Capturing acuity: How MDS accuracy has a critical impact on Medicare/Medicaid payment systems

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Steven Littlehale
Steven Littlehale
There's a familiar saying in the industry that “If it's not documented, then it's not done.” But what if it is documented, but just not documented correctly?

This puts providers at risk in two ways: The first is that it may flag them as providing medically unnecessary services, i.e., fraudulent actions by inappropriately billing Medicare and Medicaid for unnecessary or non-rendered items and services. The second risk is the impact that inaccurate data has on reimbursement.

In both scenarios, federal and state auditing agencies bring scrutiny to the Minimum Data Set (MDS) and this quickly translates into enormous pressure for ‘getting it right” on the part of the staff doing the coding.

So how can a provider ensure they're consistently “getting it right?” There's both an art and science to managing the RAI process — being selective in the assigning Assessment Reference Dates (ARDs) to capture the acuity and corresponding services provided, while remaining compliant with regulations. Concerns for payment adjustments lead to under-coding care when supportive documentation is incomplete per RAI standards, despite alternative evidence that the care was actually provided.

The tool readily available to providers is analytics, which not only helps identify when MDS errors cause decreases in CMI, but also flags errors that could create fraudulent episodes that may challenge corporate integrity. Analytics can help identify specific sections of the MDS where patterns of coding issues exist. This is important in ensuring that the teams are looking efficiently at their data, and enabling analytics to filter the data and focus the teams on top priorities of concern.

MDS accuracy is also a requirement in ensuring corporate compliance; there are new standards on the horizon that all providers must meet. Section 6102 of the Patient Protection and Affordable Care Act requires that by March 2013, each SNF and NF develop a compliance and ethics program and participate in a quality assurance and performance improvement program.

To achieve compliance, each organization must have established compliance standards and procedures to be followed by its employees and other agents that are reasonably capable of reducing the prospect of criminal, civil and administrative violations. Miscoding the MDS, resulting in inaccurate billing, is just one example of these violations providers must avoid.

Despite the importance placed on MDS coding accuracy, completing the current version of the MDS remains a challenge. In October 2010, providers began coding the MDS 3.0, and nearly 18 months later, PointRight sees an average of 2.4 coding issues per assessment (according to MDS data coming into PointRight). Collectively, these issues result in undercoding services related to acuity, including ADLs, wound care, depression, behaviors and restorative nursing. Miscoding these items may result in lower RUG and Case Mix assignments — or, in other words, lower payments.

Along with MDS 3.0 came the addition of the resident interview process designed to more accurately capture resident conditions regarding cognition, depression and pain. In both Medicare and Medicaid Case Mix systems, payments are impacted by the responses to two of these scales. Additional payments for residents who are depressed are dependent on the PHQ-9 scale total severity score being 10 or greater. They also affect 26 payment groups in Special Care High, Special Care Low and the Clinically Complex RUG groups.

The dependency on payment related to these two scales increases the importance of capturing the corresponding data driving the acuity. Providers may increase their success at accurately capturing depression payments when they review the interview process to ensure strict adherence to the instructions, include attention to time of day, environment, and qualifications of the interviewer.

MDS accuracy remains an industry challenge in two ways: overcoding will bring scrutiny with future compliance requirements, while undercoding is a clinical and financial liability to the stability of the SNF/NF and their quality programming. Facilities simply have to get it right.

Capturing acuity is all about knowing what day-to-day changes are seen in each resident's condition, and when appropriate, capturing that change on an MDS assessment. Adding services such as skilled therapy and or restorative nursing following a loss in ADL/self-care ability is consistent with best practice and quality of care standards, should result in a change of condition MDS assessment, which respectfully should capture the interventions provided to arrest the self-care loss.

The bottom line? Those facilities with systems that support frequent (near daily) communication of Medicare and Medicaid Case Mix resident conditions are the ones that will “get it right” and “keep it right.”

Steven Littlehale is EVP and chief clinical officer at PointRight Inc. He is a gerontological clinical nurse specialist and former university instructor.

 
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