Compliance, Accuracy, Quality. These are words we’ve heard over and over in long-term care. They are part of our everyday regulatory landscape and are essential to MDS data integrity. Despite two years under our belts operating under the PDPM payment model, data shows there is still room for improvement for accurate coding and reimbursement. While the MDS has always been scrutinized for accuracy, the bottom line still depends on correctly coding the MDS to reflect all care and service needs according to the instructions in the RAI User’s Manual. So how do we ensure we are compliant in our MDS coding? Let’s take a look at the some of the main areas of inaccuracies:

  1. Section GG coding: This is one of the most important areas of the PDPM payment model as it collects assessment data on self-care and mobility activities that are then used to calculate two distinct function scores which directly impact the PT, OT, and Nursing components of the per diem rate. Ensuring your MDS staff understands the difference between section G and section GG is essential.

Failure to complete the assessment during the required timeframe and/or inaccurate assessment data can lead to dollars being left on the table, or at risk for recoupment under medical review. It’s important to initiate GG assessment on the day of admission (day 1 of the 3-day assessment period for the PPS 5-day) and to ensure a collaborative approach to data collection practices. This, in turn, requires ongoing education of GG activity and coding response definitions, communication between disciplines, and appropriate documentation to support final MDS coding decisions.

  1. Section I Coding: Diagnosis coding accuracy is paramount to appropriate payment. Since the 5-day MDS establishes the PDPM payment category for the entire Medicare stay, it is essential to have good processes in place for establishing the principal diagnosis and having information to support coding all active diagnoses prior to the 5-day assessment reference date. There may be instances where more than one diagnosis meets the criteria for the primary diagnosis. If more than one diagnosis equally contributes to the need for skilled nursing care, the IDT needs to determine which code to assign based on understanding of the payment categories and the skilled services being provided. It is imperative to have systems in place for selecting the primary diagnosis and ensuring documentation to support coding for all active diagnoses prior to the 5-day assessment completion.
  2. Supportive Documentation– Understanding both the regulatory requirements and the legal aspects of documentation is critical in order to consistently complete medical record entries that prove that the standard of care was met. In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are:
      • Complete
      • Accurate
      • Readily accessible
      • Systematically organized

Providers should engage in routine education and training focused on supporting the need for daily skilled nursing services and strategies for defensive documentation that justifies that need.

Regular audits of MDS coding and supportive documentation accuracy are an important part of a comprehensive SNF QA/Compliance Work Plan. Audit should focus on ensuring Medicare standards are met and that RAI guidelines are consistently followed, as well as review payment accuracy, missed opportunities and the potential for process improvements.

Contact Proactive for information on a remote QA review of your MDS coding accuracy and make plans to join us, starting May 4, for our 8-week webinar series, MDS Mastermind; Insights for MDS Coding and Reimbursement Accuracy. Sessions will offer a refresher of critical MDS 3.0 concepts for those new to MDS, as well as expanded content for seasoned staff targeting:

      • Overcoming common coding and documentation errors
      • Avoiding the most prevalent PDPM and Case Mix Index (CMI) missed opportunities
      • Preventing MDS related survey deficiencies and current medical review risks
      • Effective Person-Centered Care Planning
      • QM & SNF QRP Accuracy



Jessica Cairns, RN, RAC-CT, CMAC
Clinical Consultant

Learn more about the rest of the Proactive team.