Medicare Compliance & Reimbursement

Identify rehab RUG patterns that shout 'come audit me.'

You need to identify RUG profiles that could raise red flags so you can see if they are justified--and if not, pull them down the flag pole.

What's the hottest audit spot? A pattern where residents receive a medium intensity of therapy minutes rather than high intensity regardless of their rehab needs. CMS has its antennae up for that to happen under the RUG-53 system. That's because residents who receive rehab high plus extensive services (RHX or RHL) will group into medium rehab plus extensive (RMX or RML). The latter two RUGs have higher case-mix indexes and thus pay more.

Some facilities may reason that they aren't getting paid more for providing rehab high therapy minutes for residents in extensive services--so why provide it, observes Peter Arbuthnot, with American HealthTech Inc. in Jackson, MS. And that would be unfortunate for residents, he adds.

Take A Clinical Snapshot

See if you can justify a resident in extensive services receiving a medium intensity of rehab therapy based on his clinical condition and nursing care requirements. How so? Medium rehab plus extensive services pays more because it has a higher nursing component, explains Maureen Wern, CEO of Wern & Associates in Warren, OH.

Thus, patients who group into that RUG typically aren't your postsurgical orthopedic-type rehab patients, but those with significant comorbidities, such as pneumonia, COPD, UTI and other clinical issues, Wern says. "Those patients can't tolerate higher levels of rehab, at least initially," she says. "But they have more intensive nursing needs."

Documentation tip: If a person is in medium rehab plus extensive services, the rehab therapist's documentation should address his level of tolerance, says Amy Combs, PT, with Rehab Care Group based in St. Louis. In such cases, "often therapists will provide split treatments in a day"--a strategy that "speaks to the person's inability to tolerate longer sessions," she says.

Also keep in mind that 30 minutes a day of therapy really isn't much, she adds. "The practice would be to provide more if the person could tolerate it to move him along in therapy." So "it should be all over the chart as to why the person could not tolerate more than 30 minutes of therapy a day."
 
Target These Additional Areas

Over-projecting therapy in Section T: If your facility has a pattern of projecting rehab minutes on the five-day MDS that often fails to materialize, take a close look. Any time that occurs, the "facility should have documentation in place to explain the rationale for projecting the resident's therapy ...quot; and why it didn't materialize," suggests Ron Orth, RN, NHA, RAC-C, president of Clinical Reimbursement Solutions LLC in Milwaukee. "An auditor should be able to glean that from reading the medical record."

Orth suggests having a quality assurance process for identifying why residents aren't receiving projected therapy minutes. That way, the facility can make changes if needed. For example, are therapy staff rescheduling the therapy at a better time for the resident?

Patients with conditions or diagnoses that don't jibe with very high or ultra high: The FI might question why the facility has elderly, frail people with lots of medical comorbidities receiving ultra-high therapy, says Pauline Franko, PT, president of Encompass Consulting and Education in Tamarac, FL. In some cases, however, a very sick resident with multiple diagnoses may require a higher intensity of therapy minutes because he moves slowly and requires more time to do therapy, Combs says.

If a resident with rehab potential required very-high or even ultra-high minutes because he did everything very slowly--"for example, perhaps a resident with Parkinson's disease--the therapist and other staff should document that scenario very well," counsels Jan Stewart, RN, a consultant with Zimmet Healthcare Services Group in Morganville, NJ.

The documentation should explain the extra time required, Stewart emphasizes.

Care planning tip: "Before embarking on a therapy treatment plan," consider and document the resident/family goals, suggests Marilyn Mines, RN, BC, director of clinical services for FR&R Healthcare Consulting in Deerfield, IL. Ask what that particular resident requires "from a therapy point of view to be as independent as possible and experience a good quality of life," she advises.