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Case Mix Medicaid Excellence

Maintaining accuracy with Medicaid reimbursement within the nursing home setting is dependent on communication throughout the clinical team and verifying all MDS coding items are reviewed.
Check out our recent webinar on case mix here:

Keep these things in mind:

  • Determine who will coordinate the communication with the multidisciplinary team
  • Prepare team members outside of the MDS department to review coding areas
  • How often will your team assess care excellence
  • Timing of clinical outcomes
Precision in coding can result in revenue exactitude. 

Leadership matters to steer the ship and maintain accountability for the overall success of the program. Educational updates for the management team as well as front line staff that are delivered by your chosen leader can highly influence the habit of confirming accuracy. Daily conversation regarding complexity documentation, residents who may benefit from skilled therapies, depression indicators and provision of Restorative services, to name a few, keep the quality care as a central focus.

Obtain your State Case Mix manual. Use this to update and create your facility policies and processes. Again we stress habit forming practices will light the path to accuracy and highest quality care. States are known to change RUG groupers or transition to new sources for reimbursement, therefore leadership must monitor for updated manuals.

Team Approach:
Clinical Grand Rounds allows for individualized and continual observation for identification of any physical, cognitive, or psychosocial changes that have occurred due to the progressive nature of a medical condition. When conducted consistently this is a great solution to facilitate IDT interaction focused on slight changes in patient presentation. Keep in touch with housekeeping, laundry services and any other staff member who can be another set of eyes during the evening and early mornings. This staff is in and out of rooms consistently and interacts with long term residents regularly. Confirm the provision of Rehabilitation interventions must be properly coded and care planned to reflect the individualized care.

Care Excellence:
How is the team using tools that aid in monitoring resident status for changes or potential changes in function or clinical presentation? Review and re-review the RUG level for long-term residents. Reduced Physical Function (the lowest case mix weight) presenting in over 50% of the assessments is worth diving deeper into those records. Keep an active trigger list for monitoring at risk patients for clinical signs or indicated services based on functional or physical changes. ADL end splits are included in this review. Full attention and exploration is productive when reviewing the RUG classification groups for an accurate representation of the amount of assistance provided. Frequency in staff interviews and record review to confirm care delivery should be a regular practice.

Completion of MDS assessments is also a team responsibility. The MDS department carries much of the load for scheduling and completion, yet there is onus on the rest of the clinical team to assist with appropriate timing for assessments. Consider having a team discussion for setting the ARD of assessments based on the suggestions above for education, Clinical Grand Rounds and verification of the Case Mix RUG level.

Guide your team to take action to maintain a CMI that is truly reflective of the care delivered. Accuracy in coding with records that contain supportive documentation lights the pathway to CMI solutions. Facilitating excellence includes Communication, Timing and Education.

Written by: Elisa Bovee, MS, OTR/L, Vice President of Clinical Strategies
Elisa's #HigherCalling: "I am a patient advocate of function through teaching caretakers in long-term care.”

Tags: Long Term Care Facilities, MDS Coding, CMI, Case Mix Index