How MDS Coding Impacts Clinical Reimbursement in Nursing Centers

Because of the unique and complex nature of the MDS process, many nursing center owners and operators are unaware they have a concern with coding until it's too late. This realization comes one of two ways: through the revenue side, or from medical record audits by an external reviewer.

Knowing what key data points to focus on will provide a helpful overview and help identify weaknesses.

To understand if your coding is negatively impacting reimbursement, follow these steps focusing on two areas -- the ARD and the HIPPS code.



Assessment Reference Date (ARD) Selection
The most important question and answer on the MDS is A2300, which is the opportunity to establish the common end point of each question on the MDS.

The look-back period varies throughout the MDS, so selecting the most optimal ARD is extremely important. The ARD determines what dates are within the look-back for each question and therefore what information can be included.

The 5 Day MDS completed for Medicare Part A residents (and some Managed Care) allows you to choose from a range of days to pick the ARD. It is up to you to make this determination, and there is no right or wrong answer if it falls within days 1-8 of the skilled stay. While there is no penalty for what date you choose as the ARD, there certainly can be financial impact.

Two Keys to ARD Selection

• Don't get in the habit of using a "standard" or "routine" ARD like day 7 or day 8 for each MDS.
• Know what you are trying to capture. Services in the hospital or care during the skilled stay can impact the HIPPS code and, ultimately, payment. Understanding this prior to ARD selection will help ensure you choose the correct look-back period, which captures the most acute clinical picture of the resident.
  
  

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• 1= 5 day MDS
• 0 = IPA MDS

• First letter = PT/OT group
  
• Second letter = ST group
• Third letter = Nursing group
• Fourth letter = Non-therapy ancillary group (NTA)

Because there is an infinite combination of letters that an make up a HIPPS, knowing which letters to focus on while looking for patterns or trends can be helpful. Here is a breakdown:

Step #1 using the ST group:

• 12 designations for the Case Mix Index (CMI): A (lowest) - L (highest)
• If the second letters in the HIPPS have more A and D, then you are capturing 0 or 1 of the potential 5 qualifiers, the lowest of the 12 CMIs

Step #2 using the Nursing group

• 25 designations for the CMI: A (highest) - Y (lowest)
• If the third letter trends R-Y, not much clinical acuity has been captured

Step #3 using the NTA group

• 6 designations for the CMI: A (highest) - F (lowest)
• 82 potential points based on capturing diagnosis, procedures, treatments and clinical conditions on the MDS
• The more points captured, the higher the case mix
• If the fourth letter tends to be E or F, you have captured 0-2 points