Factors Impacting Reimbursement Become More Complex
Under PDPM, the factors impacting reimbursement become more complex. Supportive documentation should reflect this complexity through descriptions of the relevant care and services impacting each of the five payment components. However, old habits die hard and with the former reliance on therapy as the primary skilling service, facilities may face challenges in driving sustained improvement in charting that reflects daily skilled nursing services and supports both the nursing case mix group and the non-therapy ancillary (NTA) component with documentation of the clinical support for these portions of the per diem. With the shift away from therapy treatment time as the primary driver of payment, greater scrutiny of provider & nursing supportive documentation for active conditions, Nursing Case Mix Group variables, NTA items, the GG Function Score and, of course, medical necessity for SNF level of care will be expected.
Documentation in the patient’s medical record must reflect the need for the skilled services provide, and should also convey important communication among the interdisciplinary care team regarding person-centered care plan development, the course of treatment, and outcomes of the skilled observations, assessments, care and services, and skilled training performed.
Nursing Documentation
Specifically, nursing daily skilled documentation should show the clinical decision-making process linked to the primary skilling diagnosis, other active conditions being treated (with emphasis on NTA conditions and SLP comorbidities), and individual patient risk factors. To achieve this, nurses must understand what services meet skilled level of care criteria and be competent in documenting supportively for key clinical and billing factors. Skilled documentation guidelines are recommended to guide nurses in identifying the type of information that should be documented based on the Medicare Part A resident’s clinical category and individual characteristics. For example, if their primary diagnosis maps to the acute infection clinical category, the daily skilled note should include documentation of : Infection treatment and response to interventions, signs and symptoms of infection that are present, assessment of the site/source of infection, any transmission based precautions that are in place, lab/diagnostic testing and results, and vital signs.
Provider Documentation
Physician documentation should show oversight of the skilled stay ideally including entries that speak to: specific resident deficits, medical complexity, progress in response to skilled care, remaining goals and why SNF level of care is recommended to achieve those goals, ongoing skilled need and rehabilitation potential. In addition, active diagnoses have a major impact on reimbursement under PDPM and it is important to have provider documentation to support coding of all active conditions.
Proactive experts can meet your needs for development and ongoing implementation of your PDPM transitions plan, including skilled supportive documentation auditing and monitoring. Our staff includes RAC-CT and AHIMA approved ICD-10 trainers with extensive experience in SNF operations.
Learn more about Proactive’s PDPM Implementation & Coding Support Partnerships.
Proactive Webinars for PDPM Documentation Improvement
- On-Demand PDPM Skilled Nursing Services webinar focused on justifying skilled nursing services under PDPM! This session is available on-demand to jump start your team’s skilled charting. Click here to access.
- PDPM Essentials for Physicians & Pharmacy On-Demand webinar. Click here to access.
NEW PDPM Nurse Charting Guidelines
Check out our new PDPM Nurse Charting Guidelines including documentation guidance for critical NTA item supportive documentation as well as Clinical Categories! Click here to access.
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Blog by Shelly Maffia, MSN, MBA, RN, LNHA, QCP, CHC, Director of Regulatory Services, Proactive Medical Review
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