With the implementation of the Patient-Driven Payment Model (PDPM) on October 1, 2019, facility staff are feeling the pressure to start scrutinizing the completeness of clinical documentation in support of MDS items that will determine reimbursement for Medicare Part A residents.
“Documentation under PDPM is going to be more critical than ever,” states Lynn A. Milligan, MSN/ED, RN, DNS-CT, RAC-CT. Jessie McGill, RN, RAC-MTA, RAC-MT, agrees: “We are moving from the RUG-IV payment model, which primarily uses therapy minutes and ADLs to determine payment, to a model which uses a multitude of clinical items.” Below are some important steps a director of nursing should take to ensure that proper documentation is captured and complete, which will result in accurate reimbursement for the facility and more positive outcomes for residents.
Start with education
What is the best way for directors of nursing to ensure documentation is accurate and complete under PDPM? Milligan says, “You need to start with education. The education, if it hasn’t already started, needs to start now to get your team prepared and well versed in good documentation.”
Directors of nursing need to ensure their teams are prepared for the changes that are coming and educate their staff on how PDPM works and which departments need to collaborate on information, and must develop a process now before the new payment model is implemented. “Most of the items used for the PDPM methodology are already on the MDS today. This means that you can start auditing how well a particular item is being assessed and documented today to ensure a strong process as you move forward to PDPM,” says McGill. “For example, are nurses assessing and documenting if the resident has any pain or difficulty with swallowing? If not, what education and support are needed to shore up this process?"
Many articles, tools, webinars, and workshops are available to assist you in getting you and your team prepared. Start with education as the foundation for implementation.
Visit this page for a comprehensive list of resources that AADNS has provided to help you get ready for PDPM.
Also, a new “PDPM Intensive Series for SNFs” from our sister organization, AANAC, is now available! Get details here.
Admission diagnosis and comorbidities
“One of the biggest factors for PDPM is going to be obtaining discharge information from the hospital. Upon admission, what is the resident’s admitting diagnosis?” says Milligan. “This has always been important, but now it’s really going to also affect payment, potentially for the resident’s entire stay.”
When assigning the primary diagnosis for the SNF Medicare stay, it is important to realize that it may not be the same as the diagnosis for which the resident was hospitalized. The admission nurse, or the staff member responsible for diagnosis coding, needs to ensure he or she has the correct diagnoses and is following the ICD-10-CM coding conventions. The resident’s primary diagnosis is highly impactful to accurate reimbursement in assigning the clinical category for the PT, OT, and SLP components. However, all secondary diagnoses can also impact reimbursement in the SLP-related comorbidities, nursing categories, and many non-therapy ancillary conditions.
The correct diagnosis will come from proper research by your designated ICD-10 coder and may even begin before the resident is admitted to your facility. Your coder will need to identify all physician-documented diagnoses that are still relevant to the resident’s care. Upon admission, ask the resident and his or her representative about other diagnoses to ensure the most accurate and up-to-date list. “It’s important to make sure all of the diagnoses of comorbidities are captured upon admission and throughout the stay,” says Milligan.
The coder may need to query the physician for details in order to code to the highest level of specificity possible. There will be a degree of urgency to obtaining accurate diagnoses, requesting supporting physician documentation upon admission, and not waiting for the hospital discharge summary, which may not arrive until after the 5-Day PPS ARD. Open a dialog with the hospital discharging staff about the need for physician documentation to support all diagnoses from day one. Establish a process now, which will carry over when PDPM is implemented.
“Sometimes, after a patient is admitted, a diagnosis is added by the physician, who was not the physician who looked after the patient at home. This diagnosis is added because the physician sees something that may have been overlooked in the past or was not well documented,” says Milligan, clarifying with an example of this discrepancy:
When a 96-year-old patient comes to your facility because she fell and broke a hip, she probably also has osteoporosis. However, when she comes to the facility, she may not already have that diagnosis, but the new attending physician notices the condition and puts her on a medication such as calcium carbonate, to help with her osteoporosis. And he will document that the diagnosis for that medication is osteoporosis, but nurses might overlook that note and not include it in their diagnosis list. Therefore, the director of nursing needs to have a procedure to ensure that all diagnoses are captured for each resident throughout their stay.
Section GG documentation
In its PDPM Training Presentation, CMS indicates that section GG documentation is used to determine both the PT-and-OT and nursing functional scores for PDPM.
“Section GG is going to have a much larger role under PDPM,” says Milligan. “And now there needs to be significant collaboration between nursing and the rehab department.”
Facility leaders have previously assigned the task of completing section GG to either nursing or rehab separately, but now these two departments will need to come together.
“It is my belief that the nurse assessment coordinator (NAC) should be the point person to bring these two disciplines together to make section GG as accurate as possible,” says Milligan. Both departments are going to observe different things and work with the patient on a different level, and they will need to combine their information to ensure everything is captured.
Section GG has the potential to impact Medicare reimbursement on multiple levels, explains McGill: “Section GG currently can impact Medicare reimbursement if we dash any of the items required to calculate the section GG SNF QRP measures. Failure to report at least 80% of the SNF QRP measure data can result in a 2% decline to the Annual Payment Update (APU). As we transition to PDPM, section GG will also drive the case-mix groups for the PT-and-OT and nursing components.”
The section GG functional assessment will be completed during the first three days of the Medicare stay and has the potential to set the rates for the entire Medicare stay, unless an Interim Payment Assessment (IPA) is completed. “Facility teams will need to establish a process to assess section GG in the middle of the Medicare stay if the team determines an IPA is warranted. This requires a strong collaboration among therapy, nursing, and direct care staff to collect this information quickly,” stresses McGill.
She explains that “dashes for SNF QRP items on the PPS discharge will still count against the APU threshold,” so, while the section GG discharge performance is not used to determine payment, it still matters.
The director of nursing should have a strong presence in the auditing process to ensure the accuracy of the nursing and rehab documentation. “The audit could be as simple as the director of nursing looking at the patient, observing the patient, making his or her own assessment and evaluation of the patient, and then reviewing the charts and seeing what the departments have charted. If it doesn’t look accurate, the director should talk to nursing and rehab to understand why they charted the way they did,” says Milligan.
While many audits occur retrospectively, if the director of nursing is able to audit during the look-back period of the 5-Day PPS assessment, this could lead to actually capturing the services, rather than merely identifying a missed opportunity. “For example,” adds McGill, “if the director of nursing identifies that the resident has a diagnosis of CVA, she can review and discuss with the physician an additional supporting diagnosis for which there may not be adequate documentation to capture yet, such as dysphasia, hemiparesis, or other residual effect.” If the physician provides the needed documentation, the additional diagnosis can be added before the 5-Day and used in the PDPM methodology.
Indicating the presence of depression is part of the nursing component of PDPM and will be important in determining the nursing case-mix component. Signs and symptoms of depression are used as a third-level split for the Special Care High, Special Care Low, and Clinically Complex categories. Residents with signs and symptoms of depression are identified by the Resident Mood Interview (PHQ-9) or the Staff Assessment of Resident Mood (PHQ-9-OV). Staff must be aware of the importance of conducting resident interviews during the look-back period, preferably the day of or day before the ARD. Interviews should be attempted for every resident unless the resident is rarely or never understood. For residents who are rarely or never understood, documentation to support the staff assessment is required. Licensed nurses and CNAs should be educated on the signs and symptoms used in the staff assessment to identify the presence of depression in residents in order to document appropriately and achieve accurate reimbursement.
Swallowing disorder documentation for the SLP component
While K0100 is not new to the MDS, its involvement in reimbursement is. MDS item K0100, Swallowing Disorder, documents the presence of signs and symptoms of a possible swallowing disorder during the seven-day look-back period and is used in determining the SLP case-mix component. For these items to be captured on the MDS, the clinical record must include documentation to support the MDS coding. Staff need to be educated on the importance of documenting these situations each and every time they occur.
McGill further clarifies, “Swallowing disorder is not about capturing a diagnosed swallowing problem, it is identifying signs and symptoms of possible swallowing disorders, which relies on clinical documentation. Typically, these items may be assessed once during the look-back period, and in some cases only by dietary. Now that these items will also impact reimbursement, daily nursing assessment can provide supporting documentation and identify potential problems timelier.”
The importance of the care plan
“The care plan has always been very important in taking care of the patient, but it’s even more important now than ever to have positive patient outcomes. The way to achieve positive patient outcomes is to make sure that your care plan is developed using good clinical evidence to improve and promote patient outcomes,” say Milligan.
Overall Medicare reimbursement relies on reporting of the SNF QRP measures, prevention of rehospitalization through the SNF Value-Based Purchasing (VBP) program, and PDPM reimbursement. The publicly reported measures on Nursing Home Compare also reinforce the need for good clinical outcomes to be reflected to your customers. PDPM’s emphasis on accurate and complete documentation works to help staff develop the comprehensive care plan for the resident, get the reimbursement for the level of clinical complexity, and ultimately improve resident outcomes.
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