Jennifer LaBayIn October 2019, the Patient-Driven Payment Model (PDPM) became the new payment methodology for Medicare Part A residents in skilled nursing facilities (SNFs). Although PDPM has been in effect for two years, the public health emergency may have temporarily shifted priorities for some facilities.

This temporary shift, combined with PDPM’s relative newness and recent staff turnover, may have significantly affected Medicare revenue over the past 18 months.

Here are three common missteps that may be impacting a facility’s Medicare reimbursement.

1. Managing the Assessment Reference Date (ARD)
The Medicare 5-Day assessment has an ARD range of Days 1-8 of the SNF Part A-covered stay. Nurse assessment coordinators (NACs) who insist on using Day 8 as the ARD for all 5-Day assessments may not capture all the services or conditions that impact Medicare revenue.

Since payment is no longer based on therapy minutes, facilities may benefit from finessing their ARDs to ensure documentation is in place to capture key services and diagnoses. The ARD for the 5-Day assessment must be set on a Minimum Data Set (MDS) form or in the MDS software no later than 11:59 p.m. on Day 8 of the Medicare stay. Once that time and date passes, the ARD cannot be changed, but until that point, it can be adjusted.

Ideally, on Day 8, the NAC should be completing a full chart review, including preadmission records, to determine the care and services that were provided. Using the calculation worksheets in chapter 6 of the “Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User’s Manual,” the NAC can determine the optimal ARD to capture the care and services, which will result in the best PDPM case-mix groups (CMGs).

Choosing Day 8 as the ARD instead of Day 2 could make a difference of hundreds of dollars per day, depending on what services were delivered and diagnoses assigned during the observation period.

Some examples of missed opportunities related to improper ARD selection include:

  • Not capturing cognitive impairment under the Speech-Language Pathology (SLP) component can occur when the Brief Interview for Mental Status (BIMS) is not conducted during the look-back period. If BIMS was completed on Day 1 of the stay and the ARD selected is Day 8, the BIMS is outside of the range for inclusion on the MDS.

Per RAI manual instructions, page C-2, “Item C0100 must be coded 1, Yes, and the standard ‘no information’ code (a dash ‘-’) entered in the resident interview items. Do not complete the Staff Assessment for Mental Status items (C0700-C1000) if the resident interview should have been conducted but was not done.”

Preferably, the BIMS should be completed on the day of or the day before the ARD. Staff must be aware of all services that have been provided each day so that an ARD can be selected for a timely completion of the interview.

  • Not capturing IV fluids or parenteral feeding from the hospital will impact the Nursing component of PDPM. Calculation for the Special Care High CMG comes from a 7-day look-back for both while a resident and while not a resident. If these services were received in the hospital, it may be beneficial to choose an earlier ARD to capture the IV or parenteral feeding.

2. Assigning Primary Diagnosis Codes
Part of PDPM accuracy is ensuring the appropriate primary diagnosis is selected in section I0020B of the MDS. Some common diagnoses that have historically been used as a primary reason for admission to a SNF that, per the Centers for Medicare and Medicaid Services, will not map to a billable clinical category include weakness, failure to thrive, falls, and altered mental status. All of these calculate as return to provider (RTP) diagnoses in the PDPM ICD-10-CM mapping tool.

RTP diagnoses do not reflect care and services that would meet the skilled coverage criteria outlined in chapter 8 of the “Medicare Benefit Policy Manual” and will not generate a CMG. This may lead to payment at the default rate or, worse, provider liability. When this occurs, facilities need to dig deeper and query the physician or non-physician providers (NPP) about the cause of these conditions.

The better clinicians understand the nature of the problem, the better resident care will be, and the more accurate the payment category. It is important for the SNF team to discuss as a group before and after admission to ensure the medical record and MDS reflect the true reason for all skilled care. If there is no underlying cause found, the resident may not meet Medicare skilled coverage criteria.

3. Assigning Additional Diagnosis Codes
In addition to the Primary Diagnosis at I0020B, which affects the Physical Therapy (PT), Occupational Therapy (OT), and SLP components, the additional diagnoses in section I of the MDS may impact the SLP, Nursing, and Non-Therapy Ancillary (NTA) components as well. Unlike I0020B, diagnoses coded in sections I0100 – I8000 do not have to follow the clinical category map with the RTP restriction.

However, facilities do still need to use the ICD-10-CM map. SLP and NTA comorbidities captured in I8000 must be cross-referenced with the corresponding tabs in the ICD-10-CM mapping tool to determine if the criteria have been met for capturing the comorbidity in the PDPM CMG.

Another requirement for capturing the diagnosis in section I of the MDS is that the diagnosis must be documented in the medical record by the physician or NPP within 60 days of the ARD and must be active in the 7-day look-back period (excluding UTI, which must be active in the last 30 days).

If the medical record suggests a historical diagnosis, but there is not proper documentation from the provider during the look-back period, it is beneficial to use a later ARD to allow time for the provider to include this documentation in the medical record.

Some common PDPM missteps related to ICD-10-CM coding include:

  • Assigning a primary diagnosis that affects only one discipline instead of the overall skilled needs of the resident. For example, PT, OT, and nursing are treating removal (explantation) of hip joint, which maps to Orthopedic Surgery, while nursing is treating complication of infected hip joint, which maps to Acute Infections. Because most of the skilled care is provided to treat the explantation of the hip, that should be captured as the primary diagnosis.
  • Not capturing a diagnosis such as septicemia that is active at the beginning of the Medicare stay. An earlier ARD could allow capture of an active diagnosis from the hospital.
  • Not querying the physician or NPP for diagnosis clarification when the diagnosis is only listed in past medical history. For example, a history of cerebrovascular accident (CVA) with no residual deficits identified may miss clinically present sequelae (neurologic deficits).
  • Not capturing section I diagnoses correctly. Some NTA comorbidity points are assigned by section I0100 - I7900 checkboxes and others by I8000 ICD-10-CM codes. For example, coding Diabetes Type 2, E11.9, in I8000, will not accrue NTA points. MDS item I2900 for diabetes must be checked.

NACs must diligently apply all the rules of PDPM, MDS, and ICD-10-CM coding. Understanding the “RAI User’s Manual” instructions and ICD-10-CM coding guidelines is essential to PDPM accuracy and success.

Jennifer LaBay, RN, RAC-MT, RAC-MTA, CRC, is curriculum development specialist for the American Association of Post-Acute Care Nursing (AAPACN).