By Jennifer Gross, BSN, RN-BC, RAC-CT, CPHIMS
As Skilled Nursing Facilities (SNFs) prepare for the implementation of the Patient-Driven Payment Model (PDPM) on October 1, 2019, much of the focus of training has been on diagnosis coding. Rightly so, since ICD-10 coding can make or break a facility’s capture of the correct PDPM Clinical Categories and Non-Therapy Ancillary (NTA) comorbidities. But what about the other components of PDPM? CMS has designed the new payment model to be driven by multiple clinical characteristics of the patient/resident, not just diagnoses. It’s up to SNFs to ensure that their interdisciplinary teams capture the full picture in their documentation – while also reflecting the patient’s need for daily skilled SNF care. Fortunately, the two go hand in hand.
Skilled Care – Basic Requirements
While the payment structure for Medicare is changing, the basic requirements for skilled care outlined in Chapter 6 of the Medicare Benefit Policy Manual remain the same. Very briefly, here are the basic requirements:
- Ordered by physician
- Skilled nursing or rehabilitation services (provided by or under supervision of licensed personnel)
- Provided on a daily basis (Nursing: 7 days/week, Therapy: 5 days/week)
- Skilled services must be provided for a condition for which the resident received inpatient hospital care (or which arose while in SNF receiving care for the inpatient condition)
- As a practical matter services can only be provided on an inpatient basis in the SNF
Under Medicare Fee-for-Service…
Under the Medicare fee-for-service system, SNFs have become accustomed to thinking of their patients as “skilled for therapy” or “skilled for nursing”; however, it’s usually not an either/or situation. Under RUG-IV, that’s what it seems like, though…if a patient’s RUG falls into a Rehabilitation group (excluding Rehab Plus Extensive), it doesn’t matter how many clinical comorbidities she has – the reimbursement is the same. Because of this, SNFs have been disincentivized from documenting items that were not payment drivers – even clinically significant issues like complex diagnoses, mood symptoms, and swallowing problems. Combined with the sheer number of Minimum Data Set (MDS) assessments required to set the Medicare per diem rates, this means that for many SNFs, the MDS and documentation process has been whittled down to the single purpose of supporting the RUG on the Medicare claim.
This changes under PDPM: fewer assessments are required – only the 5-day at the beginning of the Medicare stay, the PPS Discharge at the end, and an optional Interim Payment Assessment (IPA) in between. Since your MDS department will be less focused on churning out assessments, how about redirecting some of that time from MDS to CDI: Clinical Documentation Improvement? This is a relatively new concept in the SNF world, but ensuring solid documentation is key to PDPM success – not to mention good clinical practice. Use the big drivers of PDPM- the Clinical Categories – to frame your CDI plan. While these categories come from selecting the correct primary SNF diagnosis ICD-10 code, you should also capture the comorbidities that go along with that diagnosis. Here are some tips for getting the CDI ball rolling:
- If your facility treats stroke patients (Acute Neurologic Clinical Category), review your processes for identifying and documenting swallowing problems, speech and language deficits, cognitive impairment, and mood changes. These comorbidities add to the SLP, NTA, and Nursing PDPM components, so missed documentation can mean missed reimbursement.
- For the surgery categories (Major Joint Replacement/Spinal, Other Orthopedic, Non‐Orthopedic), review documentation of surgical wound care, pain management, any follow-up medications such as antibiotics or anticoagulants, and monitoring lung sounds, circulation, etc.
- For the Medical Management and Non‐Neurologic categories, there are as many possibilities for CDI as there are different complex medical conditions. Consider how your documentation captures complex medical interventions (chemotherapy, radiation, ventilator/respirator, etc.), special treatments (IV meds/hydration, TPN, tube feeding, transfusions), and other medications (such as antibiotic, anticoagulant, insulin, or psychotropic)
Good Documentation = Appropriate Reimbursement
In each of these examples, good documentation demonstrates the daily skilled services your facility’s care team provides your patients – and therefore shows that the Medicare requirements are being met. At the same time, you can capture comorbidities that feed into the PDPM components…and enable you to identify changes that mat prompt an Interim Payment Assessment. PDPM provides you the opportunity to make sure that your documentation shows the good care you provide – and get the appropriate reimbursement for it!
Jennifer Gross, BSN, RN-BC, RAC-CT, CPHIMS
Senior Healthcare Specialist, PointRight