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 [...]