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Medicare/Medicaid Reimbursement Pitfalls of

the Skilled Nursing Facility

October 2007

The case mix indices were recently published for Wisconsin SNF Medicaid residents as were the new
Medicare rates. Many facilities noted that their Medicaid rate dropped significantly from 2006 and their
overall average Medicare rate per day either dropped or remained stagnant.

Wisconsin case mix indices range from 0.629 to 1.840. With the December 31, 2006, picture date, 187
facilities decreased, 4 facilities stayed neutral, and 205 facilities increased. However, due to the reallocating
of funds and failure at the budgetary level, it is expected that as of the December 31, 2007, picture date, the
July 1, 2008, rates will show significant decreases in Medicaid per day rates with some facilities forecasted to
lose as much as $10 per day in Medicaid revenue.

There are multiple “pitfalls” that cause Medicare and Medicaid rates to be less than optimal. Facilities often fail
to stay diligent and thoroughly assess and investigate those key MDS items that will place the resident into
higher RUG (resource utilization group) and Case Mix (CMI) categories.

• Medicare vs. Medicaid

− Medicare is based on 53 RUGS.
− Medicaid is based on 34 RUGS.

Medicaid Medicare
21 of 34 affected by restorative nursing 21 of 53 affected by restorative nursing

Extensive services is at top of hierarchy Rehab PLUS extensive services is at top of hierarchy

4 Rehab RUGs 23 Rehab RUGs

Case mix indexing Case mix indexing
60-90% of the facility population Average of 10% of population

Wisconsin Medicaid
• Picture Dates
− Medicaid residents on the last day of the calendar quarter
• As of Date
− Information available in the MDS data system AND Medicaid billing system by a specific date

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For a resident to be included, there must be BOTH a payment for a Medicaid “in-house” day and a “RUG-able”
MDS. A RUG-able MDS is any comprehensive assessment, i.e., admission, annual, or significant change in
condition. Residents on bed hold will not be counted in the calculation. The key to maximizing Medicaid
reimbursement is reviewing your residents early in their “quarterly” window. If there is a change in any two
categories (even in the same MDS section), a significant change in status assessment should be completed. If
you are not performing a significant change assessment on about 50% of your residents, you are not keeping
up with their reimbursement potential.

Assignment to a RUG/CMI group is based on three factors:

1. Hierarchy of major resident types - Wisconsin Medicaid has 7 resident types. Medicare has 8 types.
2. Resident functional Activity of Daily Living (ADL) measures
3. Additional services, i.e., extensive services, depression, and nursing
rehabilitation/restorative activities

When considering Medicare/Medicaid rates, four components affect the rate the most:
1. Activity of Daily Living (ADL) measures
2. Rehabilitation/restorative activities
3. Respiratory therapy
4. Depression/behavioral coding

Facilities must remain diligent with coding of these items on the MDS.

ADL Scoring
The ADL score is used in all determinations of a resident’s placement in a RUG category. It is the MOST
important component since this score identifies the functional status of the resident and how much care is
provided. ADL scoring is 35% to 40% of the rate. There are only four ADL categories that are used to
calculate ADL scoring.
1. Bed mobility Self-performance measures what the resident actually did
2. Eating
3. Toileting ADL support measures how much staff required
4. Transfer

The key to any of these areas is being aware of the need to code for the LEAST/WORST that the resident
performs, not what they are capable of or have accomplished occasionally.

Bed mobility
Code for ALL of bed mobility:
• Side to side
• To and from a lying position
• Positions in bed or recline
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• Lifting legs into bed

Frequently MDS coders will take into account only the side-to-side factor. Consider discussing care with the
night shift. How many 80-year-old residents with a hip fracture are capable of boosting themselves up in
bed? This movement generally requires extensive to total assistance and the support of two staff. Most
residents need at least some support when going from a lying position to a sitting position in bed—even with
electric beds!

Code for all eating activities:
• How does the resident get food AND drink into their body?
• Include nourishment by other means, i.e., tube feeding, TPN, and IV therapy.

Consider the resident in bed: are they able to lift a glass, maneuver a straw, and drink independently? If the
resident has thickened liquids or mechanical meals, you should rarely code them as independent or

• How does the resident use the bathroom, urinal, and bedpan?
• How does the resident transfer on/off the toilet?
• How much assistance is needed for toilet hygiene?
• How much assistance is needed for clothing management?

Frequently coders make the error of thinking only of the porcelain device in the bathroom. They forget that
in the SNF population, it is the minority of our residents who actually use the toilet 24/7. If the majority of
our residents used the toilet, why do we have so many expenses for incontinent products? Code for the
worst the resident is able to do. If your night shift provides incontinent care, the resident should be coded as
total care in the toileting category. In addition, if staff adjust, pull up, zip, fasten, button, or buckle in
connection with toileting, it is extensive or total care.

• How does the resident move between bed to chair?
• How does the resident move between bed to wheelchair?
• How does the resident move to a standing position?

If the staff need to assist the resident by lifting their legs or feet into or out of bed, this item should be coded
extensive or total care. This item excludes to/from a bath or toilet. Also, be aware of evening or night shift
when the resident is generally more tired or confused and they require more assistance than in the morning
hour. Also, do not code for how a resident performs with an occupational or physical therapist, since they
generally perform at a higher level.

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One ADL point can make a huge difference in reimbursement RUG and CMI levels. A calculated ADL score
of 14 on a resident calculated in RUG level of RML versus an ADL score of 15, which would RUG into a
RMX, could have the following impact:

• RMX 15 - $453.44
• RML 14 - $415.91

A difference of $37.53 per day over the first 14 days is $525.42.

Restorative/Rehabilitation Nursing Activities

Many times we loose sight of the routine tasks we perform daily with our residents. When considering coding
of restorative nursing and rehabilitation nursing activities, the 2 areas most frequently miscoded or missed are
respiratory therapy and the bladder training in section P of restorative nursing. We are all aware of the
emphasis placed on section H by surveyors, but often fail to take credit on the MDS for our efforts.

Respiratory Therapy
Respiratory therapy can add up to $6 per day of reimbursement, and the definition is very broad. Respiratory
therapy can be provided by a qualified respiratory therapist or a “trained nurse.” A trained nurse has specific
training over and above the nurse training program. However, if your facility provides documented in-service
training to your staff by a Registered Respiratory Therapist, they are considered trained nurses. Respiratory
therapy is coded when nurses are providing or supervising coughing, deep breathing, heated hand-held
nebulizer treatments, aerosol treatments, and mechanical ventilation. Assessing breathe sounds is included. It
does not include hand-held medications, e.g., Albuteral or Spiriva.

Encourage your staff to be specific when transcribing nebulizer orders and to specify that the nebulizer
treatment is to be provided over 15 minutes. The nurse should also document respiratory status before and
after the treatment.

Nursing Rehabilitation/Restorative Care

The intent of this section is to determine the extent to which the resident receives nursing restorative services
from other than specialized therapy staff (PTs and OTs). Restorative care refers to nursing interventions that
promote the resident’s ability to adapt and adjust to living as independently and safely as possible. MDS
coders often fail to look at “maintaining” optimal physical, mental, and psychosocial functioning. Skill practice
including such activities as walking, dressing, grooming, eating, swallowing, and transferring can improve or
maintain function in physical abilities and prevent further impairment. Restorative programs can be of a
“maintenance” nature. However, restorative programs must have measurable objectives and interventions
evaluated periodically by a licensed nurse. Nurse assistants must be trained in restorative techniques but do
not need to be separately classified “restorative aides,” nor do all restorative modalities need to be done by
nursing. Restorative dining can be performed by trained feeding assistants and walk-to-dine programs by any
other trained personal, i.e., activities or social services.

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Consider the residents you have at feeding assistance tables (cueing). These programs, if documented, would
qualify for restorative payments if they are evaluated periodically by a nurse since they maintain the resident’s
independence and are specified on the plan of care. Consider the residents you are mandated to have on a
bladder retraining program. Are you taking credit for that in restorative nursing? Or, consider the residents
that are on a walk-and-dine program. Failure to take these programs into account will leave reimbursement
on the table. Three easy programs are ambulating, eating, and toileting.

Behavioral/Depression Add-On
Correctly coding behavioral symptoms and interventions will add approximately $1 per patient day to the
CMI. It will also add points to the RUG 53 scores, especially at the lower 18 levels. Behavioral coding is
among the most challenging for SNF staff. However, depression and behavioral add-ons to the CMI and RUG
rates have significant impact. We often fail to account for the behaviors of the resident because we become
attuned to the resident. Frequently staff will qualify the behavior with “That’s just the way Estelle is . . . ”
Failure to code for behaviors will result in $1—$2 per day less payment. Another issue is that behavioral
coding in section E is frequently left to social services for coding; however, nursing is the department that
sees most of these behaviors. It should be the responsibility of the entire interdisciplinary team to document
and code behavioral issues. Coding of behavioral symptoms almost always leads to a RAP, so staff frequent
fail to code to avoid extra paperwork.

Behavioral coding has variable time frames on the MDS and can lead to confusion. The time frames vary from
7 to 90 days within the same section. Even if a behavior has occurred only once, it needs to be recorded.
Record chronic symptoms as well as new onset behaviors if they occurred within the appropriate time frame.
Do not fail to capture a symptom of depression or anxiety because it is the resident’s “usual” mood or
behavior. Do not fail to capture a symptom because the resident has a chronic or terminal diagnosis that is
not expected to improve. “Helen has cancer; of course she’s depressed.” Do not fail to code the symptom
because it is a normal part of aging. Code the symptom regardless of what is believed to be the cause. There
should rarely be any new resident without some anxiety or depression symptoms.

Behavioral add-on is based on MDS responses in sections B, C, and E. Section F has quality and RAP
indications, but no monetary add-on. The first point set in behavioral add-ons should be to add points if
certain moods, behaviors, or interventions occur at least once. If any first point adds-on exist, then points are
added for certain conditions or treatments. If a behavior is not alterable, then points are added. Intervention
programs in P2 will also add points. Section G1eA - locomotion on unit will add points. If a resident with
behaviors is more independent, the resident would require more staff intervention.

Additional Information
If you have questions or would like additional information, please contact Dennise Derby-Bemis at or 414.431.9332 or visit

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