PDPM Prep and Skilled Nursing: Secure Skilled Coverage Starting Day One

By Caralyn Davis, Staff Writer - January 16, 2019

When the Patient-Driven Payment Model (PDPM) replaces RUG-IV as the case-mix classification system for the Skilled Nursing Facility Prospective Payment System (SNF PPS) effective Oct. 1, 2019, some SNFs may see their Part A length of stay temporarily increase, says Maureen McCarthy, BS, RN, RAC-MT, QCP-MT, DNS-MT, RAC-CTA, president/CEO of Celtic Consulting in Torrington, CT.


“The skilled coverage rules for Medicare won’t change just because we are changing payment systems. However, 95 percent of SNF days are in rehab categories, and many providers have been so focused on obtaining the best rehab RUG score that they have lost sight of what the skilled coverage is,” notes McCarthy. “So length of stay may go up for a period of time as SNFs re-learn how to skill patients for nursing services and become comfortable with understanding when the need for skilled care ends if rehab is not involved.”


Skilled nursing can be direct or management


Under skilled nursing, SNFs can provide direct skilled nursing services (e.g., intravenous or intramuscular injections and intravenous feeding) or skilled-management nursing services, including management and evaluation of a patient care plan, observation and assessment of a patient’s condition, and teaching and training activities. “Providers need to understand that nursing will be a viable primary skilled service under PDPM, so it’s a good idea to master some of these nursing skills that you may not have used in a while,” says McCarthy.


In addition, even when rehab is the primary skilled service under PDPM, providers may want to use restorative nursing as well, says McCarthy. “Restorative nursing is a skilled service in and of itself. So under PDPM, you will have an opportunity to provide skilled therapy to patients who need it and then to bring those patients over to restorative nursing to practice compensatory strategies, therapeutic exercises, and the different components that they learn from rehab. You can give them a chance to master those skills for a few days before they go home. If a patient doesn’t do well, you can call the therapist right back in. However, if they do well, then you can feel comfortable that this person will be less likely to have a rehospitalization within 30 days of discharge from your facility.”


Assessment and documentation skills matter


Assessment and documentation will be critical to using nursing services to meet the Part A skilled level of care, says Carol Hill, MSN, RN, RAC-MT, DNS-MT, QCP-MT, CPC, president of Hill Educational Services in Warrior, AL. “SNFs have always documented from a nursing perspective, but currently under PPS the focus of documentation tends to weigh more on therapy documentation rather than nursing clinical services.”


So nursing staff need to shore up both their assessment skills and their documentation skills, advises Hill. “This is the only way to capture the characteristics of your residents that require a skilled level of care and the skilled services that your team is providing to meet those needs. It will also help ensure that you have the documentation needed to support MDS coding under the PDPM.”


To learn more about nursing services that rise to a skilled level of care and to understand the related documentation requirements, providers should review Section 30, Skilled Nursing Facility Level of Care – General, in Chapter 8 of the Medicare Benefit Policy Manual. The following list adapted from the Chapter 8 table of contents shows the breadth of information in Section 30 that providers can use to guide nursing staff:


· 30 - Skilled Nursing Facility Level of Care – General: Explains the four factors needed to meet a skilled level of care.

§ 30.1 – Administrative Level of Care Presumption. Note: For additional information on how administrative presumption works under PDPM, see the Administrative Level of Care Presumption Under PDPM fact sheet.

§ 30.2 - Skilled Nursing and Skilled Rehabilitation Services

o 30.2.1 - Skilled Services Defined: Explains the two components required for a service to be skilled and why a skilled service may be required.

o 30.2.2 - Principles for Determining Whether a Service is Skilled: Explains the role inherent complexity plays in skilled services and provides examples of how to determine whether a service is skilled.

§ – Documentation to Support Skilled Care Determinations: Does not prescribe documentation formats, but explains core content requirements needed for medical review, as well as providing examples of vague or subjective documentation that would not be sufficient to validate the need for skilled care.

o 30.2.3 - Specific Examples of Some Skilled Nursing or Skilled Rehabilitation Services

§ - Management and Evaluation of a Patient Care Plan: Explains—with examples—when the development, management, and evaluation of a patient care plan constitute skilled nursing services.

§ - Observation and Assessment of Patient’s Condition: Explains—with examples—when the likelihood of change in a patient’s condition makes observation and assessment skilled services.

§ - Teaching and Training Activities: Explains—with examples—when teaching a patient how to manage their treatment regimen is a skilled service.

o 30.2.4 - Questionable Situations: Explains scenarios that raise yellow flags, requiring SNFs to show specific evidence of the need for and provision of skilled services.

§ 30.3 - Direct Skilled Nursing Services to Patients: Explains coverage requirements for direct skilled nursing services and offers examples of these services.

§ 30.4. - Direct Skilled Therapy Services to Patients

o 30.4.1 – Skilled Physical Therapy

§ - General

§ - Application of Guidelines

o 30.4.2 - Speech-Language Pathology

o 30.4.3 - Occupational Therapy

§ 30.5 - Nonskilled Supportive or Personal Care Services: Discusses services that are generally nonskilled but can be skilled if special medical complications require skilled staff to perform or supervise care or to observe the patient.

§ 30.6 - Daily Skilled Services Defined: Explains what daily skilled services means, including how many days per week skilled rehab, skilled nursing, and skilled restorative nursing services must be needed and provided.

§ 30.7 - Services Provided on an Inpatient Basis as a “Practical Matter”

o 30.7.1 - The Availability of Alternative Facilities or Services

o 30.7.2 - Whether Available Alternatives Are More Economical in the Individual Case

o 30.7.3 - Whether the Patient’s Physical Condition Would Permit Utilization of an Available, More Economical Care Alternative


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