Steven Littlehale

We’re not even two months in, and trends for the Patient Driven Payment Model are beginning to emerge. Not surprisingly, these early findings fall into three categories: 1) The need for more education on MDS coding, 2) Review of CMS PDPM PPS regulations, and 3) Documentation and care. 

One of the coolest things about my new gig is the 30-plus “Z-Team” clinical consultants. They are smart, nimble and perfectly willing to keep me in check. They bring me “the real world,” a solid understanding of what is actually happening in the skilled nursing facility, lest I get too comfortable looking at thousands of MDS and claim data points. 

I wanted you, loyal reader, to benefit as I have from their PDPM insights, which are ultimately based on their field work scouring the medical record, MARs/TARs, MDS, and UB. So let’s talk turkey and listen to the experts!

Sheryl Rosenfield, RN, BC, chief clinical officer, shared an interesting insight regarding mechanically altered diets. As you know, these diets have financial implications for the SLP component of PDPM reimbursement. Sheryl shared:

“Clearly, mechanically altered diets were under coded prior to October 1st. I’m seeing an increase in these diets indicated on MDS, but also a very liberal interpretation of the assessment item. The manual states that it is ‘a diet that is specifically prepared to alter the consistency and texture of food.’ This implies that there would be an assessment and other documentation to support the diet and its ongoing evaluation. I’ve seen the item checked only because the CNA cuts up the patient’s food before meals.”

We agree that an astute and loving CNA would do this for the patient if needed. Systematically ask the CNAs which patients they take this extra time for and conduct a proper assessment. 

Previously, I considered the coding of a swallowing disorder and mechanically altered diet a bit of a catch-22. Both items increase your SLP component score, but if the mechanically altered diet successfully addresses the swallowing disorder, then by definition you wouldn’t code for a swallowing disorder. Wait, what? 

However, I don’t consider it a catch-22 any longer. If the patient comes in with a mechanically altered diet, scour the hospital clinical record for documentation that supports a code for swallowing difficulties within the look-back period. But let’s be honest: Often you’ll not find it. Perhaps the patient was put on chopped or pureed foods because the hospital simply saw an elderly person who forgot his or her dentures, hearing aids or glasses. The elder was perceived to be in crisis, and a mechanically altered diet is a typical response. It is a quality-of-life imperative to conduct a swallowing evaluation upon admission if documentation that assesses swallowing is questionable or missing. Document the swallowing disorder if it is present and code it on the MDS. If not, carefully advance to a regular diet

Robert Gross, OT, vice president of rehabilitation services, spoke to me about the importance of Section GG (functional ability) MDS accuracy. Section GG, in place of Section G, impacts PT/OT and Nursing component scores. But GG assessment accuracy, and its importance, eludes some facilities. Robert noted:

“Yes, there are financial ‘sweet spots’ in Section GG coding, but there are also significant quality outcomes and regulatory implications of inaccurate assessment. Section GG will be used to ultimately judge the effectiveness of each SNF’s care, potentially creating a situation where the provider would be passed over as a referral partner. Section GG outcomes are also used in Five-Star. Better to focus on accurate assessment and demonstrate patient improvement using Section GG measures.”

I agree with Robert’s sentiment on accurate coding versus finding the Section GG sweet spot. Ultimately, going after the latter will distort your quality measures and potentially haunt you. He went on to speak about the assessment of cognitive impairment:

“Capturing even mild cognitive impairment on the BIMS increases reimbursement up to $17 per day. There is no extra service cost associated with direct care needs beyond the minimal additional time staff may need to spend with a client to motivate them, which has not changed since the start of the Medicare program. However, the care for this population is demonstrably different, and so it should be reflected in their care plan.”

My colleagues also shared with me several disconnects between coding a condition on the MDS and properly coding the same condition in a way that counts. For example, E66.9 (Obesity, unspecified) would not afford you any NTA points; however, you would receive points for E66.01 (Morbid obesity due to excess calories), E66.2 (Morbid obesity with alveolar hypoventilation), or Z68.4- (BMI 40 or greater). “if appropriately documented, properly coding patient’s obesity would offer the reimbursement to compensate for your care. 

Sheryl had a similar, yet different, comment about malnutrition. She’s seen that some facilities overlook this diagnosis, yet actively address it in care plans:

“We’re seeing an increase in coding for the malnutrition NTA in Section I5600, malnutrition (protein or calorie) or at risk for malnutrition. However, we are not seeing the physician or clinical team describing the specific reason for risk for the individual, or the proposed plan for care and monitoring for this diagnosis. Remember, although hospitalization may increase the risk of malnutrition for older adults, the diagnosis alone is not sufficient to support an NTA without documentation of labs, weight tracking, and other clinical interventions.” 

Several on the team also spoke about the increase in COPD with shortness of breath (SOB) while lying flat, which is a gateway to Special Care High — a “desired classification” in the Nursing component. I heard both sides of the coin on this one. Some facilities overlook the additional benefit of capturing SOB while lying flat, even though they treat it, while others code the SOB without adequate documentation. This is an issue. SOB assessment and proper treatment can significantly impact rehospitalization, engagement, quality of life and reimbursement. One astute consultant also was looking for coding patterns of SOB in anticipation of compliance concerns. Only J1100C is counted, while J1100A–B are not. Yet clinically, they often coexist. 

My colleague Vincent Fedele is a partner at ZHSG, but also the COO of CORE Analytics. Since the beginning of October, he’s been processing UB-04 data and finding significant disconnects between the claims and MDS. The disconnects almost always point to a PDPM reimbursement opportunity, says Vincent:

“The MDS and UB are two different sets of data describing the patient. They should be telling the same story, but they often do not. Systematically reviewing the claim reveals potential MDS errors and omissions which can often be corrected prior to claim submission when supportive documentation was in place. For example, we often find diagnoses on the claim, which count as NTA points or SLP items, not properly coded on the MDS. Or even line-item revenue codes associated with IV medications that pull directly from the pharmacy system, yet the MDS shows no NTA or Nursing credit for the item.”

Gobble gobble! Well, that was fun. The overarching theme my colleagues have conveyed is the continued need for MDS education (or reeducation), PDPM final rule and documentation, and thorough assessments translated into well-documented care. 

They also shared with me that you’re still standing, and so are your patients! That’s good news indeed. On Oct. 1, 2019, you passed the finish line — which is really the starting line. And you’ve proven once again that you are resilient, capable and mission driven.

Steven Littlehale is a gerontological clinical nurse specialist, chief innovation officer at Zimmet Healthcare Services Group, and chief clinical officer emeritus at PointRight Inc.