Editor’s Note: During a recent Monitor Monday broadcast, special guest Mark McDavid was asked a question by a listener inquiring about the need to review billing to ensure that therapy providers choose the correct RUG scores – specifically, the listener asked, doesn’t MDS software choose the correct scores?   Here, McDavid responds.

You are correct: Once data is entered into the Minimum Data Set (MDS) software, the software “crunches the numbers,” so to speak, and puts patients in the highest-paying appropriate Resource Utilization Group (RUG) . I made two consecutive comments on the Monitor Monday call, one referring to the triple-check process (which means reviewing the billing) and the other regarding the need for therapy to choose the correct RUG category. I think these two elements caused some confusion.

The triple-check process, as the name would suggest, involves the interdisciplinary team triple-checking several things prior to billing. These matters include but are not limited to verifying Medicare benefits, ensuring that the patient qualifies for a Part A stay, and checking that all signatures are secured (from doctors, nurses, therapists, etc.) and that nursing documentation, therapy documentation and data all have been entered into the MDS. When looking over nursing documentation, the team should look for a clear indication that the patient was receiving skilled services – and if nursing was the discipline that was treating the patient, that this treatment occurred on a daily basis and at a level and complexity that required the skills of a nurse.               

If the patient was being treated by therapy, then the triple-check meeting is held to ensure that services are meeting the skilled criteria for therapy. This check would include ensuring that the patient is being seen five times per week (or in the case of a rehab ultra-high RUG, five times per week by one discipline and three times per week by another), ensuring the presence of therapy documentation that justifies the need for skilled service, and determining that the level and complexity of the services being provided is such that it requires the skills of a therapist. 

We request that our therapists use various standardized tests to assist with justifying the need for therapy intervention. These standardized tests include the Tinetti, Berg Balance test, Timed Up and Go, RIPA-G, and the Functional Reach test. Again, all of these documentation components are being used to indicate to any reviewer that this patient required the documented level of service. The last item that many interdisciplinary teams focus on is to check the nursing and therapy documentation to determine whether they contain contradictory information. It is not necessary that the documentation matches exactly, but it at least should show the reviewer that both nursing and therapy teams are witnessing similar responses and behaviors from the patient.

The MDS itself also is reviewed to ensure accuracy, with reviewers paying close attention to items that impact reimbursement (such as activities of daily living (ADL), therapy days and minutes, extensive services, etc.) There are many pitfalls in the 38-page document that is the MDS, and errors are made easily. Often, errors are found in transposed therapy minutes, with incorrect therapy start or end dates and/or incorrect assist levels on ADLs commonly recorded. 

In 2009 the OIG found that one-quarter of all MDS claims were billed in error. Certainly, some of these errors could have been corrected by a proper triple-check process. This process is the last chance a facility has prior to submission of a claim to make adjustments or corrections of inaccurate data. Once submitted, there is a formal process for making corrections – but catching the errors prior to submission is preferable.

When I referred to therapy providers and facilities choosing the correct RUG category, I was referring to putting each patient into the correct RUG category based on his or her clinical needs during the assessment window – not to choosing an appropriate category after the software has finished the calculations. In other words, ask yourself: Can the current number of therapy minutes being provided be justified by the patient’s current level of clinical need? 

At times, I see therapists blindly treating patients in RUG levels based on the patient’s tolerance of therapy and not necessarily on their clinical needs. Some patients can tolerate hours of therapy, but will those hours really be beneficial to them and help improve their functionality? It is great, for example, that a patient can tolerate 500 minutes of very high-level therapy per week, but are those 500 minutes all benefiting the patient? Could the patient get the same benefit from 325 minutes of therapy per week? Or could the patient progress even faster if we were providing 720 minutes of therapy per week, which may allow the patient to return home sooner? 

I encourage members of all interdisciplinary teams to question therapists and ask why they are treating patients at the levels they are. This is what reviewers are doing after the fact anyway when they comb through MDS data and documentation. It is far better for you and your team to ask these questions of your therapists in advance as opposed to the state or the OIG questioning your billing after the fact.

About the Author

Mark McDavid is vice president of professional services at Rehab Management, Inc., a group of contract management therapy companies.

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