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s clinical auditors, our team has observed many inaccuracies that lead to lost reimbursement or noncompliance. Part of the problem is that administrators and CEOs do not understand the control that the admissions and Minimum Data Set (MDS) coordinators have over the facility’s Medicare reimbursement. The admissions process, the MDS assessment and coding, and discharge decisions cause inaccurate Medicare reimbursement. Inadequate employee oversight, a lack of education, and a lack of review training most often cause these problems. To follow are detailed descriptions of—and suggestions for—four other recurring problems related to the management of skilled services.

1. Valid Admissions Are Missed
       Many admissions coordinators lack adequate knowledge of the presumption of coverage regulations. Clients/patients/residents/beneficiaries who have had a three-midnight qualifying (inpatient) hospital stay and require skilled nursing services usually qualify for their Medicare skilled nursing services benefit. With a physician order for skilled services and an MDS that places the client into one of the top 35 Resource Utilization Groups (RUGs), the patient may receive Medicare skilled services.
       This presumption of coverage is valid at least until the Assessment Reference Date (ARD) of the first MDS. Admissions staff must have knowledge of the RUG components to ensure that the resident will qualify into one of the top 35 RUGs.
       Look-back information from the hospital stay is important in several RUG categories, especially the new top nine RUGs. The admissions coordinator must receive appropriate and specific information from the hospital related to the look-back qualifiers.
       The admissions staff person will often cite intravenous (IV) medications and therapy services as the only skilled services rendered. Most admissions personnel do not understand the therapy/nursing rehabilitation category for clients who need minimal professional therapy intervention but would benefit from a restorative nursing program.
       In addition to the RUG 53 criteria, many other services are skilled. The admissions coordinator must understand the administrative criteria for skilled nursing services. Management and evaluation of the care plan as well as observation and assessment of the patient’s changing condition are also skilled services. There are also instances when the combined unskilled service is of such complexity that the unskilled care rendered is considered skilled. Admissions personnel do not always understand these covered services.
       Decisions as to whether a client needs skilled services should be made on a case-by-case basis. Evaluating the complexity of each client’s needs is essential.

2. Many MDSs Are Inaccurate When Submitted
       The nurse completing the MDS plays the most critical role in Medicare reimbursement for the facility. He/she must have a comprehensive understanding of the 53 RUGs. The nurse must have detailed understanding of the Prospective Payment System (PPS) in its entirety as well as the administrative criteria for skilled nursing services. The MDS nurse must be familiar with the Resident Assessment Instrument (RAI). This manual needs to be used as a side-by-side reference guide to accurately code the MDS. The manual assists the nurse in answering MDS questions based on required regulatory logic. This required logic might differ from the nurse evaluation process taught in nursing education programs. The MDS validates a client into a RUG, on which the facility’s Medicare payment is based.
       Answers to the MDS questions are calculated into payment categories, and incorrectly coded items can reduce reimbursement. Most of the MDS questions examine client deficits. Nurse assessors are asked to speak to the most extensive client needs. Many nurses consider their assessment and documentation as a report card of their care and want to emphasize how well residents are doing. This attitude leads to inaccurate assessment. The MDS requires the deficit indicators to be recorded.
       The MDS asks the nurse to look back into the hospital stay for some treatments and needs. Many nurses include only the therapy information on the MDS and skip over hospital look-back information. They are usually trying to save time, or they mistakenly think that the therapy RUGs have the highest payment. This denies the facility its appropriate reimbursement from the higher nine combined therapy and extensive services RUGs and produces an inaccurate MDS. Hospital look-back information for the top nine RUGs include:
• IV feeding in the past 7 days
• IV medications in the past 14 days
• Suctioning in the past 14 days
• Tracheostomy care in the last 14 days
• Ventilator/respirator use in the last 14 days.
       Choosing the best ARD is critical to receiving the appropriate reimbursement. This date should be chosen in a case-by-case manner based on each client’s hospital course, the client’s current clinical condition, therapy services, the projected length of stay, and the nurse’s workload.
       In order to save time, some MDS coordinators complete the MDS from a review of the medical record only. These MDSs will not be accurate. Federal regulation does not allow this. The MDS requires a clinical assessment; it is not a paper-compliance exercise. Some nurses back-date their MDSs in violation of both federal and nurse practice regulations, and it is very difficult to detect if these practices are occurring.
       Many nurses work diligently to complete an appropriate assessment of their clients, including accurate coding of the MDS. They require and want more education. Some administrative personnel do not understand the time it takes to accurately complete the process.

3. Some Medicare Discharges Are Premature
       Many members of the care team do not understand the discharge regulations. For instance, therapists do not discharge clients from skilled services. They may make a professional judgment, in conjunction with a physician order, for therapy services to be discontinued.
       It is then up to the nursing staff in conjunction with physician orders to decide whether skilled nursing services should continue. The Centers for Medicaid & Medicare Services (CMS) expects that many clients will need a few days after all therapy is discontinued to assess for stability before the beneficiary is discharged from the Medicare services.

4. Your Reimbursement Is Often Incorrect
       The following solutions are recommended to ensure that your facility receives accurate reimbursement and manages its Medicare service delivery in compliance with federal regulations:
1. The admissions coordinator must be well educated regarding all skilled criteria, RUGs, and presumption of coverage. Easy-to-use RUG algorithms are helpful.
2. The admissions coordinator should ask for assistance from knowledgeable clinical staff when admissions decisions involve complex client issues/needs.
3. Admissions staff should ask the medical records staff to request any hospital information that was not sent at the time of admissions.
4. Admissions staff should receive orientation, education, and review education from a qualified and knowledgeable instructor.
5. The MDS nurse must have extensive detailed education regarding the PPS, the MDS, and the RAI manual, including the CMS logic, in answering the MDS questions.
6. The MDS nurse must have periodic continued education and review training from a qualified instructor.
7. The facility must have at least one back-up MDS nurse who can perform accurate MDSs within the regulatory time frames.
8. The facility must educate a nurse manager in the overall MDS/PPS process. Have this nurse manager assist in making the Medicare discharge decisions. (This is not a full-time employee but additional education for an existing nurse manager, such as the Director of Nursing.)
9. Administrative personnel must send a clear message to their employees regarding their expectations for accuracy in completing the MDS.
10. There should be a policy in place that requires the RAI manual to be used as a side-by-side reference while the MDS is being completed.
11. Periodic outside review of the MDS/PPS process is the only way that administration can be assured that their reimbursement is correct and that the regulations are being followed.
12. Administration and all MDS contributors must read and understand the MDS’s attestation statement.
13. Administrative personnel must understand the time involved in accurately completing the MDS/ RAI process.