Patient Driven Payment Model (PDPM) A Year in Reflection


Skilled nursing facilities (SNFs) have learned that there are significant changes in how we ensure accurate payment under PDPM.

The change in focus from therapy minutes and ADLs to diagnosis coding and resident characteristics impacting payment required a paradigm shift in thinking.

Under PDPM, many more items on the Minimum Data Set (MDS) impact reimbursement such as  comorbidities and diagnoses. As a result, auditors are focused on these items and are requiring supportive documentation. Resident Assessment Coordinators (MDSCs) need to possess certain personality traits such as assertiveness, diligence and detail-orientation in order to be successful in the PDPM world.

The investigative process needs to begin at admission by obtaining the best diagnosis that supports the primary reason for admission in I0020B, which determines the default clinical category for physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) under PDPM and thus impacts both payment and quality of care. The MDSC should be the key player in reviewing all the diagnoses and physician orders immediately upon admission to determine resident care needs which can improve quality of care planning decisions for the resident. This investigative process includes assessing the resident, discussing status of resident with therapy, obtaining history information from family, reviewing the entire medical record including operative reports and laboratory results, and querying the physician for more information to ensure no diagnoses/conditions are missed.

When auditing these MDS Assessments, it is surprising how many errors are found.

  • Missing an item such as a swallowing disorder documented by therapy but not coded on MDS, negatively impacting the SLP component of the rate.

  • A resident has CHF, and nurses document some shortness of breath (SOB) but the nurse failed to assess and document SOB while lying flat, which negatively impacts the Nursing Component.

  • This is revenue missed and is significant especially if a pattern of miscoding exists.

  • Four out of five residents reviewed had the exact same Primary Reason for Admission, impacting clinical category in a positive way, which would be suspect under audit.

  • ​​Simple errors, such as resident has an IV but it was not coded on the MDS. The nurse detective work failed and should include reviewing orders for Part A residents daily.

​The MDS Team should review all PDPM items coded on the MDS for accuracy prior to submission. This review should include all ICD-10 codes, comorbidities, and the final decision on the Primary Reason for Admission.

The paradigm shift under PDPM includes increased intensity the first eight days of admission to complete all the investigative work needed for MDS accuracy, as this 5-day MDS determines payment for the entire stay unless there is a significant change/decline which would warrant an Interim Payment Assessment (IPA).

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