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 [...]