THE M3 REVIEW - ARE YOU READY FOR YOUR CMI AUDIT?

Learn how MDS accuracy, documentation, and CMI directly impact Medicaid reimbursement for Missouri and Iowa, audit defense, and revenue integrity.

Transcript

SPEAKER_00 0:14

Welcome to the pilot episode of the M3 Review. My name is Melinda, and I'll be your hostess. If you have the slide deck, we'll kind of go through that together. Thank you for being here and welcome again. Before we get into the audit side of things, let's talk about how Missouri Medicaid actually is calculated. Because understanding this is a foundation that you need for accurate MDS coding. It matters so much. In Missouri, your Medicaid reimbursement rate is primarily driven by three things. Your case mix index. That's the thing that you control. It is based directly on MDS assessments. Second, your facility's cost report data, meaning your operating cost and allowable expenses. Third, the state applied trend factor, inflation, depreciation, etc. Now, while facilities can't control inflation adjustments, cost reports are historical. One thing you can control every single day is your MDS accuracy. And you need to do that. Because accurate MDS coding can drive a high CMI, and a high CMI can mean significantly increased reimbursement. So when we're talking about revenue, we're really talking about protecting the integrity of the assessment. Now, let's look at what happens when clinical drivers are missed. On slide two, if you haven't, the slide shows exactly why documentation and coding accuracy matter. On the left, we have a resident coded without key clinical drivers being captured. The NADL score is low, limited assistance is documented, no restorative nursing, no depression, no feeding tube, no IV fluids, no specialty treatments, and behavioral symptoms are not captured. That resident falls into a reduced physical function with the resulting CMI of only 0.62, which by the way is default. Now compare that to the exact same or very similar resident on the right. When documentation is complete and the MDS accurately reflects the resident's true clinical picture, then you can have an ADL score increased to 14. Extensive assistance is captured, special care high is triggered, restorative nursing is captured, which is rare. Depression is captured, feeding tube, IV fluid, specialty treatments, behaviors, all of those are documented and supported appropriately. And look at the CMI, 2.12. I will tell you that is very high. That's not gaming the system. That is an accurate reimbursement for the care that's actually being provided. The difference between 0.62 and 2.12 can be massive financially. This is why misinformation, poor documentation, and miscommunication between departments absolutely destroys your case mix. So what's this mean in dollars? Let me tell you. This is where administrators really start tuning in, usually. You know, every CMI point matters. And it all translates to dollars. You take two quarters of your CMI, average those together, and that is what's used for your Medicaid rate. Even a 0.01 increase in CMI can add approximately two to three dollars per resident per day. And that may not sound like much, two dollars per day per resident. But over time and across multiple residents, that really adds up. A CMI drop of 0.1 can equal roughly $3,600 to $5,400 per resident over six months. So if you multiply that in a 30-bed Medicaid census, the facility could lose between $110,000 and $164,000 in six months. Now that is significance. And remember, that's not from survey tags, that's not from penalties. That is simply failing to capture and support what you already do, what's already in the medical record. When people say, oh, it's just one diagnosis, or I guess we missed that, that's money walking out your door. What exactly are the clinical drivers that you should be looking for? Well, I'm gonna tell you some of them. When I audit an MDS assessment, these are some of the most common areas I'm reviewing for reimbursement opportunities and accuracy. Uh cerebral palsy, multiple sclerosis, pneumonia, sepsis, hemoplegia, or hemoparisis. Parkinson's. In Missouri, sometimes make sure that it's Parkinson's and not Parkinsonianism because they don't recognize that. Respiratory therapy, oxygen administration, COPD, asthma, or other restrictive lung diseases. We'll get into that more because I want to make sure you're doing restrictive lung disease. Diabetes with insulin or order changes, depression, impaired cognition, and then there are services that will increase your CMI, like IV fluids, IV meds, isolation, ventilator, respiratory support. You know, you've got CPAPs, tracheostomy care, radiation or chemo, dialysis or transfusions, there's special rules to support all these things if you claim them. Feeding tubes, pressure or venous ulcers, you know, they must not just exist, these drivers, but you must be able to validate them, support them in your medical record. You know, you you must code them correctly because if it's not documented, it didn't happen. And if you don't capture it on the MDS, you're not going to get paid for it. One of the biggest mistakes I see that facilities make is confusing completion with defensibility. That's not the same thing. A clicker will not help you. And there's lots of clickers out there. Just because an MDS is completed and transmitted doesn't mean that it's accurate. It doesn't mean that it will survive an audit. Every MDS coding item must be supported by documentation in the medical record during the required look back period. And you know there's different look back periods. That includes diagnoses, clinical category qualifiers, your ADL, and your section GG coding. If the primary diagnosis, the clinical category, or the functional documentation cannot be validated, the entire MDS loses value for reimbursement and audit defense. Why does this matter? Because every CMI grouper used for PDPM, except non-case mix, relies on at least one of these things. The diagnosis, the functional status, the supporting clinical documentation. The key takeaway is simple. If your diagnosis or your ADLs cannot be supported in the medical record, then the MDS will not be accurate. It will not pass audit defense. It will not support the appropriate case mix classification. A defensible MDS is not just completed, it is documented, it's validated, it's supported, it's audit ready. I keep saying that, but it's true. Let's break down how the nursing case mix groups are structured. This will help you understand, you know, the hierarchy of things, maybe. When we are talking about Medicaid case mix, understanding this is critical. That means the resident will classify into one of these categories, the highest one that they qualify for. Number one, extensive services. This includes high acuity services like isolation, ventilator, tracheostomy care. Number two, special care high. Things like chronic lung disease with qualifiers or IV feeding. Number three, special care low. This can include oxygen combined with respiratory failure and other qualifiers. Number four, clinically complex. Common examples include pneumonia, IV meds, or oxygen services, depending on the overall clinical picture. I want you to notice the difference between clinically complex and special care low when you're using oxygen. Because if you have respiratory failure with that, it goes up to special care low. Number five categories behavioral and cognitive performance. This is when residents land when they have behaviors, cognitive deficits, and when the higher clinical qualifiers are not there. And last is reduced physical function. This is where everybody else lands. And unfortunately, where residents fall when opportunities are missed sometimes. Understanding the hierarchy is critical because if you miss one qualifying service or diagnosis, your resident can drop multiple categories. Occasionally, the reduced physical function category has a CMI higher than clinically complex. What you need to worry about is just accurately coding your resident. Where does it all begin? Start with selecting a primary diagnosis. The first step in building an accurate and defendable MDS is always this. It's always selecting the correct primary diagnosis. And this is where I see major mistakes. It may or may not be the hospital diagnosis. You must scour all documentation available. This includes your hospital progress notes, the HP, summary of illness, the current problem list, active diagnosis list, discharge summaries, dietary notes, medication lists, physician notes, etc. And sometimes the hospital says things are resolved and they're not. If you have clinical documentation to support that things are not resolved, then you may use them. For PBS assessments, CMS uses some diagnosis as covariates for the you know for the discharge function score. Diagnosis selection matters. Code every diagnosis you can support and validate because you may not get revenue directly from it, but it may lower your discharge function score that CMS expects you to discharge that resident with. Does the acute condition prevent the discharge home? What were they in the hospital for? Is it a continuation of hospital care? You know, for instance, it's not always the same, like I said earlier. Aspiration pneumonia due to dysphagia after a stroke. You had a rehab-to-home patient here last year. They went home, they had dysphagia while they were here, they were treated, rehab to home success story. Now they're in the hospital with aspiration pneumonia. What are you going to claim on your MDS as primary? I'm going to claim stroke. Another example would be a resident that has a neuromuscular disease and COPD. Why are they at your facility? Are they at your facility because they were in the hospital for an exacerbation of COPD? Probably not. If they have an underlying neuromuscular degenerative disease, they might be at your facility for that because they can't go home. They're too weak. All of these details matter. Best practice, review the diagnosis list with each quarterly OBRA assessment. I used to print out the diagnosis list and give it to the physician when they made rounds. They could mark out what the they didn't consider to be current anymore. You had a signature and a date. Remember, any diagnosis coded on the MDS must be active and affect the resident's care and life, you know, threat of illness and death in the seven-day look back period signed within the last 60 days. Not historical, not resolved, not assumed. Once you identify the diagnosis, the next step is always going to be to validate it or support it. This is where some facilities get into trouble. They mark and they click and they just move right on. And you can't do that, especially if they're going to be a reimbursable item. I would for sure make sure I can support it. Just because it's in the chart somewhere doesn't mean that it qualifies for coding. MDS diagnoses must be active. We just went over that. They must have a direct relationship to the residents' current treatment, monitoring, care plan interventions. So I always ask the facility, why are they in your facility? What are they being monitored for? What are they receiving services for? Nursing care. You may not be able to code it if you can't validate those things. Because if it's not supported, it'll be denied in an audit. And the reimbursement tied to that diagnosis disappears, and then you may have to do paybacks. Once you've identified and validated a diagnosis, the next step is making sure that it meets the MDS active diagnosis criteria. As we've said, you must have the documentation to support it. Now that means that your charting should reflect the signs and symptoms of the treatment. You can't always relate a diagnosis to a medication or treatment. Most of the time you can, but sometimes you can't. So your charting in the appropriate look back period should say what you're doing for that resident because the whole purpose of this is to be able to demonstrate to CMS or Medicaid auditors what you're doing for the resident so they know how to pay you. You can't just have a declarative diagnosis. So if you have leg or calf pain when ambulating, that does support peripheral vascular disease. A chronic cough may support chronic obstructive bronchitis. You would need more details because a cough can mean so many things. A recent blood transfusion may support anemia, and your documentation should tell a story. For instance, CP, you know, sometimes there's no meds for that. Frequently there's muscle relaxers, but sometimes there's nothing. And if you have nothing, then you chart, you know, what you're doing for the resident. If they're paralyzed from a CBA and there's no way to validate it with medications or things, you're going to chart that they're paralyzed on what side or whatever, you know, no motor function, depend on staff for all cares, can't have purposeful movements or whatever the case may be. That supports hemoplegia, hemoparesis. You can't just make a diagnosis appear somewhere and expect it to be supported. Now let's move from diagnosis validation to treatment validation because sometimes treatments will validate for us. This is another major area where facilities leave money on the table. Documentation must support the treatment because you know some treatments are reimbursable. And many services require very specific documentation. For instance, respiratory therapy, you're going to need evidence of training of your licensed nurses that provided all the required modalities. I don't like this because we just went through a respiratory pandemic and nobody questioned whether or not we were trained on respiratory interventions. I don't like that we have to prove that now for reimbursement. PRA and oxygen. For Missouri Medicaid, you must document the precipitating event requiring oxygen use. That's difficult. You know, as a charge nurse working the floor, if I was going down the hall and somebody needed some O2 and I slipped it on them, I may not get all that documented. Now we have to document what the precipitating event was. The reason you put that O2 on that resident, if your MAR says keep O2 SAT above 92, da-da-da, and it has a block for you to put the SAT in, that's enough documentation that will cover you. But if your MAR just says PRN oxygen, keep SAT above 90, not gonna work. There's not enough details there for Missouri Medicaid. You need documentation of the precipitating event requiring oxygen, if it's PRN. Pressure ulcers and skin lesions. The wound diagnosis, staging, and location must be during a look back. That's not easy all the time. Let's say they go to the wound clinic on certain days of the week. You're gonna need to move the day to that MDS because you're going to want their documentation. You must have the wound diagnosis, the staging, the location, the symptoms, the drainage, the odor, the description, all of that in the look back. And you don't usually have that randomly. That has to be planned out. It is absolutely worth doing because it does affect your CMI and you're doing the work. So plan it out so you can capture it. Dialysis or radiation, specific, specific documentation requirements here too. Dialysis, you must have, same way with radiation, you must have documentation from the facility that's performing it for the resident. You must have something saying that it happened. You know, sometimes the people get in the van to go somewhere and they don't ever get there. I've had a facility that's had a van wreck before. Not good. But sometimes stuff happens and they change their mind or they go back or whatever, or their family was supposed to take them somewhere and something didn't happen. So you must have documentation from the facility saying the dialysis or the radiation took place. For dialysis, you can use weights before and after if it's documented. But for radiation, you're going to need that other kind of documentation from the provider. Hallucinations, delusions, wandering, the dates and examples of those behaviors must be documented. In restorative nursing, you need licensed nurses and evaluations and evidence of the program. You know, you have many, many details you have to fulfill. And that is very difficult to prove. I rarely see restorative nursing claimed on an MDS because of that. The details are many that must accompany restorative nursing for an MDS capture. You know, a lot of times the service may have happened, and you need to keep giving these residents restorative because they deserve it and they need it. You're just not going to be able to capture it if you don't follow all the rules. One of the biggest drivers of Missouri Medicaid, as you know, is your ADLs and your GGs. Section GG and ADL documentation can make or break you. Supportive ADL documentation is required during the appropriate three-day look back window. And it does vary. If you are in Iowa, you have default scores for discharge assessments and things that go into your CMI. So make sure you do the appropriate ADL documentation for the three days required. The window for a SNF PPS assessment starts on the first day of the SNFs day. Sometimes that's not the admission day. It usually is, but sometimes it's not. For over admissions, it's the entry date plus two days. That's your ADL assessment window. Your supportive documentation and IDT notes should accurately capture the resident's usual performance. CMS expects qualified clinicians. You can use care staff. I have seen ADLs validated by the aid charting one time. Even the family can input when it's appropriate. Sometimes you're not going to be able to get anything out of the resident. You can interview family, you can watch. You can help determine the resident's usual function. And you need to note that. Remember, if it's not documented, it wasn't done. I do a note. For instance, I say restorative therapy and PT and nursing, reviewed residence, GG abilities, and residence usual performance was applied to MDS date, etc. etc. Best practice is to document the discussion you had about the ADLs because they expect to see that in the medical record. If you're going to use narrative notes, they should align with the MDS. And if you're going to use narrative notes, that's a lot of typing. I would use an ADL tool if at all possible. The wording must align with the MDS definitions. For instance, if it was eating, it should describe whether the resident needed utensils brought to them, food opened, queuing, physical assistance to bring food or liquid to the mouth. It's very detail oriented, so use those ADL assessment tools when you can. It can trigger audits. Now sometimes the documentation is close, but not quite specific enough to support accurate coding. You cannot provide the best picture of your resident and you want to dial it to precise, and that is good. This is where a physician query comes in. A query is a written communication to the physician requesting clarification or validation of a diagnosis so that the coding and the reimbursement accurately reflect the resident's clinical picture. But there's a few things you must remember. First, remember ICD 10 codes drive reimbursement. So specificity matters. Second, queries must provide the physician choices. They cannot be leading. If your query suggests only one answer, it becomes a leading query and can create compliance concerns. Great example. Your residence on oxygen. You should consider whether or not a respiratory failure query is appropriate. We recommend them. Ask whether the oxygen is related to your respiratory condition or perhaps a cardiac condition. The goal is not to find the reimbursement, the goal is to have accurate clinical clarification. I provide the physician with. Choices, at least three, so that it's not a leading query. And as always, if it isn't documented, it isn't captured. And on the slide, I give an example of what an effective query looks like in practice. If you have a slide deck, I hope you have the slide deck because they're great slides. In this slide, this is a real-world example of a resident who has dysphagia following a CBA. The current diagnosis may not fully reflect the clinical picture. In fact, it's an R code. So the nurse formulates a non-leading query to the physician asking whether a more specific ICD 10 code would be appropriate. Notice what makes this effective. It remains non-leading, it provides multiple clinically appropriate options, and it supports accurate coding and reimbursement. This is not about phishing. It's about painting the clearest and most accurate picture of the resident's condition. And often that accuracy protects your reimbursement. Let's talk about the interviews on the MDS. One of the most common timing issues I see on the MDS are the interviews. These interviews must be completed before or on the ARD. And there's several of them. It's the demographic items, health literacy, the BIMS cognitive interview, the mood interview, the pay interview, activities, swallowing, discharge planning. And remember, if the resident can't complete these interviews, then there are staff assessment options, but you still must follow the timing rules. And because late interviews can impact coding accuracy, compliance, reimbursement, I know they seem like paperwork and it's crazy to have to do all these things, but they do affect outcomes. Quality measures, survey risk. You're going to want to do those. And what happens if they're late? It's not fun, but it's simple, and that is you can't use them. I had an MDS coordinator just tell me they they go in and they do them, even if they're late, and they use it on the MDS, and you cannot do that. That will not work at all. You must paint an accurate picture of the resident's voice, their preferences, their mood, their pain, their cognition. And some interview sections will default to staff assessment pathways or alternative coding pathways, and those pathways can affect reimbursement too. Quality measures for sure. In some cases, APU compliance, care plans. The resident interviews cannot be completed after the ARD. It's just that simple. And it's one of the easiest things to fix. Maybe I should say one of the easiest things to be in compliance for. And one of the easiest things to miss for sure. Let's talk about some specific Missouri validation requirements. These are critical. For isolation, the resident must be in a room with no roommate documented, and active infection precautions above and beyond standard. All services must be provided in the room. And by the way, you can't take a resident outside to smoke and still code isolation. Yes, I have seen that. You probably should have an order to show these things and make sure you're following all the coding rules for isolation because if the resident has C diff and they got the C diff from antibiotics, then you cannot code isolation for that. You can look that up in the RAI manual. They have to meet all three requirements, and it has to be a community-acquired infection. Most of our C diff residents do not get it from the community. So there's that. For sepsis, there must be documentation of an inflammatory process and evidence of a microbial process. Otherwise, you're just going to have to capture the underlying infection. And if you need to know what an inflammatory process is, refer to the RAI or the Missouri SDR, the supplemental documentation requirements user guide. For shortness of breath, there must be evidence or observation when laying flat for the shortness of breath. If you're going to say that your resident is short of breath, you must list the symptoms or documentation of the avoidance of lying flat to prevent symptoms. This triggers the special care high nursing CMI category. If your resident has a chronic lung disease and they avoid lying flat. So those are very important that you substantiate and validate those. Let me tell you what some of the chronic lung diseases are that is recognized: emphysema, COPD, chronic bronchitis, pulmonary fibrosis, etc. For pneumonia, there must be active treatment. It used to be that if your resident went to the hospital and they came back with the diagnosis of pneumonia, you could code that as your primary diagnosis, even if they were no longer being treated. You cannot do that for Missouri Medicaid. They don't care that your resident's body has been wrecked by the pneumonia and now they're debilitated. There must be active treatment. The requirements for frequently coded diseases don't stop there. For oxygen therapy, if it's period, like I've said, you must have the precipitating event. Having an oxygen order is likely not enough. For pressure ulcers, particularly stage 2, 3, 4, and unstageable, you need wound identification, location, description, all those things I mentioned before. We must be able to capture all of those things in the look back period. For venous or arterial ulcers, the wound must be identified correctly as venous or arterial in the look back period with location, description, all the things. For diabetic foot ulcers, you need the wound identification that it's a diabetic foot ulcer in the look back period with location and description. And I just want to add, if you are trying to say that a pressure sore on a heel is a diabetic foot ulcer, be very careful. Refer to the RAI manual for that because it talks about that specifically. I think you would be hard-pressed supporting that. And for other foot lesions, they must be open. And again, documented with location and description. This is where generic wound charting can really hurt your reimbursement. Don't get caught in that trap. For dialysis, like I said earlier, you must have proof that the treatment was actually received, not just transportation, not just intent. Pre- and post-treatment weights are sufficient. The level of detail matters because Missouri Medicaid validation is not based on assumptions. It's based on documentation and what you're actually doing for the resident. If it's missing, the reimbursement is lost. And this is exactly why internal audits are so important because you can then identify what you're missing and where you're losing money. For surgical wounds, the wound must be identified specifically as a surgical wound with location and description. Frequently, I will see surgical wound marked and not surgical wound care, or I will see surgical wound and wound care marked when all you're doing is observing, and that does not count. For restorative nursing, this is frequently missed, and it's because you do not have all the documentation in place. And I encourage you that if you don't have all the documentation for restorative nursing, do not claim this on your MDS. Your documentation must support the frequency, the modality, the days, the measurable objectives, the licensed nurse evaluation, staff training, nurse supervision. It's a lot to capture restorative nursing on the MDS and make sure you can fulfill all the requirements of the Missouri SDR if you're in Missouri or the RAI manual if you're elsewhere. Some states have their own SDR. Missouri's one of them. Louisiana's one of them. There are others. On to restrictive airway disease examples. This is a common mistake I see. Facilities misunderstand what qualifies as a restrictive airway disease. Restrictive airway disease is a condition that limits lung expansion or impairs ventilation. Like I said earlier, it's COPD, emphysema, chronic bronchitis, silicosis, I've never seen that coded in our world. Pulmonary fibrosis, asbestosis, sarcoidosis, there's probably others. These diagnoses can support certain clinical qualifiers when properly documented, but you can't just code COPD alone. You have to have the symptoms. You know, if you're gonna say someone has a restrictive lung disease, you must code their symptoms. And please just don't write their short of breath when lying flat. CMS and the auditors want to see these symptoms, not just a statement. Okay? Not all lung-related diagnoses qualify as restrictive airway disease. Many of them are cardiothoracic type things. This is where I see a lot of errors. A lot of non-restrictive conditions that I see coded here, and they should not be, is pulmonary edema, pulmonary hypertension, CHF, pneumonia, pulmonary embolism, lung cancer, bronchitis. Now, I think lung cancer sometimes is restrictive, but you're gonna have to have documentation from your physician stating that, and then you can challenge that. Notice that bronchitis is on this list. If if you have the slides, you can see this. Bronchitis is not a restrictive airway disease, but chronic bronchitis is, and that's in the RII manual. These conditions absolutely affect the care that we give, they impact reimbursement, but they don't meet the restrictive airway disease qualifiers by themselves. That's why diagnosis and understanding the RAI manual definitions are really important. On the slide deck, I went into more detail about the documentation language matters when you're trying to prove one of these things. And the reason I did that is because if you have a restrictive airway disease and shortness of breath, you will be in the special care high category. That's highly reimbursable. So let's make sure if that applies to your resident, you're doing it right. The wording used in the medical record can determine whether or not the intervention supports the coding. And there's a big difference between charting vague statements and charting language that clearly supports the resident's clinical condition. Wording matters, consistency matters. Because when you have unclear documentation, that creates doubt and doubt cost reimbursement. So let's bring all of this together and review one more time. If you're going to claim that you are doing interventions for the resident to prevent shortness of breath, which the RAI manual says we can do, you need to have specific charting, like head of bed elevated to prevent shortness of breath, pillows used for positioning to prevent respiratory distress, resident sleeps in a recliner to prevent shortness of breath when laying flat. That language supports the intervention, but vague wording will not work. It doesn't do that. Statements like interventions that may alleviate shortness of breath or encourage residents to elevate their head or does the resident have the head of their bed elevated? Positioning may improve their breathing. That doesn't work. The same happens when you're trying to capture chronic lung disease and restrictive lung disease symptoms. The documentation must clearly describe the symptoms that you observe. It's not always enough just to put, like I said earlier, that little tidbit in the chart, they have shortness of breath. Some examples, shortness of breath when lying flat, they have an increased respiratory effort when repositioned, use of accessory muscles when breathing, labored breathing, put in their respiratory rate, put in that they're having difficulty, put in that they're having any kind of cyanosis, or if their O2T falls. Those are observable, reportable symptoms that support your diagnosis. And you don't want to use vague statements. You don't want to not include your symptoms because you need those. I cover this extensively because it is so important and it comes up a lot. Now I want to talk about BIM scores and dementia and how you validate cognition. It used to be that if you had a diagnosis of dementia and in impaired BIMs, you could code and click on the MDS accordingly. You can't do that anymore. I mean, this is critical. A dementia diagnosis does not automatically define current cognition. Dementia diagnoses vary widely in severity, and there's lots of variations in dementia, and there's lots of kinds of dementia. And some residents with dementia may still do well on the BIMs. You know they hide it for a long time if they can, and I would too. The MDS coding requirements for cognition vary by item. There are three items: B0700, C0700, and C1000. B0700 must be validated and supported on every MDS, every resident, every time. You can't get around that. Let me say that again. B0700 must be supported on every resident MDS every time. And B0700 is how does the resident communicate? Put it in the charting in the look back period. Do they talk? What do they say to you? Put that in quotes. Put it in first person, put it in quotes. That's the grammar rules you may have heard me reference in the past. If they throw things, if they use a dry erase board, if they use hand signals, if they use sign language, you must validate and chart in the look back period how the resident communicates every single time on every Obra MDS. If on C0100, C0100, you put that you cannot interview the resident, you are going to have to validate C0700 and C1000. And those are different cognitive ability questions. C0700 is what the resident can recall after five minutes. And C1000 is the overall cognitive ability of the resident. Let me say that again. You're going to have to make an entry for B0700, C0700, and C1000 if you cannot interview the resident. Now, I guess it could be one entry, but you're going to have to address those three items in the entry. You're going to have to state how the resident communicates. You're going to have to put in your in your charting what their memory recall is for five minutes. If they have no memory recall or they don't talk to you or they don't respond, you have to put that in there. If they're not interviewable and you're forced to validate and support the second two steps, which is C0700 and C1000, you have to answer the questions. C0700, you know, you can walk in and say, hello, Mrs. Smith. Dinner is at five o'clock. Are you going to have the chicken or the soup? And then you can talk about her daughter and you can talk about what they did for activities. And then you can say, Do you remember what I said about dinner? And make sure you chart what the resident's response is. But also make sure you put it in your note that you waited five minutes. That has to be in there or it will not be supported. The reviewers need to know that you waited five minutes. And regarding the C1000, C1000 is about whether or not the resident knows the general activities and knows what's going on in their world, if they have appointments, what day it is, you know, you know, things like that. You have to validate that also. On the slide deck, I gave 12 text-heavy slides with examples from charts that I have procured in the business and examples of great charting, not good charting, where they got all three things right, where they got none of it right, and it's it's all in there for your use. The big takeaway here for cognition is don't assume that the diagnosis validate the cognition. The documentation and the observations must support the resident's actual current cognition. The examples of the text, the charting, they're meant to teach you the language that the auditors are looking for. So if you need to pause and rewind and review, please do that because these are very important sections. Can an MDS be thrown out because cognition was not validated? And can it affect your CMI? Absolutely. I haven't seen that happen yet. And the reason I think is because nobody gets everything right up to cognition. I've not seen that. I've not seen, oh my gosh, you guys did everything right. You've got all the GGs and all the diagnosis, and you can support everything else on the MDS, but cognition. I've not seen it ever reach that point. Usually the facilities have too much trouble with the preceding things, but they must validate cognition, and it is specifically covered in the Missouri Supplemental Documentation Requirements User Guide. The slide deck does have an example of some direct charting that I sent to Myers and Stoffer and their response. When you have to interview the staff for cognition, that's also covered. Staff interviews and observations should not be used just because the resident interview is inconvenient or you forgot, and I have seen that done. You use those when you cannot talk to the resident, or they're truly rarely or you know never understood. The resident interview should always be attempted, not just for convenience. Sometimes the staff defaults to the staff interviews because it's easier and because the resident has dementia. Don't do that. Try. If they don't communicate with you, that's what needs to be in the medical record. And when you're charting staff interviews, I want to make sure that you don't use any summarizing words. Like staff feels resident often, or sometimes, or usually, or always. Those are subjective. Don't use those words. Your documentation should support exactly why the resident interview was not completed. The examples on the slide deck show the difference between good documentation and poor documentation, and the goal is accuracy. Remember, one thing I wanted to remind everyone your payment source might not be Medicaid primary. You might have VA, you might have Medicare Part A, you might have managed care. But if A0700, the Medicaid number, is filled out on the MDS, or there's a plus sign indicating Medicaid pending, that MDS goes into your CMI calculations. The CMI from those assessments will count towards your Medicaid CMI as long as that A0700 has a number in it or plus. In Iowa, OBRA and PPS assessments should be separated for accurate Medicaid calculations. And in Missouri, when you're doing your draft rate listings, make sure you change anybody that says Medicare to Medicaid if they have Medicaid in the background. That's a potentially big financial impact. Again, I know that sounds crazy, and I have got some pushback on that, but I do have it in writing. You need to change anyone that's Medicare to Medicaid if they have Medicaid in the background. So if they're part A, but they also have Medicaid or Medicaid pending, change that on your draft rate listings in Missouri. Don't forget, you have the opportunity to do extra assessments at any time. When your clinical picture changes for your resident, you have an opportunity to do a new assessment to capture those changes that impact case mix. If the resident develops a new condition or begins receiving a service or a new intervention, please consider doing a new MDS. There's currently no strict regulatory time constraints limiting how often you can do these. And best practice is to use quarterly assessments strategically. I've done them a week apart. If the resident changes and they don't fit the sig change criteria, but you want to capture something, do it. If they fit the sig change criteria, do it. Your MDS must reflect the current clinical status and the services being provided. This is one of the easiest ways to avoid leaving money on the table. Let's talk about one of the most expensive mistakes the facility can make. The default rate trap. Missouri Medicaid sets automatic default rates when no assessment is submitted. Or when the assessment cannot be supported. Iowa has default rates too. Look at the difference in these rates. A default rate of 0.62 may reimburse around 62 bucks and 75 cents per resident per day. A very common state average of 1.10 reimburses at $111.35 per day. That's a Loss of $48.60 per resident per day, about $50. That equals $1,400 per resident per month. So take $1,400 times your Medicaid census, and that's how much you might be losing per month. Default rates hit your bottom line hard, and they're often preventable. Misdiagnoses have the same effect. On the slide deck, I have a slide that shows how misdiagnoses can create dramatic reimbursement loss and a big difference in the CMI. When the correct diagnosis is captured, whether it's respiratory therapy, chronic lung disease, respiratory failure with oxygen, your CMI can fall significantly from the higher ranges if it's not captured. When those diagnoses are missed, I have it in the slide, they fall off a reimbursement cliff. And that is true, that's huge, and that's why I say it. Capture the clinical complexity that already exists. You can do it. How do you protect against this? Your facility must have a CMI safety net. A strong CMI program creates this. It includes routine MDS documentation review, strong interdisciplinary communication. I have a home that has a meeting every day at 3 o'clock. Now that's a lot, and I'm not saying everybody can do that, but they do. I think their CMI is 1.4. Ongoing nursing documentation education, regular CMI monitoring. And the goal is not to upcode, the goal is to accurately capture the clinical complexity that already exists. You know, you're going to have to do queries, you're going to have to dig in charts, you're going to have to talk to families. Make sure you get the details. When your facility builds processes around communication, education, monitoring, it protects reimbursement and strengthens audit defense. And with that, I thank you for attending. I hope this course has helped you better understand how to protect your facility's reimbursement and be prepared for audit defense. Remember, revenue integrity, clinical excellence, and defensible results. That's what we provide. If we can help you, let me know.