1. ©2009 HP Confidential1 Indiana LTC Case Mix Audits HP Enterprise Services January 2011

2. ©2009 HP Confidential2 What’s New EDS now HP Enterprise ServicesEDS now HP Enterprise Services Frequency of auditsFrequency of audits –Refer to Bulletin BT200936 BT200936 No list of residents with traumatic brain injury (TBI)No list of residents with traumatic brain injury (TBI) No list of residents who receive outside mental health servicesNo list of residents who receive outside mental health services No abbreviation list – if needed, auditors will request.No abbreviation list – if needed, auditors will request. Audits now completed electronicallyAudits now completed electronically

3. ©2009 HP Confidential3 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.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.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.High Risk – 79.9 percent or lower validation rate will be audited every four to twelve months. Refer to Bulletin BT200936 for audit frequency. Refer to Bulletin BT200936 for audit frequency.BT200936 HP audits the minimum data set (MDS) supporting documentation maintained by nursing facilities for all residents, regardless of payer type.HP audits the minimum data set (MDS) supporting documentation maintained by nursing facilities for all residents, regardless of payer type.

4. ©2009 HP Confidential4 LTC Case Mix Audit Process HP provides advance notification to the nursing facility.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 audit includes: –The greater of 30 percent of the total assessments or a minimum of 25 assessments. The facility provides the census list.The facility provides the census list. –The MDS assessments subject to audit are those most recently transmitted to Myers and Stauffer LC.

5. ©2009 HP Confidential5 The audit team conducts an entrance conference with each nursing facility.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.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. LTC Case Mix Audit Process

6. ©2009 HP Confidential6 Alphabetical resident list, which includes the following: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 ListAlphabetic Level II Resident List Current facility e mail address for future correspondenceCurrent facility e mail address for future correspondence LTC Case Mix Audit Process Requested Information

7. ©2009 HP Confidential7 The audit team reviews the following two parts of each record: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.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. LTC Case Mix Audit Process

8. ©2009 HP Confidential8 When the audit team is unable to support a record, the team requests that the nursing facility find supporting documentation.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.The nursing facility must provide documentation to support records prior to the exit conference. LTC Case Mix Audit Process

9. ©2009 HP Confidential9 “If the percentage of assessments of all residents that are unsupported is greater than the threshold percentage … a corrective remedy shall apply.”“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.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. LTC Case Mix Audit Process

10. ©2009 HP Confidential10 The nursing facility must provide documentation to support records prior to the exit conference.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.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 auditedPrior 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.The team then informs the nursing facility that it is ready for the exit conference. LTC Case Mix Audit Process

11. ©2009 HP Confidential11 HP sends the final summary letter to the nursing facility approximately 10 business days following the exit conference.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.The letter details the Summary of Findings and the Final validation rate. LTC Case Mix Audit Process

12. ©2009 HP Confidential12 Informal Reconsideration Process The letter contains instructions for the 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.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.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.

13. ©2009 HP Confidential13 Informal Reconsideration Process The request must include specific audit issues that the nursing facility believes were misinterpreted or misapplied during the audit.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 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.HP forwards final results to Myers and Stauffer LC upon completion of the audit process.

14. ©2009 HP Confidential14 RUG Classifications Extensive Services Extensive Services Rehabilitation Rehabilitation Special Care Special Care Clinically Complex Clinically Complex Impaired Cognition Impaired Cognition Behavior Behavior Reduced Physical Reduced Physical

15. ©2009 HP Confidential15 RUG Classifications Extensive K0500A – Parenteral IV FeedingK0500A – Parenteral IV Feeding O0100D, 1 or 2 – SuctioningO0100D, 1 or 2 – Suctioning O0100E, 1 or 2 – Tracheostomy CareO0100E, 1 or 2 – Tracheostomy Care O0100F, 1 or 2 – Ventilator or RespiratorO0100F, 1 or 2 – Ventilator or Respirator O0100H, 1 or 2 – IV MedicationO0100H, 1 or 2 – IV Medication

16. ©2009 HP Confidential16 RUG Classifications Rehabilitation O0400A 1, 2, 3, & 4O0400A 1, 2, 3, & 4 O0400B 1, 2, 3, & 4O0400B 1, 2, 3, & 4 O0400C 1, 2, 3, & 4O0400C 1, 2, 3, & 4 Therapies: Speech – Language Pathology and Audiology Services; Occupational Therapy and Physical TherapyTherapies: Speech – Language Pathology and Audiology Services; Occupational Therapy and Physical Therapy

17. ©2009 HP Confidential17 RUG Classifications Special Care I4400 – Cerebral PalsyI4400 – Cerebral Palsy I5100 – QuadriplegiaI5100 – Quadriplegia I5200 – Multiple SclerosisI5200 – Multiple Sclerosis J1550A – Fever; J1550B – Vomiting; J1550C – Dehydration; K0300 – Weight loss; K0500B – Feeding tube; I2000 – Pneumonia, included in fever string impacting special careJ1550A – Fever; J1550B – Vomiting; J1550C – Dehydration; K0300 – Weight loss; K0500B – Feeding tube; I2000 – Pneumonia, included in fever string impacting special care

18. ©2009 HP Confidential18 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: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 periodCalories tube feeding provided during observation period Calories oral feeding provided during observation periodCalories oral feeding provided during observation period Percent of total calories provided by tube feedingPercent of total calories provided by tube feeding Calories by tube/total calories consumedCalories by tube/total calories consumed

19. ©2009 HP Confidential19 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 tubeK0700B – 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 ulcersM0300A – 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 UnstageableM0300B,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.Note: Documentation must include staging within the observation period. Each ulcer should have an entry noting observation date, location, and measurement/description.

20. ©2009 HP Confidential20 RUG Classifications Special Care M1030 – Number of venous and arterial ulcersM1030 – Number of venous and arterial ulcers M1040D – Open lesionsM1040D – Open lesions M1040E – Surgical woundsM1040E – Surgical wounds M1200A, B – Pressure reducing device, chair, bedM1200A, 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.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.

21. ©2009 HP Confidential21 RUG Classifications Special Care M1200C – Turning/repositioning programM1200C – Turning/repositioning program M1200D – Nutrition or hydration intervention to manage skin problemsM1200D – Nutrition or hydration intervention to manage skin problems M1200E – Ulcer careM1200E – Ulcer care All impact strings with staged woundsAll impact strings with staged wounds

22. ©2009 HP Confidential22 RUG Classifications Special Care M1200F – Surgical wound care impacting strings with surgical woundsM1200F – 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 woundsM1200G – 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

23. ©2009 HP Confidential23 RUG Classifications Special Care O0100B,1 or 2 – RadiationO0100B,1 or 2 – Radiation O0400D2 – Respiratory therapyO0400D2 – Respiratory therapy – Days and minutes – Assessment – Performed by qualified individuals

24. ©2009 HP Confidential24 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.D0200A – I, 2 – Resident Mood Interview (PHQ-9); minimum documentation – resident mood interview symptom frequency codes are sufficient. MDS will be considered source document.

25. ©2009 HP Confidential25 RUG Classifications Clinically Complex D0500A – J, 2 – Staff assessment of Resident Mood (PHQ-9-OV)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.Documented examples demonstrating the presence and frequency of the clinical mood indicators must be provided during the observation period.

26. ©2009 HP Confidential26 RUG Classifications Clinically Complex B0100-ComatoseB0100-Comatose I2100-SepticemiaI2100-Septicemia I2900 – Diabetes Mellitus included in diabetes stringI2900 – Diabetes Mellitus included in diabetes string I4900 – Hemiplegia/HemiparesisI4900 – Hemiplegia/Hemiparesis J1550D – Internal bleedingJ1550D – Internal bleeding K0700A – Portion of total calories and K0700B – Average Fld per day with feeding tubeK0700A – Portion of total calories and K0700B – Average Fld per day with feeding tube

27. ©2009 HP Confidential27 RUG Classifications Clinically Complex M1040A – Infection of footM1040A – Infection of foot M1040B – Diabetic foot ulcerM1040B – Diabetic foot ulcer M1040C – Other open lesions on footM1040C – Other open lesions on foot M1040F – BurnsM1040F – Burns M1200I – Application dressings to feet, impacting strings with skin conditions of footM1200I – Application dressings to feet, impacting strings with skin conditions of foot N0300 – Injections – impacting diabetes stringN0300 – Injections – impacting diabetes string

28. ©2009 HP Confidential28 RUG Classifications Clinically Complex O0100A, 1 or 2 – ChemotherapyO0100A, 1 or 2 – Chemotherapy O0100C, 1 or 2 – Oxygen therapyO0100C, 1 or 2 – Oxygen therapy O0100I, 1 or 2 – TransfusionsO0100I, 1 or 2 – Transfusions O0100J – DialysisO0100J – Dialysis O0600 – Physicians’ examinationsO0600 – Physicians’ examinations O0700 – Physician ordersO0700 – Physician orders

29. ©2009 HP Confidential29 RUG Classifications Impaired Cognition B0700 – Making self understoodB0700 – Making self understood C0200 – Repetition of three wordsC0200 – Repetition of three words C0300A, B, C – Temporal orientation – year, month, weekC0300A, B, C – Temporal orientation – year, month, week C0400A, B, C – RecallC0400A, B, C – Recall C0700 – Short-term memory OKC0700 – Short-term memory OK C1000 – Cognitive skills for daily decision makingC1000 – Cognitive skills for daily decision making

30. ©2009 HP Confidential30 RUG Classifications Behavior Problems E0100A – HallucinationsE0100A – Hallucinations E0100B – DelusionsE0100B – Delusions E0200A – Physical behavioral symptoms directed toward othersE0200A – Physical behavioral symptoms directed toward others E0200B – Verbal behavioral symptoms directed toward othersE0200B – Verbal behavioral symptoms directed toward others E0200C – Other behavioral symptoms not directed toward othersE0200C – Other behavioral symptoms not directed toward others E0800 – Rejection of care presence and frequencyE0800 – Rejection of care presence and frequency E0900 – Wandering presence and frequencyE0900 – Wandering presence and frequency

31. ©2009 HP Confidential31 Nursing Restorative Program H0500 – Bowel toileting programH0500 – Bowel toileting program H0200C-Current toileting program or trialH0200C-Current toileting program or trial O0500 A, B, C, D, E, F, G, H, I, J – Restorative nursing careO0500 A, B, C, D, E, F, G, H, I, J – Restorative nursing care

32. ©2009 HP Confidential32 Activities of Daily Living (ADL) Assistance G0110A, 1 & 2G0110A, 1 & 2 G0110B, 1 & 2G0110B, 1 & 2 G0110I, 1 & 2G0110I, 1 & 2 G0110H, 1G0110H, 1 Included in coma string impacting extensive services count in clinically complex and impaired cognitionIncluded in coma string impacting extensive services count in clinically complex and impaired cognition Documentation of these ADLs requires 24 hours/7days within observation period.Documentation of these ADLs requires 24 hours/7days within observation period.

33. ©2009 HP Confidential33 Supportive Documentation Guidelines (SDG) MDS 3.0 Effective for assessments dated October 1, 2010, or after

34. ©2009 HP Confidential34 Overall Documentation Instructions Supportive documentation must be dated during the assessment period.Supportive documentation must be dated during the assessment period. Each page or individual document must contain the resident identification information.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.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.

35. ©2009 HP Confidential35 Additional Information for SDG MDS 3.0 MDS 3.0MDS 3.0 –C0200 – Repetition of three words –C0300A, B, C – Temporal orientation – year, month, week –C0400A, B, C – Recall Minimum Documentation Standards –BIMS Codes are sufficient. –MDS will be considered source document.

36. ©2009 HP Confidential36 Additional Information for SDG MDS 3.0 MDS 3.0MDS 3.0 –D0200A-I, 2 – Resident Mood Interview (PHQ-9) Minimum Documentation Standards –Resident Mood Interview (PHQ-9) symptom frequency codes are sufficient. –MDS will be considered source document.

37. ©2009 HP Confidential37 Additional Information for SDG MDS 3.0 MDS 3.0MDS 3.0 –D0500A-J, 2 – Staff Assessment of Resident Mood (PHQ-9-OV) Minimum Documentation Standards –Documented examples demonstrating the presence and frequency of clinical mood indicators must be provided during the observation period.

38. ©2009 HP Confidential38 Additional Information for SDG MDS 3.0 MDS 3.0MDS 3.0 –I2900 – Diabetes Mellitus –I4300 – Aphasia –I4400 – Cerebral Palsy –I4900 – Hemi- plegia/Hemiparesis –I5100 – Quadriplegia –I5200 – Multiple Sclerosis 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)

39. ©2009 HP Confidential39 Additional Information for SDG MDS 3.0 MDS 3.0MDS 3.0 –O0500, A, B, C, D, E, F, G, H, I, J – Restorative Nursing Care Minimum Documentation Standards –Documentation during the observation must include the five criteria for restorative nursing care.

40. ©2009 HP Confidential40 Resources For auditing questions, call HP Enterprise Services Long Term Care Unit at (317) 488-5062.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.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. http://www.indianamedicaid.com.

41. ©2009 HP Confidential41 Q&A