MDS Alert
Two Cases Billed To Medicare For Behavior RUG - One Paid, The Other Not
MDS coding alone won't cut the mustard with medical reviewers. Medical Record: The resident was in the acute care setting for greater than three days for a new onset of confusion and anxiety. Documentation clearly shows these behaviors on a daily basis in the seven-day lookback period including the ARD and the behavior continued throughout the billing period. Documentation noted the need to switch the patient's medications being used to modify his behavior due to the sudden appearance of a rash over his entire body on the 4th day of his admission to the SNF. Review Determination: Medical Record: The resident was in the acute care setting for greater than three days for a new onset of confusion and anxiety. The documentation provided did not show than any of these behaviors were exhibited. Nursing notes describe the patient as "pleasantly confused, easily reoriented." Review Determination: Source: Transmittal 18 (January 17, 2002). Read the transmittal at www.cms.hhs.gov/manuals/pm_trans/R18pim.pdf.
The MDS may be exactly the same for two different claims but if the documentation doesn't back up the coding and skilled level of care, don't count on getting paid. That's the key message of a medical review transmittal providing two examples of services billed to Medicare for a resident in one of the lower 18 RUGs for behavioral issues.
Example 1:
Services Billed: BB201 for days 1-7
Supporting Documentation:
MDS: 5 day assessment
This claim would be paid as billed.
Example 2:
Services Billed: BB201 for days 1-7
Supporting Documentation:
MDS: 5 day assessment
The HIPPS code billed would be denied for the entire payment period because the services provided were not medically reasonable and necessary.
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