MDS Accuracy and Compliance: Where There s Smoke

MDS Accuracy and Compliance: Where There s Smoke November 2014 1 Objectives List the current trends in the Long Term Care industry that are driving scrutiny into the MDS assessment process Identify the interdisciplinary documentation systems that feed into the MDS assessment process Give examples of assessment and documentation issues that are impacting MDS accuracy in your facility Apply the principles of QAPI to effect improvement of your facility s assessment and documentation practices 2 1

Why Is MDS Accuracy Important? Resident assessment and care planning CAA: Care Area Assessments Quality Measures CASPER: Focus of surveyors Nursing Home Compare/Five Star: publicly reported by CMS Reimbursement Medicare scheduled and unscheduled assessments Medicare Advantage/HMO if required by plan Medicaid reimbursement is set by MDS in 30+ states 3 We ve Been Down This Road Before Data Assessment and Verification Project DAVE (2002 2004) Offsite and onsite reviews Identify inaccurate Medicare payments, safety/health concerns, areas with high rates of inaccuracy CMS released DAVE tip sheet and training DAVE 2 (2005 2007) Focused more on MDS accuracy and did away with offsite reviews More tip sheets released 4 2

5 CMS Smoke Alarms Comprehensive Error Rate Testing (CERT) CMS Clarification: Change of Therapy (COT) completion CMS Focus Surveys CMS Memo on Therapy Utilization PEPPER Reports RAC audits 6 3

CERT Comprehensive Error Rate Testing (CERT): Skilled Nursing Facility (SNF) Certifications and Recertifications MLN Matters #SE1428 SNF inpatient improper payment rate 7.7% in 2013 Failure to obtain adequate/timely certification and recertification of the resident s daily skilled needs 7 COT Clarification October 2014 COT assessments may be completed to reclassify into a therapy RUG from a non therapy RUG, provided both of the following conditions are met: Resident was classified into a RUG therapy group on a prior assessment during the current Medicare Part A stay, No discontinuation of therapy between: Day 1 of the COT observation period for the COT that classified the resident into non therapy RUG and ARD of the COT that reclassified the resident into a therapy RUG Example in manual: therapy provided only on 4 calendar days so dropped to nursing RUG with no discontinuation The COT is optional 8 4

CMS Focus Surveys A pilot announced by CMS in a Survey and Certification (S&C) Memorandum 14 22 NH Encompassing MDS Accuracy and Dementia Care Short term, small scale reviews with 5 State Survey Agencies To last approximately 2 days with an exit conference 9 CMS Focus Surveys A second Survey and Certification Memorandum 15 06 NH released 10/31/14 announced the completion of the pilot and the national implementation in 2015 Staffing will also be assessed during CMS Focus Surveys 10 5

CMS Focus Surveys Findings included: For 37% of stays, SNFs did not develop care plans that met requirements or did not follow the care plans For 31% of stays, SNFs did not meet discharge planning requirements For 47% of claims, SNFs reported inaccurate information on at least one MDS item In 24 of 25 surveys, deficiencies were cited 11 MDS Accuracy Survey Surveyors will be requiring: Access to the medical records Assessments and supporting documentation A staff member familiar with the MDS process in the center They will also be interviewing residents and staff regarding: Staffing levels MDS 3.0 coding 12 6

MDS Accuracy Survey MDS information serves as: the clinical basis for care planning and delivery a resource for payment rate setting and quality monitoring Certain patterns within a nursing home may be indicative of fraud or manipulating the quality monitoring process clinical documentation, MDS assessment or reporting practices that result in higher RUG scores, untriggering CAA(s), or unflagging QI(s) 13 MDS Accuracy Survey Surveyors will be looking for patterns or multiple examples of: submitting MDS assessments or tracking records, where the information does not accurately reflect the resident s status as of the ARD, or the Discharge or Entry date submitting correction(s) to information in the QIES ASAP system where the corrected information does not accurately reflect the resident s status as of the original ARD, or the original Discharge or Entry date and where there appears to be no error 14 7

MDS Accuracy Survey submitting Significant Change in Status Assessments where the criteria for significant change in the resident s status do not appear to be met delaying or withholding MDS Assessments, Discharge or Entry Tracking information, or correction(s) to information in the QIES ASAP system 15 CMS Memo on Therapy Trends Observations on Therapy Utilization Trends April 21, 2014 Two notable trends in therapy utilization in FY 2011 2012 Upward trend in Rehab Ultra RUG levels Therapy minutes reported on MDS just over the RUG threshold 16 8

Rehab Ultra Trend 17 Therapy Minutes and RUG Thresholds 18 9

What is PEPPER? Program for Evaluating Payment Patterns Electronic Report (PEPPER) of SNF s Medicare claims data statistics for areas that may be at risk for improper Medicare payments PEPPER compares a SNF s Medicare data with aggregate Medicare data State MAC Jurisdiction Nation PEPPER does not identify improper payments! 19 How does PEPPER ID at risk SNFs? SNF s target area percent is compared to other SNFs percents in the state, MAC/FI jurisdiction and nation If target area percent is at/above the national 80 th percentile or at/below the national 20 th percentile, SNF is identified as at risk for improper Medicare payments 20 10

PEPPER Report Target Areas: Therapy/High ADL Non therapy/high ADL Change of Therapy Assessment Ultrahigh Therapy RUGs Therapy RUGs 90+ Day Episodes of Care Latest reports distributed electronically in May 2014 http://pepperresources.org/pepper/securepepperac cess.aspx 21 Are you an Outlier? Need to audit? When reviewing this information, you may want to consider auditing a sample of records if you identify: Increasing Target Percents over time resulting in outlier status Your Target Percent (first row in the table below) is above the national 80th percentile Ultrahigh Therapy RUGs Target Percent 80% 70% 60% 50% 40% 30% 20% 10% 0% 10/1/09-9/30/10 10/1/10-9/30/11 10/1/11 9/30/12 SNF Natl: 80th %ile Juris: 80th %ile State: 80th %ile 22 11

Recovery Audit Program (RAC) After a three year demonstration project identified $900 million in overpayments and $38 million on underpayments, the national Recovery Audit program became permanent and was expanded to cover the national. In FY 2013, the Recovery Auditors identified and corrected $3.75 billion in improper payments. $3.65 billion in overpayments $102.4 million in underpayments 23 Recovery Audit Program (RAC) Other 2013 changes: The Office of the Inspector General (OIG) recommended that RAC auditors increase their referrals of potential fraud and to report those findings to the OIG as well as CMS. Therapy claims reviews are added to the prepay pilot in seven states with high incidences of improper payments and fraud: Florida, California, Michigan, Texas, New York, Louisiana and Illinois. 24 12

Recovery Audit Program (RAC) Appeals In FY 2013, providers appealed 30.7 percent of all claims with overpayment determinations Of these appeals 18.1 percent were overturned in the provider s favor Only 9.3 percent of all Recovery Auditor determinations were overturned on appeal 25 Where There s Smoke? CMS is monitoring trends in the data to identify patterns/outliers Why? Inaccuracies in: Reimbursement CAA/care planning Quality outcome monitoring Deliberate or erroneous? You can use QAPI to address this! 26 13

QAPI and Compliance QAPI Framework Five Elements Twelve Steps Your facility s QAPI program uses this framework to implement improvement Root Cause Analysis PIPs Systemic action 27 PDSA Plan: Identifying and analyzing the problem Identify exactly what the problem is using lookback trends and any patterns that have been identified Draw together any other information your team needs that will help start sketching out solutions (RCA) Do: Developing and testing a potential solution Generate possible solutions Select the best of these solutions Implement as a pilot or with a select group Study: Measuring how effective the test solution was, and analyzing whether it could be improved in any way Measure how effective the pilot solution has been Gather together any learning from it that could make it even better Act: Implementing the improved solution fully Implement your solution, but remember that the process is ongoing Loop back and reevaluate to continuously improve 28 14

Who Is On Your QAPI Team? Administrator/DON Medical Director Therapy (in house or contract) MDS Nursing (all shifts) Licensed and CNAs Social Service Activity/Dietary Resident/Family Councils 29 What s the Purpose of the QAPI Team? Teamwork is built into QAPI structure No one discipline/department is in charge Leadership is required from the top down Input from front line staff is just as valuable Identify compliance/risk areas Develop comprehensive solutions Monitor outcomes 30 15

QAPI and MDS Accuracy QAPI guidelines incorporate the use of data to identify areas for improvement Develop Performance Improvement Projects (PIPs) Look for prevalent/recurrent issues with MDS coding and supporting documentation Use Data Integrity Audit (DIA) or other auditing method to provide focus 31 Identify Areas of Focus MDS accuracy Internal/External auditing of MDS records Manual review has merits but limited only to selected sample Automated auditing of all assessments prior to CMS submission has proven most efficient 32 16

Root Cause Analysis What are the sources of information that feed into the MDS? ADL documentation (kiosk/flowsheet) Nursing documentation MD/NP notes Therapy scheduling and documentation Therapy documentation (integrated software/paper grid) Audit treatment grids against plan of care Root Cause Analysis of cases with multiple COTs 33 Root Cause Analysis (cont.) If documentation is inaccurate: Staff turnover/educational need Time management/staffing issues Copycat ADLs/weights etc. Staff becomes blind to unchanging resident behaviors/conditions Data entry errors 34 17

Root Cause Analysis (cont.) If documentation is accurate: Review policies/procedures for possible revision Form interdisciplinary work group Evaluate systems What is driving the current practice? What elements need to change? Develop action plan Monitor for results 35 Look for Patterns of Coding Issues 36 18

DIA Issues: Section M Stage 2 pressure ulcer with granulation/slough/necrotic tissue Unhealed pressure ulcer not coded in M0100A (Determination of Pressure Ulcer Risk) At risk for pressure ulcers, uses w/c, has pressure reducing device on bed but not chair Pressure ulcer and assistance w/bed mobility but not on T/R program 37 Section M PIPs Audit wound/treatment documentation Inconsistent pressure ulcer staging Potential education need re: NPUAP staging guidelines and MDS coding rules Missing documentation of preventative interventions Review care plans for residents with pressure ulcers Look for individualized positioning interventions Review product documentation of devices e.g. mattresses/cushions for pressure relieving properties 38 19

DIA Issues: Other MDS Sections Asthma/COPD/Chronic lung disease without shortness of breath Antidepressant with no diagnosis Diagnosis of dementia with no cognitive impairment Chronic diagnosis on prior MDS but not on current MDS 39 MDS Assessment PIPs Audit documentation Health conditions: SOB, Pain, cognitive impairment Ensure ordered medications have medically necessary reason in documentation Active diagnoses: MD/NP documentation within 60 days and current impact on resident s condition/treatments/monitoring Missing documentation: potential need to work with Medical Director to address 40 20

DIA Tests: Therapy Speech therapy with no functional impairment or diagnosis Occupational therapy with no ADL impairment Physical therapy with no ADL impairment 41 Therapy PIPs Review therapy documentation for treatment diagnoses/functional assessment during MDS look back period Assess communication systems between therapy and MDS departments Audit documentation of ADLs and other functional areas (e.g. swallowing problems, communication) Potential educational need for CNAs, activity and dietary staff 42 21

Therapy Delivery: Look for Patterns 43 Potential PEPPER PIPs ADL scores: Review of q shift documentation, look for patterns, CNA competencies High outlier: Possible overcoding Low outlier: Possible undercoding COT assessments: Therapy /MDS communication, coordination of scheduled and unscheduled assessments High outlier: Disconnect in planning and delivery of services Low outlier: Audit to ensure COTs were not missed 90+ day LOS: High Outlier: Continued need for skilled services 44 22

Practice Patterns: Interview vs. Staff Assessment 45 More to Come Focus Surveys will likely continue to evolve Five Star ratings are expanding to include additional Quality Measures Awaiting CMS findings from the Dementia Care Focus surveys Potential challenges with accuracy and the new ICD 10 codes 46 23

Conclusion CMS requirements for assessment accuracy and compliance have not changed Heightened scrutiny indicates that patterns have been identified Good documentation demonstrates the resident s clinical needs as well as the care provided Documentation must be clear and specific Efficiency is key Interdisciplinary communication and documentation are key to maintaining accuracy Targeted audits ensure ongoing compliance 47 For More Information CMS Memo on Therapy Trends http://www.cms.gov/medicare/medicare Fee for Service Payment/SNFPPS/Downloads/Therapy_Trends_Memo_04 212014.pdf CMS Memos on Focus Surveys http://www.cms.gov/medicare/provider Enrollment and Certification/SurveyCertificationGenInfo/Downloads/Surve y and Cert Letter 14 22.pdf http://www.cms.gov/medicare/provider Enrollment and Certification/SurveyCertificationGenInfo/Downloads/Surve y and Cert Letter 15 06.pdf PEPPER http://www.pepperresources.org/ 48 24

Questions? Jennifer Gross jennifer.gross@pointright.com Pam Kaiser pam.kaiser@pointright.com www.pointright.com 49 25