Q:
Why is nursing documentation one of the biggest risks in medical reviews?
A:
Nursing documentation is one of the biggest medical review risk areas because it supports Medicare coverage and directly affects the nursing component, Non-Therapy Ancillaries (NTA), and overall HIPPS code in the Patient Driven Payment Model (PDPM). Nursing assessment and documentation of the resident’s condition and all care and services being provided supports the coding of the MDS which drives the resident’s plan of care and is used for reimbursement through PDPM. When documentation is lacking, the MDS cannot be coded accurately or fully supported. Improving documentation processes and coding accuracy significantly reduces payment denials under PDPM.
Consider these action items to ensure your facility documentation is prepared for medical review:
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- Ensure documentation supports a skilled level of care. Daily nursing observation and assessment documentation should include the need for ongoing skilled assessment and monitoring, the risk for clinical decline, the complexity of skilled treatments and monitoring of unstable or changing conditions.
- Implement a strong process for supporting section GG. CMS anticipates that an interdisciplinary team of clinicians is involved in assessing theresident during the assessment period. Documentation by qualified clinicians—nursing and therapy during the first 3 days of the skilled admission will provide the necessary information to avoid denials related to functional performance. Best practice also includes conducting an interdisciplinary collaboration meeting comparing GG assessments to determine the resident’s ‘usual performance’.
- Strengthen internal audit processes with a focus on alignment between supporting documentation and coding requirements for the MDS. High risk areas to prioritize include: primary diagnoses, GG, NTA comorbidities, and nursing services.
- Implement strong systems for ICD.10 coding and physician supportive documentation. Ensure each diagnosis coded on the MDS is ‘active’ in the 7-day lookback period. When diagnosis documentation is unclear or unspecified, querying the physician for specificity can ensure the severity of conditions are properly captured.
Strengthen Medicare compliance and Medical Review readiness:
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- Improve working knowledge of PDPM and the medical review process by joining Proactive March 31, 2026 for a full day Medicare Bootcamp
- Join TEAM MDS!—a year-long monthly webinar series focused on strengthening facility MDS excellence. Receive all past session recordings when you join the 2026 series. Don’t miss the next live session February 24, 2026.
Written By:
Susan Pokorney, RN, GERO-BC, RAC-CT, RAC-CT
MDS Consultant
Proactive LTC Consulting
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