Even though SNFs have collectively seen higher reimbursement rates under the Patient-Driven Payment Model compared to the previous RUG IV payment model, data shows that there is still room for improvement for most facilities in terms of ensuring accurate revenue under the new payment model. While the PDPM is based on clinical characteristic of an individual, which can vary greatly at any given time, there are still a few specific facility processes providers will want to keep an eye on to drive assessment accuracy and reimbursement. Some of the top priorities include:

  1. Accurately assessing and reporting Section GG data: This is one of the most important areas of the PDPM as it collects assessment data on self-care and mobility activities that are then used to calculate two distinct function scores which directly impact the PT, OT, and Nursing components of the per diem rate. Failure to complete the assessment during the required timeframe and/or inaccurate assessment data can lead to dollars being left on the table, or at risk for recoupment under a review. It’s important to initiate GG assessment on the day of admission (day 1 of the 3-day assessment period for the PPS 5-day) and ensure a collaborative approach to data collection practices. This, in turn, requires ongoing education of GG activity and coding response definitions, communication between disciplines, and appropriate documentation to support final MDS coding decisions.
  2. Ensuring accurate and specific ICD-10 Coding: This is another significant piece of PDPM – from the primary diagnosis that maps the individual to a Clinical Category, to several secondary diagnoses that can impact the SLP, Nursing, and/or NTA components of the rate, focusing on identifying and appropriately reporting conditions and diagnoses are imperative to PDPM success. There are also nuances to MDS coding in and of itself to consider; for example, a diagnosis of Respiratory Failure can fall under the NTA umbrella “Cardiorespiratory Failure and Shock,” however, NTA points will not be awarded if the condition is indicated at I6300 – Respiratory Failure, but rather will only be recognized in terms of the calculation if the appropriate ICD-10 code for Respiratory Failure (J96.01 for example) is manually entered at MDS item I8000. Providers must also focus on coding only those conditions and diagnoses in Section I that have been diagnosed by a physician within the past 60 days AND have a direct relationship to the resident’s status during the 7-day look-back period. Need training? Join us July 27-30 from 1p-4:30 each day for ICD.10-CM for Beginners to gain the skills you need to drive clinical coding and billing practices
  3. Optimizing ARD selection: Providers need to remember that we no longer have to wait and schedule the 5-Day ARD on covered day 7 or 8, as was a long-standing habit under the RUG-IV payment model. This is primarily due to no longer having to wait for 5 days of therapy to be provided – the high-paying “therapy RUG” is no longer the driver under PDPM. We now have the opportunity to select the most appropriate ARD based on the clinical condition of the individual and the services being provided within the assessment window (days 1 – 8 of the Medicare Part A stay). This flexibility is especially beneficial in cases where the individual has received IV fluids– even if administered at the hospital. If documentation supports that the fluids were administered for a clearly indicated nutrition or hydration need during the 7-day look-back period, this will qualify the individual for the higher-paying Nursing CMG of Special Care High. For this reason, thorough and prompt medical record review is necessary to ensure optimal ARD selection.

To identify whether or not you’re on the right track, keep an eye on MDS coding trends. Coding accuracy monitoring and formal auditing are important methods to identify any errors or inconsistencies. For example, is a surgical wound coded in Section M but a major surgery is not coded in Section J? This may not be a mistake depending on the type of surgery itself, but would warrant investigation to ensure accuracy. Quality Measure management is another key tactic; review outcomes data and compare unexpected changes to MDS coding and facility practices. And as always, monitor for changes in resident conditions and services. Were these changes identified and properly reported on the MDS? From the start, changes in resident characteristics can impact optimal ARD selection or may warrant completion of the Interim Payment Assessment (IPA) throughout the length of stay.

Join us July 8th for Thriving Under PDPM: Essentials of a Successful PDPM Program as we share insights from trending 2500 PDPM coding and documentation audits with best practice applications for Medicare operations. Proactive can also assist with your facility’s PDPM performance through 3rd party audit services that point your team in the right direction for internal process improvement. Each Proactive audit provides detailed feedback on coding and charting accuracy with guidance from an MDS expert to promote long-term improvement.  Contact us at info@proactiveltcexperts.com to learn more.



Blog by Eleisha Wilkes, RN, GERO-BC, RAC-CTA, RAC-CT, DNS-CT Proactive Medical Review

Learn more about Eleisha and the rest of the Proactive team.