CMS announced that Medicare Fee for Service medical review (which was temporarily suspended due to the public health emergency,) may now resume beginning August 3, 2020.  CMS has expressed their intent to examine provider behavior, patterns of therapy provision and outcomes under PDPM. It is only realistic to expect some shift in MDS coding of nursing care, therapy volume/intensity and treatment modes under PDPM as compared to RUGs IV, but where are the top areas of coding and documentation risk that you should consider as you prepare for the start of medical review activity? Proactive has completed hundreds of PDPM coding and documentation reviews on behalf of client providers across the country and found these areas to be the most common errors or potential vulnerabilities under medical review:

PDPM Top Medical Review Vulnerabilities:

      • The Function Score (Section GG) impacts PDPM rates, as well as 5-Star, Quality Measures, and SNF QRP. The key questions to ask as part of the QAPI process are: (1) Is your process for determining usual performance collaborative? (2) Does documentation clearly support the MDS coding? (3) Does documentation support that reimbursement aligns with services provided from both a therapy and nursing perspective?
      • Swallowing disorders and mechanically altered diets are ripe for coding and documentation errors. Assess your process to validate documentation supporting K0100A-K0100D and K0500C. Is the mechanically altered diet medically necessary?  Does Speech Therapy involvement support utilization of higher SLP Case Mix Groups (CMGs)?
      • Coding Isolation has significantly increased across providers through the COVID-19 pandemic. However, the RAI requirements have not changed. Isolation may not be coded on the MDS if it is only in place to prevent contracting the COVID 19 virus as precautionary isolation does not meet RAI criteria. Similarly, isolation criteria are not met when cohorting patients together in a shared room with a similar active infection. Isolation may only be reported when the resident has an active infection and meets conditions for single room isolation as outlined per RAI, pg. 0-5.
      • Assess the amount of therapy group/concurrent treatment delivery under PDPM from October 1, 2019 through the onset of the PHE with subsequent communal activity restrictions. As group activities resume with restrictions being lifted in some areas, Providers should emphasize the clinical decision-making process for the established therapy plan (including modes of therapy), and establish a process for monitoring clinical outcomes to be sure therapy results have not suffered as a result of less one on one treatment. As always, therapy should be patient centered to meet individual needs.
      • Nursing daily skilled service documentation is more important than ever to justify the nursing case mix component of PDPM. Gone are the days of reviewing rehab documentation and ADL coding alone to support the SNF stay. High risk areas under medical review include care plans, justification of daily skill and specifically treatments and services that support all conditions coded as active on the MDS.

In addition to this priority list, providers should consider any significant changes in case mix distributions since the onset of PDPM. Consider how well the Facility Assessment supports changes in patient acuity. QAPI activities should include monitoring that promotes MDS timeliness, accuracy and validity, as well as review of the level to which documentation and care planning clearly support coding and individual services.

In short, the accuracy of coding, documentation and data monitoring is vital as we prepare for PDPM medical review audit activity.   For more information on CMS guidance for Medicare Administrator Contractors (MACs) on Medical Review Instructions related to Skilled Nursing Facilities, see Publication 100-08 Medicare Program Integrity, Transmittal 924.

Check in next week for part 2 of this blog. In the meantime, contact Proactive to schedule a remote PDPM coding and documentation audit or to learn more about Medical Review support services including ADR preparation and Appeals management. You may also find the following tools available in the Proactive shop.

Helpful Tools:



Blog by Stacy Baker, OTR/L, RAC-CT, CHC, Proactive Medical Review

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