To ensure accurate coding of all PDPM clinical conditions and comorbidities, it is essential to review the medical record prior to the 5-day MDS ARD.  This chart review process is important to identify the need for gaps which may require additional supporting documentation to capture the most appropriate Medicare reimbursement for the conditions treated and services provided. Consider these top 10 steps to an effective PDPM pre-5 Day MDS chart review process:

Primary Diagnosis & Surgical Procedure

Begin with a review of hospital documentation related to the primary diagnosis selection for the skilled stay and a check to ensure diagnosis   mapping to a PDPM clinical category.  Obtain surgical history records.  Any surgeries performed in the preceding inpatient hospital stay can change the primary clinical category which may impact reimbursement. For example, coding S42.121D, displaced fracture of acromial process, right shoulder, subsequent encounter for fracture with routine healing qualifies for non-surgical orthopedic/musculoskeletal primary diagnosis clinical category. However, coding J2500, orthopedic surgery-repair fractures of shoulder or arm qualifies for the orthopedic surgery primary diagnosis clinical category and enhanced CMI.IV Fluids

Make sure that hospital MARs have been obtained to review if IV fluids were given during the acute care stay.  Keep in mind that there must be supporting documentation that reflects the need for additional fluid intake particularly addressing a nutrition or hydration need in the last 7 days. ARD selection may depend on whether IV fluids were administered.  For example, a resident admits to your facility on 1/4/22. IV fluids were last given in the hospital on 12/31/21, then 5-day ARD should be 1/6/22 (day 3) or before. The difference between HBC1 (PDPM special care high nursing case mix group) due to IV fluids compared to PBC1 (reduced physical function nursing case mix group) can be as much as $78.96 per day.  This example reflects the importance of not selecting standard ARD days such as always choosing day 7 or day 8 causing money to be left on the table.

Active Diagnosis

Evaluate the presence of active diseases to support MDS section I coding of physician documented diagnosis and ensure physician clarification obtained, as needed, to support coding active diagnosis (including, but not limited to NTA conditions and SLP comorbidities).  Hospital chest X-ray review reflects lung hyperinflation along with density in lower lungs. Hospital H&P reveals a thirty-five-year history of smoking but does not list any chronic lung disease.  Physician query prior to the 5-day ARD could lead to confirmative diagnosis of COPD which is 2 NTA points. Additionally, interview w staff and/or resident to assess for shortness of breath or difficulty breathing when attempting or while lying flat. As well, code this as present if the resident avoids lying flat because of shortness of breath. COPD and SOB lying flat is included in the special care high nursing component.

Function Score

On day 4, discuss Section GG charting that occurred in the assessment period on days 1-3. Collaborate with the IDT team to determine the final coding for the resident’s usual ability to perform each activity. If further explanation is necessary, such as with to clarify supporting documentation variations, include a clarification note of usual performance in the medical record.

Skin Assessments

Validate that skin assessments are completed together with documented care and treatments prior to 5-day MDS ARD. Specific pressure ulcer and other wounds and skin conditions with selected skin treatments are included in the special care low and clinically complex nursing case mix groups.

SLP Comorbidities

In relation to the SLP PDPM component, the IDT should discuss the resident’s diet or need for alteration in diet and if any swallowing issues are noted. If the resident has a history of CVA, discuss if any residual deficits or late effects are active such as aphasia, hemiplegia or any speech and language deficits.

Behavioral Symptoms & BIMS

Observe for and document behavioral symptoms such as hallucinations, delusions, physical behaviors, verbal behaviors, rejection of care, and wandering. Complete BIMS and PHQ9 interviews during the look-back period of the ARD. 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. Also, be sure to document the mental status staff interview in case of an unplanned discharge from a Part A stay prior to the completion of the BIMS. If the resident falls into the behavioral symptoms and cognitive performance or reduced physical function nursing case mix categories, consider whether the resident would benefit from restorative nursing services. Reduced physical function or behavior/cognitive nursing categories qualify for restorative end splits when clinically indicated and when Restorative services meet RAI guidelines. Consequently, one of the RAI guidelines is two or more programs provided for at least 6 days during the look-back period for a minimum of 15 mins/day.  Keep in mind that Restorative would need to begin no later than day 2 of the stay in order to impact reimbursement on the 5-day MDS.

Reviewing the medical record prior to the 5-day MDS ARD can be accomplished during clinical and/or Medicare meeting to avoid supporting documentation issues or reimbursement missed opportunities. After the initial admission/readmission review, the IDT team may just discuss any clinical changes to assess for need for IPA completion or changes to plan of care.




Proactive’s MDS coding and documentation experts provide the validation and support services you need to succeed under PDPM. Our proven audit program drives coding accuracy to capture the patient-centered care you’re providing to ensure proper Medicare reimbursement. Proactive’s extensive PDPM dashboard trends client data with the option for comparison to peer performance on key coding and supportive documentation variables.  Contact Proactive to learn more about remote PDPM audit partnerships and to schedule a demo.



Kristen Walden, MSN, RN, RAC-CT
Clinical Consultant

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