Audit your PPS claims.

Knowing what to zero in on can help reduce errors

This article is a follow-up to "Submitting error-free claims" CLTC, September 1999.

WHEN SKILLED NURSING FACILITY OPERATIONS TELL US, "there are no problems with my Medicare Part A bills," we, a consulting firm, typically ask them how they can be sure. "Because all of my claims have been paid," they invariably respond.

This logic is dangerous because Medicare billing audits are conducted according to the principle of post-payment review. In other words, fiscal intermediaries (FIs) generally pay everything a SNF bills with no mechanism for pre-payment review. It is only subsequent to payment that FIs may go back and conduct audits to adjust claims long after payment.

Medicare integrity under the prospective payment system is based on the agreement of three components:

* clinical documentation, which must support the [ldots]

* Minimum Data Set (MDS), which, in turn, must support the [ldots]

* UB-92 billing form.

Any breakdown in this system compromises the integrity of the Medicare program and may result in over- or underbilling for services. As always, your claims must substantiate the need for daily skilled care for services provided by licensed staff.

During the past year, we have conducted "billing integrity audits" for more than 200 providers. The following details our approach and may be used as a model to conduct your own internal audits.

Work backward

We recommend beginning with the UB-92 and then working backward through the system. Each UB-92 may contain several lines of data regarding assessments that assign resource utilization group (RUG) scores to covered days (e.g., the 5-clay MDS covers 14 days, the 14-day MDS the next 16, etc.). You must determine whether the associated MDS assessments and clinical documentation support each RUG billed.

During the course of our audits, we have identified and cataloged more than 120 commonly occurring specific and significant errors that compromise the integrity of a Medicare claim. Of the more than 4,000 claims we have audited, at least 45 percent contained one or more significant errors. Most facilities do not have a wide range of errors. Instead, each SNF tends to repeat the same violation over and over again. It is important for you to understand where your own errors occur and which component of integrity-clinical documentation, MDS, or UB-92--is being affected.

Not all of these errors will result in denial of services or payment according to a lower RUG rate. One common error is inconsistency between the therapy minutes reported in the MDS and in the treatment logs. While this is a noteworthy discrepancy, reimbursement would not be affected if, for example, the MDS reported five days of physical therapy (PT) for 375 minutes while the logs contained five days of PT for 325 minutes. In either case, a "high rehab" RUG would be appropriate. However, if the logs correctly reported five days of PT but only 300 minutes of care, the "high rehab" RUG would have been overstated and Medicare overbilled.

Overbilling, underbilling

While some errors result in overbilling Medicare, others actually cause a facility to underbill. Omission of RUG sensitive information is a common cause of compromised reimbursement. Among the most frequent MDS omissions is the IV therapy provided in a hospital prior to discharge. Because nearly all clinically eligible SNF Medicare beneficiaries receive a qualifying IV in the hospital and require assistance with activities of daily living (ADLs), a facility should have few, if any, residents who score below Extensive Services (SE1, 2, or 3) on the five-day MDS. The capture of all clinical services and conditions within the look-back period also helps to substantiate the need for post-acute services. In addition, this information may be important for care planning.

Capture all hospital services

If you have an abundance of lower scoring admissions, you probably missed relevant hospital services. Even if you group a resident in a rehab RUG, thus reducing the reimbursement impact of other medical services, missed hospital services could still threaten payment. If, for example, therapy is audited and denied by the FI, the resident will "trickle down" to the next appropriate RUG based on the MDS. That's why an accurate and all-inclusive assessment is always important.

Clinical staff should review the MDS look-back period for each assessment. Using MDS guidelines and definitions, this review should confirm that the clinical record supports all captured items.

From a reimbursement perspective, correct billing is even more important this year than last. That's because, with most facilities being phased in to PPS, the year one, 75 percent facility-specific, 25 percent federal rate percentage calculation compressed PPS rates. As a result, the average facility received only about $70 per day more for a resident scored in the highest RUG (RUG) than for one scored in the lowest paying PA1. However year two of the transition (a 50:50 ratio), or election into the full federal rate as per the Balanced Budget Refinement Act, will greatly increase the "spread" among rates. Therefore, errors or omissions that compromise reimbursement will be at least two to four times more severe in 2000 than they were in 1999. Something as minor as miscoding an ADL for a single resident can mean thousands to a facility; systematic errors or omissions can cost a facility a great deal more.

Replacement assessments

Concerning the "UB-92," the most common error occurs in assignment of covered days per assessment (Field 46) when an "off cycle" MDS is involved (significant change in status or other Medicare required), especially when that MDS is a "replacement" assessment (referenced within the normal windows -- days 21 through 29, 50 through 59, etc.). Our audits revealed that more than 80 percent of claims containing an off-cycle replacement assessment were billed improperly, often resulting in over-or underbilling Medicare.

While some errors arc clear examples of over- or underbilling, others may have no impact on the RUG score, yet still have consequences. For instance, MDS reference date/UB-92 Service Date mismatch is a common error. While this issue has no impact on the RUG score calculated or the number of days billed per assessment, at least one FI has denied claims because of it.

Checks and balances

The impact of PPS errors on reimbursement will not be known until the FIs fully implement their audit procedures. In anticipation of post-payment review, SNFs must initiate a system of checks and balances designed to detect and prevent UB-92 and MDS errors. This system may be both concurrent and retrospective.

Review the MDS before locking it. This is especially important if the nurses complete a "soft copy" for subsequent entry into a computer by a data entry clerk. We uncover far too many data-entry errors. While some may be innocuous for payment purposes (Section AB7 "Education," for example), many result in calculation of an inappropriate RUG. A disturbing and careless error that we see too often is incorrect entry of Section P (therapy minutes). A simple slip can cause 150 minutes to be entered as "1,150" or "1,500" minutes. Errors or omissions may be corrected only before the document is locked (although a rule change allowing for clinical corrections is expected by May 2000).

UB-92 reviews may also be concurrent. However, an internal audit of previously submitted UB-92s is also a good idea, particularly those containing the troublesome off-cycle assessments and other common problems (see box). Many UB-92 errors may be easily corrected through an "adjustment bill," eliminating audit issues later on.

Even if, like most facilities, you've enjoyed relatively smooth payment of your PPS claims, don't count on this free ride from Medicare to continue. As FIs' audit processes become more sophisticated, increased scrutiny is inevitable. When more sample charts are requested, the presence of errors will result in more comprehensive chart reviews. An internal integrity review will enable you to detect accidental errors and implement corrective procedures that will limit any exposure later on.

Marc Zimmet is senior reimbursement consultant and Sheryl B. Rosenfield is director of clinical services for Zimmet-Hecht Associates, a consulting firm with offices in New York City and Old Bridge, N.J.

COMMON MISTAKES

There are many possible billing errors, but the following blunders seem to crop up most often:

UB-92 ERRORS

* UB-92 modifiers miscoded for "off-cycle" assessments (significant changes/OMRAs).

* Assignment of the wrong number of covered days to an "off-cycle replacement" assessment.

* "Service date" field does not match MDS reference date.

* "01" modifier used for a comprehensive five-day assessment that included triggers and RAPs.

MDS ERRORS

* Skilled therapy provided to a resident when MDS indicates "no rehab potential."

* Relevant medical services/conditions (especially those that occurred in the hospital prior to admission) excluded from the MDS.

* Underscored ADLs.

* Non-compliant MDS reference dates caused by a "leave of absence."

* Data entry errors (150 minutes of therapy entered in the computer system as 1,500 or 1,150).

DOCUMENTATION ERRORS

* Non-compliant physician certifications for skilled care.

* Inconsistencies between nursing or therapy notes and the MDS regarding ADLs.

* Therapy logs do not match Section P of the MDS.