Documenting Precisely and the Importance of Why

A session at the Zimmet conference on Aug. 13 featured reimbursement and compliance experts detailing how to stay off the radar of CMS and OIG investigators by making sure to cross the T’s and dot the I’s in documentation for billing for skilled services.

Experts Alicia Cantinieri, managing director, clinical reimbursement and regulatory compliance, Zimmet Healthcare Services Group, Alyssa Friedman, partner, Abrams Fensterman, LLP, and moderator Steven Littlehale, chief innovation officer, Zimmet Healthcare Services Group, made up the session.

Called the “$31 Million Question,” the discussion focused on four pillars aimed at keeping a facility safe from unwanted attention from the feds, and making sure each resident’s care is billed precisely and correctly to get full reimbursement.

The first pillar focused on the importance of investigating problems before investigators may. Cantinieri said it’s all about moving earlier and seeing the risk and patterns first.

“Look at a primary diagnosis for a patient and ask why they are receiving skilled care now,” she said. “Look at claims and make sure they are correct. I recommend a triple check. And, also, do random audits of your own assessment. . .get ahead of it.”

Some of these self-exams will find mistakes, maybe a simple coding mistake by an MDS nurse “who just doesn’t understand the coding guidelines,” Cantinieri said.

Pillars

Friedman said the feds are especially active these days in examining the use of IV medication use. “The government is all over it and it is something they are looking for, asking did you pick the most expensive way to administer medications,” she said.

Pillar two involves the problem of documentation that does not answer the question “WHY?”

This can come in the form of a doctor ordering hydration but not noting in the record why that resident needed hydration. “We have to have everyone working the ‘why’ into the record. A CNA may say a resident needed padding but needs to note the why, which could be because of a wound issue,” Friedman said.

Littlehale noted that answering questions before CMS or OIG asks is a sea change from the old days when nurses et al were told not to give any information that the feds did not ask for. The two experts agreed in noting more information is better now and more “why” is the key to get ahead of the documentation curve.

Littlehale also asked how auditors discern between a technical documentation deficiency vs. meaningful noncompliance, which involves proving a facility’s case during an appeal process.

Mistakes are made, Friedman said, but to get a reversal of a faulty audit is not easy. And it is important to bring up problems in the lower-level arbitration processes before any issue is taken before a federal judge.

“In preparing for an ALJ hearing, you may note a lot of times they get it wrong, but if you don’t get evidence in the record early, then you are precluded from bringing it in before a federal judge,” Friedman said.

“If you don’t raise all the holes, a federal judge cannot do anything,” Cantinieri said. She also recommends preparing from the start as if you are going straight to an ALJ hearing.

One Story

The third pillar dealt with making sure communication is a priority across the organization. One organization. One story.

This means there must be alignment among clinical, MDS, therapy, billing, compliance, and leadership before any scrutiny begins.

“There can be all of these disjointed pieces,” Cantinieri said. “So, look at the record as a whole for skilled services and make sure it all matches.” An example would be a resident who has issues with respiratory status and providers not all noting a shortness of breath to bill for special care for respiratory treatment.

“Coding needs to be right,” Friedman said. “One letter is worth half a million dollars.”

Pillar 4 focuses on defending before you need to by preserving evidence, validating documentation, staying organized, and making audit readiness an operating discipline.

Comments or questions? Contact Patrick Connole at pconnole@parkplacelive.com.