Harmony Healthcare Blog

MDS Validation Reports and Grouper Accuracy

Posted by The Harmony Team on Tue, Jul 17, 2018

Edited by Kris Mastrangelo


Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency

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Harmony Healthcare International (HHI)

  1. Question: Patient admitted to the facility on 6/27/XX and discharged to the hospital on 7/1/XX. Therapy evaluations were completed on 6/28/XX and therapy minutes are as follows:ST = 15 minutes – 1 day - Start & stop date 6/28/XX
    OT = 181 minutes – total of 3 days - start date of 6/28/XX, no end date
    PT = 145 minutes – total of 3 days – start date 6/28/XX, no end date

    Short-Stay rules apply and MDS Software calculated a PC1 for day one and RH for the next 3 days, 7/1/XX not a paid day.  The MDS Validation Report depicted RUG categories as PC1 and RM not RH.  Total Therapy minutes of 341 divided by 4 equals 85.25 which should yield an RH.

    Any reason that anyone can think of why this is coming back as an RM?

    Answer: This is a common scenario Harmony Healthcare International (HHI) sees across the country and it is due to the setting of the grouper within the MDS Software.

    This is not specific to a brand of software.  It reinforces the importance of reviewing a sample of validation reports to assess if the proper grouper is utilized within the software.  The MDS Software interpreted this case as a short-stay assessment with the correct RUG category, however, the QIES system dropped the RUG Level from RH to RM. 

    In addition, it is important to validate the data entry of the minutes and dates in A2400.

    If a Medicare patient’s RUG Level is recalculated for Medicare via submission as reflected on the validation report, this is a problem.  The provider must bill the RUG Level depicted on the valuation report and not the software.  In this instance, the provider must correct the grouper setting.  

    It is not uncommon for providers to set their alternate groupers for RUG-III 53 to track acuity for the staffing rating on Five-Star. Please be aware, the Five-Star grouper recently changed to RUG-IV 48 
HHI Site Visit
  1. Question: Are there financial implications for using the wrong Grouper Setting?

    Answer: During a recent monthly audit in a Medicaid Case Mix State, the incorrect grouper setting coded the patient as PE1 versus SE3.  In addition, the TBI add-on was not reflected on validation report due to the erroneous grouper setting. 

    This equates to a $28,000 reimbursement change per year.  Harmony Healthcare International (HHI) adjusted the setting.

    ($280,000 loss over the 10 years for this one Medicaid resident.)

    The validation report is very important to review to assess for potential discrepancies.

    The Harmony Healthcare International (HHI) client base is laser focused on compliance and hires us to perform monthly auditing and monitoring services as an integral component of the provider compliance program.  

The Harmony Healthcare International (HHI) site visit process is an intensive, detailed review of the medical record content to identify compliance risk areas, revenue and coding opportunities, systematic refinements with the overarching goal to improve medical record accuracy and minimize compliance concerns. 

To learn more about our site visit process, click here.

Harmony Healthcare International (HHI) is available to assist with any questions or concerns that you may have.  You can contact us by clicking here.  Looking to train your staff?  Join us in person at one of our our upcoming Competency/Certification Courses.  Click here to see the dates and locations. 

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Tags: RUGs

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