to mood symptoms and patient response Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 51
  52. 52. MDS 3.0 Section E: BEHAVIOR Copyright © 2013 All Rights Reserved 52Harmony Healthcare International, Inc.
  53. 53. Section E: Behavior Intent: The items in this section identifies behavioral symptoms in the last seven days that causes: Distress to the resident Distressing or disruptive to facility residents, staff members or the care environment This section focuses on the resident’s actions and not the intent of the behavior Copyright © 2013 All Rights Reserved 53Harmony Healthcare International, Inc.
  54. 54. E0200: Behavioral Symptom Presence & Frequency Behaviors Physically Behavioral symptoms directed toward others: Hitting, kicking, pushing, scratching, or sexually abusing others Verbally Behavioral symptoms directed toward others: Threatening others, screaming at others, or cursing at others Copyright © 2013 All Rights Reserved 54Harmony Healthcare International, Inc.
  55. 55. E0200: Behavioral Symptom Presence & Frequency Other behavior symptoms not directed toward others: Hitting, scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily waste, verbal/vocal symptoms like screaming, disruptive sounds Copyright © 2013 All Rights Reserved 55Harmony Healthcare International, Inc.
  56. 56. E: Behavior Section E also captures the effect the behavior has upon the resident, and upon other residents Captures if the behavior puts the resident or others at risk for Physical injury Affects privacy Disrupts living environment Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 56
  57. 57. Section E – Key Points For Nurses Section E is often under coded Usual is not normal! Documentation in the medical record must support coding on the MDS Behavioral management programs and Management and Evaluation of the Plan of Care must be captured in skilled nursing documentation Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 57
  58. 58. Section E – Key Points Surveyor Quality Measures: Prevalence of Psychoactive Medication Use, in the Absence of Psychotic or Related Conditions (Long)—affects exclusions Prevalence of Antipsychotic/Hypnotic Use (Long)—affects exclusions Prevalence of Behavior Symptoms Affecting Others (Long) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 58
  59. 59. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 59 MDS 3.0 Section G: FUNCTIONAL STATUS
  60. 60. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 60 Section G: Principles of Accurate Assessment 7-day look-back period (since admission or readmission only) Assess Observe Consult with all interdisciplinary team across all shifts to capture accurate assist levels Ask probing questions, beginning with the general and proceeding to the more specific
  61. 61. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 61 Section G: Principles of Accurate Assessment Do NOT include assistance provided by family or other visitors when capturing assist level Do NOT code ambulance transfer assistance or assistance from hospice Code assist provided by facility staff only No longer looks back into the hospital
  62. 62. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 62 The Four Late Loss Activities of Daily Living (ADLs) Bed Mobility Transfer Eating Toilet Use
  63. 63. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 63 The Late Loss ADLs Defined Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet)
  64. 64. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 64 The Late Loss ADLs Defined Eating - how resident eats and drinks, regardless of skill. Do not include eating/drinking during medication pass. Includes intake of nourishment by other means (e.g., tube feeding, total parenteral nutrition, IV fluids administered for nutrition or hydration) Toilet use - how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts clothes. Do not include emptying of bedpan, urinal, bedside commode, catheter bag or ostomy bag
  65. 65. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 65 Section G – Key Points For Nurses Documentation to support coding is a must Focus on four late loss ADLs Accuracy begins at the bedside with the C.N.A. all three shifts (don’t forget nights!) Ensure reporting and/or documentation all other disciplines regarding ADLs Educate frontline nursing staff as well as IDT Ensure an audit protocol (MDS and documentation)
  66. 66. Section G – Key Points Section G coding affects several QMs, as covariates, exclusions, or triggers Long Stay, Short Stay, and Surveyor Measures Daily documentation to support ADL assistance provided is critical in ensuring accurate and supported RUG- IV classification Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 66
  67. 67. Section G – Key Points Quality Measures: Percent of Residents with Pressure Ulcers That Are New or Worsened (Short)—covariate Percent of High-Risk Residents With Pressure Ulcers (Long)—stratification to define high- risk Percent of Low Risk Residents Who Lose Control of Their Bowel or Bladder (Long)— exclusion of high risk to identify low Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 67
  68. 68. Section G – Key Points Quality Measures (cont.) Percent of Residents Whose Need for Help with Activities of Daily Living Has Increased (Long)—trigger and exclusion Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 68
  69. 69. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 69 MDS 3.0 Section I: ACTIVE DIAGNOSES
  70. 70. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 70 Section I: Coding Instructions Code diseases that have a documented diagnosis in the last 60 days and have a relationship to any of the following in the last 7 days: Functional status Cognitive status Mood or behavior status Medical treatments Nursing monitoring Risk of death
  71. 71. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 71 Section I: Coding Instructions A Two-Step Process: • Diagnosis identification (Step 1) is a 60- day look-back period • Determining diagnosis status: Active or Inactive (Step 2) is a 7-day look-back period (except for Item I2300 UTI, which does not use the active 7-day look-back period)
  72. 72. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 72 Section I: Coding Instructions Do not include conditions that Have been resolved or No longer affect the resident’s functioning or plan of care
  73. 73. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 73 Section I – Key Points For Nurses Ensuring provider documentation to support coding Is physician documentation needed to add to support to the diagnosis is active in the last seven days? Documentation (including care planning) to reflect actively impacting care of the resident
  74. 74. Section I – Key Points Quality Measures for Antipsychotic, Antianxiety, and Hypnotic use have several diagnosis-based exclusions and covariates Diagnosis-driven daily documentation to support the inherent complexity of the patients condition and the need for ongoing skilled nursing observation and assessment Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 74
  75. 75. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 75 MDS 3.0 Section M: SKIN CONDITIONS
  76. 76. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 76 Section M: Skin Conditions Asks the clinician to determine if at risk for pressure ulcers Includes updated pressure ulcer definitions Must determine present on admission Includes diabetic foot wounds No longer back stage pressure ulcers Only stage pressure ulcers
  77. 77. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 77 Section M – Key Points Clear, concise, and accurate documentation of all skin areas as soon as possible after admission Measuring practices and staging competency Determination and documentation of wound etiology (scope of practice and QOC issues)
  78. 78. Section M: Key Points For Nurses Accuracy in wound documentation Clear and descriptive wound documentation Patient’s response to treatment (pain, infection, healing process) Daily documentation that supports the overall clinical picture of the wound Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 78
  79. 79. Section M – Key Points Percent of Residents with Pressure Ulcers that are New or Worsened (Short) Percent of High-Risk Residents With Pressure Ulcers (Long) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 79
  80. 80. MDS 3.0 Affect on Quality Measures and the 5 Star Rating (Long Stay) Percent of residents whose need for help with daily activities has increased Percent of high-risk residents with pressure ulcers Percent of residents who have/had a catheter inserted and left in their bladder Percent of residents who were physically restrained Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 80
  81. 81. MDS 3.0 Affect on Quality Measures and the 5 Star Rating Quality Measures information is 100% derived from MDS 3.0 data There are 35 total Quality Measures (12 Short Stay, 23 Long Stay) Nine of these Quality Measures will influence your final 5 Star Rating (two Short Stay, Seven Long Stay) Four additional surveyor measures Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 81
  82. 82. MDS 3.0 Affect on Quality Measures and the 5 Star Rating (Long Stay) Percent of residents with a UTI Percent of residents who self-report moderate to severe pain Percent of residents experiencing one or more falls with major injury Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 82
  83. 83. MDS 3.0 Affect on Quality Measures and the 5 Star Rating (Short Stay) Percent of residents with pressure ulcers that are new or worsened Percent of residents who self-report moderate to severe pain MDS accuracy leads to Quality Measure and 5 Star Rating accuracy! Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 83
  84. 84. Final Thoughts… Daily skilled nursing documentation must support the skilled services that are being provided Most claim denials are due to lack of supportive clinical documentation Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 84
  85. 85. References Medicare Program Integrity Manual, Chapter 6 http://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/downloads/pi m83c06.pdf Medicare Benefit Policy Manual , Chapter 8 http://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/downloads/bp1 02c08.pdf Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 85
  86. 86. References 5 Star Technical Users Guide http://www.cms.gov/Medicare/Provider- Enrollment-and- Certification/CertificationandComplianc/dow nloads/usersguide.pdf Quality Measures Users Manual http://www.cms.gov/Medicare/Quality- Initiatives-Patient-Assessment- Instruments/NursingHomeQualityInits/Dow nloads/MDS-30-QM-Users-Manual-V60.pdf Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 86
  87. 87. References RAI Users Manual http://www.cms.gov/Medicare/Quality- Initiatives-Patient-Assessment- Instruments/NursingHomeQualityInits/ MDS30RAIManual.html Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 87
  88. 88. Questions/Answers Harmony Healthcare Internationa 1 (800) 530 – 4413 kdutton@harmony- healthcare.com Harmony Healthcare International, Inc. 8888Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.
  89. 89. Questions/Answers Harmony Healthcare Internationa 1 (800) 530 – 4413 cdeschenes@harmony- healthcare.com Harmony Healthcare International, Inc. 8989Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.
  90. 90. Harmony Healthcare International Have you Considered a Customized Complimentary HARMONY(HHI) MEDICARE PROGRAM EVALUATION or CASE MIX ANALYSIS for your Facility? Perhaps your facility has potential for additional revenue Assess your facility against key indicators and national norms Email us at for more information RUGS@harmony-healthcare.com Analysis is cost & obligation free Harmony Healthcare International, Inc. 90Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.

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