CMS 5-claim audits so far a ‘debacle’

A new federal review process designed to lower the rate of improper government payments is sending provider staffs scurrying to justify their coding.

Information and comments provided to McKnight’s Long-Term Care News on Monday indicate growing frustration with the Skilled Nursing Facility 5-Claim Probe and Educate Review. The Center for Medicare & Medicaid Services announced in late May that every skilled nursing facility that participates in Medicare would have five Medicare Part A claims audited by Medicare Administrative Contractors (MAC). 

Providers will be offered basic education and adjustments to prepayment claims while those who have errors on more than one-fifth of their claims will get a closer look and be offered more in-depth education. 

But the rollout, which began the first week of June, has been messy, according to coding executives who spoke with McKnight’s on background calling the audits a “debacle.”

“Facilities are burdened by the request for documentation during the medical review that is above and beyond what CMS requires per the [Resident Assessment Instrument] User’s Manual,” acknowledged Jessie McGill, RN, and a Curriculum Development Specialist at the American Association of Post-Acute Care Nursing, in an email to McKnight’s Long-Term Care News. “Facility staff are spending substantial time searching the medical record for any documentation that may help to support the claims. Since the [Minimum Data Set] documentation should self-support the direct resident responses for interviews, no additional documentation is needed.”

The new 5-claim review process was in response to a nearly doubled rate of improper payments from 2021 to 2022, during which the rate went from 7.79% to 15.1%. CMS blamed missing case-mix group component documentation. 

An explainer posted to the agency’s website on June 8 stated that SNFs misunderstood billing changes when it switched from the Resource Utilization Group (RUG IV) to the Patient Driven Payment Model (PDPM) on Oct. 1, 2019.

Experts told McKnight’s when the review process was announced that audits would be conducted on a rolling basis with MACs in every region pulling facility reports and scanning for potential errors. A report from the US Department of Health and Human Services had found that skilled nursing facilities had the highest rate of improper payments, with nearly a quarter of those tied to insufficient documentation.

Coding imperatives

McGill confirmed that her organization has been asked by providers about what supporting documentation is required for scripted interviews after a MAC did not accept interview responses that were coded directly onto the MDS during that Targeted Probe and Educate (TPE) medical review. 

The association also has fielded specific questions and concerns about auditors not accepting documentation supporting a patient’s mechanically altered diet that was in a nurse’s notes. 

“This member stated the auditor expected daily confirmation of the diet the resident received either on the medication administration record or the treatment administration record,” McGill said. She noted that the RAI User’s Manual requires only that a review of the medical record be used to “determine if any of the listed nutritional approaches were performed during the 7-day look-back period.” 

“The specific expectations of daily documentation of mechanically altered diet on the MAR or TAR from the medical review do not align with the CMS requirements in the RAI User’s Manual,” McGill said, adding that facility staff are making process changes to support mechanically altered diets beyond that of a physician order and dietary or nurses’ note because of the audits.

She said the association has reached out to CMS regarding these and other concerns, but they have not yet received a response. In addition, McKnight’s did not receive a response Monday from CMS on questions pertaining to the new process and whether MACs were overreaching with some of their requests.

Not all providers contacted by McKnight’s had experienced the new audits yet, and several said they had no issues to report. But they are being extremely cautious, they said, with one highly regarded operator confirming its social work department was assisting in keeping extra-thorough records, should auditors ever ask for more. 

Eleisha Wilkes, RN, a clinical consultant with ProActive Consulting and the “Ask the Payment Expert” columnist for McKnight’s Long-Term Care News, urged facilities to refer to the RAI “frequently and pay close attention to the coding instructions for all data elements.” She pointed out that coding for nutrition tells providers to check off all approaches that were “performed” in the previous seven days prior to filling out the forms. She also noted that diet order only shows the intent to serve the diet and cannot be used to support coding that the diet has been served.

“Words like ‘performed’ indicate that documentation will need to be available during the observation period to support the coding decision,” Wilkes said. “An order may only serve to support the intent to perform. While CMS does not impose specific documentation procedures on nursing homes in completing the RAI, facilities should ensure documentation is present to support the resident’s clinical condition and provided services.”

Facilities’ use of in-house forms and an MDS coordinator to input answers to resident voice questionnaires may also come under scrutiny. 

The Indiana state RAI coordinator told Wilkes in an email exchange that a facility’s MDS coordinator “cannot sign for the accuracy of an interview conducted by someone else.” 

“I have no issues with a form being used but am concerned with how that could affect MDS coding if not done properly,” Wilkes said, adding that she has reached out to other state RAI coordinators with the same question.

Poor audits could lose dollars

Ultimately, audit problems could lead to facilities losing needed funding.

Interview responses for the Patient Health Questionnaire-9 and the Brief Interview for Mental Status as well as mechanically altered diet are all used to inform the PDPM for Medicare reimbursements. If either the PHQ-9 or the BIMS is deemed invalid and billing adjusted, that could result in a re-classification in the nursing component or speech-language pathology of the PDPM, McGill said. 

“The facilities need to appeal these decisions,” she said. “Since the documentation being requested is above and beyond the RAI requirements. This is an additional burden of time and resources on facilities.”