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OIG Utilization Review
Documentation
requirements for the
MDS 3.0
OIG Stakeholder Meeting March 24th
Section C and DSection C and D
InterviewsInterviews
Handout (Med Pass BIMS Interview)
All Interviews must be performed o...
Section GSection G
Handout: DADS Provider Letter:
Nursing facility management must determine how ADL information is
docume...
ADL DocumentationADL Documentation
When documentation is conflicting we must
provide an explanation of why there was a
ch...
Section ISection I
Active Diagnosis must impact the resident
current care in the look back period
(Aphasia)
Quadriplegia...
Section OSection O
RestorativeRestorative
Certified nurse aides meet the criteria for
training for Restorative care if tr...
Section OSection O
Respirator TherapyRespirator Therapy
 Handout: MDS Mentor
 Must be ordered by a physician
 The physi...
Section OSection O
Respiratory TherapyRespiratory Therapy
Only include respiratory services that are
provided by a qualif...
Section OSection O
Respiratory TherapyRespiratory Therapy
Training Curriculum:
◦ Should be titled, “Respiratory Therapy
T...
Can a LVN Conduct RespiratoryCan a LVN Conduct Respiratory
Training: Reference MDS MentorTraining: Reference MDS Mentor
 ...
Z0500A and S4 of LTCMIZ0500A and S4 of LTCMI
RN signature at Z0500A and the license number
at S4 must be the same person
...
ExtrapolationExtrapolation
MDS 2.0: Extrapolation amount is being
waived for providers that have open
cases and the error...
Conference Call/AudioConference Call/Audio
Recording of OIG Exit:Recording of OIG Exit:
Facilities may choose to set up t...
Reconsideration Timelines:Reconsideration Timelines:
Reconsiderations must be post-marked
on or before the 15th
day of th...
Medical Necessity ReviewsMedical Necessity Reviews
Currently reviewing PA1 and PA2s
Are making determinations even if th...
Other TidbitsOther Tidbits
OIG will make increases or decreases
based on items found on the assessments
included in the r...
Q&AQ&A
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OIG UR doc guidelines presentation

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OIG UR doc guidelines presentation

  1. 1. OIG Utilization Review Documentation requirements for the MDS 3.0 OIG Stakeholder Meeting March 24th
  2. 2. Section C and DSection C and D InterviewsInterviews Handout (Med Pass BIMS Interview) All Interviews must be performed on the ARD or in the 7 day look back Documentation of the date this was completed should be signed at Z0400 on the date the interview was done If not performed in the window will not be counted as valid and therefore dashed as undetermined at the OIG review
  3. 3. Section GSection G Handout: DADS Provider Letter: Nursing facility management must determine how ADL information is documented. CMS, DADS and HHSC rules and regulations do not mandate a specific form, format or template for ADL documentation. For example, use of ADL flow sheets, electronic or paper, completed by Certified Nurse Aides is acceptable supporting documentation for ADL coding in Section G, as long as there is no conflicting information in the rest of the clinical record. As noted on page 1-8 of the MDS 3.0 RAI Manual, “While CMS does not impose specific documentation procedures on nursing homes in completing the RAI, documentation that contributes to identification and communication of a resident’s problems, needs, and strengths, that monitors their condition on an on-going basis, and that records treatment and response to treatment, is a matter of good clinical practice and an expectation of trained and licensed health care professionals. Good clinical practice is an expectation of CMS. As such, it is important to note that completion of the MDS does not remove a nursing home’s responsibility to document a more detailed assessment of particular issues relevant for a resident.” Furthermore, when the resident’s level of self-performance or the level of support provided changes, supporting documentation in the clinical record must accurately describe the change.
  4. 4. ADL DocumentationADL Documentation When documentation is conflicting we must provide an explanation of why there was a change. ◦ Corrections to documentation errors should be made according to policy and standards of practice. Electronic ADL (Caretracker, Accunurse, Point of Care, Etc.) documentation needs an Electronic Signature policy Must be able to determine who is documenting on those forms Handout: Therapy ADL documentation crosswalk
  5. 5. Section ISection I Active Diagnosis must impact the resident current care in the look back period (Aphasia) Quadriplegia must be documented from a spinal cord injury not functional Diagnosis must be written by physician within the last 60 days. Should be recorded and signed on the consolidated orders Telephone orders initiated by nurse not acceptable
  6. 6. Section OSection O RestorativeRestorative Certified nurse aides meet the criteria for training for Restorative care if trained in Texas. If programs are beyond the normal scope such as specific splints or braces may require individualized training Must be able to show certification when asked Program must have measurable goals and interventions and clinically appropriate Should be documented in care plan Must be a periodic evaluation of the effectiveness by a licensed nurse (OIG suggested monthly) Does not require a physician order Does not have to be written by a therapist
  7. 7. Section OSection O Respirator TherapyRespirator Therapy  Handout: MDS Mentor  Must be ordered by a physician  The physician’s order includes a statement of frequency, duration, and scope of treatment;  The services must be directly and specifically related to an active written treatment plan that is based on an initial evaluation performed by qualified personnel  The services are required and provided by qualified personnel (See Glossary in Appendix A for definitions of respiratory therapies)  The services must be reasonable and necessary for treatment of the resident’s condition.  A day of therapy is defined as treatment for 15 minutes or more in the day.
  8. 8. Section OSection O Respiratory TherapyRespiratory Therapy Only include respiratory services that are provided by a qualified professional to include: ◦ Respiratory therapists ◦ Trained Nurses following the nurse practice act Methods of developing trained nurses: ◦ Training by a respiratory therapist ◦ Training by a RN who was trained by a respiratory therapist ◦ Training by a RN who has advanced academic training in respiratory therapy.
  9. 9. Section OSection O Respiratory TherapyRespiratory Therapy Training Curriculum: ◦ Should be titled, “Respiratory Therapy Training” and not Nebulizer training. ◦ Maintain copy of training records in each nurses file:  curriculum used for training  Evidence that nurse was trained by staff qualified to provide the training. (trainers credentials and training certificate or license)  Competency checklist initialed by trainer and trainee
  10. 10. Can a LVN Conduct RespiratoryCan a LVN Conduct Respiratory Training: Reference MDS MentorTraining: Reference MDS Mentor  A LVN who has demonstrated competency in providing respiratory therapy services may train other LVNs to provide respiratory therapy, using the following guidelines: ◦ The curriculum must be developed and approved by a certified respiratory therapist, registered nurse, or physician trained to provide respiratory therapy services. (The LVN may participate in developing but cannot develop independently) ◦ Must demonstrate competency in training other LVNs. This includes system to check:  LVN competency in providing respiratory therapy, and;  LVN competency in training other LVNSs  Competency must be conducted annually
  11. 11. Z0500A and S4 of LTCMIZ0500A and S4 of LTCMI RN signature at Z0500A and the license number at S4 must be the same person Can be used in LTCMI even if no longer employed Must have current RUG certification Should keep copies of all RUG certifications in employees files to produce to OIG reviewers No penalty currently if not matching but will consider in the future LTCMI should be attached to the appropriate MDS
  12. 12. ExtrapolationExtrapolation MDS 2.0: Extrapolation amount is being waived for providers that have open cases and the error rate was 15% or less ◦ Contact Linda Carlson at 512.491.2065 or linda.carlson@hhsc.state.tx.us if you have not received MDS 3.0: The OIG has decided not to apply extrapolation to MDS 3.0 reviews but have reserved the right to apply it in the future.
  13. 13. Conference Call/AudioConference Call/Audio Recording of OIG Exit:Recording of OIG Exit: Facilities may choose to set up the exit on a conference call to allow for other interested parties to participate: ◦ Must be able to receive, sign, and return Preliminary statement of findings. ◦ OIG will not conduct exit if provider attorneys are on the conference until they are able to coordinate with their attorneys to join. May record exit conference
  14. 14. Reconsideration Timelines:Reconsideration Timelines: Reconsiderations must be post-marked on or before the 15th day of the telephone exit conference: We are seeking to have these timeframes extended Extensions may be granted on a case by case basis. Contact Judy Knobloch at 512.491.2070 for extension request.
  15. 15. Medical Necessity ReviewsMedical Necessity Reviews Currently reviewing PA1 and PA2s Are making determinations even if the recipient had Permanent Medical Necessity Legislature asked DADS to conduct a Medical Necessity Review ◦ Independent review conducted in 2012 ◦ No supporting documentation in many cases to support that the recipient was unable to self medicate ◦ Handout: Med Pass – Medication Self Administration of Medications
  16. 16. Other TidbitsOther Tidbits OIG will make increases or decreases based on items found on the assessments included in the review EMR facilities do not have to print documentation for reviewers but they must be given individual access MDS Signatures: Lack of signature may impact payment on future reviews. Exit calls: Have been delayed to allow for software update.
  17. 17. Q&AQ&A

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