The MDS train is leaving the station and is transitioning into something very different. Its next stop is the  the Patient-Driven Payment Model (PDPM). 

The days of Medicare A reimbursement being managed by “Mom” and “Dad” is now dependent on the “village,” i.e. the interdisciplinary team. This transition will create a huge opportunity for MDS professionals to grow and expand their expertise. 

The “reimbursement village” will require leadership and oversight to reach the desired goal of maximizing reimbursement. This oversight will take on a case management tone. It will include several disciplines including admissions, clinical nursing, therapy and physician services. 

The coordination of the team in the first eight days of the resident’s admission will determine the resident reimbursement rate under PDPM for the entire stay, unless an Interim Payment Assessment (IPA) is completed. The IPA will create an opportunity for MDS professionals to use their knowledge of PDPM. They will provide oversight of the process to assist in determining when an IPA should be completed. 

PDPM coordination should begin early in the admission process to assure the facility is meeting the requirements for skilled levels of nursing home services. It will be imperative that comprehensive hospital records are obtained by the facility. This will allow the facility to review and code all the resident characteristics that the resident qualifies for in the PDPM Nursing and Non-Therapy Ancillary (NTA) case-mix categories. 

Under PDPM, facilities must assess which residents they can actually care for. This gives new opportunities for growth. Broadening the skill set of the clinical nurses is a win for the resident and facility. It also creates professional development opportunities for the individual nurses. Having a clear picture of the clinical capabilities, new areas of expertise and future plans for expansion will provide the marketing and admission teams valuable information in working with hospital liaisons to attract the most beneficial patients under PDPM. 

Clinical nursing will have a heightened role in reimbursement under PDPM. This will require facilities to set new expectations on the nursing staff, provide extensive training and coaching, provide resources and tools and audit their work product to assure the nursing staff is able to execute the new expectations.

Providers will have to master ICD-10 coding upon admission, to care planning for active diagnosis, to providing skilled documentation. 

There are many rumors flying around about the change in therapy importance under PDPM. Although the quantity of therapy will no longer affect the amount of reimbursement, therapy services are likely to remain the most common daily skilled service in nursing homes. The Medicare Benefit Policy Manual Chapter 8 – Coverage of Extended Care (SNF) Services Under Hospital Insurance is what guides the long term industry in coverage. The five skilled nursing home skilled services categories are:

  • Management and Evaluation of a Patient Care Plan
  • Observation and Assessment of Patient’s Condition
  • Teaching and Training Activities
  • Direct Skilled Nursing Services to Patients
  • Direct Skilled Therapy Services to Patients 

Therapists must be able to evaluate a patient and identify the root cause of the resident’s deficits. The RUG reimbursement system has valued a generalized electronic medical record (EMR) documentation and increased quantity of therapy. The PDPM reimbursement system will drive providers to develop resident/deficit specific therapy evaluations and treatment solutions that will lead to effective and efficient therapy outcomes. 

Physicians will also be pulled into the mix. They will need to assure the team is successful under PDPM: Physicians (or physician extenders) are the only ones who can diagnosis the resident. All five components of the PDPM- PT, OT, SLP, Nursing and NTA all have a component that rely on accurate ICD-10 coding. It is important to bring physicians into your education on PDPM, policy development and implementation for ICD-10 coding. This will highlight the importance of their role in PDPM and enhance their participation in a successful program. 

The MDS professionals will need to step out of the shadows and lead the team, not just during UR Meeting, but throughout the Medicare A reimbursement process. In addition to making sure ICD-10 codes have corresponding physician documentation, all skilled nursing services have to be identified by the IDT. Diagnosis must have documentation to support they have an “active” diagnosis during the lookback period. Medical records must support the skilled services provided to the resident. This type of coordination will require MDS staff to professionally interact with staff that previously did not impact the reimbursement. MDS staff will need administrative support for this shift to be successful. 

These are added responsibilities, and negate the time saved with the elimination of the 14-, 30-, 60- and 90-day assessments and with OMRA assessments. An MDS department that is strong in both reimbursement knowledge and leadership will drive the IDT to success under PDPM. 

Stacy Darling, RAC-CT, is Vice President of Operations at Post Acute Consulting.