MDS Alert

Knowing the answers to these 4 scenarios helps avoid payment recoupments.

On the 14-day Medicare PPS assessment, a resident with now resolved pneumonia has enough days of physician visits and order changes to RUG into Clinically Complex.

Question No. 1:So he qualifies for continuing skilled coverage, right?

The answer: Not necessarily.

Rationale: "Just because a resident classifies into one of the so-called skilled-level RUGs doesn't mean the person can be covered on Part A," says Rena Shephard, RN, RAC-MT, MHA, FACDONA, president of RRS Healthcare Consulting in San Diego and founding chair and executive editor for the American Association of Nurse Assessment Coordinators.

A resident could go in Clinically Complex based on physician visits and order changes but still not require daily skilled nursing care, such as observation and assessment of a patient's condition.

"Physician visits and order changes may not necessarily be a marker of acuity," Shephard says. For example, in some hospital-based transitional care units, physicians or NPs-do daily or weekly rounds, she points out. And "some HMOs have been known to track their patients and may send an NP in to assess the person weekly.

"Physician order changes can be very simple and not represent a level of acuity that justifies Part A coverage" -- for example, ordering a cold medicine or dietary changes.

In a nutshell: To qualify for a Part A SNF stay, residents have to meet all of the technical coverage requirements, level of care and medical necessity criteria just like they did before PPS went into effect, Shephard notes. "Once you figure out that someone meets all of those criteria, then you look to the RUG level to see how much the SNF will be paid."

Question No. 2: The attending physician, an internal medicine specialist, was in the building to see the medical director and came by to talk with a resident. Thus, you can count that as a day when a physician visit occurred, right?

Answer: It depends on whether the visit involved an examination.

Rationale: Shephard notes that the RAI manual says to record the number of days during the last 14-day period a physician has examined the resident. "This can be a partial or full exam at the facility or in the physician's office," she says.

"It's the standard of care for the physician, NP or PA to document the exam," she adds. And if the physician or physician extender didn't do a full or partial exam or didn't document it, even if it did occur, the FI could deny a claim if the person's RUG level is based on physician visits and order changes, Shephard points out.

What about psychiatrists? "If a psychiatrist sees the resident for a consult or to provide therapy, the exam conducted would be a psychiatric exam," says Joan Brundick, RN, RAI coordinator for Missouri.

Question No. 3: During the lookback, a resident received a psychological evaluation on one day and counseling on another day provided by Dr. Jones, a licensed clinical psychologist. Thus, in addition to capturing the psychological therapy at P1be, the MDS nurse can also count two days of physician visits when coding P7, right?

Answer: No.

Rationale: Dr. Jones is a PhD psychologist, not a medical doctor (MD) or DO (osteopath), podiatrist, dentist or physician extender.

Compliance heads up: Consultant Christine Twombly, RN, RAC-C, notes that the RAI coordinator in one state told her that the state asked the coordinator to pull information from P7 so reviewers could compare that to counseling recorded in P1. The goal is to make sure the facility isn't coding visits by a PhD psychologist in Section P7, says Twombly, with Reingruber & Co. in St. Petersburg, FL.

Question No. 4: During the lookback, a resident's attending physician in the SNF wrote separate orders on two different days titrating a psychoactive medication for a resident experiencing hallucinations and other psychotic symptoms.

Can you count both of those days of order changes when coding P8?

Answer: Yes.

Rationale: If the physician writes separate orders titrating a medication -- for example, an antipsychotic -- on separate dates, you can count the orders in coding the number of days of order changes at P8, Brundick says.

"But if the physician wrote a single order on the same date directing staff to keep the resident on 10 mg for one week and 5 mg for the next week, then you'd count that as one order."

If the FI or a government entity saw a pattern of separate physician orders titrating a medication, that might be a problem, Brundick adds. "But if the physician really isn't sure when he or she is going to change the dose of a medication, that's legitimate."