Monday, March 7, 2011

Guest Post: Accurate Documentation in a New MDS 3.0 World

March 7, 2011

As providers continue to grapple with implementation of the latest version of the Minimum Data Set (MDS 3.0)–the federal government’s required questionnaire on patient assessment, which helps determine Medicaid reimbursement rates–we continue to provide posts from experts in the field. Today’s guest post features insight from Steve Herron, director of business development for Resource Systems, and David Rokes, chief operating officer for Post Acute Consulting.

The Minimum Data Set (MDS) 3.0 and the new skilled nursing facility payment system resource utilization group IV (RUG-IV) ushered in a new era of change in the long term care world. Although this may cause some anxiety for providers, the best way to respond is to take steps now to ensure proper documentation and accurate data in 2 areas: Activities of Daily Living (ADLs) and pre-admission documentation.

Activities of Daily Living (ADLs)
Under MDS 3.0 and RUG-IV, the categories of “Late Loss” ADLs that affect reimbursement are unchanged; however, the methodology for scoring on the ADL index has been altered. As a result, many residents are expected to generate a lower ADL score under RUG-IV as compared to the previous RUG-III reimbursement system.

For example, under RUG-III, the Reduced Physical Functioning category was the only group that broke the ADL index into five different “end-splits” that were reflected as A through E in the score. RUG-IV now has four such categories with five ADL end-splits. From an operational perspective, this change introduces 15 new opportunities for a one-point documentation error that could cause a resident to drop into a lower end-split, meaning that it is much more likely that a missed ADL opportunity will cause a facility to get reimbursed at a lower rate than is appropriate.

To illustrate, under RUG-III, missing one ADL end-split meant losing, on average, approximately $20 per day. In contrast, under RUG-IV that average jumps to more than $34 per day. That’s more than a 50 percent increase in the value of one missed ADL point.
Over time, miscoded assessments could also lead to residents receiving care plans that are inadequate for their needs.

Pre-admission Documentation
Pre-admission documentation is another area that deserves attention. MDS 3.0 did away with the elimination of a look-back period, which means that facilities can no longer “look back” for most services delivered outside of the skilled nursing facility to establish acuity and appropriate reimbursement. This reinforces the importance of immediately capturing services delivered inside the walls of the facility, especially services such as ADLs and mood and behavior, which have historically been under-coded.

It is also important to leverage technology that enables facilities to capture more accurate and timely ADL data. Since the MDS focuses on activities that happen three or more times at a given level over the course of seven days, it is essential to use an electronic system where information can be added multiple times throughout a shift.

While the transition to MDS 3.0 and RUG-IV may represent the greatest challenge since the prospective payment system was implemented, it can be done successfully. Providers should stay positive and focus on capturing accurate and timely by educating employees and leveraging technological advancements.

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