As many states have or are transitioning to some form of the Patient-Driven Payment Model (PDPM) as part of their Medicaid payment model, it is critical that providers understand the importance of supporting documentation. States often review the Minimum Data Set (MDS) supporting documentation that calculated the case mix group and correlating case mix index. It is important to know who will be reviewing this information in your state and by what guidelines.
The review or audit process varies from state to state. These reviews can be as simple as the provider receives a list of residents and corresponding MDS and case mix group information and is asked to provide the supporting documentation by a specific date. Other states require an online meeting where the provider team is required to show the supporting documentation for a selection of residents based on their MDS assessment and case mix group, which can take a full eight hours to complete.
States or their contractors who conduct these reviews usually provide supporting documentation guidelines to help providers understand what is required to support each data element on the MDS that is impacting the case mix group and corresponding case mix index. It is critical that providers follow these guidelines to ensure that documentation is supportive.
Some common issues noted during these reviews include active diagnosis support, shortness of breath while lying flat, percentage of calories through a feeding tube, and functional tasks included in Section GG of the MDS. For a diagnosis to be considered active, there must be documentation from the physician or other practitioner of the diagnosis in a 60-day look-back period along with some form of monitoring or treatment in a seven-day look-back period. The assessment reference date (ARD) of the MDS is what determines the exact look-back time frame. As an example, a diagnosis of Parkinson’s disease acknowledged by the physician or practitioner in the 60-day look-back period for a patient who receives Sinemet included on the medication administration record and signed as administered by the nurse(s) in the seven-day look-back period would support an active condition.
The medication order for the Sinemet should also include that the medication is being given for the Parkinson’s disease. Shortness of breath while lying flat when combined with some chronic respiratory conditions can impact the case mix group and corresponding case mix index. It is initially important to determine if patients become short of breath while lying flat. If yes, then the intervention might be elevation of the head of bed to prevent recurrence. Having an order for the head of the bed to be elevated due to shortness of breath while lying flat is important, but providers also need to include the corresponding diagnosis to the intervention.
Patients who are not 100% tube fed (any food or fluids by mouth, including pleasure feedings) are required to have a daily calorie count of both oral and parenteral intake. Most providers document meal and snack consumption in a percentage but not the number of calories. Thus, it is important to enlist the assistance of your dietitian to make certain your documentation is adequate.
Section GG capture of functional tasks to determine the PT/OT and nursing function scores is another area where providers may have issues. Section GG uses a three-day look-back period to determine each patient’s usual performance with various tasks. For the nursing function score, those tasks would include eating, toileting hygiene, sit to lying, lying to sitting on the side of bed, sit to stand, chair/bed-to-chair transfer, and toilet transfer.
It is very important that the definitions of these tasks along with the scoring responses contain the correct definitions. Some software systems did not automatically update these changes in October 2023 but relied on the providers to make the necessary changes. Providers should review their current process and determine if they are using the correct definitions for each task along with the scoring responses.
An example of nursing documentation that would support an active diagnosis of multiple sclerosis when it has been acknowledged by the physician or other practitioner in the 60-day look-back period could include: “resident continues to receive restorative nursing services 3-5 times per week for treatment of contractures related to multiple sclerosis and immobility. Facility personnel continue to assist with mobility, passive and active range of motion with frequent rest periods due to fatigue.” It would be recommended that the nursing documentation be in the seven-day look-back period of the assessment reference date to support multiple sclerosis as an active diagnosis.
Providers should develop and follow a process that requires MDS personnel to validate that there is supporting documentation contained in the medical record for all data elements that are impacting the case mix group. This could be as simple as a detailed note indicating where the supporting documentation is located to a “tool” that encourages the addition of text indicating where to find the supporting documentation.
Providers should be proficient in locating information in their software system on demand when the case mix review is conducted remotely online. These reviews are timed and do not leave time to search for information repeatedly.
If you have questions or concerns about the case mix review process in your state, please reach out to a professional at Forvis Mazars.