The Case Mix Index (CMI) is a numerical value assigned to each resident based on their acuity level. Simply put, the higher the acuity, the higher the CMI value. Because CMI directly influences reimbursement, it is essential that it accurately reflects the clinical complexity of the residents being served.
Under the Patient Driven Payment Model (PDPM), residents are classified into case mix categories based on several factors, including clinical characteristics, resident assessments, resident diagnosis and the predicted resources needed to care for a resident during their stay.
The Minimum Data Set (MDS) serves as the primary tool used to capture a resident’s clinical status and functional abilities. Information documented within the MDS plays a critical role in determining the resident’s classification and ultimately impacts the facility’s CMI.
Key Components of the Case Mix Payment System
The case mix payment system has two major components:
- Resident Classification
- The first component uses the PDPM nursing component CMI score to classify nursing facility residents. Using data from the MDS, the resident is classified into a nursing component case mix group which is used to calculate a quarterly Medicaid (MA) case mix index.
- The nursing component score is utilized because it closely aligns with the RUG-III CMI that was used in the past.
- Price and Rate Setting
- The second component focuses on establishing reimbursement rates. This is determined by placing nursing facility costs in peer groups, determining the median cost, and multiplying by a factor to determine the peer group price.
Why Documentation Accuracy is Critical
Accurate documentation is vital to capture a true picture of the resident’s clinical status and functional abilities. Lack of documentation or inaccurate documentation can lead to lower CMI scores. Diagnosis being coded on the MDS must be active diagnosis. According to the Resident Assessment Instrument (RAI) manual an active diagnosis must:
- Be Physician documented in the last 60 days, and
- Have a direct relationship to the resident’s current:
- Functional status,
- Cognitive status
- Mood or behavior
- Medical treatments
- Nursing monitoring
- Risk of death during the 7-day lookback period
In addition, Section GG plays a significant role in determining functional performance and must accurately represent the resident’s true abilities.
Are You Capturing Your True Case Mix?
Are you confident that your documentation accurately reflects the resident population? Are you certain that opportunities are not being missed?
If there is any uncertainty, LW Consulting, Inc. can help. Our team provides comprehensive CMI coding and billing audits tailored specifically to skilled nursing providers—designed to ensure accuracy, identify missed opportunities, reduce compliance risk, and protect reimbursement.
LW Consulting, Inc. (LWCI) offers a comprehensive range of services that can 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!
