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

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

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

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

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:

OM(I)G!
New York Medicaid Case Mix Audit Success
Disclosure
Speaker:
The speaker has no relevant financial
relationships to disclose
The speaker has no relevant nonfinancial
relationships to disclose
Copyright © 2013 All Rights Reserved

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

Housekeeping

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.

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

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

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%

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.

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.

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.

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

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

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

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

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

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

Develop a team that will collect and
Review the information needed
Medical Records
MDS
Rehab
DON
Audit ahead your self ahead of time

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

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

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.

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”?

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?

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.

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.

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.”

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.”

Therapy documentation should
describe the reason for referral, change
from prior level of function, and skilled
interventions needed.

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.

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.

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.

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.

Patient # 5
MDS with ARD of 11/15/11 has no
supporting documentation of behavior
problems.

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.

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.

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.

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.

Component of a RUG
RUG-III Grouper Qualifications:
Identification of Qualifiers and
Extensive

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

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

Extensive Component of RUG:
Non-Therapy Extensive
SE1
SE2
SE3
Rehab Extensive
R_X
R_L

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

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
received or performed by the resident prior
to admission/reentry to the facility and

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.”

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

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

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

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

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

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

RUG-III: Extensive Services Count
Extensive Count RUG-III Class
4 or 5 SE3
2 or 3 SE2
0 or 1 SE1

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

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

Component of a RUG
RUG-III Grouper Qualifications:
Depression, Diagnosis and
Rehab

Depression Component of a RUG
End Split for Clinically Complex :
CD2 versus CD1
2= Positive Depressive Indicator

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

Depressive Indicator
Documentation
Section D of the associated MDS
D0300 PHQ-9 Resident Interview
D0600 PHQ-9 Staff Interview

Diagnosis Coding Component of a RUG
Special Care
Multiple Sclerosis
Cerebral Palsy
Quadriplegia
Clinically Complex
Coma
Hemiparesis
Diabetes (with daily injections and order
Changes)

Diagnosis Coding Component of a
RUG
Special Care
Dehydration (with Fever)
Pneumonia (with Fever)
Clinically Complex
Septicemia
Dehydration
Pneumonia
Internal Bleed

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

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

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.

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

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

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

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

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

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

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

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:
week AND
At least 1 discipline for at least 5 days

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)
week AND at least 5 days of any combination
of the 3 disciplines

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

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

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

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

Component of a RUG
RUG III Grouper Qualifications:
Restorative Nursing, Procedures,
Treatments and Conditions

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

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

Restorative (Continued)
O0500E Transfer training
O0500G Dressing and/or grooming
training
O0500H Eating and/or swallowing
training
O0500I Amputation/prostheses care
O0500J Communication training

Rehab Nursing Documentation
Signed logs supporting days 15 minutes
provided
Signed logs supporting 2 areas
provided 6 days

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

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

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

Skin Component Defined
Pressure Ulcers require 2 or more skin
treatments
Surgical wounds and open lesions
require 1 treatment

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

Skilled Procedures and Treatments
Special Care
Tube feeding and Fever or Aphasia
Radiation treatment
Respiratory therapy =7 days
Clinically Complex
Dialysis
Oxygen therapy
Transfusions

Defined
While a Resident
received or performed by the resident after
admission/re-entry to the facility and
While not a Resident
received or performed by the resident prior
to admission/reentry to the facility and

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

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

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

Documentation
Facility Medication/Treatment Administration
Records
Respiratory Flow Sheets
Hospital Medication/Treatment
Administration Records
Consult Reports
Nursing Notes

Conditions Component of the RUG
Special Care:
Fever in conjunction with any of the
following:
Dehydration
Tube Feed,
Weight Loss
Vomiting

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)

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.

Conditions Documentation to Support
Weight Records
Vital Signs tracking
Nursing Notes
Facility Medication/Treatment Administration
Records
Hospital Medication/Treatment Administration
Records
Consult Reports
Must support the actual date the condition occurred

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

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

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.

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

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

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

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

“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.

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

Component of a RUG
RUG -III Grouper Qualifications:
Impaired Cognition and
Behavior, ADL

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)

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

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”

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

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

Additional Documentation
Care Planning evidencing behavior
intervention
Psychiatry and Psychological notes
support
Physician documentation

ADL Component of a RUG:
Highest Audit Reduction Area
Impacts all RUG
Rehab
RUC
RML
Nursing:
SE3-ADL minimum of 7

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)

BETT
Bed mobility (G0110A)
Eating (G0110H)
Transfer (G0110B)
Toilet use (G0110I)

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

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

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

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

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

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

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

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

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

Questions/Answers
Harmony Healthcare International
1 (800) 530 – 4413
www.Harmony-Healthcare.com
bpatterson@Harmony-Healthcare.com
tcargen@Harmony-Healthcare.com

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

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

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