Resident conditions and resource needs drive reimbursement under the Patient-Driven Payment Model (PDPM). Successful facilities have developed systems to effectively recognize and capture the differences among residents, particularly in the utilization of resources. Does your process include these key action steps to facilitate winning at PDPM?

Since 2019, SNFs have been working to achieve payment accuracy under a payment system with many moving parts. To ensure this goal is met, there must be a clear understanding of how the components of PDPM work together for reimbursement, and efficient processes in place to ensure that all needed supporting documentation is complete and timely for accurate MDS completion. Priority focus areas for missed opportunities include Primary Diagnosis, supporting diagnoses, the functional assessment for section GG, and qualifiers for the nursing CMGs.

Priority Action Items

      • Active Conditions in Section I should include Physician documented diagnoses which are active during the 7-day lookback period of the MDS.
        • A basic understanding of ICD 10 coding and the correct coding guidelines is essential when assigning codes as the primary and any supporting diagnoses
        • Only physicians and physician extenders can diagnose; providers cannot infer a specific diagnosis because the documentation appears to support the specific condition or ICD.10-CM code. The specificity of the physician-endorsed diagnosis is often the critical missing link to accurate ICD 10 code assignment for PDPM. Providers should review (or develop) a physician query processes to ensure the diagnosis is accurate, active, and coded at the highest specificity. FY 2023 PDPM ICD-10 Mapping
        • Ensure staff are effectively trained in ICD.10-CM coding. Join Proactive on 3/29/23 for Virtual ICD.10 CM Coding Refresher for SNFs
        •   FY 2023 PDPM ICD-10 Mapping
      • Section GG Coding Accuracy & Routine Staff Training Are Critical
        • The accuracy of the function score (Section GG), impacts both the PT/OT components and the nursing component under PDPM. Documentation must include the completion of an interdisciplinary functional assessment during the first three days of the Medicare stay to support the coding of section GG.
        • All clinicians responsible for the completion of the functional assessment should be trained and have a basic understanding of the tasks being assessed for section GG and the scale used for coding including coding when a task was not attempted during the assessment window. PDPM Section GG Function Scoring Competency Toolkit
        • Review current processes. Ensure IDT systems include team documentation to support collaboration and usual performance. Keep in mind, Section GG accuracy not only has a major impact on PDPM rates, but may also affect 5-Star, Quality Measures, and SNF QRP.
      • Comprehensive Medical record Reviews Reduce the Risk of Missing Conditions and Services that Impact Reimbursement
        • An effective chart review should include more than just the hospital discharge summary. Key hospital documentation to include in your review are the Admission H&P and relevant progress notes, diagnostic reports, medication administration and treatment records, ER documentation, operative notes, consult reports and any other pertinent documentation. Each of these may include relevant services and conditions impacting the need for SNF service delivery and the determination of the accurate PDPM payment rate.
        • For example, hospital MARs and ER documentation for new admits/re-admissions retrieved may identify administration of IV fluids or parental feedings.  Establishing an ARD that allows for accurately coding these services plays a part in capturing the Special Care High Nursing CMG, and will potentially contribute to a significantly higher rate of reimbursement.
      • Understand Nursing Classification Criteria and Become more Familiar with NTA Comorbidities
        • Common gaps identified in documentation to support Nursing CMGs include:
          • A lack of condition application and specific interventions in the baseline or SNF care plan.
          • Insufficient information provided in skilled nursing assessments. For example, respiratory assessments often lack documentation related to SOB when lying flat for COPD patients, or documentation to support active pneumonia during the lookback period noting sign/symptoms and response to antibiotics, etc.
        • 49 conditions and extensive services can contribute NTA points. Common areas that are vulnerable for payment impact include:
          • Physician documentation of active conditions (e.g., malnutrition). Tip: involve the dietician early to allow time for physician query when necessary.
          • Understanding how MDS coding in section I impacts both the NTA and the nursing CMG is important. As a result, it may be necessary to code a diagnoses in more the one place in section I. For example, the Respiratory Failure diagnosis may need to be coded in three separate places in section I to obtain accurate reimbursement under PDPM. When Respiratory Failure is the primary skilling diagnosis reported at I0020B, the ICD-10-CM code must also be reported at I8000 to capture the associated 1 NTA point. This diagnosis is also a qualifier for the Special care Low nursing CMG when coded in I6300 and the use of oxygen is also coded


Proactive specializes in remote PDPM QA Reviews and audit solutions to ensure coding accuracy and documentation compliance—contact us to learn more and to schedule a demo. Nurse leaders interested in growing skills in overseeing the MDS process should join us April 6th for Dynamic DON MDS and Medicare Essentials.



Written By: Brandy Hayes, RN, RAC-CT
Clinical Consultant


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