PDPM Article 5: Documentation Demands And How To Meet Them

November 10, 2020

Get ready for the October implementation date of the Patient Driven Payment Model (PDPM) with our informative series of articles authored by Leah Klusch, RN, BSN, FACHCA, founder and director of The Alliance Training Center. We’ll prepare you for the new reimbursement model with detailed insights in a step-by-step guide to PDPM success. You’ll learn about everything from building staff competencies and improving your coding practices to the value of partners and how to enhance efficiencies. The series will conclude with a checklist to help you gauge your readiness.

The soon-to-be-launched Patient Driven Payment Model (PDPM) is designed to capture the individual needs and characteristics of each patient to better represent the care they need and the reimbursement the facility requires to take care of them. When the shift to PDPM goes live on October 1, initial patient assessment may be the primary focus, but there will also be a new emphasis on total diagnosis documentation. The new regulations require that all of the MDS data must be reproducible in a resident’s medical record. How do you meet the reproducibility threshold?

The two most critical resources for getting documentation right are the latest version of the RAI manual and the MDS itself. Using these materials as guides, the resident record must not only be substantiated but speak the same language. That means that if an elder has a condition, the record has to read exactly the same – with the same definitions – as the MDS. To support this exacting documentation standard, a facility should have a process in place to support the level of thoroughness and consistency required at the following three stages.

PRE-ADMISSION. Skilled Nursing Facilities need to have accurate information from the acute care facility about an elder’s condition in order to make admission determinations since you often have just hours to decide. While your staff should have very specific guidelines about caring for certain residents and understand their capabilities, it’s also critical to develop relationships with referring hospitals for earlier access to the medical record. When available, a consultant pharmacist can play a role at this point by reviewing the documentation, for example, regarding a patient’s response to medications.

TRANSITION OF CARE. During the patient’s transition to your facility, it is critical to review the records from the doctor at the acute care setting to determine whether they are complete and use the correct terminology. This is important because strengthening the transition of care communication can give the provider who will follow the resident in the facility the opportunity to improve upon the care delivered. A consultant pharmacist can assist at this time by conducting a thorough review to ensure that there are no order omissions or duplicative orders from different providers, and that the information is accurate and appropriate as it relates to each medication.

ASSESSMENT. ICD-10-CM codes aren’t used under the current RUG IV system as a direct impact on reimbursement, but there will be a direct relationship under the PDPM. To optimize payment, facilities should have a policy covering diagnostic code assignment. Then research diagnoses you’re currently capturing (since the October 2018 I10020) and maintain a list of the most frequently used codes, keeping in mind the need to code to the highest level of specificity. This step is especially crucial with the NTA component since ICD-10-CM diagnoses impact comorbidities for case-mix index points. It’s also important to note that if the claim has incomplete, incorrect or missing information, it will be sent to your Return to Provider (RTP) file for you to correct.

Leah Klusch, RN, BSN, FACHCA,
founder and director of The
Alliance Training Center

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