In this 3-part blog series we will focus on issues that were identified in the recent OIG audit of PDPM records and MDS. The first area discussed the lack of documentation to support technical requirements. This second blog will focus on the requirements for coding diagnoses that meet the active diagnosis requirements.

Billing and coding for medical services provided under the Centers for Medicare & Medicaid Services (CMS) should always be accurate and supported by requirements outlined in the regulations. For Skilled Nursing Facilities (SNF), billing for Medicare Part A is outlined in the Medicare Benefit Policy Manual Chapter 8. Billing for Medicare Part A changed from the old RUGs based system on October 1, 2019. Under the old system, therapy intensity was a driver in reimbursement. The new system for reimbursement, the Patient Driven Payment Model (PDPM), correlates the documented patient characteristics to payment.

Another reference for compliant documentation is the Resident Assessment Instrument (RAI) Manual. RAI Manual outlines the requirements for coding the Minimum Data Set (MDS) and provides examples to support the requirements. One of the primary coding factors that determines payment under PDPM are diagnosis codes. SNFs must choose the primary diagnosis, the reason for the SNF admission. Then, other diagnoses that are coded on the MDS must meet the criteria of being “active”. The RAI defines ACTIVE DIAGNOSES as Physician-documented diagnoses in the last 60 days that have a direct relationship to the resident’s current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. (Chapter 3, October 2024 Page I-7).

Often when we audit, we may find that one or the other of the criteria are missing. If the diagnosis is mentioned, but not by the physician by the Assessment Reference Date (ARD), the criteria for the physician signature may be missing. If the physician refers to the diagnosis as “history of”, and there are no active interventions, the diagnosis cannot be coded. This scenario often occurs if the patient had a stroke years ago. The Cerebrovascular Accident (CVA) may be “history”, however, if there are any residual deficits, like hemiplegia or hemiparesis or dysphagia, those might be active. Therapy care plans can often support these conditions as active. The Interdisciplinary Team (IDT) should monitor for timely physician signatures.

The Office of Inspector General (OIG) recently completed an audit of 100 sampled claims at a large SNF in New York. The OIG report found that the SNF did not comply with Medicare requirements for 99 of 100 claims. There were three overarching issues identified in the report to explain the errors. These were defined as:

  • The medical record did not support that the individual was assigned the correct reimbursement rate code (HIPPS).
  • Individuals did not require skilled nursing services.
  • Did not meet documentation requirements. [Coding of active diagnoses is one example of documentation requirements that was identified.]

One of the examples cited in the OIG article pointed out that the SLP comorbidity of aphasia was coded, however, the documentation didn’t support the requirements for an active diagnosis. A patient is not required to have SLP treatment for a diagnosis to be considered active, however, in addition to the physician’s documentation of the condition, there must be some intervention in the look back period. In the case of aphasia, perhaps a care plan to support communication might be present.

The RAI Manual very clearly provides coding expectations and examples that should be followed for accurate coding. Although there are some “grey” areas in the CMS regulations, deviation from the RAI manual is a risk area when it comes to audits.

The documentation must paint the picture of why the diagnosis is being coded. The IDT should discuss diagnoses that are active during the weekly Medicare meeting. If physician documentation needs to be expanded, the appropriate use of a query form could be an option to meet regulations.  Use of a query should not be consistent and should follow the regulations for using a query.

If you need an external review to ensure that your documentation is clearly supporting your coding, LW Consulting, Inc. (LWCI) can help!

The third and last blog in the series will discuss the importance of demonstrating medical necessity.

LW Consulting, Inc. (LWCI) offers a comprehensive range of services to assist your organization in maintaining compliance, identifying trends, providing education and training,  or conducting documentation and coding audits. For more information, contact LWCI to connect with one of our experts!