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Care Watch Best Practice RUG Potential. Ensuring Appropriate Medicare Part A Reimbursement Becky LaBarge, RN, RAC-CT, CPRA VP Clinical Reimbursement Tutera Family Communities. RUG Watch. Care Watch tools - MDS accuracy & appropriate reimbursement

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Care Watch Best Practice RUG Potential

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Care watch best practice rug potential

Care Watch Best PracticeRUG Potential

Ensuring Appropriate

Medicare Part A Reimbursement

Becky LaBarge, RN, RAC-CT, CPRA

VP Clinical Reimbursement

Tutera Family Communities

Rug watch

RUG Watch

  • Care Watch tools - MDS accuracy & appropriate reimbursement

    • First Step - Review eHDS flags to ensure MDS accuracy

      • Over and above the CMS edits

      • ID coding inaccuracies/inconsistencies that can be corrected during encoding period, prior to submission to CMS

      • ID opportunities for training & documentation

      • Identify reimbursement impacts

Rug potential

RUG Potential

  • Go a step further and utilize the RUG Watch table to review the RUG scoring methodology on all Medicare Part A residents PRIOR to completion & submission

    • Helps ensure not missing payment opportunities

    • Helps to minimize risk of audits if RUGs accurately reflect care & services delivered & are supported by documentation

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RUG Potential

Rug potential2

RUG Potential

  • Providers can no longer afford to miss any payment opportunities related to mistakes in MDS coding

  • Provider liability is HUGE in today’s regulatory environment and MDS accuracy is paramount in ensuring appropriate $

Rug potential3

RUG Potential

  • Use all tools in our arsenal to earn and keep the Medicare A $ to which we are entitled

  • Care Watch RUG Potential is one of these valuable tools to help us review the MDS and correct costly mistakes before they affect payment and inaccurately reflect resident status in look back period

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RUG Potential

  • Not all mistakes can be modified - New CMS guidance on Inactivating Assessments (see CMS Clarification memo dated 3/30/2012)

    • Type of Assessment (A0310)

    • Assessment Reference Date (A2300)

    • Entry (A1600) or Discharge (A2000) date

    • Type of Provider (A0200)

      above items cannot be modified

Rugs potential

RUGs Potential

  • CMS Clarification “...if the ARD or Type of Assessment is entered incorrectly, and the provider does not correct it within the encoding period, the provider must complete and submit a new MDS 3.0 record...a new ARD date must be established based on MDS requirements, which is on or after the date the error is identified, but not earlier...”

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RUGs Potential

  • Help Guard Against Medical Reviews

    • RAC (Recovery Audit Contractors)

    • ZPICs (Zone Program Integrity Contractors)

    • ADRs (Additional Development Requests)

    • CERT Reviews (Comprehensive Error Rate Testing)

    • Managed Care audits for skilled residents even after obtaining pre-authorization for services

    • The list goes on and on

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RUG Potential

  • The MDS is the focal point

    • if it’s inaccurate - the RUG and resulting payment may be wrong

    • the resident may not receive care & services necessary to achieve highest practicable level of function

    • Quality outcomes may be misrepresented via Quality Measures / Five Star Report

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RUG Potential

  • Are ADLs coded accurately

    • Coding instructions are complex and Section G is probably the most often ‘mis-coded’ section of the MDS

    • Included in all 66 RUGs

    • Is Rule of 3 followed?

    • Is Support Provided capturing ALL staff assistance provided during ENTIRE 7 day look-back period

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RUG Potential

  • RUG Potential will demonstrate assessments with ADL opportunities

    • Focus on Late Loss ADLs: Bed Mobility, Transfer, Eating &Toilet Use which make up the ADL Index

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RUG Potential

  • ADL Coding makes a BIG difference in reimbursement

    • RUB pays $581.82

    • RUA pays $486.49

    • Difference = $95.33

    • x 30 days = $2,859.90

      • for 1 resident for 1 MDSpayment period

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RUG Potential

  • Should the resident be receiving Rehab or Restorative Nursing?

    • PE2 pays $352.81

    • PE1 pays $336.08

    • Difference = $16.73

    • x 30 days = $501.90

      • for 1 resident for 1 MDS payment period

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RUG Potential

  • Did you choose the best ARD?

    • Moving the ARD can significantly impact the care and services

    • Getting only 4 days of therapy instead of 5?

      • Actual example - missed $605 on 5 day assessment

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RUG Potential

  • Are interviews being conducted appropriately

  • Is staff following the scripted guidelines?

  • Are interviews done during appropriate look back period?

  • PHQ-9 scores can affected reimbursement significantly

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RUG Potential

  • Inaccurate PHQ-09 potential:

    • HE2 pays $473.22

    • HE1 pays $392.94

    • Difference = $80.28/day

    • x 30 days = $2,408.40

      • for 1 resident for 1 MDS payment period

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RUG Potential

  • Bottom Line - If you don’t double check your MDSs for accuracy:

    • Miss out on $ you earned

    • Open the door for Medical Review

    • Skew your Quality Measures (QMs)

    • Negatively impact Survey

    • And Most Importantly - not give the resident the care plan and the services they deserve

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