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June 2003

By Kerry Dunning, MSH

Prosthetic Help For Those In Need

Kerry Dunning, HSH

Five years after the initiation of the Prospective Payment System (PPS) for Long Term Care, costly miscalculations still occur in the nursing home setting. To secure the most appropriate clinical and reimbursement Resource Utilization Group (RUG), therapists must coordinate with other disciplines. Therapists must also learn the ins and outs of the Minimum Data Set (MDS).

The MDS, and thus the PPS reimbursement system, penalizes disjointed, inaccurate, and poorly conceived planning. Too many sites put the burden of proof on the MDS coordinator when, in fact, documentation by licensed personnel is the primary source of data for MDS responses.

Consider this five-step audit as a review of a nursing home’s accuracy in providing and billing therapy.

A QUESTION OF DAYS

Rule number one, plan ahead to look back. Under the Medicare regulations, three assessments must be completed within the first 30 days. Days 1 through 13 determine two clinical and payment RUG scores. If there are not at least regular stand-up meetings, incorrect RUGs are recorded.

If every therapist on your team cannot give you the Assessment Reference Date (ARD) on each patient they are treating, errors are being made. The last 7 days must include at least 5 days of therapy and daily minutes no less than the RUG established by the care plan.

Omissions can include missing minimum minutes or days for the agreed-upon RUG, or residents being dropped from Medicare A because they do not “RUG out” or fall into one of the specified categories. Miscounts might also lead to cost-versus-reimbursement issues when the minutes provided fall under just the next category. When I see that happen, I know there has been no planning ahead and/or no reaction to a change in patient status.

In multiple sites I have witnessed examples of residents refusing treatment, of holiday coverage, and other potential causes for errors. Therapists sometimes forget that nursing services can keep a resident in the Medicare program after rehab is completed. An MDS coordinator submits an Other Medicare Required Assessment (OMRA), but if he or she is not informed of a rehab discharge in time, the opportunity—and ongoing Medicare reimbursement—is forfeited.

UNDER THE RUG

Each therapist must understand the rehab RUG categories. Sites track residents in all RUG categories to prevent audits because the patterns cannot be explained clinically. For most sites, the test audit is on a bell curve.

Because residents will most likely move through several RUG categories before being discharged, the high usage is usually in the middle RUG scores. If sites have ultrahigh or very high usage and thus the curve is high-end loaded, the site could be targeted for review. There are reasons for using these categories, but the audit requires supporting clinical need. Conversely, if sites rarely have medium usage and never have low usage, it signals other problems.

Consider this example: a resident comes in from a lengthy hospital stay. The individual had been living at home independently but now there are ambulation, strength, and safety issues. Therapy maps a strategy placing the resident in a very high category because the individual wants to return home.

Sounds reasonable until you factor in the resident is 86 years old, or that 2 weeks after admission the discharge plan is changed by nursing to an indefinite stay but rehab does not pick up on that factor. Also, fear is a factor. One of the first questions I ask a newly admitted individual, if they have fallen at home, is how long they were on the floor before help arrived. It often seems the longer they stayed on the floor, the less likely they are invested in returning home alone.

Rehab low is an underutilized category in many nursing homes. Clinically, usage of the low is a multidisciplinary approach to a resident coming off skilled therapy but still in need of restorative and/or nursing care. In states with Medicaid case mix, it assists the team in developing a strong and measurable restorative plan. Financially, it provides additional reimbursement under Part A.

GOING OVER THE PLANS

Another audit for rehab is review of established restorative plans. First, screens should establish the need for an ongoing plan or the establishment of a new one. Second, therapy assistance in establishing measurable goals with a reasonable time frame assists nursing reviews.

In sites I work with, I ask therapy to audit restorative plans initiated by each discipline. It is not uncommon to find physical therapy activities of daily living (ADLs), but often lacking are plans written by occupational therapy and speech-language pathology (SLP). Again, in case mix states, this is invaluable in establishing a suitable restorative case load.

At this point in the evolvement of PPS, rehab and activities need to coordinate programming that assists residents on skilled rehab, restorative care, and activities plans. It is time to build a true rehab continuum.

One of the homes I like to visit on Fridays has a happy hour. In the morning, rehab patients work with those in restorative care or in individualized activities to fix the food for the party. Everyone gets to enjoy the benefits of this therapy. This program is jointly led by an OT and an activities director, who goes to great lengths to determine what people enjoyed doing before they became residents.

SPEAKING THE LANGUAGE

Having audited ARDs, RUGs, and ADLs, I find the most complex review involves the usage of MDS language. Practically, therapists must document their work to be recorded on the MDS. It is therefore imperative they understand both MDS language and CMS definitions and use that as the basis for their documentation. Problems appear when a therapist considers only Section P, T, and G of the MDS.

The quickest audit is to ask an OT if Section AC is provided for his or her review on every skilled patient. Ask a PT if they can tell you the questions in Section G8 and if they review those questions when establishing a care plan. Ask the speech pathologist if they review Sections B and C before each new ARD. What an admissions coordinator, a CNA, or nurse records in different sections may contradict the therapy plan.

All disciplines should review Sections E and O before initiating care. Patient depression and the number of medications provided can impede the delivery of rehab services. A note I see more often than I should, simply paraphrased, states, “The patient was lethargic but we still did 45 minutes of therapy.” Section after section impacts the total care plan and thus the rehab potential of the resident. One more warning: rehab potential and prior functioning level must be recorded in every evaluation. Therapists must learn the MDS definitions. There is the weight-bearing definition learned in school and there is a federal definition. Guess which one is correct during review!

THE DIAGNOSIS PROBLEM

The final problematic area requires review of treatment diagnoses. Many times the admission diagnosis is not the reason for therapy treatment. An example might be an individual weakened by pneumonia who enters the facility with PT and/or OT orders. The selected ICD-9 (weakness, gait disturbance, etc) should be recorded on the MDS and the bill.

The other end of the spectrum often involves SLP services. Commonly, I review the chart of a hip fracture patient receiving dysphagia care. The audit is threefold: I want to make sure there is a physician-declared diagnosis on the chart. I review the MDS to make sure the treatment diagnosis has been picked up. Finally the bill must reflect the diagnosis. If you want to be targeted for review, then have SLP units on a bill when there is no obvious reason for that service.

Initially, a therapy review would involve a limited number of charts to make sure the treatment diagnoses are making it to the MDS and then the bill. If there is a problem, then a team discussion is the next step. Therapists need to remind the MDS coordinator of a treatment diagnosis that differs from the list established at admission.

All five audits are both the primary responsibility of a therapist and a therapy team serving as the double-check in a system demanding accuracy. The more therapists learn about the overall system, the more reliable operations become for a nursing home.

It is not just about delivering units; it is planning the business of health care.

Kerry Dunning, MSH, specializes in postacute systems, including nursing home, inpatient rehabilitation, and outpatient rehabilitation programs. She speaks regularly on the MDS, PPS, and rehabilitation programming.

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