PDPM Reimbursement Dollars

In one of my past roles, I was a Corporate Compliance Officer for a long-term and post-acute care provider. I still maintain my CHC (Certified in Healthcare Compliance) credential through the Healthcare Compliance Board and stay connected to the LTPAC compliance community.  Understandably, there is a lot of discussion about what will happen from a compliance and enforcement standpoint now that the Patient-Driven Payment Model (PDPM) has been implemented. Back in May 2019, I speculated that documentation and accurate coding would be key to PDPM success – and this is still true now that October 1 has come and gone. 

PDPM Guidance from CMS

CMS has been very clear about compliance risk areas for providers under PDPM. In CMS’ provider training, John Kane stated specifically, “Given the more holistic style of care emphasized under PDPM, program integrity and data monitoring efforts will also be more comprehensive and broad. For program integrity, we expect provider risk will be more easily mitigated to the extent that reviews focus on more clearly defined aspects of payment, such as documentation supporting patient diagnoses and assessment coding.”¹

Beware of PDPM ‘Optimizers’

There are some PDPM tools out there that allow you to get the highest payment without any regard to supporting documentation. One example, a diagnosis optimizer, allows you to select any ICD-10 code from a hierarchical list, whether or not that code has been assigned to that particular resident through proper diagnosis coding procedures, which of course would include a comprehensive review of the patient’s medical record documentation. This concerns me (and many other compliance professionals!) because we already know the compliance-related lessons that have been learned from other types of healthcare providers who used similar approaches in the past. From a compliance perspective, you should use only tools that help you get the highest payment that your medical record documentation actually supports.

Rely on Proven MDS Audit Applications

Some LTPAC EHR and billing software vendors are offering MDS audit features and MDS analytics within their applications. From a compliance perspective, you’ll be best-positioned if you use a well-respected and proven third party application that is separate from your EHR to audit your reimbursement-related MDS coding. The proverbial fox guarding the henhouse concept applies here. And beware of anything that’s free – in my experience, you usually do get what you pay for!

By following compliance best practices in your auditing and monitoring activities, in the event of an audit or investigation, you’ll be much better-positioned to keep the PDPM reimbursement dollars that your teams are working very hard to achieve.

Sources:

¹ CMS Quality Reporting Program Provider Training; “Patient Driven Payment Model: What is Changing (and What is Not)” slide 65; Centers for Medicare & Medicaid Services, May 8, 2019.