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Triple-check reviews are a compliance cornerstone. In Part 2 of this two-part series, compliance auditors offer suggestions based on common problems they find in facility triple-check systems:

* Scrutinize final validation reports.

Technology has given many providers a false sense of security about whether or not the CMS database has accepted an MDS, says Judy Wilhide Brandt, RN, BA, RAC-MT, president of Judy Wilhide MDS Consulting in Virginia Beach, Va. “Few software systems have a way to ensure that the MDS has been accepted into the CMS database. Typically, the MDS coordinator transmits the data, and CMS provides back the final validation report, which is the only security that the assessment was accepted. Then that MDS coordinator goes to the facility’s software and answers, ‘Has the MDS been accepted? Yes/No.’ So when the business office looks into the software to see if the MDS has been accepted, they are taking the word of the MDS coordinator who pushed a button in the software.”

That process is subject to human error, points out Brandt. “For example, when MDS coordinators get very busy, sometimes they feel like they don’t have time to immediately check the validation report line by line. So they indicate in the software hat the MDSs were all accepted, and they plan to go back later to check the report, but that never happens. In Medicare compliance audits I do around the country, once or twice a quarter I will uncover assessments that were never accepted into the CMS database but the claim was already billed. It’s always a big surprise to the facility—and always a situation where the MDS coordinator had something more important to do on that day than check the final validation report line by line.” (Learn how to read final validation reports here. Learn error message definitions here.)

* Pay attention to physician certs/recerts.

“A valid physician certification/recertification is a technical requirement for Medicare Part A services,” says Brandt. “You aren’t supposed to bill the claim if you don’t have the cert/recert on file.”

However, many providers, especially those that have never endured a medical review, tend to become lax about certs/recerts, says Brandt. “The preprinted forms that providers often use have lines and checkboxes for a reason. You have to write in the continued need for skilled care, the plans for home care, the estimated time, and whether or not the stay is related to something that was treated in the hospital or something that arose while in the SNF. If the physician just signs at the bottom and no one fills in all of the required information, then you don’t have a valid cert/recert.”

* Pay attention to all physician signatures.

While physician certs/recerts are a perennial problem area for SNFs, meeting signature requirements is an across-the-board issue on all documentation, points out Amie Martin, OTR/L, director of operations for Proactive Medical Review in Evansville, Ind. “From a physician’s standpoint, providers often obtain signatures, but they fail to obtain corresponding dates, for example, on physician orders and therapy plans of care. Recently, this has been a particular issue for providers undergoing Part B therapy medical reviews (e.g., recovery auditor reviews and over-threshold reviews). Auditors require providers to validate that the physician was providing timely oversight, and having physicians date their signature is basically your proof for the timeliness.”

* Issue Medicare beneficiary notices correctly.

Providers sometimes issue beneficiary notices incorrectly or even issue the wrong notices, which is invalid notice, says Brandt. “For example, some facilities go years issuing denial letters for Part A residents when they should have been issuing the notice of Medicare noncoverage.”

Most often, this type of catastrophic failure results from a combination of factors, starting with inadequate staff training, says Brandt. “In addition, these providers often don’t have a robust compliance program. So if the providers have never been in medical review and the state surveyors aren’t as up-to-date as they should be, issuing the wrong notices or issuing them incorrectly can be a long-term problem that isn’t corrected until the providers undergo medical review and claims are denied for invalid notice. They assume the surveyors would have said something if they’d been doing it wrong, and that’s not a safe assumption.”

* Have a clinician validate ICD-10 coding.

“Problems with ICD-10 diagnosis coding often occur when the staff member who is assigned to validate or even select the codes initially is a nonclinician (e.g., someone from the business office or medical records),” says Martin. “You really need someone with a clinical background, such as the MDS nurse or a designated admissions nurse, who has been trained in ICD-10 coding.”

The issue with nonclinicians is that “they often just carry over codes that were appropriate for the acute-care setting but aren’t appropriate for the SNF setting,” explains Martin. “That was a problem with ICD-9, but it’s even more of a problem with ICD-10 now that there is so much specificity. Quite a few facilities have relied on software to bridge ICD-9 and ICD-10, but you still need to go in and validate those codes because GEMS (general equivalence mapping) isn’t going to cover every scenario. If you rely on the software to make the selection for you, very often it will revert to the most basic code. You then have to go in and select the specificity based on the resident detail (e.g., laterality, stage of healing, etc.), and that really takes reviewing the medical record.”

Further, a clinician is able to ensure that “the physician’s documentation is clinically validating the codes that you’re selecting,” she points out. “In addition, if therapy is your primary skilling service, you need a process for making sure that the diagnoses are pulled together from therapy, and that all of the diagnoses used on the UB-04 are tied together with Section I of the MDS. Diagnosis coding involves a lot of coordination and good systems, and the triple check can bring all of that together in a formal way.”

* Check for documentation quality, not just its presence.

“It is rare that I find an internal audit system where the organization is already making a point to read for quality and not just the presence of documentation,” says Brandt. “For example, many providers that do triple-check reviews ask, ‘Do we have a therapy evaluation, progress notes, and discharge summaries?” But they don’t often ask, ‘Do the notes support the level of care we billed?’ Similarly, they might look on a computer dashboard to see, ‘Yes, we have a nursing note for every day.” But they fail to read to see what those nursing notes say and if they would support a skilled level of care in a medical review.”

Once providers conquer the technical aspects of triple check, “I really push them to move toward tying clinical content review into their program,” agrees Martin. “That is the long-term goal: to work toward not just making sure, for example, that every piece of your cert form is completed, but actually reading it for content as part of your ongoing monitoring process. You should take feedback back to clinicians to guide them in how they might reflect medical necessity and skilled justification better in their documentation.”

* Don’t forget non-Medicare A payers.

Often providers focus their triple checks on Medicare Part A, but it’s important to include other major payer sources, says Martin. “For example, if you do a lot of Medicare Part B or insurance billing, you should also have systems to validate those non-Medicare A payers as well.”

By Caralyn Davis, Staff Writer – April 20, 2016