Social Services PDPM Impact

The Social Service department plays a significant role in daily nursing facility operations. From patient care planning, patient adjustment to facility admission, discharge planning, engaging with family/representatives, and beyond, social service staff members wear multiple hats and hold key responsibilities in facilitating success for both the patient and the facility. Among an extensive list of job duties, obligations include thoroughly documenting and accurately coding assigned sections on the Minimum Data Set (MDS), which has a potentially significant impact on PDPM (Patient Driven Payment Model) reimbursement.

Providers generally assign the social service department to oversee the social aspects of care, including cognition and behavioral management. These areas of care impact the SLP and Nursing Components of PDPM. Social services should consider these key points to ensure success:

MDS Items Frequently Assigned to Social Services that Impact PDPM:

What you need to know about completing the BIMS & Staff Assessment

• • • Either the BIMS or Staff Assessment is used to determine the level of cognitive performance at the time of assessment.
    • The RAI User’s Manual clarifies that the BIMS must be attempted with all residents.
    • The interview should be conducted during the assessment reference period and preferably on or one day prior to the Assessment Reference Date (ARD).
    • In certain cases where the BIMS cannot be or was not conducted, the Staff Assessment should be completed.
    • The Staff Assessment of Mental Status is completed if the BIMS Summary Score is 99, Dashed, or Blank.
    • Be sure to document the mental status and any memory deficit noted in case of an unplanned discharge from a Part A stay prior to the completion of the BIMS.
    • Only in the case of PPS assessments, staff may complete the Staff Assessment for Mental Status for an interviewable resident when the resident is unexpectedly discharged from a Part A stay prior to the completion of the BIMS.
    • If neither the BIMS nor the staff assessment is completed, a patient will be classified under PDPM as if the patient were “cognitively intact.” In other words, even if the patient has a cognitive impairment, without the BIMS or staff assessment completed, the cognitive impairment will not be considered part of the patient’s PDPM classification.
    • If the BIMS score suggests no cognitive impairment, but after admission, confusion and short-term memory issues are noted, it may be beneficial to repeat the BIMS to accurately reflect any cognition variations.

What you need to know about the Patient Health Questionnaire (PHQ-9) or Staff Assessment of Mood (PHQ-9 OV)

• • • The interview screens for symptoms of depression in which the assessor records the presence or absence of specific clinical mood indicators.
    • The interview should be conducted during the assessment reference period and preferably on or one day prior to the Assessment Reference Date (ARD).
    • The interview is successfully completed if the resident answered the frequency responses of at least 7 of the 9 items.
    • If the patient is rarely or never understood, skip to D0500, PHQ-9-OV (staff assessment).
    • CMS does not allow the staff assessment to be completed for an interviewable resident when an unplanned discharge occurs before the PHQ-9 interview has been completed. That means the payment will automatically default into a non-depressive case-mix classification in the nursing component.

Reinforce Interview RAI Techniques & Guidance

• • • Staff who are conducting interviews should follow the guidance in Appendix D of the RAI, Interviewing to Increase Resident Voice.
    • This guidance should be reviewed routinely, along with Steps for Assessment for conducting the PHQ-9.
    • Providers should also review internal processes for ensuring timely BIMS completion and for compliance with signing Section Z0400. According to RAI coding instructions (pg. Z-5), “if a staff member cannot sign Z0400 on the same day that he or she completed a section or portion of a section, when the staff member signs, use the date the item originally was completed.” Payment implications apply in circumstances where the patient presents with a mild, moderate, or severe cognitive impairment.

Understanding the Behavioral Symptoms and Cognitive Performance Nursing Case Mix Group (CMG)

• • • The resident can qualify for this category by meeting either the cognitive impairment or the behavioral symptoms identified below; both criteria are not necessary to classify into the category
    • BIMS Summary Score ≤ 9 OR CPS ≥ 3
    • Any one of the following behavior symptoms are qualifiers:
      • Hallucinations (E0100A)
      • Delusions (E0100B)
      • Physical behavioral symptoms directed toward others (E0200A = 4 or more days)
      • Verbal behavioral symptoms directed toward others (E0200B = 4-6 days or daily)
      • Other behavioral symptoms not directed toward others (E0200C = 4-6 days or daily)
      • Rejection of care (E0800 = 4-6 days or daily)
      • Wandering (E0900 = 4-6 days or daily)
    • Observe for and document behavioral symptoms such as hallucinations, delusions, physical behaviors, verbal behaviors, rejection of care, and wandering. Code any documented behaviors present during the 7-day assessment look-back period.

Proactive’s MDS coding and documentation experts provide the validation and support services you need to succeed under PDPM. Our proven PDPM audit program drives coding accuracy to capture the patient-centered care you’re providing to ensure proper Medicare reimbursement. Contact Proactive to learn more about remote PDPM audit and training partnerships and for assistance in supporting effective Social Services department systems.  Social Services department heads should make plans to join us March 28, 2023 for the webinar “Strategies for Social Services”, a session in the Mission Possible SNF Department Head Briefing Series.

 References

• • • • The Centers for Medicare & Medicaid Services. (2019, October). Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.17.1.  https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_october_2019.pdf

Written By: Stacy Baker, OTR/L, CHC, RAC-CT
Director of Audit Services

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