PDPM should be included in the Compliance and Ethics program work plan

Challenges during the transition to PDPM (Patient Driven Payment Model) are unavoidable, but compliance oversight doesn’t need to be one of them. PDPM should be included in the Compliance and Ethics program work plan for 2020, including updating current auditing and monitoring systems.

Auditing and monitoring plans should be based on facility-specific risks that include identified situations, and processes that may cause harm to the organization. Auditing is often accomplished through a 3rd party or a department outside of the service area being reviewed. Monitoring includes internal quality checks and processes incorporated into routine daily operations.

As we shift toward the new payment model, provider auditing and monitoring plans should focus on documentation to support individual resident characteristics and clinical need driving care practices. This is not a new concept, but providers must be intentional in addressing the evolving compliance risks inherent in PDPM reimbursement.

Ten compliance risk focus areas:

  1. ICD-10 Coding Accuracy & process for supporting active diagnoses
  2. Therapy service intensity justification & risks of underutilization, as well as negative patient outcomes
  3. Oversight of accurate & effective Section GG Process
  4. Mechanically Altered Diets & Swallow Impairments
  5. Increased Coding for Depression
  6. Exceeding 25% Limit for Group/Concurrent Therapy
  7. Premature Discharge to eliminate impact of reduced reimbursement beginning day 21
  8. Over use of IPA assessments & internal policy application
  9. Interrupted Stay Policy & rates of re-hospitalization >3 consecutive midnights
  10. Defensive documentation for daily skilled nursing care

During the recent SNF QRP Provider Training day, CMS highlighted the need for clinical documentation improvement, “PDPM does not change these documentation requirements, but rather strengthens the importance of documenting all aspects of a patient’s/resident’s care, consistent with PDPM’s focus on a more holistic care model. Given the increased relevance of a greater set of data elements supporting payment under PDPM, providers should ensure that there is strong documentation and support for the care associated with each PDPM component.” (slide 76)

Consider the following steps in developing your PDPM auditing & monitoring work plan:

Proactive’s PDPM experts offer remote audit solutions for coding and documentation compliance and reimbursement accuracy. Contact us today to learn more.

Under PDPM, CMS will continue to ensure appropriate safeguards for program integrity with focus on Medical Review & Data Monitoring.

Source: CMS Quality Reporting Program Provider Training May 8, 2019

“Given the more holistic style of care emphasized under PDPM, program integrity and data monitoring efforts will also be more comprehensive and broad. For program integrity, we expect provider risk will be more easily mitigated to the extent that reviews focus on more clearly defined aspects of payment, such as documentation supporting patient diagnoses and assessment coding.” (slide 65)

Download SNF QRP Provider Training Day 2 Resource here.

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Blog by Stacy Baker, OTR/L, RAC-CT, CHC, Director of Audit Services, Proactive Medical Review

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