Indiana LTC Case Mix Audits
HP Enterprise Services
January 2011
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©2009 HP Confidential
What’s New
• EDS now HP Enterprise Services
• Frequency of audits
– Refer to Bulletin BT200936
• No list of residents with traumatic brain injury
(TBI)
• No list of residents who receive outside mental
health services
• No abbreviation list – if needed, auditors will
request.
• Audits now completed electronically
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LTC Case Mix Audit Process
HP Enterprise Services completes a Level of Care
audit for all IHCP facilities in the state of Indiana
according to the following categories:
• Low Risk – 90-100 percent validation rate will be
audited at a maximum of every three years.
• Medium Risk – 80-89.9 percent validation rate will
be audited at a maximum of every two years.
• High Risk – 79.9 percent or lower validation rate will
be audited every four to twelve months.
Refer to Bulletin BT200936 for audit frequency.
• HP audits the minimum data set (MDS) supporting
documentation maintained by nursing facilities for all
residents, regardless of payer type.
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LTC Case Mix Audit Process
• HP provides advance 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 includes:
– The greater of 30 percent of the total assessments or a
minimum of 25 assessments.
• The facility provides the census list.
– The MDS assessments subject to audit are those most
recently transmitted to Myers and Stauffer LC.
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LTC Case Mix Audit Process
• 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 MDS
assessment that is transmitted, which is the basis
for the MDS audit.
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LTC Case Mix Audit Process
Requested Information
• Alphabetical resident list, which includes the following:
–Last name
–First name
–Date of birth
–Date of admission
–Medicaid number or Social Security number
• Alphabetic Level II Resident List
• Current facility e mail address for future correspondence
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LTC Case Mix Audit Process
• The audit team reviews the following two parts of
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.
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LTC Case Mix Audit Process
• 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.
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LTC Case Mix Audit Process
• “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
include the greater of an additional 20 percent of the
assessments or a minimum of 10 additional
assessments consisting of 90 percent Medicaid payer
source assessments and 10 percent non-Medicaid
payer source assessments.
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LTC Case Mix Audit Process
• The nursing facility must provide documentation to
support records prior to the exit conference.
• The threshold percent is 20 percent and therefore, the
required validation rate for case mix audits is 80 percent
or greater.
• Prior to exit auditors will observe all residents that were
audited
• The team then informs the nursing facility that it is ready
for the exit conference.
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LTC Case Mix Audit Process
• HP sends the final summary letter to the nursing
facility approximately 10 business days following the
exit conference.
• The letter details the Summary of Findings and the
Final validation rate.
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Informal Reconsideration
Process
• The letter contains instructions for the informal
reconsideration process.
• Informal reconsideration is conducted by an HP LTC
registered nurse (RN) who is separate and distinct from
the audit.
• During the informal reconsideration process, the HP 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.
• HP must receive the request in writing no later than 15
business days from the date of the letter.
• HP forwards final results to Myers and Stauffer LC upon
completion of the audit process.
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RUG Classifications
• Extensive Services
• Rehabilitation
• Special Care
• Clinically Complex
• Impaired Cognition
• Behavior
• Reduced Physical
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RUG Classifications Extensive
•
•
•
•
•
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K0500A – Parenteral IV Feeding
O0100D, 1 or 2 – Suctioning
O0100E, 1 or 2 – Tracheostomy Care
O0100F, 1 or 2 – Ventilator or Respirator
O0100H, 1 or 2 – IV Medication
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RUG Classifications
Rehabilitation
•
•
•
•
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O0400A 1, 2, 3, & 4
O0400B 1, 2, 3, & 4
O0400C 1, 2, 3, & 4
Therapies: Speech – Language Pathology and Audiology
Services; Occupational Therapy and Physical Therapy
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RUG Classifications Special
Care
• I4400 – Cerebral Palsy
• I5100 – Quadriplegia
• I5200 – Multiple Sclerosis
• J1550A – Fever; J1550B – Vomiting; J1550C –
Dehydration; K0300 – Weight loss; K0500B –
Feeding tube; I2000 – Pneumonia, included in fever
string impacting special care
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RUG Classifications Special
Care
• K0700A – Proportion of total calories the resident
received through parenteral or tube feeding. For
residents receiving po nutrition and tube feeding,
documentation must demonstrate how the facility
calculated the percentage of calorie intake the tube
provided and include:
• Calories tube feeding provided during observation
period
• Calories oral feeding provided during observation
period
• Percent of total calories provided by tube feeding
• Calories by tube/total calories consumed
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RUG Classifications Special
Care
• K0700B – Average fluid intake per day by IV or tube; and
I4300 – Aphasia are included in string impacting special
care with feeding tube
• M0300A – Number of Stage I pressure ulcers
• M0300B,1 – Number of Stage 2; M0300C,1 – Number of
Stage 3; M0300D,1 – Number of Stage 4; M0300F,1 –
Number of Unstageable
• Note: Documentation must include staging within the
observation period. Each ulcer should have an entry
noting observation date, location, and
measurement/description.
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RUG Classifications Special
Care
•
•
•
•
M1030 – Number of venous and arterial ulcers
M1040D – Open lesions
M1040E – Surgical wounds
M1200A, B – Pressure reducing device, chair, bed
• Note: Facilities providing pressure-reducing
mattresses for all beds should have a documented
policy noting such and be prepared to provide
evidence of the policy to the audit team.
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RUG Classifications Special
Care
• M1200C – Turning/repositioning program
• M1200D – Nutrition or hydration intervention to manage
skin problems
• M1200E – Ulcer care
• All impact strings with staged wounds
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RUG Classifications Special
Care
• M1200F – Surgical wound care impacting strings with
surgical wounds
• M1200G – Application of non-surgical dressings other
than to feet; and M1200H – Application of
ointments/medications other than to feet both impact
strings with staged wounds and surgical wounds
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RUG Classifications Special
Care
• O0100B,1 or 2 – Radiation
• O0400D2 – Respiratory therapy
– Days and minutes
– Assessment
– Performed by qualified individuals
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RUG Classifications Clinically
Complex
• D0200A – I, 2 – Resident Mood Interview (PHQ-9);
minimum documentation – resident mood interview
symptom frequency codes are sufficient. MDS will be
considered source document.
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RUG Classifications Clinically
Complex
• D0500A – J, 2 – Staff assessment of Resident Mood
(PHQ-9-OV)
• Documented examples demonstrating the presence and
frequency of the clinical mood indicators must be
provided during the observation period.
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RUG Classifications Clinically
Complex
•
•
•
•
•
•
B0100-Comatose
I2100-Septicemia
I2900 – Diabetes Mellitus included in diabetes string
I4900 – Hemiplegia/Hemiparesis
J1550D – Internal bleeding
K0700A – Portion of total calories and K0700B –
Average Fld per day with feeding tube
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RUG Classifications Clinically
Complex
•
•
•
•
•
M1040A – Infection of foot
M1040B – Diabetic foot ulcer
M1040C – Other open lesions on foot
M1040F – Burns
M1200I – Application dressings to feet, impacting strings
with skin conditions of foot
• N0300 – Injections – impacting diabetes string
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RUG Classifications Clinically
Complex
•
•
•
•
•
•
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O0100A, 1 or 2 – Chemotherapy
O0100C, 1 or 2 – Oxygen therapy
O0100I, 1 or 2 – Transfusions
O0100J – Dialysis
O0600 – Physicians’ examinations
O0700 – Physician orders
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RUG Classifications Impaired
Cognition
• B0700 – Making self understood
• C0200 – Repetition of three words
• C0300A, B, C – Temporal orientation – year, month,
week
• C0400A, B, C – Recall
• C0700 – Short-term memory OK
• C1000 – Cognitive skills for daily decision making
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RUG Classifications Behavior
Problems
• E0100A – Hallucinations
• E0100B – Delusions
• E0200A – Physical behavioral symptoms directed
toward others
• E0200B – Verbal behavioral symptoms directed toward
others
• E0200C – Other behavioral symptoms not directed
toward others
• E0800 – Rejection of care presence and frequency
• E0900 – Wandering presence and frequency
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Nursing Restorative Program
• H0500 – Bowel toileting program
• H0200C-Current toileting program or trial
• O0500 A, B, C, D, E, F, G, H, I, J – Restorative nursing
care
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Activities of Daily Living (ADL)
Assistance
• G0110A, 1 & 2
• G0110B, 1 & 2
• G0110I, 1 & 2
• G0110H, 1
• Included in coma string impacting extensive services
count in clinically complex and impaired cognition
• Documentation of these ADLs requires 24 hours/7days
within observation period.
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Supportive
Documentation
Guidelines (SDG) MDS 3.0
Effective for assessments
dated October 1, 2010, or
after
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Overall Documentation
Instructions
• Supportive documentation must be dated during
the assessment period.
• Each page or individual document must contain
the resident identification information.
• Corrections/Obliterations/Errors/Mistaken Entries:
At a minimum, the audit teams must see one line
through the incorrect information, the staff’s
initials, the date the correction was made, and the
correct information.
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Additional Information for
SDG MDS 3.0
• MDS 3.0
– C0200 – Repetition of
three words
– C0300A, B, C – Temporal
orientation – year, month,
week
– C0400A, B, C – Recall
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• Minimum Documentation
Standards
– BIMS Codes are
sufficient.
– MDS will be considered
source document.
Additional Information for
SDG MDS 3.0
• MDS 3.0
– D0200A-I, 2 – Resident
Mood Interview (PHQ-9)
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©2009 HP Confidential
• Minimum Documentation
Standards
– Resident Mood Interview
(PHQ-9) symptom
frequency codes are
sufficient.
– MDS will be considered
source document.
Additional Information for
SDG MDS 3.0
• MDS 3.0
– D0500A-J, 2 – Staff
Assessment of Resident
Mood (PHQ-9-OV)
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©2009 HP Confidential
• Minimum Documentation
Standards
– Documented examples
demonstrating the
presence and frequency
of clinical mood indicators
must be provided during
the observation period.
Additional Information for
SDG MDS 3.0
• MDS 3.0
–
–
–
–
I2900 – Diabetes Mellitus
I4300 – Aphasia
I4400 – Cerebral Palsy
I4900 – Hemiplegia/Hemiparesis
– I5100 – Quadriplegia
– I5200 – Multiple Sclerosis
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• Minimum Documentation
Standards
– Diagnosis was active
during look-back period.
Active diagnosis signed by
the physician within the
past 60 days (plus 10-day
grace period permitted by
410 IAC 16.2-3.1-22(d)(2)
Additional Information for
SDG MDS 3.0
• MDS 3.0
– O0500, A, B, C, D, E, F,
G, H, I, J – Restorative
Nursing Care
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• Minimum Documentation
Standards
– Documentation during the
observation must include
the five criteria for
restorative nursing care.
Resources
• For auditing questions, call HP Enterprise Services Long
Term Care Unit at (317) 488-5062.
• For more information, including bulletins and copies of
Supportive Documentation Guidelines, go to
http://www.indianamedicaid.com. Click Bulletins to
access bulletins for updates and copies of the
Supportive Documentation Guidelines.
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Q&A
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