Beware: Recent Changes to MDS Could Cause Audits

Recent changes to the minimum data set (MDS) assessment and recent audit activity targeting skilled nursing facilities (SNFs) appear to be an emerging issue. 

As a reminder, the MDS assessment is a standardized assessment used in SNFs and some swing-bed facilities to capture administrative and clinical data for residents. The information compiled in the MDS assessment is used to create resident care plans, determine reimbursement, and help providers understand the impact of quality measures. 

On Oct. 1, there were substantial changes to the MDS assessment, including how functional abilities and goals are scored, the introduction of tracking of indications for medication use, and the addition of new measures for tracking communication of transfer-of-health information (specifically reconciled medication lists on transfer to providers and on discharge). There are also new questions to capture information on the social determinants of health (SDoH). The SDoH has been a popular topic lately, as more focus is being placed on capturing these conditions and understanding their impact to help inform policies and programs.

These recent changes to the MDS assessment to help capture SDoH information are part of a broader movement from the Centers for Medicare & Medicaid Services (CMS) through the Standardized Patient Assessment Data Elements (known as SPADES), whereby there is standardization not only with the MDS assessment for SNFs, but with other post-acute care assessments, including home health’s Outcome and Assessment Information Set (OASIS), the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI), and the Long-Term Acute Care (LTACH) data set. One area to watch is how CMS will marry SDoH data collected in these standardized post-acute care assessments and the data captured via ICD-10 codes in other provider settings, such as hospitals and physician offices.

In addition to these substantial MDS changes, SNFs have been dealing with increased audit activity. Earlier this year, CMS announced that based on the improper payment error rate doubling from 2021 to 2022, each Medicare Administrative Contractor (MAC) must conduct a five-claim Targeted Probe-and-Educate (TPE) medical review for every SNF. The audits have started on the top 20 percent of providers that CMS deems to be of the highest risk. 

So, if your facility has received notice of a TPE review, it means you were targeted as being at high risk for improper payments. Although still early on with the reviews, initial feedback is that the audit requests include providing supporting documentation that is not listed as required for MDS scoring in the MDS Resident Assessment Instrument (RAI) manual. 

Facilities can prepare for this type of audit (and other payment audits) by ensuring that MDS coordinators compliantly follow RAI manual guidance for scoring the MDS assessment, monitor compliance through a concurrent triple-check process, provide ongoing education to staff on documentation requirements, and ensure that their medical record practices support complete, accurate, and timely documentation. It is also prudent to monitor their Program for Evaluating Payment Patterns Electronic Reports (PEPPER) to see whether their facility may be an outlier. SNFs should also be on the lookout for any denials related to new ICD-10 codes that became effective Oct. 1. They should have already run reports on residents with invalid ICD-10 codes (such as changes with the Parkinson’s disease codes), and all residents with invalid codes will need them to be updated before billing – or denials can be expected.