Documentation hot spots.

Capture the right information and boost reimbursement

GOOD DOCUMENTATION SKILLS HAVE ALWAYS BEEN IMPORTANT clinically speaking, but they take on new significance under Medicare's prospective payment system. Originally, the minimum data set, the tool used to determine resident-specific RUG III rates, was considered a "source" document that did not require additional documentation. But because of its payment implications under PPS, MDS coding must now include supporting documentation. Keep an eye on the following MDS sections, which have the biggest impact on payment and are most in need of supporting documentation:

* Mood, Capture verbal expressions of distress, sleep-cycle issues, sad physical appearance, and loss of interest in others. Use on interdisciplinary flow sheet that allows for daily documentation of the 16 mood-specific MDS items. Because a formal diagnosis of depression is nor needed to document the mood indicators, call it-and code it-as you see it. Your ability to document can boost reimbursement by $8 to $14 per diem for residents in the RUG III clinically complex categories.

* Activities of daily living, Too many providers have ADL documentation systems that are cumbersome and difficult to monitor. Because the MDs has 10 ADL items to code, daily flow sheets are common. Although use of flow sheets is effective, it's overkill. Requiring daily documentation of all ADL related items, for every shift, and for an indefinite period makes monitoring for accuracy and compliance difficult. Instead, capture critical information only, namely "late-loss" ADLs.

Late-loss Adls are resident skills that are the last to deteriorate. They include bed mobility, transfer, toileting, and eating ability. Capture this information over 24 hours, perhaps assigning the third shift to assess and document bed mobility, the second shift to assess and document transfer and toileting abilities, and the first shift to assess and document eating ability. By doing so, you get an accurate snapshot of both the resident's ADL self-performance skills and the amount of support provided by staff. Comparing ADL sum scores across PPS assessment periods supports the necessity and effectiveness of specialized therapy services.

Therapists themselves can be a source of late-loss ADL documentation, but if they use an ADL rating scale different from the MDS, it can be difficult to compare therapy's and nursing's respective assessments of resident functioning. To avoid this, have therapy "MDS-ize" their documentation.

The ADL, sum score accounts for 30 percent of the scoring, in determining the appropriate RUG III group and can mean the difference between a RUC and a RUB classification, which translates into an additional $38 per diem.

* Nutrition. Weight loss and parenteral or tube feeding, including the total caloric and fluid intake a resident receives from a parenteral or tube feeding, must be documented. If the MDS is coded as though the resident did not receive the majority of his or her intake by parenteral or tube feeding, the clinical significance of this treatment will not be captured by the RUG III system.

* Skin assessment, In addition to identifying the number and effectiveness of skin treatments, it's essential to accurately stage pressure ulcers. If you don't "down stage" them as they heal, note on your skin assessment flow sheet how a particular pressure ulcer is coded on the MDS. Without an explanation, inconsistencies in staging can result in problems in the medical review process.

* Time awake. Although the amount of time a resident is awake during the day is generally coded by the activities department, nursing assistants should capture time-awake information on a daily flow sheet, If this information is not correctly captured, it could result in a resident being erroneously assigned to a RUG III category below clinically complex, reducing reimbursement by $6 to $48 per diem.

* Special treatments and procedures. Document treatments within the 14-day look-back period, especially for the first two PPS assessments, whose look-back periods extend into the qualifying hospital stay. Drain the hospital record dry, obtaining copies of flow sheets and progress notes that substantiate MDS coding for intravenous medications, oxygen therapy and transfusions. Doing so can mean a $59 per diem difference.

Rehabilitation services require supporting documentation in two areas. The days and minutes of therapy coded on the MDS should be supported by specialized therapy treatment logs. And the numbers of days coded on the MDS should be documented by nursing rehab flow sheets, progress notes, and the resident care plan.

Because they account for 75 percent of the MDS Items used to calculate the RUG III categories, these hot spots must be thoroughly documented by members of your care planning team.

Rita Roedel, RN, is a clinical operations consultant and Randall Severson, CPA, is a partner is the health care advisory services division at the Milwaukee-based accounting and consulting firm BDO Seidman, LLP.