MDS Review Sample Clauses
MDS Review. The IRO shall perform the MDS Review annually to cover each of the five Reporting Periods. The IRO shall perform all components of each MDS Review. For each Reporting Period, the IRO shall randomly select ten facilities to review. The ten facilities shall be known as the “Subject Facilities.”
MDS Review a. The IRO shall obtain all appropriate medical records, billing records, and related supporting documentation.
b. For each Paid Claim selected in the Discovery and Full Samples, the IRO shall review the MDS and the medical record documentation supporting the MDS. The review process shall consist of an evaluation of the MDS and verification that each MDS entry that affects the RUG code outcome for the MDS is supported by the medical record for the corresponding period of time consistent with the assessment reference date specified on the MDS.
c. The IRO shall perform an evaluation of the data on the Paid Claim and determine whether the variables that affect the RUG assignment outcome for the MDS are supported by the medical record for the corresponding time period consistent with the assessment reference date specified in the MDS. This shall include the following issues:
i. The accuracy of the MDS coding based on the documentation within the medical record.
ii. Verification of medical necessity in the medical record by verifying the presence of physician orders for the services reflected as necessary in the MDS.
iii. The accuracy of the associated Paid Claims. At a minimum, these shall be reviewed for the following:
MDS Review. The IRO shall review claims submitted by FHS and reimbursed by Medicare Part A, to determine whether the items and services furnished were medically necessary and appropriately documented and whether the claims were correctly coded, submitted and reimbursed (MDS Review) and shall prepare a MDS Review Report, as outlined in Appendix B to this CIA, which is incorporated by reference.
MDS Review a. The IRO shall obtain all appropriate medical records, billing records, and related supporting documentation.
b. For each Paid Claim selected in the Discovery and Full Sample, the IRO shall review the Minimum Data Set (MDS) and the medical record documentation supporting the MDS. The review process shall consist of an evaluation of the MDS and verification that each MDS entry that affects the RUG code outcome for the MDS is supported by the medical record for the corresponding period of time consistent with the assessment reference date specified on the MDS.
c. The IRO shall perform an evaluation of the data on the Paid Claim and determine whether the variables that affect the RUG assignment outcome for the MDS are supported by the medical record for the corresponding time period consistent with the assessment reference date specified in the MDS. This shall include the following issues:
i. The accuracy of the MDS coding based on the documentation within the medical record.
ii. Verification of medical necessity in the medical record by verifying the presence of physician orders for the services reflected as necessary in the MDS.
iii. The accuracy of the associated Paid Claims. At a minimum, these shall be reviewed for the following:
A. Coverage Period;
B. Revenue Codes;
X. XXXXX codes (RUG categories and the modifiers for assessment type); and