Harmony Healthcare Blog

10 Tips for a Better Case Mix Index

Posted by Kris Mastrangelo, OTR/L, LNHA, MBA on Tue, Jan 07, 2014
Kris Mastrangelo, OTR/L, LNHA, MBA
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When the MDS is completed, it calculates a clinical score (RUG level, Resource Utilization
Case Mix System by State Group) which impacts the direct care costs under the Case Mix reimbursement system. The notion is that the higher the amount of resources rendered to care for the patient/resident, the higher the reimbursement level. There are different types of RUG systems and each state has the ability to create its own system.

The MDS is a very dynamic, complex tool used for resident/patient assessment.  One can only imagine the vast opportunity for error when completing said tool. Over 1,000 points of information, of which 108 plus points yield one of 34 RUG levels. In order to mitigate inaccuracy and ultimate underpayment of resources, the following 10 tips may help in the quest for precision.

1. Emergency Room Visits:  Ensure the facility has a tracking system for ER visits. Many times residents/patients leave the facility and the MDS Coordinator is unaware of this trip. Procedures such as IV medications, IV fluids, oxygen and blood transfusions may be administered to patients while in the Emergency Room. Data collection  of services rendered in this environment is essential for the MDS Coordinator to support the coding on the MDS while these services are also critical for the Nursing staff to understand the resident’s/patient’s condition.

2. Hospital Stays of Less Than Three Days: Whenever a resident/patient leaves the facility, skin conditions inevitably appear to arise. Surgical Wounds, pressure ulcers, diabetic ulcers all require close attention during medical leaves.

3. Flu Symptoms: Medical outbreaks during an assessment period and medical status changes that qualify for a change in condition assessment can vastly impact the RUG levels. These levels are influenced by physician visits, physician orders, fever, vomiting and oxygen. Patients with a diagnosis of pneumonia (with fever) or weight loss (with a fever) also require more resources and hence a higher level of payment.

4. Podiatry Visits: Foot lesions are defined as any cuts, ulcers or fissures. Foot issues may arise after the podiatry visit or may be the etiology for the podiatry visit. Remember, ankle problems are not considered foot problems and should not be coded in this section of the MDS.

5. Skin Issues: Any skin issue that occurs should be followed by a chart audit to determine the cause of the breakdown. It is important to identify if the skin issue is a result of pressure, venous stasis or excoriations due to incontinence. Early identification and coding of skin issues on the MDS assures that these medical complexities are being care planned and treated.

6. Rehabilitation: The Rehabilitation Department should alert the MDS Coordinator whenever a patient is placed on caseload for therapy services. The MDS Coordinator, in collaboration with the Therapy staff, can determine if a Significant Change MDS or an early MDS Assessment is warranted. These assessments may be required to properly reflect the additional resources rendered.

7. Tracking of Physician Visits: It is beneficial and easier to track physician visits in comparison to days of physician order changes. When a resident/patient receives two physician visits in a 14 day window, the MDS Coordinator should review the chart to determine if there are also two days of order changes within the assessment period. The premise is that the more MD orders and MD visits, the more resources the resident/patient requires, and hence, once again, a higher rate of reimbursement.

8. Review of Daily Census: The daily census is a phenomenal trigger for every staff member to reconcile resident/patient departures. Census variation alerts the MDS Coordinator of hospitalizations and ER visits.

9. Review of Daily Shift Communications: Reviewing the communication between shifts informs the MDS Coordinator to symptoms of flu, pneumonia, fevers, vomiting, oxygen use or other medical conditions that may require additional nursing services.

10. Respiratory Therapy: Respiratory Therapy is an ongoing service that seems to be under coded throughout the country. This is primarily due to the misconception that only Respiratory Therapists can render the service, when in fact, nurses are performing Respiratory Therapy all the time.  Simply review all residents/patients with orders for nebulizer treatments. Evaluate these medical records to determine if the resident/patient is receiving 7 days of respiratory therapy services (15 minutes each day). Respiratory Therapy includes teaching and training of breathing exercises, nebulizer treatments, evaluation of lung sounds, and oxygen saturation level assessment.

These quick tips should help guide the team in capturing the acuity level of the current patient population which will significantly impact accurate case mix reimbursement. In addition, constant medical record review and team discussion affords the milieu for optimal care and optimal reimbursement.

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Topics: Case Mix

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