More than two weeks into dealing with a large-scale update to the Minimum Data Set, providers continue to grapple with a range of coding concerns, including an inability of some software systems to capture respiratory therapy services.
Software conflicts are leading to errors regarding HIPPS codes when facility staff attempt to submit a completed MDS form, a number of providers have told the Centers for Medicare & Medicaid Services officials.
Many are being hit with error messages that their HIPPS code is improperly calculated, and a verification message provides a new code. But providers have said the “correct” code is actually inaccurate, and they have been unsuccessful in trying to resolve the issue at the vendor level.
The HIPPS code is a five-digit code that captures scores for the five patient case-mix areas and determines payment rates under the Patient Driven Payment Model. When the number calculated through the verification process doesn’t align with the number created by on-site assessment and calculations, that can lead to denial of payment.
Problems have been reported since the MDS Oct. 1 implementation date.
Tough MDS choices
Providers are facing a hard choice of either dashing problematic areas, indicating patients were not assessed, or delaying their submission until an expected system edit is issued Nov. 1. Nurse assessors are telling the American Association of Post-Acute Care Nursing that their most frequent issue is with coding a patient’s need for respiratory therapy, which can push a nursing score into the special care high rate.
The organization is, for now, urging providers to submit what they have and be prepared to track and modify any affected MDS submissions as soon as possible after a fix is announced.
“With the MDS, it’s a very complex assessment where you’re held to the compliance of maintaining the accurate assessment. You’re held to the compliance of completing it timely. You’re held to the compliance of submitting it timely,” Jessie McGill, curriculum development specialist for AAPACN, told McKnight’s Long-Term Care News Monday.
“You’re in a situation where you’re saying, ‘OK, I know we have these software issues, and we know there’s a correction coming, but if I wait for that correction, I’m now out of compliance with the next three steps. I’m out of compliance with care plan completion; I’m out of compliance with submission,’” she added. “I would say go ahead and submit that assessment … because now we’re only out of compliance with one out of four rather than out of compliance with all four. I think it’s the lesser of the evils.”
It’s unclear whether the issue is solely one created by software transitions during the ramp up of the new MDS or whether there also could be issues with the Centers for Medicare & Medicaid Services own grouper software.
McGill said she has heard of problems using at least three different vendor software products. She believes the problem may be traced back to instructions that were left out of the final Resident Assessment Instrument. Directions on when to use 0400 codes, under which respiratory therapy falls, were included in earlier item sets and guidance issued over the summer but weren’t enumerated in the RAI, McGill said.
No quick or easy answers
Whatever the cause, providers appeared last week to be deeply frustrated over a lack of a quick fix.
During a CMS Open Door Forum conference call, Meir Waxman, vice president of clinical reimbursement for New Jersey-based ExcelCare Health Management, raised concerns about incorrect HIPPS codes when his company tries to submit transitioned MDS items including altered diet and IV fluids. There remains a conflict between the codes calculated in the software and one in the CMS validation system, and providers like Waxman are left wondering which is correct.
“Now, that it is the 12th of the month and we don’t have a resolution, and I know many other nursing facilities are dealing with the same question, how should we go about billing when our software has incorrect codes?” Waxman asked. “Can we go ahead and bill … based on the final validation report once that assessment is submitted and not worry about if our software is properly showing that information?”
Hit with several like questions, CMS SNF Team Lead John Kane said that providers would need to work with their vendors to address those concerns.
“That’s not something that we can speak to,” Kane said, later noting that CMS could also look into how its grouper might be calculating specific codes. “With regard to the billing questions or what should be billed, anytime where you’re having issues where the reported HIPPS code is being reverified through iQIES and is providing something different, one of the things I think we always encourage providers do is to reach out to their MAC [Medicare Administrative Contractor] to ensure that they’re billing the appropriate HIPPS code. The MACS are likely aware of these kinds of discrepancies already.”
McGill echoed that advice, adding that state Medicaid agencies should also be made aware of the concerns, since changes to certain codes affect the OBRA form used by many to calculate payments. She also urged providers to be prudent about modifying any inaccurate coding sooner rather than later, whether it impacts payment or not.
“The whole purpose of the MDS is to accurately capture that resident condition. And if you have these software issues that result in inaccurate assessment, then we do want to correct those,” McGill said. “This is something that the providers will have to track themselves, so they’ll need to pay attention to the residents who they needed to capture respiratory therapy on, and where the final validation reporter might not tell them that there was a difference. They’ll need to manually track that outside of the CMS edits and checks. And then once it goes through, then they’ll be able to modify those assessments.”
