Ask the payment expert ... about the observation stay loophole

Most of our residents are covered under rehab services, so why do we need to worry about capturing clinical qualifiers? 

Clinical qualifiers can be just as important as your rehabilitation qualifiers. Comorbidities can show why the resident may need therapy for a longer period of time, or why therapy is taking more time each day.

A facility we worked with was going through medical review and had 30 to 40 claims reviewed.  When all was completed, they had an outcome of a zero error rate (100% payment). In almost every case, the findings by the medical reviewers were that the resident’s level of therapy was justified due to the medical complexity of care. The clinical documentation (which was very well done) supported the level of therapy.  

That is not the typical result of medical review. Many cases have had reductions in therapy due to the therapy being considered excessive in levels or duration. In addition, the process for medical review states that if a service is found not to be justified, then the RUG reimbursement will convert to the next available RUG.

For example, say your resident’s RUG level is RUB. If the medical reviewer determines that rehab services are excessive and lowers justified minutes of therapy from 730 to 0, if the resident has clinical qualifiers (such as wound care), the RUG level could go from RUB to an LB1. The alternative, if the wound care is not captured on the MDS, is that the RUB would go to no reimbursement at all. 

The best advice is to make sure the MDS and clinical documentation paint a comprehensive picture of your resident. Make sure nursing is supporting therapy by showing the resident response. These clinical factors can help demonstrate the need for services you are providing.