The theme of our recent audits for our clients has been review of claims with a RUG score in one of the lower 18 categories. Any RUG score that falls below the level of CA1 is considered to be in the lower 18 group. This includes RUG scores for Impaired Cognition, Behavior and Reduced Physical Functioning (For example: IB1, BB1, PE1 respectively) These scores are significant for facilities to be watching for because the fiscal intermediaries and Medicare Administrative Contractors are sensitive to claims submitted with a RUG score in the lower 18. These claims are more likely to be requested for audit with question of why the patient required the daily skilled care of a nurse or therapist.
Harmony recommends facilities institute the following procedures:
1. Review of all lower 18 prior to payment period in order to:
a. Assess for lower 18 accuracy,
b. Assess for skilled needs,
c. Assess for appropriate documentation that supports skilled care.
2. If the resident accurately falls into lower 18 level and does not require the daily skills of a nurse, Medicare Part A benefits need to be denied.
3. Denied lower 18 beneficiaries require constant scrutiny during the 30 day window opportunity to assess for resumption of Medicare Part A coverage.
When a patient is found to be correctly coded in a lower 18 category and requires daily skilled care, it is imperative that the facility educate staff in regards to the rational for skilling the patient and assure that there is a daily note describing the care provided. The rationale for this above procedure is that lower 18 have a high likelihood of audit. An audit that deems the patient unskilled may lead to a pre-payment review, which significantly impacts accounts receivable. In summary, the lower 18 RUG levels need to be managed by the process described above.
Harmony will provide examples of skilled documentation for patients correctly coded in one of the lower 18 RUG categories in next week's newsletter. Stay tuned...
For additional information on this topic contact Harmony Healthcare or visit our web site at
www.harmony-healthcare.com
