PDPM Rate Drivers – What do they reveal?

Let’s break down the rate drivers to expose the potential audit vulnerabilities.

Extensive Services

I do not think anyone is surprised that there is an increase in coding of this nursing case mix group (CMG) because this is where isolation, trachs, and vents are captured. The jump in ES in FYQ3 aligns perfectly with COVID, but do not be too complacent here. CMS may see this as a potential area of fraud and dig deeper to make sure the definition of isolation in the RAI manual was followed. This case mix group (CMG) could likely remain high through early to mid 2021 depending upon the status of the pandemic.

Depression/Cognitive Impairment

A huge red flag for all providers should be the more than doubling of MDSs coded with depression and more than tripling of cognitive impairment in FYQ1. It is highly unlikely that the entire nation had a dramatic increase in residents with these conditions suddenly being admitted to their facilities. Now that depression and cognitive impairment drive the rate, there is certainly an incentive to capture them. But if your documentation supports your coding, don’t fret. We all know that if we provide additional training and focus on an area, we typically will see improvement in assessment. But you may want to consider documenting all your unusual trends and subsequent investigation in the QAPI committee minutes and confirm that this is truly the case. Consider any changes you made to the interview process or interviewer as well.

Restorative Nursing

This PDPM rate driver saw a much slower increase but still nearly doubled from pre-PDPM to FYQ3. However, capturing restorative minutes on a PPS assessment is much harder now if Assessment Reference Dates (ARDs) are set early in the stay because it requires 15 minutes per day for at least 6 of the last 7 days. Earlier ARDs could be a logical explanation, but don’t assume. Test your theory especially if your quality measures may indicate declines in Activities of Daily Living (ADL) function.

Swallowing Disorders/Mechanically Altered Diet

The coding of swallowing disorders calculating close to 4x’s the pre-PDPM rate is yet another example of a concerning trend that will likely grab CMS attention. It makes sense that if the swallowing disorders increase, the mechanically altered diets might increase as well. However, not every resident with a swallowing disorder needs a mechanically altered diet, but most residents who are on a mechanically altered diet would have some condition to warrant it such as a recent oral surgery, poor dentition or extreme weakness making chewing difficult. The reason for the altered diet should be clearly documented and re-evaluated for continued need.

Non-Therapy Ancillaries (NTA)

Variability in resident acuity is normal so fluctuations in the distribution of assessments across the 6 NTA case mix groups is expected. Nationally, PointRight customers saw approximately 53% of their assessments land in the lowest two groups. How will CMS perceive high percentages of assessments in the higher CMI groups? We do not have any pre-PDPM comparison since NTAs were not in play prior to October 2019, but it certainly could be a high priority area for auditors. NTAs are a significant multiplier in the per diem calculations so it stands to reason that providing evidence that these comorbidities exist, or services/treatments were provided, will be a crucial step to avoid audit nightmares.