THE M3 REVIEW - IS MISINFORMATION KILLING YOUR CASEMIX?

Are you a victim of the Reaper?  Misinformation is everywhere!

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Hello, and welcome back to the M3 Review. Today we are tackling a problem that I see across many facilities every single week. And that's misinformation. Not malicious misinformation, not necessarily intentional misinformation. I mean maybe it is, but I hope not. Just myths, assumptions, outdated practices. And then they get repeated so often that eventually everyone believes that they're true. Or they come from a webinar that you've paid for. So you're assuming that what they're saying is true. The problem is that when misinformation drives MDS coding, it impacts reimbursement, increases audit risk, creates documentation vulnerabilities, and this is all difficult to defend. Over the next few minutes, we're going to separate myth from fact and examine some of the most common misconceptions I encounter during MDS, PDPM, or Medicaid case mix reviews. Because in today's regulatory environment, it's not enough to know what you've always done. You need to know what CMS actually requires, what the documentation supports, what Medicaid is expecting in your state, and whether your coding decisions are defensible. Following along with our awesome slide deck, which I hope you have the slides, myth number one. If the diagnosis is in the chart, we can code it on the MDS. That is not how CMS looks at it. Just because a diagnosis appears somewhere in the medical record does not automatically make it MDS codable. To code a diagnosis on the MDS, it must be an active diagnosis. That means there must be evidence during the seven-day look back period that the condition had an impact on the resident's care through monitoring, treatment, evaluation, nursing interventions, or symptoms that affected the resident status. In addition, the diagnosis must be physician documented, signed, and supported within the requested time frame, which is 60 days. This is where many facilities get into trouble. During an audit, the reviewer isn't asking whether the diagnosis exists somewhere in the chart. They're asking whether the diagnosis was active and supported during the assessment reference period. When we code diagnosis, they are no longer active, or when we can't demonstrate monitoring, treatment, or impact, we create audit risk. And in some cases, that can lead to a reduction in case mix and reimbursement. One of the most valuable exercises an MDS team can perform is to stop asking, is it in the chart? and start asking, okay, it's in the chart, can I defend that? Can I validate it? Can I support it? Because at the end of the day, revenue integrity depends on documentation integrity. Myth number two, Section GG doesn't impact Medicaid much. I hear this one all the time. And this could not be farther from the truth. In many states, Section GG is one of the most important sections on the entire assessment because it directly influences your case mix classification and ultimately reimbursement. When facilities underestimate the importance of GG, they end up with inflated functional scores. The resident appears more independent on paper than they actually are, or they appear more dependent. What makes this especially frustrating is that the care is often being provided. Staff are assisting the resident. The documentation may even support the assistance. But if the GG coding doesn't accurately reflect the resident's usual performance during the proper assessment period, the facility may never receive credit for the care that's being delivered. During audits, one of the first places I look is section GG because even small coding differences can have a significant impact on your reimbursement. GG's not just a therapy section. It's very important. It's a case mix section, it's a PDPM section. It's one of the most important areas to get right if you want your Medicaid and Medicare rate to accurately reflect the acuity of the residents you're serving. Bad GG coding doesn't just create documentation problems. It can directly lower your case mix and lower your reimbursement. In Missouri, you're going to want an IDT note. That's in the RAI manual that CMS expects the IDT to be qualified clinicians. Missouri would like you to write a note and identify who participated in that decision of residents' usual performance. Just remember that. Number three, late MDS submissions only cause small issues. This is one of the most dangerous misconceptions in long-term care because the consequences of a late assessment can be significant. When an assessment is not completed, signed, or submitted within the required timeframes, the impact can extend far beyond a simple compliance concern. Depending upon the circumstances, facilities may be exposed to default rates, loss of case mix, reimbursement reductions, and increased audit scrutiny. I've seen facilities lose substantial revenue because one assessment missed a critical deadline. The care was provided, the documentation existed, the resident qualified. And like I've said before, you usually have the case mix index, it's processed by years. The assessment was not completed or submitted timely, and the reimbursement opportunity was lost. The reality is that the timeliness is not an administrative detail. It's a reimbursement issue. It's a compliance issue and it's a revenue integrity issue. Strong facilities don't leave MDS timing to chance. They maintain tracking systems, they monitor upcoming assessment schedules, and they identify potential delays before they become missed deadlines. The bottom line is simple. One light MDS can cost you thousands of dollars because that CMI does not go into your average. That's why timely completion, signature management, and submission oversight must be treated as critical operational priorities. Myth number four. Surveyors only care about clinical care. Are you kidding me? You've evidently never been through a real survey where they dig through the chart and come and ask you 50 million questions. You know, I do hear that they don't care. They just go through other things that they concentrate on. Absolutely, clinical care is important. Surveyors, auditors, and regulatory reviewers are looking at much more than bedside care alone. They will tear a chart up if they're good at their job. They're reviewing whether the documentation supports the story being told in the medical record. They are evaluating whether diagnoses are supported, whether assessments are accurate, whether care plans align with the residents' needs, and whether the MDS reflects what's actually occurred during the look back period. In reimbursement and case mix audits, reviewers routinely examine diagnosis support, ADLs, therapy records, physician documentation, signatures, assessment timing, coding accuracy. They're not just looking at what you're doing when they're observing care. They're looking whether or not the medical record supports what you're doing. One of the most common statements I hear is we know the resident has that problem. The problem is that knowing it and proving it are two different things. And I hear that. I hear people say they don't take any medicine for it. We're not doing anything for them. How am I going to support this? Are you kidding? Of course you're doing something for them, or they would be at home alone. The facilities that perform best are not necessarily the ones providing different care or the fancy facilities. They're the ones that can clearly demonstrate through documentation that the care was provided, the diagnosis were active, and the coding was accurate. Remember, if it isn't documented, it's not done. And if it can't be defended, it may not survive an audit. Myth number five. This is one of my favorite in this slide deck. I hope you can see it. It's a nurse sitting a desk. It's the grim reaper nurse, actually, because misinformation kills your case mix. So this entire presentation is centered around the grim reaper. But this is the Grim Reaper filing his or her nails. It's a nurse wearing a nurse hat, filing their nails to the desk, not doing anything else. And the myth is if therapy documented, nursing doesn't need to document it. This creates problems every day. And I just heard that last week. While therapy documentation is certainly important, Section GG is not intended to be based solely on what therapy observes. We've already covered this. CMS expects facilities to use information from the IDT to determine the resident's usual performance during the assessment period. That means nursing observations matter. CNA documentation does matter. That came up more than once because they're not allowed to assess, but it is written that their input matters. Each discipline sees the resident at different times in different situations and under different conditions. The resident will have different energy levels, may feel differently, different effects from medication at different times of the day. A resident may perform well during a scheduled therapy session but requires significantly more assistance during routine evening care. We know that's true. If we rely on only one source of information, we risk creating a picture that does not accurately reflect the resident's true functional status. And the goal of Section GG is not to capture the resident's best performance, it's to capture the usual performance based on the input from the IDT. So who's your IDT? AIDS, restorative, nurses, therapy, physician. When nursing documentation is missing, inconsistent, or not considered during the coding process, facilities increase the risk of inaccurate functional scoring. And you know this affects everything, including your audit defensibility. The strongest GG processes bring together therapy, nursing, CNA documentation, MDS staff to validate and support the resident's usual performance before the assessment is finalized. Remember, section GG is a team sport. No single discipline should be carrying the entire assessment alone. When you're making your IDT note in Missouri, make sure that that note is completed before the signature date of the RNZ, as in Zebra, 0500. Myth number six. Here we see the Grim Reaper walking out of the hospital with a chart. Only hospital diagnosis count for coding. I see the MDS coordinator scour the chart for diagnosis and adding every single one of them. That's good per se. But you must be able to validate and support every diagnosis that you put on that MDS. Include every single one of them that you can validate and support because number one, it paints the most accurate picture of the resident, and number two, CMS uses it as a covariate for your discharge function score. Diagnosises can come from a variety of qualified sources. Hospital records is one. And there are some diagnosis that you must fine-tune even more if it's in the hospital record, those being sepsis, one being pneumonia, and for sure schizophrenia. Physician documentation, nurse practitioner documentation, physician assistant, discharge summaries, radiologist, those are all allowable medical record documentation. PAs, NPs, and they may support your coding decisions. The key is not where the diagnosis originated. You know, sometimes the hospital has those diagnoses resolved and they're not. And why they come to you is not always going to be why they were in the hospital. And why your resident is admitted to your facility today may not be why they're there in six months. Things change. The key is whether or not the diagnosis is valid, active, and supported, and meets CMS coding requirements. This is where facilities get into trouble. It may be on the hospital discharge summary, but if there's no evidence that it remains active during the assessment period, you can't code it. For instance, sepsis pneumonia. On the other hand, a diagnosis that is clearly documented and actively managed by the attending physician or the practitioner may be appropriate to code, even if it was not on the hospital list. Remember, nobody cares whether or not the hospital mentioned it. It's whether or not you can support it as active. The goal is not to collect diagnoses, don't put every single thing down that you find. You should put every single thing down that you can find that you can support. Accurately capture active conditions that impact the resident's care and can be supported through documentation. In the world of MDS coding, supportability is what matters most. A diagnosis that cannot be supported creates audit risk. A diagnosis that is active, documented, and supported creates defensible reimbursement. The goal is not to collect diagnoses. The goal is to capture active, supportive diagnosis. Myth number seven: a diagnosis only needs to appear once in the chart. This myth is responsible for many unsupported diagnosis identified during audits. A single mention of a diagnosis somewhere in the medical record does not automatically make it appropriate. You know that it must be validated and supported. CMS expects facilities to demonstrate this, showing that the diagnosis is active and has a meaningful impact on the residence care during the assessment period. When auditors or surveyors are reviewing, they're looking for the evidence. Was the condition monitored? Was it evaluated? Was treatment provided? Did it affect the residence care plan, nursing interventions, medications, or clinical decision making? For instance, if you have diagnoses on the face sheet that was documented months ago, but there's no evidence that they're being monitored, treated, or affecting care today, that is not supportable for coding purposes. That's why diagnosis validation is so important. The question is not whether the diagnosis exists. The question is whether the medical record demonstrates that the diagnosis is active and relevant during the proper look back. One of the most valuable things that an MDS coordinator can learn and practice is if you code a diagnosis, ask yourself, how am I going to support that? How am I going to validate that? Can I show monitoring? Can I show treatment? Can I show symptoms? If the answer is no, the diagnosis will be difficult to defend. Number eight. On this slide, we see money falling off of the clipboard. Nursing documentation doesn't affect reimbursement. Oh yes, it does. It drives many of the coding decisions that ultimately impact reimbursement. If it doesn't support the diagnosis, the services provided, the resident's functional status, or the clinical complexity, the facility may not receive credit for the care being delivered. Compliance and reimbursement are not separate issues. They're directly connected. Number nine, survey and reimbursement are separate. Nope. Not true. Ask any facility that's ever had to pay for an IJ. Many facilities think survey findings only affect compliance while reimbursement issues only affect payment. In reality, they're very closely connected. Serious survey deficiencies can result in what they call CMPs, civil monetary penalties, denial of payment for new admissions, and in extreme cases, Medicare payment sanctions or termination from participating in the Medicare or Medicaid program. The financial impact of poor compliance can be substantial. That's why the most successful facilities treat compliance and reimbursement as separate departments or separate goals. Strong clinical systems support strong survey outcomes, accurate documentation supports reimbursement, and both contribute to the overall financial health of the facility. The bottom line is simple. Compliance protects reimbursement, and reimbursement depends on compliance. Myth number 10. The MDS is just paperwork. Oh boy. This may be the most dangerous myth of all. The MDS is not paperwork. It's the document that tells the story of your resident's clinical complexity, functional status, services provided, and ultimately the reimbursement your facility receives. Every diagnosis coded, every GG score entered, every clinical condition captured, and every assessment completed contributes to their story, to the resident's story. When the MDS is accurate and supported, it protects reimbursement and demonstrates the care being provided. When it's inaccurate or incomplete or unsupported, facilities have serious compliance risk, audit risk, and potential reimbursement loss. That's why the MDS cannot be viewed as a data entry exercise, and you should stay away from a clicker. It is clinical, regulatory, and a financial document, all rolled into one. The MDS is your facility's revenue story. Every coded item should be accurate, every diagnosis should be supported, and every assessment should be defensible. Myth number 11: guidance can come from any source. I'm gonna say misinformation and bad guidance is why I started the M3 review. I'm just gonna throw that out there. This is one of the biggest reasons that misinformation spreads in long-term care. Someone hears something at a conference, someone posts an opinion online, someone says we've always done it this way, and then before you know it, opinion becomes accepted as fact. Maybe you paid $75 per person for a webinar that gave you wrong information. The problem is that MDS coding and regulatory compliance cannot be based on rumors, assumptions, or unsupported interpretations. When making coding decisions, you should rely on source documents, official guidance, read your RAI, read your Missouri Supportive Documentation Requirements User Guide. Look stuff up. Use reputable educational resources that can be verified. One question I often ask is simple. Show me the source. Show me where that guidance is. If it can be traced back to a reliable source, then it should be implemented. Good decisions come from good information. In today's regulatory world that we live in, your coding practices cannot depend on myths, opinions, or outdated guidance. Always follow the source, not the rumors. Myth number twelve, coding isn't important. Well, if that was the case, CMS wouldn't spend so much time auditing it. You know, coding must be accurate for the facility to receive appropriate reimbursement for the care that's being delivered. You cannot capture things on that MDS that didn't happen. And you need to capture things that are happening. And I see both every day. The reality is that it's not an administrative task. I've already said that. Don't put a clicker into that position. It's too important. Every code tells part of the resident's story, every code should be supported, and every code should be defensible. At the end of the day, this coding that is accurate protects the facility and the resident it serves. Myth number 13, lucky 13. I can document the look back later. The problem is that the further you get from the assessment period, the harder it becomes to accurately reconstruct what actually happened. Memories fade, staff change shifts, details get lost, and what seemed obvious during the look back period suddenly becomes difficult to verify or document. Facilities risk inaccurate coding when this happens, and you may fail an audit. Remember, they won't put the pieces of the puzzle together. They won't try to make it all make sense. You must reconstruct history and capture reality in the medical record. Myth number 14. If care was provided, it's going to count. You know that's not how it works. Facilities don't receive credit for care simply because they know something was done. It must be documented, supported, and validated. Your goal is to provide excellent care and be able to prove it. Myth number 15. Our CMI is what it is. We can't change it. Man, I hear that all the time. And the truth is that while resident acuity absolutely matters, case mix is heavily influenced by the systems used to capture, document, validate, and code. Two facilities can care for very similar residents and have very different case mix outcomes. And why is that? I hear that complaint from administrators all the time. So and so down the street has the same kind of people we do, and they're getting a lot more money. Well, that's because one facility has strong documentation and accurate coding and active IDT. Involvement while the other leaves opportunities, uncaptured, money on the table. Case mix is not luck, it's the result of successful processes. Your CMI is more controllable than you think. Myth number 16: any lung disorder can be coded as a chronic lung disease. I try to cover this every time I speak. This myth creates significant risk because chronic lung disease that's restrictive places the residents that have Medicaid in the special care high category. I frequently see facilities attempt to use diagnoses that do not qualify. Like bronchitis, pulmonary edema, CHF, I see a lot. Respiratory failure is another one. You can't use those. Conditions like emphysema, chronic bronchitis, pulmonary fibrosis, COPD are examples of diagnosis that meet the chronic lung disease criteria when they are properly documented and active. You know, residents may have a respiratory condition, but that does not automatically place them into the chronic lung disease category. Double check the chronic lung disease coding. The reason I talk about these things about shortness of breath while lying flat and chronic lung disease is because it comes up so frequently and I see it frequently misinterpreted and a great source of misinformation. So I wanted to make sure we covered it. Myth number 17: any shortness of breath counts as shortness of breath while lying flat. Nope, not true. And you gotta be really careful how you word that. For MDS coding, the key is not simply whether the resident experiences shortness of breath, the key is whether the shortness of breath occurs while lying flat and whether they have a restrictive lung disease. If you're trying to get that high reimbursement, you gotta have both of those things. And you should not go looking for that. It should reflect an accurate picture of the resident. We do say in our reviews all the time, ask the physician if this is appropriate because we don't make those decisions, they do. If staff observes symptoms, then document it if they report it to you. And so far, the definition of what is not lying flat has not been defined. And I don't know anybody that doesn't use at least pillows or their head partially elevated. And I don't think I've ever seen a resident or a patient laying completely flat with no pillows and no head elevation. Many facilities know that a resident cannot tolerate lying flat. They know who the chronic lung people are. You must document to support that. And do not intimidate the resident upon interview. Do not walk in and scare your resident saying, honey, are you short of breath? They're going to maybe get scared and deny it. Again, documentation turns observations into defensible coding. The issue is not whether the resident has the shortness of breath, the issue is whether or not you can validate and support how you code it. Myth number 18: coding more diagnoses increases CMI. Sometimes, if you can validate and support them, the goal is that you must be accurate, and simply adding diagnoses does not automatically increase reimbursement. In fact, coding those that are not active, supported, or relevant can create audit risk and expose the facility to take backs and repayment demands and other issues that you don't want to start. Nobody's impressed by a long diagnosis list. In fact, we hate it. Reimbursement is driven by resident complexity that can be supported and defendant, that is accurate, that is pertinent to your resident, not by the number of codes entered on an assessment. If you can support them, if they're active, if they're validated, include them. But don't just include everything listed on the chart from the hospital because it is there. Defensible diagnosis coding is not that. Speaking of that, again, myth number 19. If it's documented as sepsis, we can code it. No. That is a diagnosis that deserves special attention because the word sepsis in the medical record does not automatically make it a valid coding choice. As with all our diagnoses, they must be supported and validated. When reviewing sepsis, facilities should be looking for evidence of an infectious process and clinical indicators that support it. A diagnosis listed on a discharge problem list or discharge summary is not enough. You must show evidence of an inflammatory process. That can be in your labs. Review the current sepsis guidelines before you code this on your MDS. A diagnosis label alone does not justify it. Our last myth is number 20. I know PDPM. I went to training. I've heard that. I have seen MDS coordinators shut us down mentally completely when we walk in because they think they know everything. And the facility is in trouble financially, and that's too bad for them. PDPM isn't something that you just learn one time and master. Regulations change frequently, the guidance changes, audit focus changes, documentation requirements evolve. Boy, do they evolve frequently. Attending a class does not guarantee accurate coding six months later. It just doesn't. The facilities that consistently perform well don't rely on memory, they rely on processes, they verify diagnoses, they validate GG, they review documentation, they challenge assumptions, they use current guidance, they stay apprised of changes from CMS, they know what is current, and they're also aware of misinformation and who's been guilty of putting it out. So remember, don't believe everything you hear. If it sounds wonky, challenge it. It might be wrong. Knowledge is important, but without validation, it creates risk. Misinformation is killing your case mix. Not because people don't care, but because too many people have stopped learning, stopped validating, and started assuming. Over the course of this presentation, we have challenged some of the most common myths in reimbursement for long-term care. We've talked about diagnosis validation, section GG, audit risk, case mix, timing, coding accuracy, and one thing keeps appearing over and over and over. The biggest threat to reimbursement isn't regulations, it's misinformation. It's lack of knowledge base. It's the things we've heard for years that are never really true. It's the shortcuts, the clickers. We've always done it that way mentality. That's the Reaper. The Reaper isn't a person. It's unsupported diagnoses, missed opportunities, incomplete documentation, invalid coding, failed audits, lost revenue, late MDSs. The good news is that every one of those risks is preventable. When facilities focus on accurate coding, defensible documentation, IDT collaboration, maintaining current regulatory guidance, they protect far more than their reimbursement. They protect their credibility, they protect their compliance, they protect the resources needed to care for the residents. That's what it's all about. You're usually not a charity, and you need resources to take care of these people the way that they deserve. So don't let misinformation kill your case mix. Stop the Reaper, protect the CMI, and protect the revenue.