The final blog in our PDPM “Looking Back/Planning Ahead” series focuses on strategies to address the unfavorable data patterns and compliance risks we discussed in the two previous blogs. Let’s start with cost-effective and proactive strategies that can help prevent problems and lower risks from the start.
Ensure accurate MDSs are submitted to CMS in the first place.
The MDS is complex, even for the experienced interdisciplinary team (IDT). Take some time to review your auditing process and evaluate the efficacy. Confirm that the feedback from the audit is reviewed and considered carefully by the IDT. Comprehensive auditing tools are now a “must have” for providers as there are too many MDS items that impact quality measures and reimbursement to leave it to chance.
- Do you know what percentage of the audit feedback was corrected?
- Were there improvements in the accuracy from the initial MDS to the final one that went to CMS?
- Are you able to recognize potential coding trends quickly that might indicate a weak IDT member?
Confirm all payment drivers for PDPM are captured.
Part of the proactive audit should also include a review of all the payment drivers for PDPM. Preventing missed opportunities is a big part of ensuring accuracy in reimbursement and this is especially true with capturing comorbidities. If you have access to a resident level PDPM report, use it in your morning meetings where Medicare residents are discussed. Ask each team member to review the report. Are there any items on the report that look incorrect or are some items you expected to see missing?
Three key areas to check:
Diagnoses without comorbidities
- ALS without swallowing problem or mechanically altered diet
- CVA without hemiplegia/hemiparesis, swallowing problem, or cognitive impairment
Comorbidities without diagnoses
- Diabetic foot ulcer without diabetes
- Hemiplegia/hemiparesis without CVA
Treatments without diagnosis
- Isolation without MDRO
- Suctioning without trach, ventilator, COPD, pneumonia etc.
- Insulin injections without diabetes|
With the right tools, this can be a quick review process that gives you peace of mind that your reimbursement is correct prior to the MDS being submitted to CMS.
Build bench strength in the MDS department via your IDT.
Turnover in MDS Coordinators can be disastrous for a provider. No doubt that COVID-19 has created situations where MDS Coordinators were pulled to the floor to work shifts or possibly coordinators have left positions to care for children who are now home from school. Even pre-COVID, turnover was an issue. If there wasn’t a team member ready and waiting in the wings, MDS completion and accuracy likely suffered.
Building bench strength or backups in these key positions is a proactive strategy that saves providers some dollars and anxiety. Cross training a charge nurse or other staff nurse on MDS and the RAI process overall can also serve as a nice career path for a nurse. Also consider contingency plans should you have turnover in IDT members. Many participate in the MDS completion and the sudden loss of a team member can impact the process as well. Make sure there is a backup for their assigned MDS sections. Ongoing training on assessment techniques and staying on top of coding instruction changes in the RAI are also critical to maintaining highly accurate MDSs.
Quality Improvement & the MDS
Quality improvement strategies are another approach to achieving PDPM success. These strategies are more retrospective or reactive to your data patterns and trends but still have a valuable role in your PDPM success. If you have access to your PDPM rate driver trends over time, take some time to dig into these metrics.
In Part 1 of this blog series, we shared PointRight’s national trends in several of the key rate drivers, including depression and cognitive impairment. Both drivers more than doubled in their percentage of assessments from the last quarter of RUGs to the first quarter of PDPM. CMS expected PDPM to be budget neutral so perhaps they were not expecting this dramatic of a change; it is also not likely that the resident population in SNFs changed so dramatically in one quarter. If this is similar to what happened in your facility, why did it happen?
A good quality improvement process can get to the root cause and develop action plans to address any issues that need correction. Sharp increases in coding of these rate drivers that cannot be defended will likely receive the same attention that Rehab Ultra High did in the RUGs system and increase provider risk for RAC audits and potential loss of revenue
For these two rate drivers, encourage collaboration among the IDT as they each possess skills that can help the other. Both cognitive impairment and depression rely on resident interviews and are frequently a challenge for providers. In my role at PointRight, I see interviews skipped all too easily due to mild to moderate cognitive deficits even without attempting the interview, yet they are not coded as “rarely or never understood.” Consider these best practices for capturing resident voice.
Cognitive Mood Interview – Best Practices
Collaboration between Nursing/MDS, Social Service, and SLP
- SLP: Help with guidance on residents with communication deficits to ensure that interviews are not being skipped, use of alternative methods to capture resident voice
- Social Service: Help with guidance on interviewing techniques
- MDS: Ensure that all assessors are following the RAI Manual instructions for both the resident interviews and the staff assessment (Appendix D)
- Make sure the assessor knows the Assessment Reference Date (ARD) so the interviews are done timely
Are you ready to defend your data?
There is no doubt that 2020 presented significant challenges to SNF providers that distracted them from PDPM, and those challenges are likely to continue into 2021. CMS has yet to speak up about any analysis they may have conducted related to PDPM rate drivers likely due to their focus on COVID as well. The opportunity to investigate and address any problems areas is now. Be ready to defend your data!