October 2009

LTC Case Mix and Level of Care Audit ReviewPresented by theEDS Long Term Care Unit

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2 / October 2009LTC CASE MIX AND LEVEL OF CARE AUDIT REVIEW

Agenda

• Introduction

•Objectives

•LTC Case Mix Audit Process

• Informal Reconsideration Process

•Helpful Reminders

•LTC Help Desk

•Updates and Program Clarifications

– Autoclosure Reminder (B98)

– Clarification on Bed Hold Days

•Billing for Bed Hold Days

•Questions

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Objectives

•Following this session, providers will better understand:

– LTC Case Mix Audit Process– Informal Reconsideration Process– About Altering Documents– What the LTC Help Desk can do for you– How Autoclosure affects Level of Care– Billing for Bed Hold Days

4 / October 2009LTC CASE MIX AND LEVEL OF CARE AUDIT REVIEW

LTC Case Mix Audit Process

•EDS Long Term Care (LTC) completes a Level of Care audit for all Indiana Health Coverage Programs (IHCP) facilities in the state of Indiana at least once every 15 months

– EDS LTC audits the minimum data set (MDS) supporting documentation maintained by nursing facilities for all residents, regardless of payer type

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

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LTC Case Mix Audit Process

• EDS provides advanced notification to the nursing facility

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

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

• The audit will include:

– A minimum of 40 percent of the nursing facility population or 25 records, whichever is greater

• The facility will provide the census list

– A sample of those residents in each of the Resource Utilization Group (RUG) III classification groups

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

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•Alphabetic Level II Resident List

•Residents Receiving Outside Mental Health Services List

•Stage 3 or 4 Ulcers List

•Traumatic Brain Injury List

Other Required Lists

LTC Case Mix Audit Process

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

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

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

LTC Case Mix Audit Process

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

– Activities of daily living (ADL) component

– Element component

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

LTC Case Mix Audit Process

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

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

LTC Case Mix Audit Process

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

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

•When the preliminary validation rate for the initial sample is below 80 percent, the audit expands to 100 percent of the remaining records on the roster

– For 79.99 percent or less, expansion will occur

LTC Case Mix Audit Process

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

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

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

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

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

LTC Case Mix Audit Process

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•The EDS audit team discusses the results of the Level of Care (LOC) and Case Mix audit in an exit conference

•The nursing facility does not need to modify and resubmit records to Myers and Stauffer LC that have been found to be unsupported per the final audit letter

•This information will be forwarded to Myers and Stauffer LC after the request/response time frame for an informal reconsideration has elapsed

Note: A facility may modify a MDS record if a significant correction to the resident’s assessment is necessary

LTC Case Mix Audit Process

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•EDS mails the final summary letter to the nursing facility approximately 10 business days following the exit conference

•The letter includes copies of the following:

– Final validation rate

– Copies of unsupported worksheets

– Referrals for Level II residents, if applicable

– Validation improvement plan, if applicable

Post-Exit ConferenceLTC Case Mix Audit Process

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Informal Reconsideration Process

•The letter contains instructions for the informal reconsideration process

• Informal reconsiderations will be conducted by an EDS LTC registered nurse (RN) who is separate and distinct from the audit

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

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

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Informal Reconsideration Process

•The request must include specific audit issues that the nursing facility believes were misinterpreted or misapplied during the audit

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

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

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Helpful Reminders

•Suspected intentional alteration of clinical documentation, or creation of documentation after MDS assessments have been transmitted, is referred to the Medicaid Fraud Control Unit (MFCU) of the Indiana Attorney General’s Office for investigation

•Such investigation could result in a felony or misdemeanor criminal conviction

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

Altering Documents

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LTC Contact Information

•The EDS LTC Unit has a help desk to answer calls regarding B98s, LOC, 450B, or claim problems regarding LOC

– Leave your message at(317) 488-5094

– Calls are returned the third full week of each month in the order they were received

• Issues related to Case Mix, the audit process or Supportive Documentation, call the EDS Long Term Care Review Unit at (317) 488-5062 or one of the auditors at the number on his or her business card

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Updates and Clarifications

Medicaid Bulletin BT200903

•Autoclosure (B98)

– Provides a reminder that the 450B/LOC is updated when a discharge status code is billed. To ensure that residents are able to receive items or services after discharge from the facility, the appropriate discharge status code must be billed on the claim. This will end date the 450B/LOC and allow services to be considered for payment after the discharge date.

•Clarification Regarding Bed Hold Days

– Nursing facilities should bill a discharge status code ONLY when a resident is truly discharged from their care. Bed holds, with the expectation of return, no matter the duration, are not discharges and should not be coded as such on the LTC claim.

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Billing for Bed Hold Days

•Bill with patient status code– 30 – Still patient

•Use the following revenue codes as defined– 180 – Bed hold days not eligible for payment

• Census is less than 90 percent– 183 – Therapeutic bed hold days eligible for payment

• When census is 90 percent or greater

– 185 – Hospital bed hold days eligible for payment• When census is 90 percent or greater

•Leave days or bed hold days must be billed whether or not they are reimbursable by the IHCP

•Reference bulletin BT200903

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Questions

October 2009

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