5DOWN - Medical Review Downcode
The services billed were paid at a lower payment level. Based on medical review, the original Resource Utilization Group (RUG) code was down coded. Documentation should support the data on the Minimum Data Set (MDS), paint a clear picture of the beneficiary’s medical condition, and meet coverage criteria.
Under the Prospective Payment System (PPS), Medicare reimbursement rates are based on the beneficiary’s health condition and care needs. The medical documentation submitted did not support the RUG code billed. As a result, reimbursement has been adjusted to a lower payment level.
To prevent this denial:
- Documentation should support treatment of a condition for which the beneficiary was receiving inpatient hospital services, or for a condition that arose while receiving care in a skilled nursing facility (SNF) for treatment of a condition for which the beneficiary was previously treated in the hospital
- Submit all documentation to support the services billed and the medical necessity of those services. Services must be medically reasonable and necessary and supported by documentation.
- Submit a copy of the qualifying hospital stay transfer/discharge summary that relates to the services provided in the skilled nursing facility (SNF)
- Submit a physician’s certification and subsequent recertification of the need for continuing daily skilled SNF services
- Submit the corresponding Minimum Data Set (MDS) for each RUG code billed. If more than one RUG code is billed, an MDS for each RUG code must be submitted for review. This may include all MDS from the start of care through the dates of service billed.
- Submit all documentation used to complete each MDS. This includes the documentation to cover relevant look back periods for each MDS submitted.
- Submit dated physician’s orders for all services billed, including services provided during the look back period(s). If orders for services rendered during the look back period(s) were written prior to the look back period, they must be submitted with the documentation.
- Include any separate forms used for documentation of medication, wound care, staging of wounds, therapy minutes, weights, vital signs, intake and output, enteral feedings, nutritional consults, percentage of meals consumed, bladder and bowel function with the submitted records
- Ensure any changes in condition or treatment that would warrant daily skilled care are documented and submitted for review. This documentation includes, but is not limited to, nurses’ notes, social worker notes, nutritional services, activity reports, progress notes, consultations, laboratory and X-ray reports, and treatment plans.
- Documentation should include the beneficiary’s functional level and mental status, changes in treatment or medications, the skilled services provided in response to physician’s orders, and visits from the physician or other professional personnel
- Documentation in the form of checklists must include documentation of the beneficiary’s response to the services rendered
- Clinical documentation that furnishes a picture of the beneficiary’s care needs and response to treatment helps to establish the need for Part A services in a SNF
Therapy-specific information and hints, if applicable:
- The initial therapy evaluation must be performed in the SNF and the actual minutes used for this evaluation cannot be included in the minutes of therapy on the MDS
- Minutes recorded on the MDS must be the actual minutes of therapy rendered and must be supported by the therapist’s documentation
- The initial therapy evaluation must reflect the resident’s ability to retain instructions
- When therapy services are provided, there must be an expectation of improvement within a reasonable period of time
- Repetitious therapy exercises that could be performed by aides and/or nursing personnel are not considered skilled services
- Therapy is not required in a situation where a beneficiary suffers a transient and easily reversible loss or reduction in function, which could reasonably be expected to improve spontaneously as the beneficiary gradually resumes normal activities
- If speech-language pathology (SLP) services are rendered for the treatment of dysphagia, submit all supporting documentation to establish the medical necessity of the billed services. This may include, but is not limited to, physician’s notes and test results, for example, modified barium swallow (MBS) and/or a fiber optic endoscopic examination of swallowing (FEES).
- Specific documentation related to therapy services must be submitted for review. This includes, but is not limited to, the following:
- Physician’s orders for therapy services
- Documentation to establish that the therapy services are of a complexity that requires the skills of a licensed therapist
- A written therapy plan of treatment established by the physician after consultation with the therapist. The physician must sign this plan of treatment.
- Documentation to establish the medical necessary of the therapy services as it relates to the illness/injury of the beneficiary
- Short-term and long-term goals (measurable)
- Actual minutes of therapy rendered as documented on a log/grid or in the clinical documentation
- Progress notes and documentation of treatment modalities rendered
- Level of function just prior to the spell of illness
- Functional decline
- Current level of function
- Documentation must clearly establish that occupational therapy (OT) and physical therapy (PT) are not duplicating services
- If the beneficiary is readmitted to the facility and therapy is continued, a new evaluation must be performed and submitted for review
For more information refer to:
- CMS Internet-Only Manuals (IOMs), Medicare General Information, Eligibility, and Entitlement Manual, Publication 100-01, Chapter 4 (PDF, 122 KB)
- CMS Internet-Only Manuals (IOMs), Medicare Benefit Policy Manual, Chapter 8 (PDF, 296 KB)