F1 MDS: Accuracy Quality Reimbursement

1
F1 MDS Accuracy Quality Reimbursement

• Sandy Fitzler, RN
• Senior Director of Clinical Services
• American Health Care Association
• Joy Morrow, RN, PhD
• Senior Clinical Consultant
• Hansen, Hunter, Co., PC

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MDS 3.0 Introduction

• The final info is NOT out
• 3.0 has been validated in the field. 2.0 was not
• 3.0 is an interview assessment
• Yes/No questions not good
• Choices better

3
3.0 Validation 5 yr Pilot. 2.0 revisions needed

• To make MDS more clinically relevant
• Improve ease 7 efficiency of tool
• Integrate selected standard scales
• Elicit res voice thru interview questions

4
Changes to MDS Will Continue to Achieve

• Federal payment mandates
• Quality initiatives

5
Resident Interview

• Emphasizes Res quality of life
• Facilitates Res centered care
• Improves accuracy
• Is feasible
• Improves efficiency

6
Assessor Talks To

• Resident
• Family
• Staff across all shifts
• (And reviews the record)

7
Simple Resident Interview

• Using standardized items
• For cognitive assessment
• Mood
• Preferences
• Pain
• Can be the SOLE source information

8
3.0 and pain assessment

• 3.0 is an improvement
• Self reported pain has been proven to be very
  valid

9
Cognitive Assessment

• You can use old format if res is unable to be
  interviewed
• This was RARELY a problem during the pilot and
  the old format was used very little
• Delirium detection much better in 3.0
• New tool for cognition

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If Res Cannot Do Interview

• In these rare cases, move on to observational
  items

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Mood/Depression

• Under detection with 2.0
• New standard for identifying depression
• Some nurses in pilot thought the questions too
  personal most thought they were appropriate

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Many 2.0 old labels were pejorative not valid

• 3.0 wording is much better
• Resists care Not good
• Behavior that interferes with care much
  better

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Customary routine activities

• 2.0 not valid using historic preferences
• 3.0 asks what is important NOW

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Interview/Information Details

• Using info reported by other staff is fine
• If resident cannot be interviewed
• Interview items are improved
• They are more accurate
• Again, self reported pain is really the 5th vital
  sign

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Pressure Ulcers

• Reverse staging is eliminated
• M6 colors of slough/eschar not clear more
  work is being done not completed for 3.0 yet
• DTIs not included. Instruction manual may incl.
  info on this but too new for inclusion per CMS

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Other 3.0 improvements

• Catheters are no longer continent
• Toileting trials are documented
• ADLs have single response
• There are goals for care
• Swallowing info is better
• Restraints for bed chair separate

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Improvements (cont.)

• Hearing aide part is good
• Observation part for pain is better even if res
  cannot relate themselves

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Hearing Deficits vs. Cognitive Deficits

• Historically not handled well
• New focus on hearing
• Evidence that there is less cognitive deficit
  more hearing deficit
• USE OF AMPLIFIER VERY IMPORTANT

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Pilot Performed by Nurses

• Nurses liked 3.0!
• Validity better
• More accurate
• Better clinical standards
• (some items dropped based on nurses input)

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Time to do 3.0

• Reported as reduced by 45
• New nurse doing 3.0 62 mins
• New nurse doing 2.0 112 mins
• (these were full assessments)

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Look Backs

• 5 days on most clinical issues
• Some issues, like therapy, stayed at 7 days
• Look back study continues

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Some Things Not Decided

• RUGs payment
• Raps
• QIs for 3.0 will be finalized 2011

23
Specific Times

• Cognitive Patterns conduct interview on day
  before, day of, or day after ARD
• Mood Section same as above
• Sec M skin record date of assessment

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Section G - ADLs

• It appears that these questions and answers will
  more easily allow CMS/Fiscal Intermediaries to
  correlate Sec G info w/Sec T and decide if
  therapy is reasonable necessary

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3.0 Can Be Accomplished By Nurse

• Social service dietary wanted more pilots with
  their staff
• Not going to happen
• Cognitive Assessment test can be administered by
  nurse, or other trained staff
• Mood questions might be better asked by nurse

26
3.0 Works!!

• Under reporting was not an issue in pilot
• Over reporting is not issue as nurse is not
  developing a medical diagnosis

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Remember 3.0 Is Currently a Draft

• It is similar to what will be the final
• Some items will change
• Some missing items will be added
• Using it as a style introduction is fine
• It is NOT the final product

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Discussion Of Some MDS Sections
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Discussion Of Parts of Crosswalk
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MDS 3.0 and RAPs

• Will There Be An Update?

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Introduction

• February 08 CMS tells AHCA that MDS 3.0
  contract does not include updating the RAPs
• CMS not sure if update will occur

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CMS RAP Concerns

• No funds to update RAPs or to provide updates on
  a regular basis to ensure information is current
• Even if funding is available, not sure if
  updating a process that is poorly utilized is a
  wise investment

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Issues with RAPsAHRQ Survey Results

• In the fall of 2004, AHRQ pulled together a RAP
  workgroup, conducted a survey on RAP utilization
  and released a report
• Survey encompassed 1,835 AANAC, MDS Coordinators
  and 56 VA respondents

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AHRQ Findings

• 76 found RAPs are somewhat, rarely or never
  helpful
• RAP completion does not involve the
  interdisciplinary team as they are often
  completed separately by multiple individuals
  (30) or by individuals who do not participate in
  care (26) like MDS Coordinators having no
  clinical responsibility

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AHRQ Findings Continued

• 31 saw RAPs as too time consuming
• 27 stated RAPs are done for paper compliance
• Physicians often uninvolved in the RAP and do not
  consider the care plan when making resident
  treatment decisions
• CNA work is not reflected in care plans

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AHCA Next Steps

• Conducted a non-scientific survey to assess if
  the AHRQ findings remain constant
• Surveyed AHCA members, state associations,
  multi-corporations and others
• Use 2 survey tool
• Recommendations to keep or not keep RAPs also
  received via email

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AHCA Survey Findings

• Use feedback only received from surveys
• The majority of survey and non survey respondents
  indicated they do not want to keep RAPs as they
  currently exist.

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AHCA Recommendations to CMS

• Do not update RAP Utilization Guidelines RAP
  Summary
• Go back to the basics for care planning use
  interdisciplinary team
• Consider retaining revising Trigger Legend
  renaming it Triggers for Analysis and Planning
  (TAP)

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AHCA Recommendations to CMS - Continued

• To help clinicians make decisions about care
  planning to support clinical approaches use
  evidence-based clinical practice resources found
  on www.nhqualitycampaign.org, www.medqic.org,
  AMDA CPGs and other recognized resources

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Justification for AHCA Recommendations

• Title 42, Part 483.20, Section K the facility
  must develop a comprehensive care plan for each
  resident that includes measurable objectives and
  timetables to meet a residents medical, nursing,
  and mental and psychosocial needs that are
  identified in the comprehensive assessment.

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Justification for AHCA Recommendations - Cont

• Section K (2) (ii) the comprehensive care plan
  is prepared by the interdisciplinary team that
  includes attending physician, a registered nurse
  with responsibilities for the resident, and other
  appropriate staff and disciplines as determined
  by the residents needs, and to the extent
  practicable, the participation of the resident,
  the residents family or the residents legal
  representative.

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Justification for AHCA Recommendations - Cont

• Section K (2) (iii) calls for periodic review
  and revision of care plans by a team of qualified
  persons after each assessment
• Note the law does not reference RAPs but use of
  the interdisciplinary team

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RAPs in Regulation

• CMS identifies the RAP as the recommended nursing
  home care planning tool in the RAI
• F279 Interpretive Guidance mentions RAP summary
  and triggers

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RAPs in Regulation - Cont

• RAI MDS 2.0 Users Manual OBRA 87 requires the
  Secretary of HHS to specify a minimum data set of
  care elements for use in conducting comprehensive
  assessments. It further requires the Secretary
  to designate one or more resident assessment
  instruments based on the minimum data set
• CMS uses this to justify RAPs

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Justification for Change

• AHCA believes that adding, changing or
  eliminating RAPs require no change in law
• The MDS already meets the OBRA requirement for
  the Secretary to specify a tool for comprehensive
  assessment
• The RAP is Not an assessment tool but an
  analytical tool

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RAPs

• Survey results showed that RAPs confuse
  clinicians in purpose, use sequencing
• Clinicians are not sure if RAPs are a
  continuation of the resident assessment or an
  analytic step in nursing process
• Some of the confusion stems from inconsistent use
  of RAP descriptors in the RAI Manual

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RAP Descriptors in RAI

• Manual states RAPs follow nursing process
  assessment, planning, implementation
  evaluation.
• ANA nursing process assessment, diagnosis,
  outcomes/planning, implementation evaluation

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RAP Descriptors in RAI - cont

• RAI omits process step Diagnosis or the analysis
  phase of process
• RAI contradicts the notation of a 4 stages
  process by offering a chart having a 5-stage
  model

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RAP Descriptors in RAI - cont

• Manual defines RAPs as Structured,
  problem-oriented frameworks for organizing MDS
  information and examining additional clinically
  relevant information about the individual
  Analytic tool?
• In another instance, states RAPs identify causes
  for each problem area and guidance for further
  assessment and resolution or intervention
  Assessment tool?

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Current RAP Activity

• Independent effort underway to develop an
  electronic decision tree for depression.
• There has been some discussion at CMS about the
  development of a RAP for Return to the Community

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MDSAccuracy, Quality, and Reimbursement

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Quality

• As nurses, we care about quality of service
  delivered to clients (res, pts, beneficiaries)
• Nurses may view MDS as not important paper
  compliance
• Nurses would prefer if MDS was not reimbursement
  tool
• MDS also measures quality

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GOAL Quality and Accuracy Meet to Provide
Appropriate Reimbursement
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The Resource Utilization Group (RUG) sets Payment

• The RUGs established to pay you for amnt of time
  it takes to adequately, appropriately care for
  res based on their acuity
• But, some res take lots of time for low
  reimbursement
• Some take little time for high reimbursement

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Did you know?

• Activities of Daily Living (ADLs) can be captured
  in hospital look back.
• The two-person assistance from the ambulance crew
  and/or the facility staff on admission usually
  occurs during the assessment reference period and
  should be counted.

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Did you know? (cont.)

• If a res goes to the BR dribbles on way we
  clean it up for safety and dignity, this is
  toileting assistance should be coded.
• A dy 2 ARD may allow an RMX RUG by coding sec T
  for needed therapy rather than taking SE3.
  Compare the reimbursement.

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Admission Decisions Lost Revenue

• Belief that skilled service is limited to therapy
  maybe IVs wounds
• Lack of knowledge of Administrative criteria
  not knowing that non-skilled service w/complex
  issues can be skilled
• Not looking at pt on dy 1 for look backs, dy 1
  deficits, start of therapy best ARD

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Restorative Nursing Services

• Client (in hosp) doesnt look like he/she would
  fit an eligible category for SNF admission
• BUT, they are not ready to be in their home or
  assisted living
• Consider Rehab Low/nursing rehab program
• Therapy ready to dc care rest nursing Part A
  instead of ICF

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Set ARD on Case by Case Basis

• Compare decisions RUG rates
• Should you set the 5 14 day at same time (i.e.
  day 8 and day 11 in some cases)
• Per regulation, the nurse assessor sets the ARD

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MDS Nurse Make Professional ARD Decisions

• ARD based on personal preferences facility will
  lose appropriate reimbursement
• (Facility party day, etc.)

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Consider Having Occasional Weekend Limited
Therapy Service Available
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Significant Change Assessments

• Medicare payment changes as of the ARD of the
  SCSA
• (Exception Beginning of payment period, ARD is
  day 63 of stay, payment changes as of day 61)
• How to determine the best ARD
• Is payment going up or down?

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SCSA Timelines

• You have 14 dys to determine if a sig chg has
  occurred
• Then SCSAs must be completed no later than 14th
  calendar day following determination that sig chg
  has occurred
• Exception to VB 14 dys rule

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Other Medicare Required Assessments (OMRAs)

• Required 8 to day 10 after all therapies are
  discontinued client is continuing on Part A
  stay for longer than 7- 9 dys
• OMRAs lower payment from a therapy RUG to next
  appropriate medical/nursing non-therapy RUG

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OMRAs and the ARD

• You may perform the OMRA any day after day 7 and
  before day 11 from therapy discontinuation.
• What day will you choose?
• What will the payment change be?

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Combining MDSs

• Follow the most stringent guidelines
• Consider the revenue impact for setting the ARD

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ADLs

• How important is it to capture all deficits?
• Should I really consider the hospital look back?
• How accurate is the nurse aide information?
• What happens on the night shift?

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ADL Scores Are Calculated in some way in all of
the RUGs
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Late Loss ADLs

• Which ADL do nurses chart to the most?
• Ambulation!
• We need to educate our staff to speak to late
  loss ADLs.

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Good vs. Better ARD

• Example Pt admitted to SNF on w/orders for
  skilled nursing, PT OT eval treat
• (Hospital diagnosis pneumonia)
• Therapies eval on day 2 project that pt will
  tolerate RM level of service (150 mins/week)

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Good vs. Better ARD (cont.)

• MDS nurse ADLs as follows
• Bed Mobility 2/3, Transfers 3/2, Eating 2,
  Toileting 3/3 14 points
• Hospital look backs include I.V.P. Morphine
  given for pain 1/30 I.V.F. given to for
  dehydration on 1/27/08.
• MDS Nurse sets ARD for dy 6 to achieve 5
  days/150 mins between days 2-6 capture I.V.
  meds at hospital.

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Good ARD vs. Better ARD (cont.)

• With dy 6 ARD, RUG is RML
• With use of day 2 as the ARD, the RUG is RMX
  based on a sec T therapy projection of 10 dys/330
  mins I.V.F. given 1/27/08 which increases the
  eating ADL score by 1 pt for a total ADL score of
  15 points.

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Good vs. Better ARD (cont)

• The 15 or above ADL score with day 2 ARD, RUG is
  RMX
• Payment difference of 40.44/day higher than RML
• Over 14 days, reimbursement is 566.16 higher

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The Art of Negotiation

• Example Pt is admitted to SNF w/orders for P.T.
  O.T. eval/treat. (Dx Right below knee
  amputation)
• Therapies evaluate on dy 3 are estimating pt
  will tolerate RV (500 mins/wk). They want day 8
  as ARD

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Art of Negotiation (cont.)

• MDS nurse examines record for ARD, sees dy 5 is
  best ARD for reimbursement (ADL is 15)
• Therapy pushes for day 8 nurse backs down
• Dy 8 ARD gets RVB RUG w/5 dys/505 mins of therapy
  
• Reimbursement is 430.65/day

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The Art of Negotiation (cont.)

• Dy 5 ARD, w/sec T projection, results in RMX RUG
  RUG coding I.V. med in hosp 2 dys/205 mins of
  therapy projection 10 dys/1000 mins ADL score
  of 15
• RMX reimburses at 488.55 a dy, a difference of
  57.90/day higher than RVB.

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One Point Can Make a Big Difference!

• Pt. is admitted to SNF w/resolving urosepsis.
• Pt. appears to needs little ADL assistance
• Therapies not needed
• MDS nurse sets ARD for dy 4 due to IV/meds
  fluids, vomiting w/fever, open lesion with
  treatment

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One Point(cont.)

• MDS Sec G1 is coded as
• Bed mobility 0/0
• Transfers 0/0
• Eating 0
• Toilet Use 0/0 4 pts
• 2 for IV fluids to total 6 pts for a RUG of
  SSA

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One Point Can Make a Big Difference (cont.)

• Closer review shows 2 occasions of 1 pers limited
  assist w/transfers 3 dys before admission to SNF
  1 occasion of 1 pers limited assist in SNF on
  day of admission
• Coding the ADLs correctly as 2/2, the ADL score
  is now 8

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One Point Can Make a Big Difference (cont.)

• RUG is now SE3 which pays 122.93/day higher than
  SSA
• Over 14 dys, reimbursement is increased by
  1,721.02.
• Note Extensive Services qualifiers may be coded
  on MDS but ADL under-coding will result in missed
  RUG or lower RUG w/lesser end split.

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MDS Accuracy

• Do not skip look back info when client is in a
  therapy category
• Do not skip info for other categories because
  client is receiving therapy
• Feds demand accurate MDSs

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AND If Therapy Denied, RUG will drop to
Non-Therapy Category

• If info is missing, the RUG could drop to a very
  low one
• Instead of the higher non-therapy nursing service
  RUG such as SE or SS
• Appropriate reimbursement would be lost

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Coding

• Sec P accurate therapy days minutes
• Sec P accurate restorative coding
• Sec T accurate projections
• Do Sec G and P and T make sense when compared?

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Behavior Only Category

• Client has aberrant behaviors all the time. We
  view this as normal their baseline. We do not
  code the behaviors as such
• Wrong - payment system wants to pay for extra
  time care these clients take
• Code all behaviors per RAI manual

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Part A Stay After Therapies

• Therapies are D/Cd pt continues to need
  skilled care
• CMS expects that there will be many cases in
  which res will be discharged from the facility
  shortly after rehabilitation services end

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How Many Days After Therapies Discontinued?

• Not everyone
• Decide case by case
• A few days
• Usually around 3 days

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What Do I Document?

• Assess stability
• Make sure spouse knows how to assist client at
  home
• Document nursing assessments, interventions,
  teaching, evaluations of strength stability
• Medication responses

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Therapy Staff Does Not Discharge From Part A
Service

• The therapist decides in conjunction with the
  physicians order when therapy service should be
  discontinued
• The facility staff in compliance with federal
  regulations and a physicians order decides when
  a client is discharged from skilled service

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Consolidated Billing

• Know consolidated billing regs before sending
  clients for medical procedures unrelated to
  skilled stay
• Educate physicians staff nurses so facility
  does not get billed for expensive services that
  could wait until after skilled stay

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Recommended

• Do MDS on every client
• Code as completely as possible on clients who
  leave early

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Final Reminders

• Code accurately
• Code completely/do not skip known info to save
  time
• Know the Part A criteria for admission
• Know the RUGs

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Reminders continued

• Select the best ARD
• Complete MDSs w/knowledge of reimbursement impact
• Combine MDSs w/knowledge of reimbursement impact
• Have copy of RUG rates

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Discharge Records
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Discharge Record

• CMS looking for a way to assure that nursing
  facilities document residents condition on
  discharge from the facility
• CMS looking at the PAC Payment Reform
  Demonstration CARE Tool

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QIO 9th SOW Care Transitions

• All QIOs will strive to get 10 of providers to
  use the CARE tool
• This is a separate effort from the PAC
  demonstration except NE
• The purpose To identify elements missing from
  the CARE tool that are needed to improve
  transition

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PAC Demo Next Steps

• CMS collecting care transition literature
• 11/08, RTI plans to told a TEP to start
  discussion on what additional items need to be
  added to the CARE tool to address transition
  issues
• QIO will nominate people to the RTI TEP
• Concurrently, QIOs will be working on
  identifying transition of care items that are
  needed on the tool

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Discharge Records

• Many states have developed and are using transfer
  records
• Caution is needed when evaluating the usefulness
  of these records
• Need to make sure the resident condition and
  status is clearly documented

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Discharge Records - cont

• An effective discharge/transfer record needs to
  be more than a compilation of data elements
• Research shows that most diagnoses are made from
  medical history
• Records need to allow clinicians to tell the
  story

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Further Questions

• joymorrow_at_earthlink.net
• sfitzler_at_ahca.org