As part of the Center for Medicare & Medicaid Services (CMS) “Patient over Paperwork” initiative, PDPM¹ will replace Resource Utilization Groups (RUGs) Medicare Part A Skilled Nursing Facility Prospective Payment System (SNF PPS) for reimbursement. This will move reimbursement from a focus on therapy minutes to a more patient-centered and value-based approach. The attention will be on the patient’s progress and whether or not care plan goals are being met. Implementation of the new payment model is planned to take effect on October 1, 2019.

Fewer resident assessments, more comprehensive medical documentation

Under PDPM, CMS will eliminate the mandatory 14-, 30-, 60- and 90-day resident assessment. Only the PPS 5-day and PPS Discharge Assessment will be required. An optional Interim Payment Assessment (IPA) will be allowed when clinical changes warrant a new PPS assessment that will affect a change in reimbursement.

With this change, Medicare reimbursement for SNFs will be determined by the primary diagnosis at admission. This will require assessing many factors up front including surgical history, functional scores, clinical conditions and comorbidities, restorative nursing, diet modification, and swallowing disorders.

Five clinical categories will be scored individually: physical therapy (PT), occupational therapy (OT), speech-language pathology (SLP), non-therapy ancillary (NTA), and nursing. The total of these scores will assign the case mix group which will determine reimbursement rates.

The switch to the PDPM system is expected to greatly reduce the amount of paperwork currently generated from multiple MDS assessments and therapies. However, more comprehensive medical documentation will be needed in order to capture the characteristics and conditions of each resident so that a proper initial diagnosis can be made. An accurate primary diagnosis code on the MDS will be critical to ensure a claim is not automatically returned to the provider.

Greater scrutiny of medical records

A recent article from Skilled Nursing News² discusses why providers should expect increased scrutiny of nursing records under PDPM, warning that documentation habits will have to change. SNFs will now need to capture information they haven’t had to in the past, specifically NTAs. Because of this, “…receiving complete information from the hospitals prior to and at admission is paramount.” The article also cites nurse’s notes as being “crucial to achieving seamless documentation.” A challenge for most SNFs will be figuring out how to engage physicians outside their facilities and gain access to hospital documentation.

The June 2019 issue of the Journal of AHIMA³ further explores these challenges in an article titled “Revolutionary Payment Changes Prompt Skilled Nursing Facilities to Eye CDI Programs.” It outlines the advantages of implementing clinical documentation programs at SNFs and identifies several areas in which CDI can have an impact. Per the article, the adoption of CDI can help SNFs:

• Clarify specificity of all diagnoses
• Ensure nursing documentation supports medical necessity of 24/7 skilled nursing care as well as all information reported on the MDS assessment
• Identify any major surgical procedures that occurred during the inpatient hospital stay that immediately preceded the SNF admission
• Obtain copies of physician progress notes, which can be omitted from the transfer/admission process
• Obtain copies of the complete hospital record
• Work with acute care hospitals to clarify the date of the preceding hospital admission

How Excelas Can Help

As a national provider of medical record organization and analysis, Excelas handles millions of pages of medical records each year. Our health information specialists can help identify the strengths and weaknesses of your organization’s documentation so that you are better prepared for the switch to PDPM. Contact us to learn more.

¹https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html
² https://skillednursingnews.com/2019/06/under-pdpm-providers-should-expect-close-scrutiny-of-nursing-records/
³ http://www.ahimajournal-digital.com/ahimajournal/june_2019?pg=20#pg20