Ask the payment expert: Is 'look back' documentation still required

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Ask the payment expert
Ask the payment expert
Q: With the new MDS 3.0, is “look-back” documentation still required?

A: CMS has never required “look-back” documentation. Some states have had the requirement due to State reimbursement systems.

Although not required, we have always been advocates of look-back documentation to optimize reimbursement. That reason has not changed with the MDS 3.0 and the new RUG-IV system. Facilities that do a good job with documentation have better reimbursement.

Electronic systems also have assisted facilities to maintain better reimbursement. Now with the interview process for some of the key areas for reimbursement, facilities may be tempted to eliminate look-back documentation. However, good look-back documentation still gives the facility critical information that it needs to complete the MDS.

It is true that the facility is paid based on what is coded on the MDS but good look-back documentation can identify key issues with your resident. First, it may identify that the person completing the interview process is not instructing the resident properly.

Or it may be that the resident does not feel he or she has a problem but the staff has identified issues. This information can then be utilized for “charting your thinking” for the CAAs and moving on to the care plan. This will mean better care provided to the resident.

Please send your payment-related questions to Patricia Boyer at