Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency
Every month we arrive at our client sites to perform monthly audits. The Harmony HealthCARE Specialists review a litany of metrics invaluable to the integrity of the Compliance Auditing and Monitoring System established by Harmony Healthcare International (HHI). We work diligently prior to the visit to hit the ground running with a checklist of areas of interest for our review.
What is trending you ask? Interestingly enough, Lower 14 RUG Days. Yes, these days were on the rise after the 10.1.11 implementation of the Change of Therapy Assessment. However, since 2011, the industry adjusted to this impact. Now the question one asks oneself is:
- Does your Facility RUG distribution yield any Lower 14 Days?
- If yes, why?
If the answer to question number one is yes, please read this blog post. Any occurrence of a Lower 14 RUG Level on the 5-Day PPS MDS requires further attention. Historically, a Lower 14 RUG Level is an “edit” for further scrutiny by CMS. A Lower 14 RUG Level is perceived as a non-skilled level of care and a higher risk for audit.
On this same topic, an Upper 52 RUG Level on a 5-Day PPS MDS establishes the Presumption of Coverage Criterion. Under SNF PPS guidelines, beneficiaries admitted or readmitted directly to an SNF (after a qualifying hospital stay) are considered to meet the skilled level of care requirements up to and including the ARD (assessment reference date) if the 5-Day PPS MDS Assessment results in a Upper 52RUG Level. This applies when the RUG Level is assigned to one of the Resource Utilization Groups (RUGs) that is designated as representing the required level of care. The coverage that arises from this Medicare Presumption of Coverage remains in effect for as long thereafter as it continues to be supported by the facts of the beneficiary's condition and SNF care needs. (While the wording “remains in effect for as long thereafter…” was removed from the original regulation, we keep this in for discussion.)
By the same token, a Lower 14 RUG Level negates the Presumption of Coverage Criterion established with the 5-Day PPS MDS Assessment. In these instances, Harmony Healthcare International (HHI) recommends a review of each case for the opportunity to:
- Complete a Short-Stay MDS,
- Review all hospital data for the receipt of IV Fluids and
- Use Assessment Reference Date Selection Strategies to allow a further look-back period into the hospital stay.
In some instances, the completion of a 5-Day PPS MDS Assessment with an ARD of day 1 may be needed when followed by the discharge. Combining the 5-Day PPS MDS Assessment with the Discharge MDS is optional in cases where the Short-Stay MDS does not apply. “RUGs Intimacy” is a powerful foundation and platform for navigating the MDS completion and ARD selection process. The ability to identify Non-Therapy RUGs Levels that yield a higher acuity and reimbursement than the lower Rehabilitation RUG Level over the length of stay is increasingly important.
While this blog post is a great start if you are experiencing Lower 14 RUG Days, please note that multiple factors may contribute to the answer to the second question: “Why are there Lower 14 RUG Days?”
Stay tuned for more blog posts on this subject matter! Or better yet, join us at harmony17.
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