OM(I)G! New York Medicaid Case Mix Audit Success

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This New York Medicaid Nursing Facility Case Mix Seminar discusses the necessary documentation needed to support the assigned Medicaid RUG to ensure accurate reimbursement for care provided. New York OMIG Auditors are focused on auditing "high risk" Medicaid Case Mix MDSs for Nursing Facilities with a change in CMI by more than five percent for 2012.

1. Learn to identify the specific components of NY RUG-III 53 categories.

2. Learn to identify high risk NY RUG-III 53 categories.

3. Learn to identify documentation requirements to support the RUG components.

4. Learn to identify strategies for organization of the Medical Record in preparation for OMIG Audits.

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OM(I)G! New York Medicaid Case Mix Audit Success

  1. 1. OM(I)G! New York Medicaid Case Mix Audit Success HARMONY UNIVERSITY The Provider Unit of Harmony Healthcare International, Inc. (HHI) Presented by: Barbara Patterson-Paul, Regional Consultant Terese Cargen, Field Operations and Regional Consultant
  2. 2. Regional Consultant for Harmony Healthcare International, Inc. Over 30 Years Experience in Nursing with a Focus on Long- Term Care Speaker has Provided Extensive Training for Members of the Inter-disciplinary Team on MDS, Reimbursement, and Management Skills Over 16 Years in Management of an Acute Rehabilitation Hospital Hospital Performance Improvement, Quality Assurance Program, with expertise in preparation for JCAHO, CARF and DOH Survey Certification in Rehabilitation Nursing (CRRN) Speaker Bio (Barb Patterson) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 2
  3. 3. Speaker Bio (Terese Cargen) Field Operations and Regional Consultant for Harmony Healthcare International, Inc. Over 18 years of experience in the Long-term Care OTR/L, RAC-CT Occupational Therapist Rehab management/ Consulting therapist Trainer for advanced Clinical Strategies. Expert in NYS Case Mix Reimbursement and Compliance Medicare Part B Program Development Knowledge in Medicare/ Medicaid documentation and Compliance Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 3
  4. 4. OM(I)G! New York Medicaid Case Mix Audit Success Disclosures: The planners and presenters of this educational 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: Barbara Patterson-Paul, Regional Consultant Terese Cargen, Field Operations and Regional Consultant Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 4
  5. 5. Harmony Healthcare International, Inc. OM(I)G! New York Medicaid Case Mix Audit Success Disclosure Speaker: Barbara Patterson-Paul, Regional Consultant Terese Cargen, Field Operations and Regional Consultant The speaker has no relevant financial relationships to disclose The speaker has no relevant nonfinancial relationships to disclose Copyright © 2013 All Rights Reserved
  6. 6. Harmony Healthcare International, Inc. OM(I)G! New York Medicaid Case Mix Audit Success 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
  7. 7. Housekeeping Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 7
  8. 8. OM(I)G! New York Medicaid Case Mix Audit Success Objectives The learner will be able to identify the specific components of NY RUG-III 53 categories. The learner will be able to identify high risk NY RUG-III 53 categories. The learner will be able to identify documentation requirements to support the RUG components. The learner will be able to identify strategies for organization of the Medical Record in preparation for OMIG Audits. Copyright © 2013 All Rights Reserved 8Harmony Healthcare International, Inc.
  9. 9. OMIG Audits NY noted an increase in CMI from Jan 2011 to Jan 2012 of 6%, equating to $200 million Cap of 5% for facilities with a significant increase in CMI Increase over 5%, they would receive the balance of payment beyond the 5% cap following an audit. 304 Homes met the criteria Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 9
  10. 10. OMIG Audits January 2012 Roster 304 Homes had an increase of 5%+ OMIG’s plan was for 90 Homes to be audited by mid March The remaining 214 Homes by July Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 10
  11. 11. OMIG Audits June 2013 Dear Administrator Letter Update on Case Mix Audits and Rates released. 79 facilities were reviewed 58 had no decrease in CMI 21 facilities had a decrease in CMI Some facilities had a decrease in CMI of over 10% Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 11
  12. 12. OMIG Audits Following the first audit sample of 79 facilities, DOH released rate adjustments reflecting the full Case Mix on August 14, 2013. DOH also announced the January 2012 census audits would continue and be combined with July 2012 census to process the audits more quickly. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 12
  13. 13. OMIG Audits 171 facilities remained to have both their January 2012 and July 2012 census audited. An additional 79 facilities to be reviewed for July 2012. 250 facilities to be audited with each Case Mix census submission. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 13
  14. 14. OMIG Audits OMIG updated their audit protocol. Additionally, OMIG announced they would review BMI, Dementia, and Payor responses. Hiring of Nurses to augment their staff. All Nurses to be RNs with MDS 3.0 training and OMIG audit training. Educational resources on MDS/Case Mix will be available to facilities in the future. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 14
  15. 15. OMIG Audits Post Audit the facility’s CMI will be recalculated The Medicaid Rate will be recalculated based on the new CMI MDS 3.0 RAI Instruction Per OMIG, some issues require the auditors interpretation Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 15
  16. 16. Audit Process Notified by mail 3 to 5 Days prior to scheduled Audit Date List of residents records to be audited Audit complete in 1 to 2 Days Auditors will review what is provided to them May request additional information An exit conference with review of findings will be conducted at the end of the visit Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 16
  17. 17. Audit Process Written report of findings will be left on site Draft report will be received within 30 days Fax Number will be provided at the end of the visit Additional information to support the RUG can be faxed within 30 days of the audit Final Report Can appeal based on information already sent Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 17
  18. 18. High Risk NY RUG-III 53 “If 1 or 2 items were corrected the RUG Score would change” Critically important to understand how the RUG was derived in order to ensure that all data to support the RUG is on file and readily available to auditors Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 18
  19. 19. Observed High Risk NY RUG-III 53 Categories Extensive Rehab Change from previously submitted October PD1January SSC Modified MDSs ADL one point into the next category CC1 SSC Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 19
  20. 20. Organization of the Record
  21. 21. Organization of the Record Ensure all staff are on the look out for the letter Identify RUG Qualifiers associated with the medical record auditors have identified Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 21
  22. 22. Organization of the Record Develop a team that will collect and Review the information needed Medical Records MDS Rehab DON Audit ahead your self ahead of time Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 22
  23. 23. Organization of the Record Know the RUG qualifiers that achieved the RUG. Where is the documentation located? Ensure all documentation to support RUG components are accessible to auditors Ensure all documents have the residents name and date/month visible on copies Prompt response to Auditor requests 30 days if unable to locate Work as a Team Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 23
  24. 24. Tips for Organization of the Record MDS Notes: In System or handwritten identifying where information is located for less obvious coding Process for physician documented Diagnosis Copying acute care documentation specific to coding and keeping in specific section of the medical record. (i.e. IV meds while in hospital) Ensure Therapy logs are one file at the end of each month Ensure ADL Flow Sheets are on file in the medical record to support ARD period Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 24
  25. 25. Tips for Organization of the Record Prepare packets for auditors with only the information necessary to support the RUG. OMIG auditors have requested that facilities not provide them with the entire medical record. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 25
  26. 26. Tips for Organization of the Record Care Plans Some auditors are requesting Care Plans and some are not. How does the RUG score relate to daily care needs? Is the resident receiving PT for difficulty walking and the Care Plan reflect “ambulates independently throughout unit”? Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 26
  27. 27. Tips for Organization of the Record Care Plans Is patient coded as having hemiparesis, generating a clinically complex RUG score without hemiparesis documented as a problem on the care plan with interventions to address? Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 27
  28. 28. Areas of Focus During OMIG Audit ADL s CNA Flow sheets and electronic trackers. Major area of focus Adjustment in ADL Coding may significantly impact payment. Component of every RUG score. Most OMIG auditor findings appear to be ADL coding errors. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 28
  29. 29. Areas of Focus During OMIG Audit Rehabilitation RUG Area of greatest risk Significant impact on CMI RHC versus PD1, 1.40 vs. .72, a difference of .68 points. Follow Medicare Part B guidelines for documentation. Consider appealing if coverage allowed by Medicare Part B but denied by OMIG. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 29
  30. 30. Areas of Focus During OMIG Audit Rehabilitation RUG (cont) Nursing documentation should reflect a change in condition or new limitation warranting the need for skilled therapy. For example: “Patient is requiring increased assistance with meals due diagnosis of Parkinson’s disease causing hand tremors. Patient expresses a desire to maintain her functional independence. Recommend OT evaluation to assess need for adaptive feeding devices.” Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 30
  31. 31. Areas of Focus During OMIG Audit Example: “Patient’s upper respiratory infection has resolved, however, patient has been unable to regain prior functional level due to prolonged illness with reduced strength and mobility. Recommend PT/OT evaluations to address functional decline in ADLs and mobility.” Example: “Patient noted with knees buckling daily when CNAs ambulate patient to the toilet.” Example: “Patient noted with excessive chewing prior to swallowing during meals.” Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 31
  32. 32. Areas of Focus During OMIG Audit Therapy documentation should describe the reason for referral, change from prior level of function, and skilled interventions needed. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 32
  33. 33. OMIG Interpretation/Sample Findings Patient #1 MDS with ARD of 5/10/12 has transfer self performance as a 4, total dependence. CNA tracker for 5/10/12 @1:40pm has extensive assist. Level 4 needs to be every time event occurs. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 33
  34. 34. OMIG Interpretation/Sample Findings Patient #2 MDS with ARD of 1/9/12 has restorative PT/OT modalities. There was no decline noted in resident’s condition which indicated a significant change in condition which required restorative therapies. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 34
  35. 35. OMIG Interpretation/Sample Findings Patient #3 Eating: MDS with an ARD of 11/23 self performance = 3. CNA ADL tracker indicates independent. MDS Coordinator has indicated that this resident is tube fed. Although there was documentation provided to support tube feedings, there was no documentation to support that there was one person doing the tube feeding. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 35
  36. 36. OMIG Interpretation/Sample Findings Patient # 4 The MDS with an ARD of 1/24/12 has a 3 for self performance of bed mobility. The facility ADL tracker for the week of 1/18 – 1/24 indicates a self performance of 2. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 36
  37. 37. OMIG Interpretation/Sample Findings Patient # 5 MDS with ARD of 11/15/11 has no supporting documentation of behavior problems. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 37
  38. 38. OMIG Interpretation/Sample Findings Patient #6 MDS with ARD of 1/16/12 had 2 days of MD visit and 2 days of order change. Documentation indicates 1 day of order change. Patient #7 PT 166 minutes claimed, 143 minutes of documented treatment. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 38
  39. 39. OMIG Interpretation/Sample Findings Patient #8 MDS with ARD of 1/15/12 has a RUG score of RVC. There is no documentation of a physician’s order for Physical Therapy or Speech Therapy. There is no evaluation or reassessment documented for PT, OT, or SLP. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 39
  40. 40. OMIG Interpretation/Sample Findings Patient #9 MDS with ARD of 1/6/12 has restorative PT. Record review shows resident was placed on PT one day before the start of the ARD look back due to lack of coordination, muscle weakness, and difficulty walking. There was no decline in level of function which caused a significant change in status necessitating a restorative modality. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 40
  41. 41. OMIG Interpretation/Sample Findings Patient #10 MD Order Changes: 5/4/12 order clarification and 5/7/12 order dosage change are not considered new orders when dose is changed or clarified. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 41
  42. 42. Component of a RUG RUG-III Grouper Qualifications: Identification of Qualifiers and Extensive
  43. 43. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 43 RUC PD2 1st Position Major RUG-III Classification Categories R=Rehabilitation P=Reduced Physical 2nd Position 1st End Split Rehab RUG Level Nursing ADL split Lower 18 U=Ultra High D= ADL 3rd Position 2nd end split Rehab ADL Nursing depression or restorative end split Extensive Rehab C=Highest ADL split 2=Restorative Component of a RUG
  44. 44. Component of a RUG Know qualifiers of the RUG Audits have been highly focused on the technical components of the RUG Expect clinical focus as auditors learn the process Documentation must be on file to support each component or qualifier of the RUG Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 44
  45. 45. Extensive Component of RUG: Non-Therapy Extensive SE1 SE2 SE3 Rehab Extensive R_X R_L Copyright © 2013 All Rights Reserved 45Harmony Healthcare International, Inc.
  46. 46. Extensive Defined Extensive Services qualification based on ADL Sum 7 or greater and one of the following services: IV feeding in last 7 days IV medications in last 14 days Suctioning in last 14 days Tracheostomy care in last 14 days Ventilator/respirator in last 14 days Special Care with ADL score 6 or less Copyright © 2013 All Rights Reserved 46Harmony Healthcare International, Inc.
  47. 47. Extensive Defined While a Resident Treatments, procedures, and programs received or performed by the resident after admission/re-entry to the facility and within the 14-day look-back period While not a Resident Treatments, procedures, and programs received or performed by the resident prior to admission/reentry to the facility and within the 14-day look-back period Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 47
  48. 48. IV Parenteral/IV Feeding Defined K0510A1 and K0510A2 includes any and all nutrition and hydration received in the last 7 days provided they were administered for nutrition or hydration “Supporting documentation that reflects the need for additional fluid intake specifically addressing a nutrition or hydration need. This supporting documentation should be noted in the resident’s medical record according to State and/or internal facility policy.” Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 48
  49. 49. IV Parenteral/IV Feeding Defined DO: Administered for nutrition or hydration IV fluids or hyperalimentation, including total parenteral nutrition (TPN), administered continuously or intermittently IV fluids running at KVO (Keep Vein Open) IV fluids contained in IV Piggybacks Hypodermoclysis and subcutaneous ports in hydration therapy Prevent dehydration if the additional fluid intake is specifically needed for nutrition and hydration Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 49
  50. 50. IV Parenteral/IV Feeding Defined DO NOT: IV fluids NOT administered for nutrition or hydration IV fluids administered solely as flushes. In conjunction with Dialysis, Chemotherapy, Surgical procedure or Diagnostic procedure IV fluids used to reconstitute and/or dilute IV medications Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 50
  51. 51. IV Medication Defined Code any drug or biological given by intravenous push, epidural pump, or drip through a central or peripheral port in this item Do not include IV medications of any kind that were administered during: Dialysis Chemotherapy Surgical procedure Diagnostic procedure Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 51
  52. 52. IV Medication Defined Do not code flushes to keep an IV access port patent Do not code IV fluids without medication here. Dextrose 50% and/or Lactated Ringers given IV are not considered medications Epidural, intrathecal, and baclofen pumps may be coded Subcutaneous pumps may not be coded Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 52
  53. 53. Extensive Defined May code treatments, programs and procedures that the resident performed themselves independently or after set- up by facility staff in Section O Tracheostomy care Suctioning Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 53
  54. 54. RUG-III: Extensive Services Count RUG III Non-Therapy SE Count: Parenteral IV – K5A = 1 IV Medication – P1ac = 1 Special Care = 1 Clinically Complex = 1 Impaired Cognition = 1 Copyright © 2013 All Rights Reserved 54Harmony Healthcare International, Inc.
  55. 55. RUG-III: Extensive Services Count Extensive Count RUG-III Class 4 or 5 SE3 2 or 3 SE2 0 or 1 SE1 Copyright © 2013 All Rights Reserved 55Harmony Healthcare International, Inc.
  56. 56. Extensive Services Documentation Facility Medication Administration Records for IV Medication and IV Hydration Hospital Medication Administration Records for IV Medication and IV Hydration Emergency Room Records Hospital documentation evidencing actual administration of for IV Medication and IV Hydration Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 56
  57. 57. Additional Documentation to Support IV Hydration facility administered Dietary notes to support administration for hydration Care Plan supporting Dehydration risk MDS Notes indicating location of the data MDS System may allow MDS Note in MDS Staple a copy of documentation to support to printed MDS or MDS Signature Scan document into Electronic Medical Record Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 57
  58. 58. Component of a RUG RUG-III Grouper Qualifications: Depression, Diagnosis and Rehab
  59. 59. Depression Component of a RUG End Split for Clinically Complex : CD2 versus CD1 2= Positive Depressive Indicator Copyright © 2013 All Rights Reserved 59Harmony Healthcare International, Inc.
  60. 60. Depressive Indicator Defined Depression End Splits: Signs and symptoms of depression are used as a third-level split for the Clinically Complex category D0300 PHQ-9 Total Severity Score is greater than or equal to 10 but not 99 or D0600 PHQ-9 Total Severity Score is greater than or equal to 10 Copyright © 2013 All Rights Reserved 60Harmony Healthcare International, Inc.
  61. 61. Depressive Indicator Documentation Section D of the associated MDS D0300 PHQ-9 Resident Interview D0600 PHQ-9 Staff Interview Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 61
  62. 62. Diagnosis Coding Component of a RUG Special Care Multiple Sclerosis Cerebral Palsy Quadriplegia Clinically Complex Coma Hemiparesis Diabetes (with daily injections and order Changes) Copyright © 2013 All Rights Reserved 62Harmony Healthcare International, Inc.
  63. 63. Diagnosis Coding Component of a RUG Special Care Dehydration (with Fever) Pneumonia (with Fever) Clinically Complex Septicemia Dehydration Pneumonia Internal Bleed Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 63
  64. 64. Diagnosis Coding Defined Require a physician-documented diagnosis Active diagnosis: Direct relationship to the resident’s current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 64
  65. 65. Diagnosis Coding Defined Medical record sources for physician diagnoses include: Progress notes, the most recent history and physical, transfer documents, discharge summaries, diagnosis/ problem list, and other resources as available If a diagnosis/problem list is used, only diagnoses confirmed by the physician should be entered Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 65
  66. 66. Diagnosis Defined Hemiparesis: Includes Hemiplegia Must have a specific diagnosis Weakness due to CVA is not supportive Quadriplegia: Excludes Quadriparesis Clarified on Open Door Forum February 2013: Must be related to spinal cord injury. Excludes Functional Quadriplegia. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 66
  67. 67. Diagnosis Defined Dehydrated (two or more present) 1) Intake less than 1,500 ml of fluids daily 2) Clinical indicators: dry mucous membranes, poor skin turgor, cracked lips, thirst, sunken eyes, dark urine, new onset or increased confusion, fever, or abnormal laboratory values (e.g., elevated hemoglobin and hematocrit, potassium chloride, sodium, albumin, blood urea nitrogen, or urine specific gravity, etc. 3) Resident’s fluid loss exceeds intake Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 67
  68. 68. Diagnosis Defined Internal Bleed: Frank Bleeding or Occult (such as guaiac positive stools). Vomiting “coffee grounds,” hematuria (blood in urine), hemoptysis (coughing up blood), and severe epistaxis (nosebleed) that requires packing. Excludes Menses or a urinalysis that shows a small amount of red blood cells Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 68
  69. 69. Diagnosis Defined Coma (Persistent Vegetative State): Diagnoses by a Physician Excludes progressive neurologic disorders or severe cognitive impairment as they are usually not comatose or in a persistent vegetative state Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 69
  70. 70. Diagnosis Coding Defined Active Diagnosis: Do not include conditions that have been resolved, do not affect the resident’s current status, or do not drive the resident’s plan of care during the 7-day look-back period, as these would be considered inactive diagnoses Medical treatments Medication Symptoms Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 70
  71. 71. Diagnosis Component Documentation Physician Orders (Monthly/ Interim) Physician Signed in the last 60 days Physician Progress Notes Emergency Department Report History and Physical Documentation must support diagnosis is active Diagnosis list must be supported by Physician Physician Order or Signature Supported by relationship in the Care Plan Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 71
  72. 72. Accurate Diagnosis Coding Tips What is the facility process for adding and resolving diagnosis to the medical record? Supported by Physician Physician Orders Diagnosis lists alone do not support if not signed and dated by the physician What is the facility process for identifying resolvable diagnosis Pneumonia Copyright © 2013 All Rights Reserved 72Harmony Healthcare International, Inc.
  73. 73. Rehab Component of a RUG Extensive Rehab “X” or “L” in last position Combination of Rehab and the Extensive service Based on actual minutes of Physical, Occupational and Speech Therapy minutes combined during the 7-Day Look-back period Copyright © 2013 All Rights Reserved 73Harmony Healthcare International, Inc.
  74. 74. Rehab RUG Levels Defined Ultra High Intensity Criteria: 720 minutes or more (total) of therapy per week AND At least two disciplines, 1 for at least 5 days, AND 2nd for at least 3 days Very High Intensity Criteria: In the last 7 days: 500 minutes or more (total) of therapy per week AND At least 1 discipline for at least 5 days Copyright © 2013 All Rights Reserved 74Harmony Healthcare International, Inc.
  75. 75. Rehab RUG Levels Defined High Intensity Criteria (either (1) or (2) below may qualify) 325 minutes or more (total of therapy per week AND At least 1 discipline for at least 5 days Medium Intensity Criteria (either (1) or (2) below may qualify) 150 minutes or more (total) of therapy per week AND at least 5 days of any combination of the 3 disciplines Copyright © 2013 All Rights Reserved 75Harmony Healthcare International, Inc.
  76. 76. Rehab RUG Levels Defined Low Intensity Criteria (either (1) or (2) below may qualify): (45 minutes or more (total) of therapy per week AND At least 3 days of any combination of the 3 disciplines AND 2 or more nursing rehabilitation services* received for at least 15 minutes each with each administered for 6 or more days Copyright © 2013 All Rights Reserved 76Harmony Healthcare International, Inc.
  77. 77. RUG III Leveled Rehab ADLs Splits REHAB RUG-III RUG-III ADL Score Class 15 – 18 R_C 8 – 14 R_B 4 – 7 R_A REHAB RUG-III RUG-III Extensive Class 16-18 R_X 7-15 R_L Copyright © 2013 All Rights Reserved 77Harmony Healthcare International, Inc.
  78. 78. Rehab RUG Documentation Actual Minutes supported by Therapy logs Actual Minutes not units Legible Patient name Rehabilitation Nursing (Restorative) minutes provided for Rehabilitation Low Minutes signed by the therapist that provided care Physician Orders for therapy Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 78
  79. 79. Additional Documentation to Support Reason for Referral Supported by Nursing and or Physician Documentation Prior Level of Function supported by Medical record Change in status supported by medical record: Nursing ADL Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 79
  80. 80. Component of a RUG RUG III Grouper Qualifications: Restorative Nursing, Procedures, Treatments and Conditions
  81. 81. Rehab Nursing Component of RUG End Split is restorative nursing rehab/restorative 6 days in 2 areas Reduced Physical/Behavioral /Cognitive BB2 versus BB1 PB2 versus PB1 Rehab Low RLA RLB Copyright © 2013 All Rights Reserved 81Harmony Healthcare International, Inc.
  82. 82. Rehab Nursing Component of RUG 2 areas for 15 or more minutes a day for 6 or more of the last 7 days: H0200C, H0500** Urinary toileting program and/or bowel toileting program O0500A,B** Passive and/or active ROM O0500C Splint or brace assistance O0500D,F** Bed mobility and/or walking training Copyright © 2013 All Rights Reserved 82Harmony Healthcare International, Inc.
  83. 83. Rehab Nursing Component of RUG Restorative (Continued) O0500E Transfer training O0500G Dressing and/or grooming training O0500H Eating and/or swallowing training O0500I Amputation/prostheses care O0500J Communication training Copyright © 2013 All Rights Reserved 83Harmony Healthcare International, Inc.
  84. 84. Rehab Nursing Documentation Signed logs supporting days 15 minutes provided Signed logs supporting 2 areas provided 6 days Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 84
  85. 85. Additional Documentation to Support RAI criteria for rehabilitation nursing must be met: Measurable objective and interventions must be documented in the care plan and in the medical record Evidence of periodic evaluation by the licensed nurse must be present in the medical record Copyright © 2013 All Rights Reserved 85Harmony Healthcare International, Inc.
  86. 86. Additional Documentation to Support Nursing Supervision State specific Minimum 30 Days Does not include groups with more than four residents per supervision helper or caregiver Evidence of Restorative Nursing Aid training Copyright © 2013 All Rights Reserved 86Harmony Healthcare International, Inc.
  87. 87. Skin Component Defined Special Care 2 Stage I or II Pressure Ulcers or Venous/Arterial ulcers (crosswalk) Stage III, IV or Unstageable Pressure Ulcer Open lesion Surgical wound Clinically Complex Burns Foot infection/wounds Copyright © 2013 All Rights Reserved 87Harmony Healthcare International, Inc.
  88. 88. Skin Component Defined Pressure Ulcers require 2 or more skin treatments Surgical wounds and open lesions require 1 treatment Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 88
  89. 89. Documentation to Support Skin Weekly sizing and staging reports or nursing note evidencing present in the 7-day Look-back period Treatment sheets to support treatment administered in the 7-day Look-back period Documentation to support the highest stage the pressure ulcer was if healing Wound Care Consult Reports Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 89
  90. 90. Skilled Procedures and Treatments Special Care Tube feeding and Fever or Aphasia Radiation treatment Respiratory therapy =7 days Clinically Complex Dialysis Oxygen therapy Transfusions Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 90
  91. 91. Skilled Procedures and Treatments Defined While a Resident Treatments, procedures, and programs received or performed by the resident after admission/re-entry to the facility and within the 14-day look-back period While not a Resident Treatments, procedures, and programs received or performed by the resident prior to admission/reentry to the facility and within the 14-day look-back period Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 91
  92. 92. Skilled Procedures and Treatments Defined Oxygen: 14-Day Look-back Oxygen actually administered in the Look-back Period PRN order must have documentation to support actual administration Continuous oxygen with documentation evidencing administered Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 92
  93. 93. Skilled Procedures and Treatments Defined Tube Feeding: 7-Day Look-back Actual intake through parenteral or tube feeding routes Proportion of total calories received 51% or more or 26% to 50% and greater than 501 cc Average Fluid Intake per Day Documentation in the Look-back period to support for patients eating and receiving tube feed Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 93
  94. 94. Respiratory Therapy Respiratory therapy services are for the assessment, treatment, and monitoring of patients with deficiencies or abnormalities of pulmonary function. Respiratory therapy services include coughing, deep breathing, heated nebulizers, aerosol treatments, assessing breath sounds and mechanical ventilation. RAI Manual Appendix A November 2012 Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 94
  95. 95. Skilled Procedures and Treatments Documentation Facility Medication/Treatment Administration Records Respiratory Flow Sheets Hospital Medication/Treatment Administration Records Emergency Room Records Consult Reports Nursing Notes Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 95
  96. 96. Conditions Component of the RUG Special Care: Fever in conjunction with any of the following: Dehydration Tube Feed, Weight Loss Vomiting Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 96
  97. 97. Conditions Defined 7-Day Look-Back Period Fever: Defined as a temperature 2.4 degrees F higher than baseline. The resident’s baseline temperature should be established prior to the Assessment Reference Date. Vomiting: Regurgitation of stomach contents; may be caused by many factors (e.g., drug toxicity, infection, psychogenic) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 97
  98. 98. Conditions Defined Weight Loss: Includes weight loss either physician-prescribed or not physician-prescribed Weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days Compare the resident’s weight on in the 7-day look-back period to his or her weight in the observation period 30 and 180 days ago. New Admissions ask the resident, family, or significant other and consult. Review transfer information. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 98
  99. 99. Conditions Documentation to Support Weight Records Vital Signs tracking Nursing Notes Facility Medication/Treatment Administration Records Hospital Medication/Treatment Administration Records Emergency Room Records Consult Reports Must support the actual date the condition occurred Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 99
  100. 100. Additional Documentation to Support Accuracy of Weight: Most recent weight measure in the last 30 days If the last recorded weight was taken more than 30 days prior to the ARD of this assessment or previous weight is not available, weigh the resident again. If the resident’s weight was taken more than once during the preceding month, record the most recent weight Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 100
  101. 101. Physician Orders and Visits Component 14-Day Look-Back Period Clinically Complex: 2 Days of Physician Orders and 2 Physician Visits 4 Days of Physician Orders and 1 Physician Visit Diabetes mellitus and injection 7 days and 2 Physician days of order changes Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 101
  102. 102. Physician Visits Defined Physician Visit: Includes medical doctors, doctors of osteopathy, podiatrists, dentists, and authorized physician assistants, nurse practitioners, or clinical nurse specialists working in collaboration with the physician as allowable by state law Examination (partial or full) can occur in the facility or in the physician’s office. Included in this item are telehealth visits as long as the requirements are met for physician/practitioner type as defined above and whether it qualifies as a telehealth billable visit claims proessing manual. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 102
  103. 103. Physician Visits Defined Do not include physician examinations that occurred prior to admission or readmission to the facility (e.g., during the resident’s acute care stay) Do not include physician examinations that occurred during an emergency room visit or hospital observation stay Off-site (e.g. while undergoing dialysis or radiation therapy) with documentation of the physician’s evaluation Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 103
  104. 104. Physician Orders Defined High Audit Area Physician Orders: 14-Day Look-back Period in Section O: Days of Order changes not the actual number Medical doctors, doctors of osteopathy, podiatrists, dentists, and physician assistants, nurse practitioners, or clinical nurse specialists working in collaboration with the physician as allowable by state law. New or altered treatment Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 104
  105. 105. Physician Orders Defined Excludes: Orders prior to the date of admission or re- entry Orders for activation of a PRN order A sliding scale dosage schedule that is written to cover different dosages depending on lab values, does not count as an order change simply because a different dose is administered based on the sliding scale guidelines (Coumadin) Orders for transfer of care to another physician Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 105
  106. 106. Physician Orders Defined Excludes: Standard admission orders, return admission orders, renewal orders, or clarifying orders without changes Orders on day of admission with unexpected change/deterioration in condition or injury are considered as new Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 106
  107. 107. Physician Orders Defined “Orders written to increase the resident’s RUG classification and facility payment are not acceptable” An order written on the last day of the MDS observation period for a consultation planned 3-6 months in the future should be carefully reviewed. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 107
  108. 108. Documentation to Support Accurate Counting of Days (not number of orders) Physician orders legibly dated Interim and Monthly orders sheets Physician progress report and consults Must evidence at least partial assessment Nursing documentation that a visit occurred is not sufficient Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 108
  109. 109. Component of a RUG RUG -III Grouper Qualifications: Impaired Cognition and Behavior, ADL
  110. 110. Impaired Cognition Impairment Defined ADL=10 or Less One of the 3 following criteria: 1) Cognitive Impairment: A BIMS interview score of less than or equal to 9 will meet the criteria for cognitive impairment. 2) C1000 Severely Impaired Decision Making (3) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 110
  111. 111. Impaired Cognition Impairment Defined 3) Impaired Cognition Two or more of the following impairment indicators are present C0700 = 1 Short term memory problem C1000 > 0 Cognitive skills problem B0700 > 0 Problem being understood AND One or more of the following severe impairment indicators are present: C1000 >= 2 Moderately Impaired B0700 >= 2 Sometimes understood Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 111
  112. 112. Additional Documentation to Support Care Planning for evidencing impaired cognition Other conflicting assessments Mini-Mental Verification of Completion of BIMS in the 7-day look-back period “If a staff member cannot sign Z0400 on the same day that he or she completed a section or portion of a section, when the staff member signs, use the date the item originally was completed” Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 112
  113. 113. Behavior Problem ADL=10 or Less E0900 Wandering (2 or 3) E0200B Verbal Behavior Directed at others (2 or 3) E0200A Behavior Directed at others (2 or 3) E0200C Other Behavior not Directed at others (2 or 3) E0800 Resisted care (2 or 3) E0100C Delusions E0100A Hallucinations Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 113
  114. 114. Documentation to Support Behavior Documentation supports 4+Days in Look Back period Impact on others Behavior Monitoring sheets Nursing CNA Social Services notes support Daily Nursing notes Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 114
  115. 115. Additional Documentation Care Planning evidencing behavior intervention Psychiatry and Psychological notes support Physician documentation Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 115
  116. 116. ADL Component of a RUG: Highest Audit Reduction Area Impacts all RUG Rehab RUC RML Nursing: SE3-ADL minimum of 7 Copyright © 2013 All Rights Reserved 116Harmony Healthcare International, Inc.
  117. 117. ADL Defining RUG Qualifier RUG-III ADL score of 7 or more Extensive and Special Care Coma All ADL must be Dependent or did not occur (48) Copyright © 2013 All Rights Reserved 117Harmony Healthcare International, Inc.
  118. 118. BETT Bed mobility (G0110A) Eating (G0110H) Transfer (G0110B) Toilet use (G0110I) Copyright © 2013 All Rights Reserved 118Harmony Healthcare International, Inc.
  119. 119. ADL Self Performance Rules of 3 Weight-bearing support 3 or more times Extensive Assist Non weight-bearing support 3 or more times code Limited Assist Copyright © 2013 All Rights Reserved 119Harmony Healthcare International, Inc.
  120. 120. ADL Self Performance Supervision: Encouragement or cueing provided by the staff Limited Assistance: The resident received physical help in guided maneuvering of limbs or other non weight-bearing assistance Extensive Assistance: The resident performed part of the activity and received assistance of the following types: Weight-bearing support or Full staff assistance in the task/or portion of the task, during part but not all shift Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 120
  121. 121. ADL Self Performance 7. Occurred 1 or 2 times 8. Activity Did Not Occur during ENTIRE look back period The activity did not occur or family and/or non-facility staff provided care Examples: The resident was on bed rest so transfer did not occur. The resident is non-ambulatory Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 121
  122. 122. Self Performance The ENTIRE Look-back period: 0. Independent: No staff assistance or supervision New in MDS 3.0 Page G-6 Algorithm 4. Total Dependence: Full staff assistance of the entire activity each time it occurs. There was no participation by the resident Comments on Audit not impacting RUG Copyright © 2013 All Rights Reserved 122Harmony Healthcare International, Inc.
  123. 123. ADL Support ADL Support Provided: Code for the most support provided over the entire shift. No Support Set up help only One person physical assist Two or more provided physical assist Activity itself did not occur during entire shift Copyright © 2013 All Rights Reserved 123Harmony Healthcare International, Inc.
  124. 124. RUG-III ADL-Step 1 Self-Performance Column 1 Support Column 2 ADL Score 7,0,1 Any number 1 2 Any number 3 3 2 4 4 2 4 8, 3 or 4 3, 8 5 Calculate for Bed Mobility, Transfer and Toilet Use Copyright © 2013 All Rights Reserved 124Harmony Healthcare International, Inc.
  125. 125. RUG-III ADL-Step 2 Self-Performance Column 1 Support Column 2 ADL Score 0,1 -,0, 1,8 1 2 2 2 3 2 3 4 2 3 Calculate for Eating Copyright © 2013 All Rights Reserved 125Harmony Healthcare International, Inc.
  126. 126. RUG-III ADL Nursing Varies by Category (see Handout): Example Special Care RUG-III ADL Score RUG-III Class 17 – 18 SSC 15 – 16 SSB 7 - 14 SSA Copyright © 2013 All Rights Reserved 126Harmony Healthcare International, Inc.
  127. 127. Documentation to Support ADL CNA Flowsheets Reflect Month and Resident Name Identify specific documentation utilized for 2 Assist provided by facility staff if single episode coded in the Look-back period Ensure 3 episodes of assist are provided by facility staff are evident in the Look-back period Ensure Dependent coded only if occurred during the entire look-back period Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 127
  128. 128. Questions/Answers Harmony Healthcare International 1 (800) 530 – 4413 www.Harmony-Healthcare.com bpatterson@Harmony-Healthcare.com tcargen@Harmony-Healthcare.com Copyright © 2013 All Rights Reserved 128Harmony Healthcare International, Inc.
  129. 129. 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. 129Copyright © 2013 All Rights Reserved

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