kentucky case-mix classification, accuracy, documentation
TRANSCRIPT
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Kentucky Case-Mix Classification, Accuracy, Documentation, and Management
PART 11
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Objectives
1. Understand RUG Grouper Reimbursement Model & classification method
2. Review RUG conditions & services for each category group and pertinent to therapy
3. Discuss rehabilitation and restorative program criteria & utilization 4. Review supporting documentation guidelines 5. Identify best practices for accurate case mix reimbursement
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General Concepts of Time-Weighted Methodology
Generated MDS CMI # of Days
Average Weight
CMI
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Calculation of Days
• Includes Day of Admission – Not discharge
• Count 1st Day of Quarter Until:– ARD of next assessment– End of quarter or– Until discharge
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Missing Assessment Report
• OBRA target date > 138 days prior. – Other than discharge or death record
• No OBRA record submitted for current episode >60 days prior• Default rate=
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Missing Assessment Report
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Time Weighted: Determination of Payer Source
Medicare
•PPS assessment & no Medicaid # entered in A0700
Medicaid
•Medicaid# entered or + for pending in A0700
Other
•Non-PPS assessment•No valid Medicaid
number in A0700•NOT Medicaid
Pending+
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Index Maximizing Classification
RUG CMI
RAA 1.21
SSA 1.41
• Designated Case-Mix Indices (CMI) for each RUG Group
• Placed into Only 1 Case-mix Class• 1st zstep: RUG Group(s)
Qualifications• Choose the RUG Group with
Highest CMI
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Resident Roster Example
A complete list of the Item Set Codes can be found in the RAI Manual in Chapter 2.
1.61
1.61
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Resident Roster Summary Page
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MDS Calendar Quarter & Posting Schedule
Report Type
MDS Calendar Quarter
January 1 toMarch 31
April 1 toJune 30
July 1 toSeptember 30
October 1 toDecember 31
First Preliminary April 29 July 30 October 30 January 30
Second Preliminary May 31 August 31 November 30 February 28
Final July 29 October 29 January 29 April 28
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Final ValidationReport
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Review Roster for Errors
• Payer Source• Correct Assessment Type• Missing Assessments• Changes with or incorrect RUG• Default Days
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Rate Periods
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RUG-III 34 Grouper Reimbursement Models
Extensive Services
Rehabilitation
Special Care
Clinically Complex
Impaired Cognition
Behavioral Problem
Reduced Physical Function
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ADL Assistance
CONSIDERATIONS: • Variations by shift, within shifts or day to day• All activities 24 hours a day• Accurate documentation = true amount of
staff time & resources required to care for the resident
• Includes direct care observed/reported by others & staff including contract/agency staff
• Double-check accuracy of software• EDUCATE, EDUCATE, EDUCATE• Consider review of one ADL topic a week in
Daily Huddle Meetings
PURPOSE: • Document and communicate the
patient’s functional status• Track progress or decline in
function• Allows for accurate care plans• Allows appropriate
reimbursement for the care you are providing.
• Helps determine staffing levels
Section K ADL Score
K0510A. Parental/IV feeding while/while not a resident
=3 OR
K0510B. Feeding tube while/while not a resident & K0710A3. Total calories 51% or more
=3 OR
K0510B. Feeding tube while/while not a resident & K0710A3. Total calories 26-50% + K710B3. 501cc/day or more average fluid intake
=3
Step 1: Sum of Bed Mobility, Transfer & Toilet Use Step 2: Eating: If no parental/IV or feeding tube, return to G0110H.Total ADL Score= Sum of Step #1 + Step #2
Calculation of ADL Score
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Phase Out of Section G from MDS
• CMS Allowed States the Option to Collect Section GG Items – For accurate comparison RUGs vs. PDPM – Development of crosswalk from Section G to GG– For development of more accurate payment weights to better
measure acuity levels
RUG-III 34 Grouper
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Rapid RUG Guide
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Extensive Services Count Special Treatments, Procedures, or Programs Count
Parental/IV while/while not a resident in last 7 days 1
Suctioning while/while not a resident in last 14 days 0
Tracheostomy care while/while not a resident in last 14 days 0
IV medication while/while not a resident in last 14 days 1
Sum of Extensive Services Count 0-2
Evaluate for special care, clinically complex or impaired cognition No match=0For each matching=1
Total Extensive Services Count 0-5
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Extensive Services Count
Classification Total Extensive Services Count
ADL Score CMI
SE3 4 or 5 7-18 2.35
SE2 2 or 3 7-18
1.91
SE1 0 or 17-18
1.63
If ADL score <7=Special Care
Parental/IV Feeding
The following fluids may be included when there is supporting documentation that reflects the need for additional fluid intake specifically addressing a nutrition or hydration need.7-day Reference Period
When to Code: • ACTIVE diagnosis of dehydration must be present in
order to code• IV fluids or hyperalimentation, including total parenteral
nutrition (TPN), administered continuously or intermittently
• IV fluids running at KVO • IV fluids contained in IV Piggybacks• Hypodermoclysis and subcutaneous ports in hydration
therapy• IV fluids to prevent dehydrationWhen not to Code:
– Fluids used for reconstitution/dilution– Part of routine operation or procedure or recovery room– IVs given during chemo– IV medications– Additives: electrolytes & insulin (IV meds)
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Other Extensive Services
• Suctioning– Tracheal and/or
nasopharyngeal suctioning– NOT oral suctioning– Code if resident performs
• Tracheostomy Care – Cleansing of the tracheostomy
and/or cannula– Code if resident performs
IV Medications
• Biological or Drug Given By:– IV push– Epidural – Intrathecal – Baclofen pumps – Drip via central line or peripheral
line
• Do Not Code: – Flushes for patency or IV fluids
without medications– Subcutaneous pumps – IV medications given during
dialysis or chemotherapy– Dextrose 50% & Lactated Ringers
as IV meds
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Extensive Service Capture
Hospital Records:– Were records received and reviewed
upon admission/readmission/ER visit?
– Are electronic hospital records accessed if we have ability or can we obtain access?
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Case Example #1
Mr. J admitted 3/28/21 with Medicare as primary & secondary is Medicaid. He had IV fluids, IV meds & blood transfusion 3/24/21.
Therapy is unable to have 5 days of therapy by 4/2/21. What ARD would you use?
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Case Example #1Special Treatments, Procedures, or Programs Count Parental/IV while/while not a resident 1
Suctioning while/while not a resident 0
Tracheostomy care while/while not a resident 0
IV medication while/while not a resident 1
Sum of Extensive Services Count 2
Evaluate for special care, clinically complex or impaired cognition 1 point for each matchingBlood transfusion=Clinically complex
1
Total Extensive Services Count 3
ARD no later than 3/30/21 SE2 CMI= 1.91
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Case Example #2
Mrs. S was sent to the ER on 4/17/21 and received a bolus of IV fluids for dehydration and IV antibiotic for UTI. She was sent back to the facility the same day with oral antibiotics to continue for 7 days.
What should the MDS Coordinator do?
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Case Example #2 Answer
First of all, the ER documentation should be retrieved.
Next, schedule an assessment to capture extensive services. The ARD should be ASAP because extensive services CMI would begin with the ARD if this is a quarterly or significant change (unless the admission assessment has not been completed yet).
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Rehabilitation
•150 Minutes and 5 days or more (15 min per day minimum) in any combination of therapy in last 7 days OR
•45 Minutes and 3 days or more (15 min per day minimum) in any combination of therapy in last 7 days AND at least 2 nursing rehabilitation services
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Rehabilitation Classification Example
What could have been done differently?
Grouper is single level: Total of 150 minutes & combination of 5 days
ARD
Monday Tuesday Wednesday Thursday Friday
OT PT OT PT OT PT OT PT OT PT
30min.
26 33 32 28 25 34 29 30 24
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Rehabilitation Classification Example Answer
150 minutes & a combination of 5 days was achieved by Wednesday. OT saw 3 days & PT saw 3 days Monday thru Wednesday for a total of 6 days and 174 minutes total minutes. If this was realized & communicated to the MDS Coordinator on Wednesday, the ARD could have been changed to Wednesday instead of Friday.
Monday Tuesday WednesdayARD
Thursday Friday
OT PT OT PT OT PT OT PT OT PT
30min.
26 33 32 28 25 34 29 30 24
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Rehabilitation Grouper Category
RUG Class ADL Score CMI
RAD 17-18 1.90
RAC 14-16 1.61
RAB 10-13 1.46
RAA 4-9 1.21
Therapy RUG
Start of therapy– Data retrieved from:• MDS Section O
• Admission MDS – Rehab RUG will begin on day 1
• If criteria met during reference period
• Quarterly & Significant Change MDS – Rehab RUG will begin with ARD
• Important to meet rehab criteria classification as soon as clinically indicated
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Special Care Grouper Category
RUG Class ADL Score CMI
SSC 17-18 1.58
SSB 15-16 1.46
SSA 7-14 1.41
If ADL score is >7=Clinically Complex
Diagnosis Identification
Active Diagnosis: • MD has documented dx
within last 60 days AND• Active in 7-day look-back
period.
Special Care Diagnosis: ADL Score>=10
• Cerebral Palsy• Quadriplegia• Multiple Sclerosis
Quadriplegia • Complete paralysis that affects ALL 4 limbs.• Caused by injury to the spinal cord in area of the
neck.• Usually defined by which vertebrae injured & how
complete the severing of the spinal cord is.
EXAMPLES: Spastic quad type cerebral palsy is not due to a
spinal cord injury and would be coded in I4400. Cerebral Palsy.
Functional quadriplegia refers to complete immobility due to severe physical illness or frailty that extends to all limbs and would be coded in I8000.
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Fever
• 7-day reference period• Temperature 2.4 degrees F higher than
baseline• Baseline temperature should be established
prior to the ARD• A temperature of 100.4 degrees F on
admission
TIPS: Routinely establish baseline temp. shortly after admission & update annually. Monitor nurse’s notes, vital reports, etc. for residents with fever.
Fever plus one of the following:
Pneumonia
Vomit ing
Dehydrat ion
Weight loss
Tube feed ing*
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Special Care Conditions
Pneumonia
• Must be an active diagnosis. Examples: CXR, S/S of pneumonia (i.e. cough, lung sounds), MD orders for treatment, therapy for functional limitations due to pneumonia.
Vomiting• Regurgitation of stomach contents in last 7 days; not phlegm from throat.
Dehydration
• Intake < 1500 ml. One or > clinical signs/indicators of dehydration such as dry mucous membranes, poor skin turgor, cracked lips, thirst, sunken eyes, dark urine, new onset or increased confusion, fever, abnormal labs in last 7 days. Fluid loss > intake.
Weight Loss• 5% in last month or 10% or more in last 6 months.
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Tube Feeding Requirements
• 51% or more of total calories OR
• 26% to 50% of total calories AND 501 cc or more per day fluid intake in last 7 days
• For purpose of nutrition or hydration
• Include documentation with calculation of % of calories.
Special Care High: Feeding Tube + Aphasia
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Special Care: Respiratory Therapy
Provided by a qualified professional
•Respiratory therapists or respiratory nurses•Respiratory nurse must be proficient in the respiratory modalities
Services are for the assessment, treatment, and monitoring of patients with deficiencies or abnormalities of pulmonary function.
Includes coughing, deep breathing, nebulizer treatments, assessing breath sounds and mechanical ventilation, etc.
Treatment time is documented in minutes.
•Must include at least 15 minutes per day.
TIP: Consider adding order template that includes respiratory assessment and monitoring before and after service (i.e. lung sounds, pulse, respirations, oxygen saturation). Provide respiratory training with every nurse in orientation. 42
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Other Special Care Conditions
• Radiation while a resident– Intermittent– Radiation implant
• Two or > pressure or venous or arterial ulcers any stage*
• Any Stage 3 or 4 Pressure Ulcer*• Open lesions*
– Develop as a result of diseases and conditions (e.g. syphilis and cancer)
*With selected skin treatment
Surgical Wound*– Healing & non-healing, open or closed
surgical incisions, skin grafts or drainage sites
– Pressure ulcer that is excised & a graft and/or flap applied
Do Not Code: – Healed surgical sites & stomas or
lacerations that require suturing or butterfly closure
– PICC sites, central line sites, and peripheral IV sites
– Surgical debridement of pressure ulcer– Eye or oral surgery
Selected Skin Treatments
2 or > Ulcer Selected Skin Treatments
• Pressure relieving device to chair and/or bed – Does not include egg crate or doughnut/ring
• Turning/repositioning program– Specific approaches & frequency with
monitoring & evaluation. • Nutrition or hydration intervention
– Include documentation for purpose of preventing or treating the specific skin condition
• Pressure ulcer care• Application of dressing (other than to feet)• Application of ointments/medications (other than
to feet)
Open Lesion & Surgical Wound 1 or > Selected Skin Treatments
• Surgical wound care– Does not include:
• Care for eye/oral surgery• Surgical debridement of pressure ulcer• Observation only of wound
• Application of non-surgical dressings (other than to feet)– Does not include:
• Band-Aid or Tegaderm applied prior to only checking if intact
• Application of ointments/medications (other than to feet)
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End of Part 1
Part 2 will begin with theClinically Complex Category
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QUESTIONS
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References
• Centers for Medicare & Medicaid Services. https://qtso.cms.gov/reference-and-manuals/cms-approved-mds-30-final-section-s-items-are-available-download
• Centers for Medicare & Medicaid Services. (2020, September 28). CASPER Reporting User’s Guide for MDS Providers. https://qtso.cms.gov/reference-and-manuals/casper-reporting-users-guide-mds-providers
• RAI Manual• Myers and Stauffer. (November, 2019). Stakeholder Update:
Nursing Facility Payment Modernization Case Mix Overview.