Understanding the criteria and components of RUG Leveling (53 levels) and Categorization is imperative for accurate and appropriate reimbursement under the New York Case Mix reimbursement system. Protocols and defined processes are essential for success and require implementation throughout the year, (not just during the case mix "window"). Ongoing MDS coding oversight and refinements are even more important given the regulatory and reimbursement changes impacting quality measures and the ultimate crescendo of value based purchasing. The following tips may help you in preparing your documentation to properly reflect all necessary data to support the appropriate payment level.
1) IV Parenteral/IV Feeding
Code any and all nutrition and hydration received by the resident in the:
- last seven days
- either at the nursing home, at the hospital as an outpatient or an inpatient
- provided they were administered for nutrition or hydration.
The supporting documentation that reflects the need for additional fluid intake specifically addressing nutrition or hydration needs should be noted in the resident’s medical record according to State and/or internal facility policy. For IV facility administrated hydration the Dietary Notes need to support the administration for hydration and Care Plans need to be in place to support the risk of dehydration.
2) Extensive Services
The following documents should be located in the medical record to support extensive services coded on the MDS:
- Facility’s IV medication administration records
- Facility’s IV hydration administration records
- Hospital IV medication administration records
- Hospital IV hydration administration records
- Emergency Room records and hospital documentation evidencing actual administration of IV medication and IV hydration
Section D of the associated MDS should have the PHQ-9 resident interview or staff interview accurately completed. The supportive documentation that should be included in the medical record is a depression Care Plan and verification of the completion of the PHQ on the ARD or the day before the ARD.
4) Diagnosis Coding
This includes such diagnoses as Multiple Sclerosis, Cerebral Palsy, Quadriplegia, Coma, Hemiparesis, Diabetes (with daily injections and order Changes), Dehydration (with Fever), Pneumonia (with Fever), Septicemia, Dehydration, Pneumonia and Internal Bleeding.
The supportive documentation required to code these diagnoses includes a physician-documented diagnosis in addition to daily skilled nursing notes that reflect a direct relationship to the resident’s current functional, cognitive, mood or behavioral status, medical treatments, nursing monitoring, or risk of death during the 7 day look back period.
The medical record sources for physician diagnoses include:
- progress notes,
- the most recent history and physical,
- transfer documents,
- discharge summaries,
- diagnosis/problem lists, and other resources as available.
If a diagnosis/problem list is used, only diagnoses confirmed by the physician should be entered.
5) Rehabilitation RUG Level
- Documentation to support the Rehabilitation RUG level achieved must include the actual minutes provided, which is supported by therapy logs and Restorative Nursing Program minutes provided for the Rehabilitation Low.
- The therapy minutes provided must be signed by the therapist who provided the care.
- Additionally, a physician order for therapy or the Therapy Plan of Care signed by the physician must be present in the medical record.
- The reason for referral and change in status needs to be supported by nursing and or physician documentation. The prior level of function needs to be supported in the therapy documentation.
6) Restorative Nursing Program
To support the provision of Restorative Nursing services:
- signed logs identifying the two areas provided
- each totaling 15 minutes per day,
- 6 days per week need to be in the medical record.
- Additionally, measurable objectives and interventions must be documented in the Care Plan and evidence of periodic evaluation by the licensed nurse.
7) Skin Issues/Wounds
- and wound care consult reports should also be included in the medical record.
- Treatment sheets to support the treatments being administered
- Documentation in the medical record needs to reflect weekly sizing and staging records or a nursing note evidencing this present for the 7 day look- back period.
The medical record should support that oxygen was actually administered PRN or continuous in the look-back period.
9) Respiratory Therapy
Respiratory Therapy services are for the
- and monitoring
of patients with deficiencies or abnormalities of pulmonary function. Respiratory Therapy services include coughing, deep breathing, heated nebulizers, aerosol treatments, assessing breath sounds and mechanical ventilation.
Documentation in the medical record to support Respiratory Therapy includes:
- facility medication/treatment administration records,
- respiratory flowsheets,
- hospital medication/treatment administration records,
- emergency room records,
- consult reports and daily skilled nursing notes.
10) Weight Loss
Weight loss includes weight loss either physician-prescribed or not physician-prescribed and weight loss of:
- 5% or more in the past 30 days or
- 10% or more in the last 180 days.
The documentation to support the MDS coding of weight loss must reflect the actual date the condition occurred and include weight records, vital signs tracking, nursing notes, facility and hospital medication/treatment administration records, emergency room records, and consult reports.
Weight Loss, combined with Fever, places a patient into the Special Care Category.
11) Physician Visits/Orders
Documentation to support the coding of physician visits and orders needs to include:
- an accurate counting of days (not the number of orders).
- Physician orders must be legibly dated and interim and monthly orders sheets present
- as well as physician progress reports and consults.
- There must be evidence of at least a partial assessment completed by the physician, as nursing documentation that a visit occurred is not sufficient.
12) Impaired Cognition
Additional documentation to support the coding of impaired cognition on the MDS includes care planning for the evidence of impaired cognition, other conflicting assessments such as the Mini Mental State Exam, and verification of completion of the BIMS in the 7 day look back period.
The documentation to support behaviors should include
- Additional documentation includes care planning evidencing behavior intervention, Psychiatry and Psychological notes and Physician documentation.
- and Social Services notes.
- CNA documentation,
- skilled nursing notes,
- behavior monitoring sheets,
- the behavior’s impact on others,
- four or more days in look back period,
14) ADL Coding
- The documentation for ADL self performance and ADL support coded on the MDS includes CNA flowsheets, which need to reflect the month and resident name.
- Specific documentation where the utilization of two assist provided by facility staff is coded for a single episode in the look back period should be clearly identified.
- Ensure three episodes of assist are provided by facility staff and are evident in the look back period and
- Dependent is coded only if it occurred entirely during the look -back period.
Harmony Healthcare International (HHI) encourages facilities to take a proactive approach and review each medical record to validate the supporting documentation supports the Case Mix RUG Level. Harmony Healthcare International (HHI) is available to assist you in training, education, as well as pre-audit preparation.
If you have questions about New York State Case Mix, please contact Harmony Healthcare International by clicking here or calling our office at (800) 530-4413. If you would like to download the New York State Case Mix Index Classification Grid, click here.