Auditors are paying special attention to isolation and quarantine coding amid already heightened Medicare nursing home audits that are expected to increase in coming months, experts warn.
The ongoing staffing crisis in long-term care may be leaving some providers in danger of improper documentation, according to Brenda Sowash, director of clinical assessments, standards and practices for Trinity Health Senior Communities.
“Nursing staff have to prioritize resident care,” she said, writing for the American Association of Post-Acute Care Nursing. “Documentation often is the last task that they complete, so it can be haphazard if the nurse assessment coordinator and the director of nursing services don’t collaborate to assist staff to achieve timely, high-quality documentation.”
While the coding requirements for resident isolation are fairly simple, rushed documentation can be an easy target for Medicare administrative contractors, Sowash wrote.
“It’s an easy way for them to issue at least a partial denial based on case-mix reclassification,” Sowash explained.
Auditors and regulators have come increasingly under pressure to recoup potential overpayments since the end of the pandemic — such as when the Government Accountability Office pressured the Centers for Medicare & Medicaid Services to recoup more Medicaid overpayments in June.
Isolation coding is an especially important area to review because of its high impact on reimbursements, according to Sabrena McCarley, director of clinical reimbursement at Transitional Care Management.
“Capturing isolation on a MDS for a Medicare patient places the resident in the highest reimbursement nursing clinical category,” McCarley told McKnight’s. “Additionally, capturing isolation on MDS Item O0110M1b gives you 1 NTA point. There are very specific criteria that must be met in order to accurately capture isolation on the MDS.”
Taking precautions
Proper documentation for isolation and quarantine has been a significant sticking point since 2020, both for auditors trying to protect government resources and for nursing homes trying to ensure they are fully compensated for the care they provide.
“If you don’t document that you are giving the right care, you face payment risks and survey risks,” Sowash wrote. “It all comes back to having supporting documentation for what you code on the MDS.”
Educating staff on proper documentation is a vital step to take, according to Judy Wilhide Brandt, principal of Wilhide Consulting. A key point in that education should include avoiding insufficient documentation, she wrote for AAPACN — such as merely saying isolation protocols were used rather than specifically documenting which ones were used.
If there is a gap in documentation, a NAC often can write a retroactive summary using information gathered at the time.
“You can write the note after the ARD as long as it specifically references assessment information that was obtained during the look-back period,” Sowash explained. “Most auditors will accept that.”
Systematically verifying documentation should be a regular part of a facility’s practices, McCarley told McKnight’s Friday.
“It is imperative that there are systems in place to review the documentation that supports the daily skilled need,” she said. “In this situation, it would be: What is the diagnosis that requires isolation? Is there documentation that supports that the resident is in isolation and alone? And what is the skilled nursing need? The key is having specific systems in place for checks and balances. I always say ‘trust but validate.’”
Another strategy is to ensure that at least one day of isolation is documented in as much detail as possible by nursing staff. Future days of isolation can then more quickly and simply refer back to those details. As long as one full day of isolation is clearly handled, nursing homes should be able to clear audits, Sowash said.
Sowash noted that this strategy of auditors targeting relatively simple requirements that may not always be clearly documented will likely extend to other areas of MDS in the future — such as mechanically altered diet codes.
