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How do we tell each patient’s comprehensive clinical story?

An important goal of PDPM is to boost payment accuracy for the services skilled nursing facilities provide. To accomplish this, SNF teams in turn must also maximize the accuracy & timeliness of the documentation they provide to CMS.


While RUG-IV required at least five assessments over a 90-day stay, the number of assessments under PDPM has been reduced to just two: the five-day initial Medicare assessment; and the discharge assessment on a resident’s last day of stay.


CMS predicts that fewer assessments will reduce the administrative burden for SNF teams. However, because the initial five-day assessment will be the primary determinant of reimbursement, providers must be as accurate and consistent as possible in the patient data they report on the MDS and in the medical record.


How do we effectively capture each patient’s clinical story?


SNF teams now have just eight days to understand a patient’s full clinical picture, gather the necessary data, and submit the five-day assessment. During that short window, collaboration and communication will be imperative. As PDPM approaches, MDS coordinators and SNF teams are honing their internal processes in the following ways:


  • Pre-admission process: Thorough communication with the referring hospital &/or physician will be necessary to clearly understand each patient’s background and the reasoning behind their referral to the SNF.
  • Determination of primary diagnosis: While a patient may have been in the hospital for one reason (e.g. surgery), the reason for their need for skilled services may be different (e.g. infection). SNF teams will have to collaboratively determine what primary diagnosis they will be treating together and what resources will be required for that diagnosis. MDS coordinators must also become experts at the more than 24,000 “Return to Provider” codes, which if used as the primary diagnosis, will cause rejection of the MDS.
  • Describing all comorbidities and services: Teams must determine a strategic approach to understanding all of the comorbidities and related treatments & services that determine an individual’s case mix.
  • Pre-bill Claim Review: Ahead of PDPM, members of the IDT are reviewing claims together, validating the information, and ensuring that supporting documentation is in the medical record. This ensures accuracy and lowers the risk of audit or denial of payment.


In addition, SNF teams must decide on the timing for submitting the initial MDS. For example, when should the 5-day assessment be completed – when patient is on IV, begins therapy, or receives a certain treatment? What point in time will best capture the services/resources necessary to treat the patient? 


What if the patient’s clinical story changes during their SNF stay?


The five-day assessment classifies the patient/resident for their entire stay, unless an Interim Payment Assessment (IPA) is filed. CMS says IPAs are “optional” and can be filed when clinical changes warrant a change in PDPM per-diem payment rates. However, note that an IPA could increase or decrease your payment, and filing too many of them could bring scrutiny from CMS.


Discharge assessments: How do we describe what we accomplished during each person’s time under our care?


The ultimate goal of PDPM is to provide better care and achieve better outcomes for patients, while at the same time ensuring that SNFs are appropriately paid for providing that care. While discharge assessments are not tied directly to payment, the data collected therein drives quality measures, five-star ratings, and internal measures for SNFs and their partners.


By accurately capturing and reporting patient data at the end of a skilled stay, SNFs can show how people under their care improve functionally & cognitively, and are able to effectively move to the next level of care. When discharge data is shared with families, physicians, hospitals, and other partners, your accomplishments shine through and tell the story of your SNF’s teamwork, expertise, and quality of care.


Further notes about MDS coding accuracy (especially as it relates to therapy):


Section C – Cognitive Patterns

Under PDPM, residents will be classified into four cognitive levels based on how they score on the Brief Interview for Mental Status (BIMS) or the Cognitive Performance Scale (CPS). A resident’s cognitive level will be used to calculate the SLP category for payment. For example, residents who score 12 or below (on the BIMS 15 point scale) will be categorized as cognitively impaired, and this will increase your reimbursement. Make sure your staff is trained to do interviews with a standard script and interpreter as needed.


Section G – Functional Status

Under the RUG-IV case-mix classification system, the activities-of-daily living (ADL) score derived from MDS Section G (Functional Status) factored into the calculation of every case-mix group. Under PDPM, Section G will still play a role in care planning and some quality measures, but Section GG (Functional Abilities & Goals) will take center stage when determining payments. There are MANY scoring item differences between Section G and GG. Section G notes a resident’s self performance and need for support with ADLs. Guidance on the MDS says to code for the most amount of assistance provided within a 7 day look back window.

Section GG – Functional Abilities & Goals

Section GG captures residents’ prior level of function, admission performance, discharge goals, and discharge performance. Section GG also impacts SNF QRP, and it will become the end split for determining PDPM classifications (for nursing, PT & OT).


Under PDPM, Section GG will be used in case-mix classification for three of the five case-mix-adjusted payment components: physical therapy (PT), occupational therapy (OT), and nursing. PT & OT will use 10 questions to determine a calculation for each resident, while nursing will use 7 questions for their score.


Because both therapy and nursing will be performing the Section GG assessments, a collaborative approach will be vital, as team members from nursing and therapy compare their Section GG scores and have conversations about each resident. Your Rehab Director, nursing team (including aides), and MDS coordinators must speak the same language on Section GG, so they can reduce discrepancies/errors in scoring, and understand how to demonstrate improvement. This could mean that therapy is more involved when weighing in at discharge. Moreover, since your aides spend the most time with residents, they must understand their role in observing, reporting on, and assisting with each resident’s ADLs. Open communication with aides will be essential to good documentation, accurate scoring, and the ability to demonstrate improvement.


Section I

Section I of the MDS is dependent on accurate ICD-10 diagnosis coding and management. The MDS and the Medicare claim must contain the same information in the same order. Even if your clinical software enters diagnosis codes onto the bill, be sure your SNF has a process in place to check that admitting and primary diagnoses are in the right location on the bill, and the conditions on the bill support the amount being billed.


Section K

Under PDPM, the SLP payment does not decrease over time. Be sure to capture accurate SLP-related comorbidity opportunities on the MDS.  This could include the primary diagnosis that affects speech or swallowing (ALS; Apraxia;, Dysphagia; Laryngeal cancer;, oral cancer; speech & language deficits; Aphasia; CVA, TIA or Stroke; Hemiplegia or Hemiparesis; tracheostomy; ventilator or respirator).


Section O

“Section O: Special Treatment, Procedures, and Programs” along with Section G were payment drivers under RUG-IV. Now Section O will tell a much smaller part of the MDS story, and therapy’s front seat role as the driver of reimbursement will be greatly reduced.


Ready to consider a more collaborative therapy partner?


Under PDPM, a collaborative relationship with your therapy provider will be vital, as the way you care for patients together will determine your patient satisfaction, quality measures, and the overall position of your SNF or CCRC in the marketplace.  


Let’s talk about the relationship we could sustain together for many, many years to come.  Email me or call 877-TMI-8171.