Acuity-based state Medicaid programs currently make up more than half of U.S. Medicaid programs and utilize a methodology to calculate the severity of illness within each provider’s patient population to determine reimbursement. States with acuity-based Medicaid reimbursement have completed or are working on completing a transition to the Patient Driven Payment Model (PDPM), which is the current methodology for Medicare reimbursement, by 2025. This has resulted in a significant change in how nursing homes are reimbursed by state Medicaid programs and additional/differing supporting documentation and processes needed for providers to be successful in this new environment.
State Medicaid programs often require providers to undergo a case mix review to verify the existence and accuracy of underlying support for data elements on the Minimum Data Set (MDS) assessments that drive the acuity factor(s) used to determine reimbursement. These reviews are often conducted remotely and require facility personnel to locate information efficiently and effectively within the electronic health record (EHR). For providers still utilizing paper charting, the review process may require uploading information to a secure portal to allow the reviewer to visualize the information since there is no EHR to navigate. In addition, states may offer an option to provide the reviewer direct access to the facility software; however, this is not recommended as a best practice.
To facilitate review of the MDS data elements, for internal and external purposes, providers should consider implementing a process that documents, in a detailed list, where supporting documentation is located for each data element on the MDS that is calculated into specific case mix groups. This process will vary by state, as state Medicaid plans nationwide use different models to calculate patient acuity.
For example, many states have elected to transition to only the PDPM Nursing Component, while others have elected to also include speech-language pathology (SLP) and non-therapy ancillary (NTA) components. There are also states using all five PDPM components, including the physical therapy (PT) and occupational therapy (OT) components. Regardless of the components in each state’s model, it is a best practice for providers to consider implementing a process that requires MDS personnel to provide a road map of detailed information regarding the location of supporting documentation for the data elements that calculate the case mix group(s).
Validating an MDS for accurate data element capture is a very detailed process. Organizations that develop and follow a process (to confirm existence and location of appropriate documentation for each data element impacting reimbursement) will be more successful in obtaining positive results from case mix reviews. In addition, it is even more critical that providers understand the documentation requirements for each data element impacting reimbursement, as many states are currently transitioning to some form of PDPM for their Medicaid payment model.
Forvis Mazars developed an electronic template to assist providers with documenting the location of supporting documentation in the EHR for each data element impacting payment. Our template can be provided as part of a mock case mix review service provided by a clinician from Forvis Mazars.
If you have questions or would like to schedule a remote mock case mix review for your organization, please reach out to a professional at Forvis Mazars.
Appendix: Example
Below is an example of what would be required to validate information for various data elements on the MDS that result in the calculation of one specific case mix group.
Nursing Component case mix group of HBC2: Diagnosis of COPD captured at data element (I6200), shortness of breath while lying flat captured at data element (J1100C), a nursing function score of 10 (captured in Section GG), with a PHQ total severity score of 11 (captured in Section D from the patient interview). During the case mix review process, the reviewer would request the following information be validated in the medical record:
- Active diagnosis for the COPD. The provider would need to show physician documentation acknowledging the COPD as active within 60 days back from the assessment reference date (ARD) of the MDS and nursing treatment or monitoring of the COPD within the seven-day look-back period. If the reviewer cannot validate both of these, then this data element would be unsupported.
- Shortness of breath while lying flat. The provider would need to show documentation of the presence of or observation of shortness of breath or trouble breathing, including symptoms experienced when lying flat during the observation period (the ARD of the MDS and six days prior).
- Nursing Function score of 10. The provider would need to show the information collected for the following data elements on the ARD of the MDS and two days prior unless this was an admission assessment. If this was an admission assessment, the information should cover the first three days of the nursing home stay.
- GG0130A Self-Care - Eating: The ability to use suitable utensils to bring food and/or liquids to the mouth and swallow once meal is placed before the resident.
- GG0130C Self-Care - Toileting Hygiene: The ability to maintain perineal hygiene and adjust clothes before and after toileting. If managing an ostomy, include wiping the opening, but not managing equipment.
- GG0170B Mobility - Sit to Lying: The ability to move from sitting on the side of the bed to lying flat on the bed.
- GG0170C Mobility - Lying to Sitting on the Side of Bed: The ability to move from lying on the back to sitting on the side of the bed with no back support.
- GG0170D Mobility - Sit to Stand: The ability to come to a standing position from sitting in a chair, a wheelchair, or on the side of the bed.
- GG0170E Mobility - Chair/Bed to Chair Transfer: The ability to transfer to and from a bed to a chair or wheelchair.
- GG0170F Mobility - Toilet Transfer: The ability to get on and off the toilet or commode.
The nursing function score can be 0–16 depending on how each task above is coded at each data element. Zero to four points are assigned for each of the following items: eating, toilet hygiene, an average of sitting to lying and lying to sitting on the side of the bed, and an average of sitting to standing, chair/bed to chair transfer, and toilet transfer. Along with the data collected for each resident during the observation period, the provider will be required to provide documentation supporting that an interdisciplinary decision-making process was used to determine each resident’s usual performance with each of the above tasks on or before the ARD of the MDS assessment being validated.
PHQ total severity score of 11. If the patient interview was conducted and recorded in Section D0500A-I of the MDS assessment, the reviewer will ask to see Section Z0400 to validate that this section of the MDS was signed and dated on or before the ARD of the MDS assessment. If a staff interview was completed, the reviewer would ask to see documentation in the medical record of the date(s) and names of staff member(s) interviewed, the date(s) and name(s) of any family member(s) interviewed, date(s) and details of significant other observations, and the frequency reported for each applicable item at D0500 A-J.