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By Paola DiNatale

Healthcare providers understand too well that the patient’s clinical record documentation is based on the clinical situation, however too often we get trapped in the mindset of ‘when it’s too much or too little reporting’. Long passed are the good ole days when the clinical record documentation meant ensuring that the correct color ink was used to document and recognize the shift worked during a 24-hour period (Blue/Black Ink-Day shift, Green Ink-Evening shift and Red Ink-Night shift). Well, time has since moved on, and the focus of the clinical record documentation shifted from what color ink pen to use, to documenting services rendered associated with providing quality of care, promoting quality of life, identifying level of care need for reimbursement purposes, and most importantly, mitigating liability risk.

Origins of Nursing Documentation

Florence Nightingale
Source – Wikipedia

Looking back through nursing history, we can credit Florence Nightingale as the first nurse theorist and founder of nursing documentation. In Notes on Nursing, she stressed the importance of gathering patient information in a clear, concise, and organized manner with a strong focus on consistency (known as the three C’s). Nightingale’s theories on nursing gained acceptance, as she raised the status of nursing education, and clinicians began to accept her notion about the value of nurse’s perceptions and observations. As her hypothesis evolved, so did the theory that the clinical/medical record should contain a road map of actual and potential patient driven care, identifying problems and appropriate interventions, while also being easy to read and accessible to all members of the health care team. The patient’s clinical record documentation has many purposes, but essentially it assists all caregivers in coordinating patient treatment, ensuring accurate reimbursement, and guarding against liability issues.

In Documentation, Less Is Not More

As technological advances paved the way for the electronic health record (EHR/EMR) and providers’ ability to streamline the documentation process through customizable templates, it gave rise to a mindset that perhaps less documentation is more. Regardless of what clinical record format or software platform is in place, lack of patient care documentation has a potential impact to the REITs who own and operate income producing real estate in a range of property sectors. For example, if a Skilled Nursing Facility (SNF) has an active risk profile including increased claims activity relevant to allegations of malpractice, and the plaintiff’s clinical records are lacking pertinent documented details to support a defense, then the SNF may be at jeopardy with trickled down effects for meeting its financial obligations to the REIT.

In the decades since the establishment of REITs, scholarly articles and abstracts have been published on the topics of institutional shareholder investments; although, opinions differ on the importance of identifying litigation risk factors relative to tenant and property risk. However, from both the SNFs and the REITs perspective, the focus should be geared toward decreasing future risk and balancing it with meeting clinical record documentation standards. 

Clinical Record Documentation Strategy

Well known evidence-based documentation strategies focus on a clear and complete plan of care that:

  • legibly communicates pertinent patient information,
  • supports a proficient and competent level of care, and
  • creates a strong defense against potential allegations of malpractice by aligning patient and provider expectations.

Documentation Is Your Defense

“Documentation is your defense”- words that should permanently ring in our ears. Without documentation to support the care given, it is difficult to help defend a case, thus making it easier for plaintiff to prevail. The most powerful defense in the event of a claim or lawsuit is to document the basis for the clinical decision making.  Broadly speaking, documentation addresses the preparation and maintenance of clinical records that describes a patient’s care with a focus on attention to details.  Let’s face it – it’s all about the details, regardless of the color ink being used!

Author:

Paola DiNatale, MSN, RN, NHA
Senior Healthcare Specialist

Filed Under: Blog

Jennifer GrossBy Jennifer Gross, BSN, RN-BC, RAC-CT, CPHIMS

As Skilled Nursing Facilities (SNFs) prepare for the implementation of the Patient-Driven Payment Model (PDPM) on October 1, 2019, much of the focus of training has been on diagnosis coding.  Rightly so, since ICD-10 coding can make or break a facility’s capture of the correct PDPM Clinical Categories and Non-Therapy Ancillary (NTA) comorbidities.  But what about the other components of PDPM?  CMS has designed the new payment model to be driven by multiple clinical characteristics of the patient/resident, not just diagnoses.  It’s up to SNFs to ensure that their interdisciplinary teams capture the full picture in their documentation – while also reflecting the patient’s need for daily skilled SNF care.  Fortunately, the two go hand in hand.

Skilled Care – Basic Requirements

While the payment structure for Medicare is changing, the basic requirements for skilled care outlined in Chapter 6 of the Medicare Benefit Policy Manual remain the same.  Very briefly, here are the basic requirements:

  • Ordered by physician
  • Skilled nursing or rehabilitation services (provided by or under supervision of licensed personnel)
    • Provided on a daily basis (Nursing: 7 days/week, Therapy: 5 days/week)
  • Skilled services must be provided for a condition for which the resident received inpatient hospital care (or which arose while in SNF receiving care for the inpatient condition)
  • As a practical matter services can only be provided on an inpatient basis in the SNF

Under Medicare Fee-for-Service…

Under the Medicare fee-for-service system, SNFs have become accustomed to thinking of their patients as “skilled for therapy” or “skilled for nursing”; however, it’s usually not an either/or situation.  Under RUG-IV, that’s what it seems like, though…if a patient’s RUG falls into a Rehabilitation group (excluding Rehab Plus Extensive), it doesn’t matter how many clinical comorbidities she has – the reimbursement is the same.  Because of this, SNFs have been disincentivized from documenting items that were not payment drivers – even clinically significant issues like complex diagnoses, mood symptoms, and swallowing problems.  Combined with the sheer number of Minimum Data Set (MDS) assessments required to set the Medicare per diem rates, this means that for many SNFs, the MDS and documentation process has been whittled down to the single purpose of supporting the RUG on the Medicare claim.

Under PDPM…

This changes under PDPM: fewer assessments are required – only the 5-day at the beginning of the Medicare stay, the PPS Discharge at the end, and an optional Interim Payment Assessment (IPA) in between.  Since your MDS department will be less focused on churning out assessments, how about redirecting some of that time from MDS to CDI: Clinical Documentation Improvement?  This is a relatively new concept in the SNF world, but ensuring solid documentation is key to PDPM success – not to mention good clinical practice.  Use the big drivers of PDPM- the Clinical Categories – to frame your CDI plan. While these categories come from selecting the correct primary SNF diagnosis ICD-10 code, you should also capture the comorbidities that go along with that diagnosis.  Here are some tips for getting the CDI ball rolling:

  • If your facility treats stroke patients (Acute Neurologic Clinical Category), review your processes for identifying and documenting swallowing problems, speech and language deficits, cognitive impairment, and mood changes. These comorbidities add to the SLP, NTA, and Nursing PDPM components, so missed documentation can mean missed reimbursement.
  • For the surgery categories (Major Joint Replacement/Spinal, Other Orthopedic, Non‐Orthopedic), review documentation of surgical wound care, pain management, any follow-up medications such as antibiotics or anticoagulants, and monitoring lung sounds, circulation, etc.
  • For the Medical Management and Non‐Neurologic categories, there are as many possibilities for CDI as there are different complex medical conditions. Consider how your documentation captures complex medical interventions (chemotherapy, radiation, ventilator/respirator, etc.), special treatments (IV meds/hydration, TPN, tube feeding, transfusions), and other medications (such as antibiotic, anticoagulant, insulin, or psychotropic)

Good Documentation = Appropriate Reimbursement

In each of these examples, good documentation demonstrates the daily skilled services your facility’s care team provides your patients – and therefore shows that the Medicare requirements are being met.  At the same time, you can capture comorbidities that feed into the PDPM components…and enable you to identify changes that mat prompt an Interim Payment Assessment.  PDPM provides you the opportunity to make sure that your documentation shows the good care you provide – and get the appropriate reimbursement for it!

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Author: 

Jennifer Gross,  BSN, RN-BC, RAC-CT, CPHIMS
Senior Healthcare Specialist, PointRight

Jennifer Gross’s experience in the nursing field includes work in psychiatric rehab and in long term care as a staff nurse, MDS coordinator, and as a consultant. Her role at PointRight is to support our clients in understanding the intricacies of the MDS, enabling them to maximize quality of care, identify residents at risk, and prevent decline.

Filed Under: Blog

Pam Kaiserby Pam Kaiser, MSN, RN

In the past, changes to the payment system for Skilled Nursing Facilities (SNFs) impacted other health care sectors. When the Balanced Budget Act of 1997 (BBA) went into effect, many hospital dialysis patients had a hard time getting places in SNFs. Under Consolidated Billing at the time, the SNF was responsible for transportation to the dialysis center and the high cost of Epoetin Alfa (EPO), if administered in the SNF. It took some time before providers determined that the medication could be administered at the dialysis center and not have to be billed by the SNF on the Part A claim, and it took legislation to unbundle the costs of transport to the dialysis center for the SNF.

In October 2019, the Patient-Driven Payment Model (PDPM) will go into effect for SNF providers and it means a significant change for reimbursement in this sector. Currently, Medicare A payments are driven in large part by volume of services. In the SNF, volume is primarily the number of days and minutes of therapy provided to a resident; under PDPM, the focus shifts to resident need. Therapy, after October 1, 2019, will not impact the reimbursement for the SNF. Rather, verifiable, resident-specific characteristics, treatments, and diagnoses will combine for a daily payment rate. Additionally, there are payment changes (reductions) that automatically kick in over the course of a SNF stay.

What will PDPM mean for Hospitals?

We don’t know exactly; that is the trouble with unintended consequences, you don’t know that they are going to happen, until they do. However, we can make some assumptions of changes that are likely to occur once PDPM becomes reality.

Comorbidities

SNF payment will be based on patient characteristics and complexity. So, expect that residents with more comorbidities and moderate ADL scores to move up in referral preference over those residents with high rehab needs and fewer comorbidities.

ICD 10 Codes

Capturing ICD-10 codes will be essential for SNF providers. With only one required, early in the stay, assessment to determine Medicare A payment, SNFs will have a greater sense of urgency around receiving solid documentation describing the reason for hospitalization.  Be prepared for requests for quicker access to discharge summaries and clear documentation of any surgery performed during the hospital stay.

Diabetics

Don’t be surprised if diabetics with complications become a referral of choice. Under the new payment model, there are several diagnoses that add to the SNF per diem payments like diabetes, diabetic retinopathy, diabetic foot ulcer, wound infections, and morbid obesity.

Care Transitions

SNF care transitions might improve. Currently, there are many assessments that must be completed within defined timeframes or the SNF misses the opportunity to be paid for services rendered. Under PDPM, there are fewer required assessments. Once the learning curve levels off, SNF resources will likely be reallocated. If you have a collaborative or quality improvement initiative that crosses the care continuum, and that has languished, reach out again to your provider network. There may be more of an opportunity to collaborate on important shared improvement projects.

Readmissions

Be prepared for potential issues with readmissions. Although hospitals and SNFs share the goal of reducing rehospitalizations, PDPM will institute automatic payment reductions over the course of a Part A stay. One adjustment is for Non-Therapy Ancillaries (NTA); for three days post admit to SNF, the NTA component is multiplied by 3, after day 3, the multiplier ends. This increase actually is an improvement over the current payment model, but some providers might interpret the adjustment as an incentive to reduce length of stay.

PT and OT Components

Also, there is an 2% downward adjustment made to the PT and OT components for the daily rate starting on day 21 of a resident’s stay in a SNF. Again, SNFs may look to work towards a decreased length of stay.  Using the PPS Urban unadjusted rate as a guide, the decrease at day 21 equates to a $2.29 reduction. That reduction is for that resident for the next week or up to day 27 which is probably close to their traditional length of stay.  Hopefully, SNF teams will remember that Value Based Purchasing is still in effect and increased rehospitalization rates may impact their entire Medicare population negatively for the year.

What can Hospitals do today?

Likely, there will be other consequences as the new SNF reimbursement program matures and we will have a much better understanding of what they are in early 2020. Until that happens, hospitals will need to anticipate increased outreach and communication from the SNFs and be ready to collaborate as the anticipated changes unfold.  A solid partnership with open communication lines goes a long way to ensuring success when managing through change that is predicted and change that is not.

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Author:

Pam Kaiser, MSN, RN
Vice President, Provider Services, PointRight

Pam has enjoyed 27 years in the healthcare field. A second career for her, she worked her way from a certified nursing assistant through the long term care ranks to become a leader in clinical reimbursement and compliance for several large long term care providers. She has a B.A in Advertising from Michigan State University and an MSN in Community Health Nursing from the University of Southern Maine.

Filed Under: Blog

Janine SavageBy Janine Savage, RN, RAC-CT, CHC

Since the CMS Final Rule announcing the Patient-Driven Payment Model (PDPM) was released, there has been much speculation among SNF providers and industry experts about what compliance will look like under the new reimbursement system. Under RUG-IV, compliance primarily depends on one key metric: medical necessity for therapy services. Due to the high percentage of billed days in therapy groups, Medicare program integrity was laser-focused on documentation and billing for therapy services, to ensure that the therapy furnished to the SNF beneficiary was reasonable and necessary.

But PDPM is very different than RUG-IV. PDPM payment is based upon patient characteristics and diagnoses as reported on the Minimum Data Set (MDS), not the amount of therapy delivered. MDS coding determines payment as MDS items drive the calculation of the five case-mix components. For proper reimbursement, MDS coding must be accurate. [Learn more about the Minimum Data Set (MDS) ]

Compliance Changes Under PDPM

At this year’s HCCA annual Compliance Institute, held in Boston in April, at least seven educational sessions addressed compliance under PDPM, with several national industry experts weighing in.  ICD-10 diagnosis coding and MDS item coding accuracy were two compliance risk areas consistently projected as becoming prime targets for “government enforcers.” And at the Quality Reporting Program Provider Training on May 8, 2019, CMS fired an unmistakable warning shot across the bow:

“Given the more holistic style of care emphasized under PDPM, program integrity and data monitoring efforts will also be more comprehensive and broad. For program integrity, we expect provider risk will be more easily mitigated to the extent that reviews focus on more clearly defined aspects of payment, such as documentation supporting patient diagnoses and assessment coding.”1


Clearly medical necessity reviews under PDPM will concentrate on the provider’s medical record documentation to support MDS coding. But if you think that therapy doesn’t matter anymore, think again. CMS will also monitor therapy service provision under PDPM as compared to RUG-IV, and “significant changes in the amount of therapy provided to SNF patients/residents under PDPM, as compared to RUG – IV, or the manner in which it is delivered, may trigger additional program reviews and potential policy changes.”2

What’s A Provider To Do?

First, beware of PDPM “solutions” that are designed to help you get the highest payment, no matter what. Tools like “diagnosis optimizers” should be used with extreme caution. In the short term, they may help get you get a higher payment rate – but recoupment of overpayments may follow if medical necessity is not supported by medical record documentation. In the worst-case scenario, they could help the government show intent to defraud in a False Claims action, leading to fines and even a Corporate Integrity Agreement.

An effective and compliant PDPM solution ensures you get the highest payment your documentation supports, so you can keep it. PointRight’s actionable analytics insights identify risk areas to form the foundation of a comprehensive, data-driven PDPM compliance program. Resident MDS-level analysis identifies potential issues before the assessment data even creates the Medicare claim, so they can be corrected before you bill. Ongoing insight into PDPM compliance-related outcomes at the facility level highlights compliance risks so they can be addressed in your compliance monitoring and auditing plan.

The transition to PDPM is going to have many unavoidable challenges, but compliance doesn’t need to be one of them! Educate yourself, listen to industry compliance experts, and use your trusted partners to help you successfully navigate these choppy waters.

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Author:

Janine Savage, RN, RAC-CT, CHC
Vice President, Product Management, PointRight

Janine is Certified in Healthcare Compliance (CHC) and leverages her knowledge of relevant regulations and expertise in compliance processes to assist organizations in promoting organizational integrity through the operation of effective compliance programs.

Sources:

1 CMS Quality Reporting Program Provider Training; “Patient Driven Payment Model: What is Changing (and What is Not)” slide 65; Centers for Medicare & Medicaid Services, May 8, 2019.

2 CMS Quality Reporting Program Provider Training; “Patient Driven Payment Model: What is Changing (and What is Not)” slide 66; Centers for Medicare & Medicaid Services, May 8, 2019.

Filed Under: Blog

CMS is “thawing out” the freeze on Five-Star Ratings effective April 2019. We were all expecting the thaw this spring, and CMS doesn’t disappoint! Remember that spring showers bring May flowers, and for some of you, “flowers” will take the form of an improvement in your Five-Star Rating. CMS did more than just unfreeze the Five-Star Health Inspection ratings as anticipated. Let’s review some additional updates. 

  • Health Inspection (HI) – The Health Inspection (HI) domain will now include survey points “earned” on or after November 28, 2017. The HI Five-Star rating will revert to the original three-survey cycle calculations and 36 months of complaint inspections. The weighting for the three survey cycles also reverts to previous weighting factors (Cycle 1 -1/2 (50%), Cycle 2- 1/3 (33.33%), and Cycle 3- 1/6 (16.66%), instead of the current 60% (Cycle 1) and 40% (Cycle 2).
  • Special Focus Facilities (SFF) – Special Focus Facilities (SFF) will have no star ratings for Overall as well as the three domains. Currently an SFF would show a star rating but would be capped at three stars overall. This is being taken away with the latest changes: beginning in April, a yellow “warning” icon will be displayed instead, and “Not Available” displayed for all the other domains (essentially, the eye will see no star ratings).
  • Registered Nurse (RN) Staffing – Registered Nurse (RN) staffing HPRD given increased weight in the overall Staffing star calculation (we expected this change, right?). Additionally, the threshold has been lowered for the number of days with no reported RN staffing from seven days in the quarter to four days, (makes sense since ongoing Payroll Based Journal (PBJ) data being submitted-increased transparency into staffing patterns).  Facilities reporting four or more days without RN 8+ hours onsite will receive a 1-star Staffing rating (the take away–Facilities with fewer RNs on staff will need to ensure daily RN coverage or risk their Overall rating).
  • New Quality Measures – Two new claims-based Quality Measures (QM) were added: Long-Stay Hospitalizations and Long-Stay Emergency Department Visits. CMS introduced separate star rating calculations for Short Stay and Long Stay Quality Measures. This is in addition to the overall QM Domain Star rating (the overall QM domain rating will be equally based on SS and LS quality ratings).  Each individual QM will be weighted and scored differently.  CMS established two different weighting levels for scoring: medium and high.  The thresholds for the ratings will be regularly updated every six months.
  • QM Removed – And finally, so to speak…Long-Stay Physical Restraints QM is taken out… (although will still be reported in Nursing Home Compare (NHC) but not included in the Five-Star QM Domain calculations).

Spring Has Sprung – Now What?

April is regarded as a month of renewal, when flower buds begin to sprout and eventually bloom into magnificent beauties, that is if you have a green thumb! Seriously though, in anticipation of constant change to our regulatory landscape and what faces us in the upcoming weeks, are we ready as we await our Five-Star Rating? What will our stars disclose? What is looming down the road may be challenging at best, but we can look forward to the revival that change brings whether we have a green thumb or not!

More Information

For more specific details about the Five Star Changes Please refer to Five-Star Quality Rating System: Technical User’s Guide April 2019.

Filed Under: Blog

by Steven Littlehale

December 2018 marked Five Star’s ten-year “birthday.” When you read its birth certificate, you’ll see its given name is: “Five-Star Quality Rating System,” though interestingly enough, the only direct measures of quality (the CMS quality measures) carry the least weight. Over the last ten years Five-Star has certainly matured considerably and if you believe it measures quality, then you are also likely convinced that nursing home quality has improved. (We at PointRight agree with you, but choose other ways to validate the long-term care industry’s improvement.)

However, for an accountable care organization (ACO), Five-Star is a confusing metric to use when measuring and monitoring nursing home performance. For better or worse, CMS has exaggerated the relevance of Five-Star by linking a variety of bonuses to a three-Star rating. For example, in an alternative payment model, CMS will waive the requirement for a three-day inpatient hospital stay prior to a Medicare-covered, post-hospital extended care service for three, four and five-Star skilled nursing facilities (SNF). This is great news for upstream financial stakeholders, the SNF, and dare I say the patient! However, without an apparent correlation to rehospitalization rates, care processes, quality, length of stay, or satisfaction, a Five-Star rating does not prove a useful tool in successfully managing your post-acute network, nor is it a suitable proxy for financial performance of the facility. Perhaps worse, it might just lead you astray. Let’s discuss why.

Five Star Treats All People the Same

Recall that the primary goal in launching this nursing home rating system was to provide consumers with an easy way to understand quality of nursing home care and make informed decisions around placement. (Notice what is not listed on Nursing Home Compare: rehospitalization reduction, total cost of care, and patient satisfaction.) Yet a fatal flaw is that Five-Star doesn’t ask individuals being admitted to a nursing home upfront “why are you here?” Some people enter the facility as a patient with full expectations to return to the community, while others come in as residents and intend to live out the rest of their lives in the facility. These two types of people have vastly different needs, yet they and their outcomes data are comingled into and measured by the same system.

Not All Nursing Homes Are Alike

Not only are the people entering a nursing home/SNF unique, so too is each facility. Over the past ten years, many facilities have emerged as de facto specialty care centers, focused on one or two highly specialized areas. While they still accept a broad range of people, their true value may lie in a select area of care, such as complex medical and post-surgical management, wound care, dementia, end-of-life care, or mental illness. CMS’ Five-Star system doesn’t account for the unique needs of the person requiring care, nor the specializations of the facility providing that care, causing a missed opportunity for understanding how the facility is truly performing due to a lack of this crucial information.

Five-Star Leads ACOs Astray

Creating and monitoring a post-acute network is often guided by principles of CMS’ Triple Aim: reduce costs, improve quality, and satisfaction. Yet CMS’ Five-Star has very low correlation to costly rehospitalizations, with less than one-point difference in adjusted rehospitalization rates between two- and four-Star SNFs.

The other challenge is that Five-Star is a bit of a moving target. Over the last ten years CMS made several important and appropriate changes to the system. These changes include the following:

  • Adjusting the cut points which determine Star rating within each domain
  • Changing the data source from which the Staffing Domain is calculated
  • Adding new Quality Measures to the Quality Measure Domain
  • Freezing the survey domain for about 18 months while new survey data outcomes are understood

What’s the Bottom Line?

CMS’ change to Five-Star results in both winners and losers. Some nursing homes, for instance, will lose their mandatory overall three-star rating and potentially not qualify for your preferred provider network. For example:

When CMS transitioned from three to two survey cycles (November 2017):

  • 22% of the nation’s nursing homes saw a change in their survey star
    • 93% had a change of 1 star
    • 7% experienced a change of 2 or more stars

When CMS implemented changed data source for staffing (April 2018):

  • 68% SNFs remained the same*
    • 50% nursing homes declined
    • 82% nursing homes improved
    • 428 nursing homes lost their 3-star or higher overall rating

* controlling for impact of Survey and Quality Measure domain

There are anticipated Five-Star changes in store for 2019. CMS will ultimately decide how to include the outcomes from the new survey process into the Survey Domain. Survey outcomes data from November 2017 to the present is currently “in the freezer” and not being used in Five-Star calculations. However, you can see the outcomes data that is accumulating….and it’s not flattering. When analyzing this data, we see a greater number of deficiencies overall and a greater scope and severity across the majority of the nation. CMS will likely take good care to ensure these new data are managed appropriately by recalibrating the state cut points which generate a one- through five-Star rating. However, as long as Five Star is open for tinkering , some facilities stand to be hurt by having their rating dropped by a star or two, despite have absolutely no change in quality.

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Author:

Steven Littlehale, MS, GCNS-BC
Chief Clinical Officer Emeritus, PointRight

Filed Under: Blog

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