Strategies for timely estimation of potential care needs and costs are essential to SNF success, as well as systems for identifying clinical conditions and services that impact reimbursement under PDPM. Follow these steps to drive payment accuracy.

Prior to Admission

Identifying reimbursement potential and the need for supporting documentation related to key clinical conditions and services that impact the PDPM rate should begin as soon as the referral is considered for admission to the skilled nursing facility.  Awaiting HIPPS code determination until MDS assessment completion could risk missed reimbursement opportunities due to the lack of early identification of clinical conditions and inadequate supporting documentation during the look back period.  A best practice is to capture the most accurate coding before the ARD of the 5-day MDS. Many hospital systems allow EHR user access for at least one SNF staff member, so that supporting documentation is at the facilities’ fingertips. Hospital H&P, consults, labs/diagnostics, MAR, operative reports, nutritional progress notes, DC Summary, and other pertinent clinical supporting documents should all be reviewed for any active clinical conditions and services provided during the acute care stay. Active diagnoses coded in MDS section I can impact the PT/OT component, nursing component, SLP comorbidities, and the NTA component. Pre-admission is also an opportune time to request any needed clarification, seek additional information, and initiate physician queries as applicable.

Effective Medicare/PPS Meeting

Newly admitted Medicare beneficiaries should be reviewed by the IDT team in Medicare/PPS meeting by the next business day to establish the predicted PDPM case-mix groups for PT/OT, SLP, nursing & NTA components. This will assist with scheduling an optimal 5-Day ARD, as well as determining documentation expectations. Also, do not forget to monitor for significant changes in the resident’s condition and care needs after completion of the 5-day assessment that may warrant completion of the IPA. Suggested team members to attend the PPS meeting include a nursing representative, restorative nurse (if applicable), therapy, business office, MDS, social services, and the administrator as the leader.  The meeting should consistently occur each day with all IDT members sharing purposeful information, and focusing on staying on topic with a consistent meeting format and agenda.

PT/OT Components

Determining the PT/OT component begins with the identification of the primary diagnosis, followed by whether any major surgical procedures related to the primary skilled need were performed. The primary diagnosis should be an active condition as defined in the RAI Manual and can indicate eligibility for one of the two orthopedic surgery categories (major joint replacement or spinal surgery J2300, J2310, J2320, J2330, J2400, J2410, or J2420, and orthopedic surgery (except major joint replacement or spinal surgery) J2500, J2510, J2520, or J2530 or for the non-orthopedic surgery category (J2600, J2610, J2620, J2700, J2710, J2800, J2810, J2900, J2910, J2920, J2930, or J2940).  Also, any surgical procedures must have occurred in the last 30 days, and during the inpatient stay that immediately preceded the resident’s Part A admission.  Refer to the CMS PDPM ICD-10 Clinical Category Crosswalk to classify SNF residents into one of ten PDPM Clinical Categories.  Next, calculate the PT/OT function score. Review Section GG documentation completed during the first three days of admission each day during Medicare/PPS meetings for accuracy, collaborate among the IDT team qualified clinicians, and then determine and document final Section GG usual performance coding responses.

SLP Component

Determining the SLP component begins with the identification of any diagnosis in the Acute Neurologic clinical classification and the identification of any of the SLP-related comorbidities.  These SLP comorbidities include aphasia, CVA, TIA or stroke, hemiplegia/paresis, TBI, laryngeal cancer, apraxia, dysphagia, ALS, oral cancers, speech and language deficits, and tracheostomy care or ventilator/respirator while a resident. Next, determine if the resident has a cognitive impairment by completing the BIMS assessment at an appropriate time of day, in an optimized environment, and using the most effective communication strategies for each resident so that the actual cognitive abilities are captured.  The BIMS interview should be conducted on or before the ARD and signed for this date in Z0400. The difference between a BIMS score of 13 and a score of 12 impacts the SLP Case Mix Group (CMG).  Review MDS Section K Items with input from SLP / rehab designee, Dietitian reports, nursing, and MDS for determination of a swallowing disorder and/or mechanically altered diet.

Nursing Component

Calculate the nursing function score just as the PT/OT function score, and then determine the resident’s nursing case-mix hierarchical classification. Classification groups include extensive services, special care high, special care low, clinically complex, behavioral symptoms and cognitive performance, and reduced physical function.  Appropriate documentation is crucial to support active diagnoses, clinical conditions, special treatments and procedures, wounds and skin conditions and selected skin treatments, behaviors, restorative nursing programs, PHQ-9 score, and other conditions impacting the nursing component. It is imperative to review the medical record for documentation to support coding items included in the nursing component. For example, inaccurately coding isolation or omitting coding IV fluids given while not a resident of the facility can significantly impact the nursing case-mix group and overall reimbursement.

NTA Component

Focus on the most common comorbidities which include Diabetes Mellitus, COPD/Asthma/Chronic Lung Disease, IV medications given while a resident used in the facility, feeding tubes, Intermittent catheterizations, and ostomy needs.  Refer to the CMS PDPM ICD-10 NTA Comorbidity Crosswalk for I8000-derived comorbidities with acceptable ICD-10 codes that map to the NTA component and the NTA item listing for a complete list of NTA conditions/services.  Do not be apprehensive to query the physician if a diagnosis is not clear or is suspected and not documented. For example, a resident admits with a diagnosis of only obesity; however, the resident’s BMI and obesity-related conditions indicate morbid obesity.

Commonly Missed NTA’s

      • Wound infection
      • Multi-Drug Resistant Organism (MDRO)
      • Opportunistic Infections- 37 different ICD-10 codes can be coded in I8000 to qualify for the NTA comorbidity
      • Cardio-Respiratory Failure & Shock
      • Malnutrition or Morbid Obesity

QAPI/Compliance Program Action Items

Regular audits of MDS coding and supportive documentation accuracy are an important part of a comprehensive SNF QA/Compliance Work Plan. Audit should focus on ensuring Medicare standards are met and that RAI guidelines are consistently followed, as well as review payment accuracy, missed opportunities and the potential for process improvements.  Contact Proactive for assistance in establishing an effective PDPM audit program in your facility.



Kristen Walden, MSN, RN, RAC-CT, Proactive Medical Review

Learn more about the rest of the Proactive team.