Nursing home validation audits so far show MDS coding gaps tied to insufficient or missing documentation, often because of inadequate record-retention practices. And while penalties currently focus mainly on submission timelines, federal agencies could use the findings to inform future regulations related to quality reporting, experts said.
MDS accuracy and documentation are a growing area of scrutiny from not only the Centers for Medicare and Medicaid Services (CMS), but also state agencies, and facilities might be getting caught off guard.
The most common problem reflected in CMS’ validation audits is not necessarily incorrect MDS coding, but facilities’ inability to reproduce the documentation used to support their coding – particularly for Section GG, which is used to measure a patient’s functional abilities and independence, Danielle Dang, VP of Clinical Reimbursement at EF Senior Care, told Skilled Nursing News. With documentation and data validation requirements receiving greater attention than they have in the past, nursing homes need to strengthen their record keeping and ensure that documentation supporting MDS assessments remains accessible for potential audits well after the assessment or claim is completed, she said.
“I would say not having the supporting documentation for GG readily available and reproduced, having the interdisciplinary worksheet completed, and whether it’s uploaded in their health record or maintained in their paper chart, but being able to reproduce that on demand is a huge issue right now,” Dang said.
Facilities also should not rely on a single source of information either when determining a resident’s functional status, she advised. Instead, documentation from multiple members of the interdisciplinary team should be available to support the MDS response.
Record retention is becoming especially important because audits may occur long after a claim is submitted, Dang explained.
Some of EF Senior’s clients have recently received requests for records from the prior year, creating challenges when staff must locate documentation months later. In some cases, the facility may have coded the MDS appropriately, but auditors cannot validate the coding because the supporting documentation is no longer readily available.
“In a lot of the audits, you may have submitted the claim last week, but [CMS] most likely won’t pull that for the audit for quite some time,” Dang said.
Top areas of heightened scrutiny besides GG
The heightened scrutiny also appears to be extending beyond Section GG. Dang said she is seeing surveyors pay more attention to supporting documentation for other MDS-related assessments, including the Brief Interview for Mental Status (BIMS) and Patient Health Questionnaire (PHQ). That trend suggests that facilities should view documentation supporting MDS data broadly—not simply as paperwork needed to complete an assessment, but as evidence that must be preserved and produced if regulators later seek to validate the data.
And so, accurate coding alone may not be sufficient. Facilities need systems that ensure the documentation behind MDS responses is complete, consistent and retrievable long after the assessment is finalized.
Out of facilities that have been audited in the latest phase, Tara Altenritter, director of solution management at Simple, a subsidiary of Netsmart, a health information technology company, said it looks like current audits are reviewing 150 MDS data elements across 10 records, with particular attention to Section GG discharge function and pressure ulcers/injuries.
“Auditors compare MDS responses against medical records to determine whether documentation supports the coding,” she said.
“We’ve been working with a lot of facilities who are getting these summary reports back, and the findings that are being reported is that the documentation is inconsistent with what was on the MDS,” she said. “This is really just highlighting the need for strong assessment practices as well as supporting clinical documentation,” Altenritter said.
According to Veronica James, VP of clinical reimbursement at Health Dimensions Group, the most frequent discrepancies her clients are seeing involve Section GG functional abilities, particularly differences between MDS coding and the clinical documentation intended to reflect a resident’s usual performance during the assessment period.
Documentation discrepancies can also arise because multiple members of the care team document the same resident from different perspectives. Nursing staff, therapists, nurse aides and MDS coordinators may all produce credible records, but those records can differ depending on what each discipline observed and when the observation occurred, James said.
For example, one clinician’s documentation may reflect a resident’s performance during a particular therapy session, while nursing or aide documentation may capture the resident at another point in the day. When those accounts do not align with the MDS coding, facilities can have difficulty demonstrating that the final response accurately reflects the resident’s usual performance.
“When discrepancies occur, it becomes essential for the interdisciplinary team to collaborate and reach a consensus on a resident’s usual performance. It is critical that all team members involved participate in and agree upon the documentation prior to finalizing MDS coding,” James told SNN.
Moreover, rather than treating MDS coding as the responsibility of the MDS coordinator alone, facilities should involve the various disciplines whose observations contribute to the assessment.
“Communities must implement comprehensive processes that support high standards in documentation and coding,” she said. “Proactively adopting best practices and establishing a robust documentation system tailored to the community’s needs is crucial, rather than waiting for an audit to prompt changes.”
Future focus on QRP and VBP data accuracy
Although audit findings are currently informational and penalties primarily concern submission timelines, the expectation is that CMS could eventually use these findings to increase scrutiny of data used for programs such as quality measures (QMs) and value-based purchasing (VBP). Skilled nursing facilities (SNFs) should therefore strengthen assessment and clinical-documentation processes.
“Right now, those audit results are informational only, but as we know, anytime CMS does anything that’s information only, it usually turns into future regulation,” Altenritter said. “The current compliance penalty is only around the submission timeline. However, we do know that there’s probably going to be a future focus on the scrutiny of the QRP and VBP data accuracy. So, just make sure that your facilities have really good processes in place to support anything that’s documented on the MDS.”
As CMS validation audits are highlighting a recurring challenge for skilled nursing facilities: ensuring that MDS coding is consistently supported by documentation across the interdisciplinary team.
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