©2009 HP Confidential1 Indiana LTC Case Mix Audits HP Enterprise Services January 2011.

©2009 HP Confidential1

Indiana LTC Case Mix Indiana LTC Case Mix AuditsAudits

HP Enterprise ServicesHP Enterprise Services

January 2011January 2011


What’s New What’s New • EDS now HP Enterprise ServicesEDS now HP Enterprise Services

• Frequency of auditsFrequency of audits– Refer to Refer to Bulletin Bulletin BT200936

• No list of residents with traumatic brain injury No list of residents with traumatic brain injury (TBI) (TBI)

• No list of residents who receive outside mental No list of residents who receive outside mental health serviceshealth services

• No abbreviation list No abbreviation list –– if needed, auditors will if needed, auditors will request.request.

• Audits now completed electronicallyAudits now completed electronically


LTC Case Mix Audit ProcessLTC Case Mix Audit ProcessHP Enterprise Services completes a Level of Care HP Enterprise Services completes a Level of Care audit for all IHCP facilities in the state of Indiana audit for all IHCP facilities in the state of Indiana according to the following categories:according to the following categories:

•Low Risk – 90-100 percent validation rate will be Low Risk – 90-100 percent validation rate will be audited at a maximum of every three years.audited at a maximum of every three years.

•Medium Risk – 80-89.9 percent validation rate will be Medium Risk – 80-89.9 percent validation rate will be audited at a maximum of every two years.audited at a maximum of every two years.

•High Risk – 79.9 percent or lower validation rate will High Risk – 79.9 percent or lower validation rate will be audited every four to twelve months.be audited every four to twelve months. Refer to Bulletin Refer to Bulletin BT200936 for audit frequency. for audit frequency.

• HP audits the minimum data set (MDS) supporting HP audits the minimum data set (MDS) supporting documentation maintained by nursing facilities for all documentation maintained by nursing facilities for all residents, regardless of payer type.residents, regardless of payer type.


LTC Case Mix Audit ProcessLTC Case Mix Audit Process• HP provides advance notification to the nursing facility.HP provides advance notification to the nursing facility.

– This notification is as many as 72 hours before the This notification is as many as 72 hours before the audit.audit.

– See See 405 IAC 1-15-5 405 IAC 1-15-5 for more information.for more information.

• The audit includes:The audit includes:

– The greater of 30 percent of the total assessments or a The greater of 30 percent of the total assessments or a minimum of 25 assessments.minimum of 25 assessments.

• The facility provides the census list.The facility provides the census list.

– The MDS assessments subject to audit are those most The MDS assessments subject to audit are those most recently transmitted to Myers and Stauffer LC.recently transmitted to Myers and Stauffer LC.


• The audit team conducts an entrance conference The audit team conducts an entrance conference with each nursing facility.with each nursing facility.

• The nursing facility is required to produce, upon The nursing facility is required to produce, upon request, a computer-generated copy of the MDS request, a computer-generated copy of the MDS assessment that is transmitted, which is the basis assessment that is transmitted, which is the basis for the MDS audit. for the MDS audit.

LTC Case Mix Audit ProcessLTC Case Mix Audit Process


• Alphabetical resident list, which includes the following:Alphabetical resident list, which includes the following:

–Last nameLast name

–First nameFirst name

–Date of birthDate of birth

–Date of admissionDate of admission

–Medicaid number or Social Security number Medicaid number or Social Security number

• Alphabetic Level II Resident ListAlphabetic Level II Resident List

• Current facility e mail address for future correspondenceCurrent facility e mail address for future correspondence

LTC Case Mix Audit ProcessLTC Case Mix Audit ProcessRequested InformationRequested Information


• The audit team reviews the following two parts of The audit team reviews the following two parts of each record:each record:

– Activities of daily living (ADL) componentActivities of daily living (ADL) component

– Element componentElement component

• The team considers a record to be unsupported The team considers a record to be unsupported when there is a lack of documentation to support when there is a lack of documentation to support the RUG as a result of the audit.the RUG as a result of the audit.



• When the audit team is unable to support a record, When the audit team is unable to support a record, the team requests that the nursing facility find the team requests that the nursing facility find supporting documentation.supporting documentation.

• The nursing facility must provide documentation to The nursing facility must provide documentation to support records prior to the exit conference.support records prior to the exit conference.



• ““If the percentage of assessments of all residents that If the percentage of assessments of all residents that are unsupported is greater than the threshold are unsupported is greater than the threshold percentage … a corrective remedy shall apply.” percentage … a corrective remedy shall apply.”

– See See 405 IAC 1-14.6-4405 IAC 1-14.6-4 for more information. for more information.

• When the preliminary validation rate for the initial When the preliminary validation rate for the initial sample is below 80 percent, the audit expands to sample is below 80 percent, the audit expands to include the greater of an additional 20 percent of the include the greater of an additional 20 percent of the assessments or a minimum of 10 additional assessments or a minimum of 10 additional assessments consisting of 90 percent Medicaid payer assessments consisting of 90 percent Medicaid payer source assessments and 10 percent non-Medicaid source assessments and 10 percent non-Medicaid payer source assessments.payer source assessments.



• The nursing facility must provide documentation to The nursing facility must provide documentation to support records prior to the exit conference. support records prior to the exit conference.

• The threshold percent is 20 percent and therefore, the The threshold percent is 20 percent and therefore, the required validation rate for case mix audits is 80 percent required validation rate for case mix audits is 80 percent or greater.or greater.

• Prior to exit auditors will observe all residents that were Prior to exit auditors will observe all residents that were auditedaudited

• The team then informs the nursing facility that it is ready The team then informs the nursing facility that it is ready for the exit conference.for the exit conference.



• HP sends the final summary letter to the nursing HP sends the final summary letter to the nursing facility approximately 10 business days following the facility approximately 10 business days following the exit conference.exit conference.

• The letter details the Summary of Findings and the The letter details the Summary of Findings and the Final validation rate.Final validation rate.



Informal Reconsideration Informal Reconsideration ProcessProcess• The letter contains instructions for the informal The letter contains instructions for the informal

reconsideration process.reconsideration process.

• Informal reconsideration is conducted by an HP LTC Informal reconsideration is conducted by an HP LTC registered nurse (RN) who is separate and distinct from registered nurse (RN) who is separate and distinct from the audit.the audit.

• During the informal reconsideration process, the HP audit During the informal reconsideration process, the HP audit team does not review supporting documentation provided team does not review supporting documentation provided after the audit exit conference .after the audit exit conference .

– See See 405 IAC 1-15-5405 IAC 1-15-5 for more information. for more information.


Informal Reconsideration Informal Reconsideration ProcessProcess• The request must include specific audit issues that the The request must include specific audit issues that the

nursing facility believes were misinterpreted or misapplied nursing facility believes were misinterpreted or misapplied during the audit.during the audit.

• HP must receive the request in writing no later than 15 HP must receive the request in writing no later than 15 business days from the date of the letter.business days from the date of the letter.

• HP forwards final results to Myers and Stauffer LC upon HP forwards final results to Myers and Stauffer LC upon completion of the audit process.completion of the audit process.


RUG ClassificationsRUG Classifications• Extensive ServicesExtensive Services

• RehabilitationRehabilitation

• Special CareSpecial Care

• Clinically ComplexClinically Complex

• Impaired CognitionImpaired Cognition

• BehaviorBehavior

• Reduced PhysicalReduced Physical


RUG Classifications ExtensiveRUG Classifications Extensive• K0500A – Parenteral IV FeedingK0500A – Parenteral IV Feeding• O0100D, 1 or 2 – SuctioningO0100D, 1 or 2 – Suctioning• O0100E, 1 or 2 – Tracheostomy CareO0100E, 1 or 2 – Tracheostomy Care• O0100F, 1 or 2 – Ventilator or RespiratorO0100F, 1 or 2 – Ventilator or Respirator• O0100H, 1 or 2 – IV MedicationO0100H, 1 or 2 – IV Medication


RUG Classifications RUG Classifications RehabilitationRehabilitation• O0400A 1, 2, 3, & 4O0400A 1, 2, 3, & 4• O0400B 1, 2, 3, & 4O0400B 1, 2, 3, & 4• O0400C 1, 2, 3, & 4O0400C 1, 2, 3, & 4• Therapies: Speech – Language Pathology and Audiology Therapies: Speech – Language Pathology and Audiology

Services; Occupational Therapy and Physical TherapyServices; Occupational Therapy and Physical Therapy


RUG Classifications Special RUG Classifications Special CareCare

• I4400 – Cerebral PalsyI4400 – Cerebral Palsy

• I5100 – QuadriplegiaI5100 – Quadriplegia

• I5200 – Multiple SclerosisI5200 – Multiple Sclerosis

• J1550A – Fever; J1550B – Vomiting; J1550C – J1550A – Fever; J1550B – Vomiting; J1550C – Dehydration; K0300 – Weight loss; K0500B – Dehydration; K0300 – Weight loss; K0500B – Feeding tube; I2000 – Pneumonia, included in fever Feeding tube; I2000 – Pneumonia, included in fever string impacting special carestring impacting special care


RUG Classifications Special RUG Classifications Special CareCare• K0700A – Proportion of total calories the resident K0700A – Proportion of total calories the resident

received through parenteral or tube feeding. For received through parenteral or tube feeding. For residents receiving po nutrition and tube feeding, residents receiving po nutrition and tube feeding, documentation must demonstrate how the facility documentation must demonstrate how the facility calculated the percentage of calorie intake the tube calculated the percentage of calorie intake the tube provided and include:provided and include:

• Calories tube feeding provided during observation periodCalories tube feeding provided during observation period

• Calories oral feeding provided during observation periodCalories oral feeding provided during observation period

• Percent of total calories provided by tube feedingPercent of total calories provided by tube feeding

• Calories by tube/total calories consumedCalories by tube/total calories consumed


RUG Classifications Special RUG Classifications Special CareCare• K0700B – Average fluid intake per day by IV or tube; and K0700B – Average fluid intake per day by IV or tube; and

I4300 – Aphasia are included in string impacting special I4300 – Aphasia are included in string impacting special care with feeding tubecare with feeding tube

• M0300A – Number of Stage I pressure ulcersM0300A – Number of Stage I pressure ulcers• M0300B,1 – Number of Stage 2; M0300C,1 – Number of M0300B,1 – Number of Stage 2; M0300C,1 – Number of

Stage 3; M0300D,1 – Number of Stage 4; M0300F,1 – Stage 3; M0300D,1 – Number of Stage 4; M0300F,1 – Number of UnstageableNumber of Unstageable

• Note: Documentation must include staging within the Note: Documentation must include staging within the observation period. Each ulcer should have an entry observation period. Each ulcer should have an entry noting observation date, location, and noting observation date, location, and measurement/description.measurement/description.


RUG Classifications Special RUG Classifications Special CareCare• M1030 – Number of venous and arterial ulcersM1030 – Number of venous and arterial ulcers• M1040D – Open lesionsM1040D – Open lesions• M1040E – Surgical woundsM1040E – Surgical wounds• M1200A, B – Pressure reducing device, chair, bed M1200A, B – Pressure reducing device, chair, bed

• Note: Facilities providing pressure-reducing Note: Facilities providing pressure-reducing mattresses for all beds should have a documented mattresses for all beds should have a documented policy noting such and be prepared to provide policy noting such and be prepared to provide evidence of the policy to the audit team. evidence of the policy to the audit team.


RUG Classifications Special RUG Classifications Special CareCare• M1200C – Turning/repositioning programM1200C – Turning/repositioning program• M1200D – Nutrition or hydration intervention to manage M1200D – Nutrition or hydration intervention to manage

skin problemsskin problems• M1200E – Ulcer careM1200E – Ulcer care• All impact strings with staged woundsAll impact strings with staged wounds


RUG Classifications Special RUG Classifications Special CareCare• M1200F – Surgical wound care impacting strings with M1200F – Surgical wound care impacting strings with

surgical woundssurgical wounds

• M1200G – Application of non-surgical dressings other M1200G – Application of non-surgical dressings other than to feet; and M1200H – Application of than to feet; and M1200H – Application of ointments/medications other than to feet both impact ointments/medications other than to feet both impact strings with staged wounds and surgical woundsstrings with staged wounds and surgical wounds


RUG Classifications Special RUG Classifications Special CareCare• O0100B,1 or 2 – RadiationO0100B,1 or 2 – Radiation• O0400D2 – Respiratory therapy O0400D2 – Respiratory therapy

– – Days and minutesDays and minutes

– – Assessment Assessment

– – Performed by qualified individualsPerformed by qualified individuals


RUG Classifications Clinically RUG Classifications Clinically ComplexComplex• D0200A – I, 2 – Resident Mood Interview (PHQ-9); D0200A – I, 2 – Resident Mood Interview (PHQ-9);

minimum documentation – resident mood interview minimum documentation – resident mood interview symptom frequency codes are sufficient. symptom frequency codes are sufficient. MDS will be MDS will be considered source document.considered source document.


RUG Classifications Clinically RUG Classifications Clinically ComplexComplex• D0500A – J, 2 – Staff assessment of Resident Mood D0500A – J, 2 – Staff assessment of Resident Mood

(PHQ-9-OV)(PHQ-9-OV)• Documented examples demonstrating the presence and Documented examples demonstrating the presence and

frequency of the clinical mood indicators must be frequency of the clinical mood indicators must be provided during the observation period.provided during the observation period.


RUG Classifications Clinically RUG Classifications Clinically ComplexComplex

• B0100-ComatoseB0100-Comatose• I2100-SepticemiaI2100-Septicemia• I2900 – Diabetes Mellitus included in diabetes stringI2900 – Diabetes Mellitus included in diabetes string• I4900 – Hemiplegia/HemiparesisI4900 – Hemiplegia/Hemiparesis• J1550D – Internal bleedingJ1550D – Internal bleeding• K0700A – Portion of total calories and K0700B – K0700A – Portion of total calories and K0700B –

Average Fld per day with feeding tubeAverage Fld per day with feeding tube


RUG Classifications Clinically RUG Classifications Clinically ComplexComplex• M1040A – Infection of footM1040A – Infection of foot• M1040B – Diabetic foot ulcerM1040B – Diabetic foot ulcer• M1040C – Other open lesions on footM1040C – Other open lesions on foot• M1040F – BurnsM1040F – Burns• M1200I – Application dressings to feet, impacting strings M1200I – Application dressings to feet, impacting strings

with skin conditions of footwith skin conditions of foot• N0300 – Injections – impacting diabetes stringN0300 – Injections – impacting diabetes string


RUG Classifications Clinically RUG Classifications Clinically ComplexComplex• O0100A, 1 or 2 – ChemotherapyO0100A, 1 or 2 – Chemotherapy• O0100C, 1 or 2 – Oxygen therapyO0100C, 1 or 2 – Oxygen therapy• O0100I, 1 or 2 – TransfusionsO0100I, 1 or 2 – Transfusions• O0100J – DialysisO0100J – Dialysis• O0600 – Physicians’ examinationsO0600 – Physicians’ examinations• O0700 – Physician ordersO0700 – Physician orders


RUG Classifications Impaired RUG Classifications Impaired CognitionCognition• B0700 – Making self understoodB0700 – Making self understood• C0200 – Repetition of three wordsC0200 – Repetition of three words• C0300A, B, C – Temporal orientation – year, month, C0300A, B, C – Temporal orientation – year, month,

weekweek• C0400A, B, C – RecallC0400A, B, C – Recall• C0700 – Short-term memory OKC0700 – Short-term memory OK• C1000 – Cognitive skills for daily decision makingC1000 – Cognitive skills for daily decision making


RUG Classifications Behavior RUG Classifications Behavior ProblemsProblems• E0100A – HallucinationsE0100A – Hallucinations

• E0100B – DelusionsE0100B – Delusions

• E0200A – Physical behavioral symptoms directed E0200A – Physical behavioral symptoms directed toward otherstoward others

• E0200B – Verbal behavioral symptoms directed toward E0200B – Verbal behavioral symptoms directed toward othersothers

• E0200C – Other behavioral symptoms not directed E0200C – Other behavioral symptoms not directed toward otherstoward others

• E0800 – Rejection of care presence and frequencyE0800 – Rejection of care presence and frequency

• E0900 – Wandering presence and frequencyE0900 – Wandering presence and frequency


Nursing Restorative ProgramNursing Restorative Program• H0500 – Bowel toileting programH0500 – Bowel toileting program• H0200C-Current toileting program or trialH0200C-Current toileting program or trial

• O0500 A, B, C, D, E, F, G, H, I, J – Restorative nursing O0500 A, B, C, D, E, F, G, H, I, J – Restorative nursing carecare


Activities of Daily Living (ADL) Activities of Daily Living (ADL) AssistanceAssistance• G0110A, 1 & 2G0110A, 1 & 2

• G0110B, 1 & 2G0110B, 1 & 2

• G0110I, 1 & 2G0110I, 1 & 2

• G0110H, 1G0110H, 1

• Included in coma string impacting extensive services Included in coma string impacting extensive services count in clinically complex and impaired cognitioncount in clinically complex and impaired cognition

• Documentation of these ADLs requires 24 hours/7days Documentation of these ADLs requires 24 hours/7days within observation period.within observation period.


Supportive Supportive Documentation Documentation Guidelines (SDG) MDS Guidelines (SDG) MDS 3.03.0

Effective for Effective for assessments dated assessments dated October 1, 2010, or afterOctober 1, 2010, or after


Overall Documentation Overall Documentation InstructionsInstructions• Supportive documentation must be dated during Supportive documentation must be dated during

the assessment period.the assessment period.

• Each page or individual document must contain Each page or individual document must contain the resident identification information.the resident identification information.

• Corrections/Obliterations/Errors/Mistaken Entries: Corrections/Obliterations/Errors/Mistaken Entries: At a minimum, the audit teams must see one line At a minimum, the audit teams must see one line through the incorrect information, the staff’s through the incorrect information, the staff’s initials, the date the correction was made, and the initials, the date the correction was made, and the correct information.correct information.


Additional Information for Additional Information for SDG MDS 3.0SDG MDS 3.0• MDS 3.0MDS 3.0

– C0200 – Repetition of C0200 – Repetition of three wordsthree words

– C0300A, B, C – Temporal C0300A, B, C – Temporal orientation – year, month, orientation – year, month, weekweek

– C0400A, B, C – RecallC0400A, B, C – Recall

• Minimum Documentation Minimum Documentation StandardsStandards

– BIMS Codes are BIMS Codes are sufficient. sufficient.

– MDS will be considered MDS will be considered source document.source document.


Additional Information for Additional Information for SDG MDS 3.0 SDG MDS 3.0

• MDS 3.0MDS 3.0

– D0200A-I, 2 – Resident D0200A-I, 2 – Resident Mood Interview (PHQ-9)Mood Interview (PHQ-9)


– Resident Mood Interview Resident Mood Interview (PHQ-9) symptom (PHQ-9) symptom frequency codes are frequency codes are sufficient.sufficient.

– MDS will be considered MDS will be considered source document.source document.



• MDS 3.0MDS 3.0

– D0500A-J, 2 – Staff D0500A-J, 2 – Staff Assessment of Resident Assessment of Resident Mood (PHQ-9-OV)Mood (PHQ-9-OV)


– Documented examples Documented examples demonstrating the demonstrating the presence and frequency presence and frequency of clinical mood indicators of clinical mood indicators must be provided during must be provided during the observation period.the observation period.



• MDS 3.0MDS 3.0

– I2900 – Diabetes MellitusI2900 – Diabetes Mellitus– I4300 – AphasiaI4300 – Aphasia– I4400 – Cerebral PalsyI4400 – Cerebral Palsy– I4900 – I4900 –

Hemi-plegia/HemiparesisHemi-plegia/Hemiparesis– I5100 – QuadriplegiaI5100 – Quadriplegia– I5200 – Multiple SclerosisI5200 – Multiple Sclerosis


– Diagnosis was active Diagnosis was active during look-back period. during look-back period. Active diagnosis signed by Active diagnosis signed by the physician within the the physician within the past 60 days (plus 10-day past 60 days (plus 10-day grace period permitted by grace period permitted by 410 IAC 16.2-3.1-22(d)(2)410 IAC 16.2-3.1-22(d)(2)



• MDS 3.0MDS 3.0

– O0500, A, B, C, D, E, F, O0500, A, B, C, D, E, F, G, H, I, J – Restorative G, H, I, J – Restorative Nursing CareNursing Care


– Documentation during the Documentation during the observation must include observation must include the five criteria for the five criteria for restorative nursing care.restorative nursing care.


ResourcesResources• For auditing questions, call HP Enterprise Services Long For auditing questions, call HP Enterprise Services Long

Term Care Unit at (317) 488-5062.Term Care Unit at (317) 488-5062.

• For more information, including bulletins and copies of For more information, including bulletins and copies of Supportive Documentation Guidelines, go to Supportive Documentation Guidelines, go to http://www.indianamedicaid.com. Click Bulletins to Click Bulletins to access bulletins for updates and copies of the access bulletins for updates and copies of the Supportive Documentation Guidelines.Supportive Documentation Guidelines.


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©2009 HP Confidential1 Indiana LTC Case Mix Audits HP Enterprise Services January 2011.

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