Medicare Compliance & Reimbursement

Follow these strategies to secure fair reimbursement for services.

MDS teams that don't know when and how to do significant change-in-status assessments for Part A-stay residents will end up leaving more than chump change on the RUG table.

That's because a significant change in a resident's condition can lead to a new RUG score and different payment, according to Christine Twombly, RNC, chief clinical consultant for Reingruber & Company in St. Petersburg, FL.

The first step: Know what the RAI user's manual counts as a significant change and the time frame for completing an SCSA, which is 14 days from when you determine a resident has improved or declined in a way that:

• will not normally resolve itself without staff intervention or by implementing standard disease-related clinical interventions; e.g., it isn't self-limiting;

• impacts more than one area of the resident's health status; and

• requires interdisciplinary review and/or revision of the care plan.

What wouldn't count as a significant change? "The RAI manual says you don't do an SCSA for a self-limited condition but rather for a decline or improvement in two areas now thought to be permanent," says Twombly. And a resident with a UTI who develops confusion and urinary incontinence may appear to require an SCSA because he's had changes in two or more areas, she notes. But the UTI is causing the mental status change and incontinence, which will likely resolve when the infection clears, she adds. "So that's one situation where an SCSA isn't really warranted," Twombly says. Even so, the care plan should always be up to date.

Conversely, some resident declines may actually require a SCSA that could result in a new RUG category, even though the change doesn't appear initially to affect more than one area of the resident's functioning or clinical status.

Example: A new Stage II pressure ulcer may not appear to meet the definition of an SCSA if you go strictly by the manual's criteria, observes Cathy Sorgee, RN, a consultant with The Broussard Group in Lake Charles, LA. But in such cases, you will usually find the resident has experienced more than one decline. "Maybe the person required extensive assistance with bed mobility and transfer but now requires total assistance," says Sorgee. "The person may have had a decline in nutritional intake or weight."

Strategically Manage The ARD

You have 14 days to do an SCSA after determining a resident has had a significant change. Within that time frame, select an ARD for the assessment that doesn't penalize the facility financially, says Marilyn Mines, RN, BC, director of clinical services for FR&R Healthcare Consulting in Deerfield, IL. To pull that off, consider two objectives:

Goal #1: Set the ARD within the 14-day time frame to capture the "worst" clinical picture of the resident where he used the most services, resulting in a RUG with the highest case-mix index and, thus, best payment.

Examples: The resident develops a Stage III pressure ulcer that becomes infected, and he receives IV fluids and IV antibiotics. The staff determines the person has also had an ADL decline. You'd want to set the ARD to capture both of the IV services because that can affect what SE category the person goes into--and the ADL score for SE, which is a minimum of 7, says Patricia Boyer, RN, MSM, NHA, president of Boyer & Associates in Brookfield, WI.

A resident receiving rehab who develops an infected pressure ulcer and receives IV medication or IV fluids and has an ADL score of at least 7 would go into one of the new rehab plus extensive services groups. But you'd have to set the ARD to capture the services, Boyer notes.

Goal #2: Set the ARD for a sicker resident at the best payment level as early as possible because the new RUG rate changes as of the ARD.

Example: A resident is coming up on a 30-day Medicare-required assessment, offers Boyer. And you determine on day 21 that he has suffered a decline that will put him in a RUG with a higher case-mix index. If you set the ARD on day 21 for a combined SCSA and 30-day Medicare-required assessment, then the payment would change on day 21 and run through the entire cycle for the 30-day MDS or until the patient is discharged.

You could also identify the SCSA on day 18 and set the ARD on day 21 for the combined SCSA and 30-day Medicare MDS assessment, as long as you capture the resident's highest acuity/service utilization, Boyer adds.

When The Resident Improves

How would you manage the ARD in doing an SCSA for a resident who is improving? Say a resident starts eating again so his nutritional and ADL status improves and his two Stage II pressure ulcers heal. "Strategically managing the ARD, you could wait until your next MDS-required assessment--if it's within 14 days of when you determined the resident had a significant change," says Boyer.

Anytime you can combine assessments, that's a plus, Boyer adds, because staff don't spend extra time doing two MDSs.

One day can make a difference: For example, you note a resident has a significant change by the 14th day of his stay, resulting in a lower-paying RUG category.

If you set the ARD even for day 15 rather than day 14 for a combined SCSA and 14-day MDS, the payment will change on day 15 rather than day 14--and run through day 30, notes Mines. That means the facility won't lose the 14th day of higher payment, since the payment changes as of the ARD, she says.

One day of higher payment may not sound like much, Mines notes, but if it's happening10 times a month, that adds up, she says.