Clinical Data Collection: The Top Steps for MDS Accuracy, and Greater Reimbursements

Jayne Warwick, RN, HBScN, AWCN
Solutions Specialist – Marketing, PointClickCare                                                                          

MDS Accuracy–It’s simple, really.  No residents, no income.  At the very core of your business is your ability to admit and care for residents.  Documenting that care is where providers often leave money on the table. 

Getting paid for the care provided is critical to financial viability, but are you also capturing the supporting documentation?  Would your documentation stand up to an audit?  It’s difficult to do on paper, easier with technology.

We’ve all seen those complicated charts that show the detail behind a RUG calculation.  Stare at it long enough and your eyes might cross.  But, the reality is that it’s critical to understand both how RUGs are calculated and the impact they have on our ability to get paid for the care we provide.  Substantiating the MDS with accurate and complete documentation makes the difference — between what you think was done to what is known to have been done.

MDS accuracy is a common problem for facilities.  This is where you either get it right or lose out on possible reimbursement.  ADLs drive 40% of the RUG for PPS reimbursement.  ADL calculations for reimbursement are not second nature and, as a result, are prone to errors.  Manual charting, especially at shift end, invites trouble – such as gaps in documentation.  Employing frequent, electronic capture of ADLs, providers increase the reliability of reimbursement and protection during audit.  Electronic charting ensures a more complete record of the care provided, while allowing users to report on data more accurately and easily than if using paper.

ARD Planning—Why you might be losing thousands by defaulting to Day 8 

When asked, it’s common to hear an MDS nurse say that Day 8 is the day they use for every ARD.  Don’t do it!  The ARD drives the RUG score, which drives reimbursement—choosing a day before or after may allow you to recoup significantly more reimbursement than blindly choosing day 8. 

Often, MDS nurses won’t include ADLs in their calculations, or maybe they’ve left out the therapy minutes or extensive services when determining the ARD.  The best MDS nurses are worth their weight in gold because they include all the clinical data possible to make sure they’re capturing a complete picture for their organization. 

Smart Electronic Health Record software is the most efficient method of capturing this information and pulling it together.  Manual documentation and compilation of the data is time consuming, often missing some of the actual services provided.

Some electronic health record systems provide automated tools that aggregate applicable data into one tool that the MDS nurse can use to evaluate the ARD.  They may have built-in intelligence to guide the user to optimize the RUG score. 

Not only does automation help in optimizing reimbursement by capturing the documentation for actual care provided, but it also ensures there is a solid audit trail left behind to leverage during documentation reviews.

Consider automating your facility.  You’ll have more accurate and complete documentation, get paid for all the care you provide, improve overall care for residents and surveyors will never again leave your facility with a paper cut.  Everyone wins!

Check back next week for the next article, as I will discuss the impact staff satisfaction has on revenue and technology’s role in census management.

Webinar: Improving Reimbursement through Wound Management Technology 

Burgess Healthcare Center will share their best practices for improving reimbursement by leveraging wound management technology and an EHR. Join John Vrba, CEO with Wound Nurses Michelle Balduff and Gia Fite on January 20 at 1:00 pm ET for a live webinar. Register now.


Jayne Warwick is an RN with almost 30 years of experience in LTC in both US and Canada and has been a floor nurse, DON, Corporate Clinical Consultant, Director of Quality and Director of Operations for both small and large LTC chains. Over the past ten years with PointClickCare, Jayne has worked with homes throughout North America to more effectively improve business operations and quality of care while optimizing reimbursements through the implementation and use of EHR. Jayne has extensive industry and regulatory knowledge for initiatives such as EHR, Vendor Certification, MDS 3.0 and QAPI. Jayne is now the Solutions Specialist (SME) for PointClickCare Marketing team and a steadfast champion and advocate for PointClickCare customers.

Topics: Articles , MDS/RAI , Technology & IT