The Ohio Department of Medicaid (ODM) has awarded Myers and Stauffer with the contract to conduct exception reviews. “Exception review” is a review of minimum data set (MDS) assessment data. The purpose of an exception review is to identify any patterns or trends related to resident assessments submitted that could result in inaccurate case mix scores used to calculate the direct care component of the nursing facility per diem rate. Reviewers will use the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual version 1.16 to validate assessment data, and will NOT be allowed to use or rely on guidelines from the Ohio Supportive Documentation Requirements as originally proposed.

Here is what you need to know to prepare for the review process:
  • Myers and Stauffer will give a two-day notice by calling the facility and following up with an email.
  • One contracted nurse is expected to take one to two days to complete the review, depending on the facility size.
  • The contracted vendor will upload the facility’s MDS data prior to arrival. The review will include record review only; the review will not include resident observations.
  • The facility will receive communication throughout the review and have the opportunity to provide supporting documentation.
  • Upon completion, the facility will know which resident RUG categories were unable to be validated.
    • A record will not be validated if the reviewer determines that the reviewed MDS inaccurately represent the aspects of the resident’s condition that affect the RUG classification of that record during the specified assessment time frame based upon supportive documentation in the medical record during the assessment reference period. MDS coding may be deemed unsupported if inconsistencies are found in the sources of information through verification activities.
  • A summary of the exception review will be sent to the facility within 10 days of the exit. The facility will be able to file a reconsideration within 30 days. Further information regarding Exception Reviews can be found here.

Contact your Proactive Consultant for assistance with Exception Review preparation including MDS Data Integrity audits, training and education.