Has nursing documentation and internal auditing suffered due to COVID-19 prevention or outbreak efforts? Many facilities have had to prioritize staff and resources in order to meet the challenge of the public health emergency and the many additional responsibilities being faced in nursing homes. However, as Medicare medical review activity has restarted, we are seeing the start to ADR requests. Leaders should be mindful of systems to facilitate compliant documentation and coding.

Training Programs

Training is essential to accurate MDS coding and strong supportive documentation for compliant billing of SNF care and services. Consider these training essentials:

      • Ensure your MDS/RAI staff are well-versed on coding requirements under PDPM and high-risk focus areas. MDS staff should have customized orientation to ensure coding proficiency and competency and be equipped to guide the interdisciplinary team on coding and documentation standards. Check out the section by section MDS coding proficiency training geared toward meeting these obligations, which can be completed on-demand as time allows and may be viewed repeatedly as new staff join your team.
      • Provide effective orientation and annual training on nursing documentation standards with case examples and competency assessment. Check out Proactive’s PDPM Skilled Nursing Charting Guidelines for examples of effective documentation for nursing staff.  This tool may be used as a quick stand-alone inservice or pull the documentation examples provided to supplement existing training sessions.
      • Periodically review key documentation and coding principals in areas of high-risk coding which may be vulnerable under medical review. Change of shift inservices, assigned “quick page” reading and staff newsletter articles that highlight key concepts are helpful tools. Check out this on-demand webinar for recommended content of discipline specific education sessions
      • Section GG Function Scoring is one of the highest risk variables under PDPM. Include specific competency training for this section as part of orientation for nursing and therapy staff, as well as annual training or when coding problem trends are noted during audits.  The Proactive PDPM Section GG Competency Toolkit provides inservice material and videos to assess staff competency in this high risk area which significantly impacts reimbursement.

Audit Processes

Should your facility fall short of meeting established auditing and monitoring goals as a result of a COVID-19 outbreak, it is understandable that documentation and PDPM coding audits may take a backseat to crisis management. However, as soon as you are able, it is recommended to go back and review those assessments from the outbreak period with a focus on assessing compliance with items on the MDS impacting reimbursement.


Consider these steps to promote coding and documentation compliance through audit systems:

      • Review and access options available through existing MDS software to analyze claims and screen for errors.
      • Develop and implement internal audit systems as part of the ongoing QA/Compliance process. When possible, assign audits of the MDS to persons outside of the RAI office.
      • In conjunction with internal audits, develop processes for conducting regular 3rd party auditing of PDPM claims for coding accuracy and supportive documentation compliance. Even a small sample of audits each month or quarter can help to provide critical feedback including:
        • How your facility documentation will stand up under medical review compared to peers
        • Driving priorities for focused internal audit projects
        • Avoiding missed coding opportunities which equate to lost revenue
        • Identifying trends in inadequate supportive documentation and priority training needs


Proactive’s MDS experts offer the support your team needs to achieve your clinical assessment, coding and reimbursement goals. Contact us to ensure consistently accurate MDS coding, quality measures, and clean claims through a budget-friendly third-party audit partnership.



Caralyn Davis, PDPM Internal Audits: How to Be Proactive in a Time Crunch (6 October 2020)


Blog by Amie Martin, OTR/L, CHC, RAC-CT, Proactive Medical Review

Click here to learn more about Amie and the rest of the Proactive team.