As we shift gears into 2021, we can all agree, no one wants to look back.

You see the theme everywhere. People want to evolve and learn from 2020. However, no one wants to go in reverse.

Driving in the rearview is never a good idea.

Thank goodness for automatic brakes, that forced reminder to stop and be aware of what is in front of, behind and around us. 

Twice in the last week I attempted to back out of our narrow driveway and was fortunately halted by the safety provided from an automatic braking system. Once from a car coming the wrong way down our one-way street and the second time to avoid a runner. Scary stuff.

Since, I have taken the additional time needed to drive down the little alley between our home and the neighbor’s, turn around and face forward. 

Prospective review takes longer, but provides the safety needed to avoid a nasty or unnecessary clean-up.

In a similar sense, I have witnessed the risks and frustration experienced when skilled nursing facility teams aim to identify trends or risks by completing clinical, documentation or MDS reviews in retrospect.

What do you mean, Renee?

Review means “look-back” in retrospect, correct? That is how we assess documentation accuracy, coding trends and medical necessity.

Additionally, a retrospective review allows us to increase the volume of claims we review.


Well, yes and no. 

Remember we provide care currently under a PPS, prospective payment system. 

Furthermore, the Patient-Driven Payment Model aimed to improve payments made under SNF PPS by improving payment accuracy and appropriateness by focusing on the patient, rather than the volume of services provided. 

The patient, the individual, the you-are-here-in-front-of-me-needing-care, patient.

Retrospective review at the individual patient level could result in gaps in needs or care.

Retrospective review of claims to identify trends may limit your teams’ opportunity to engage patient care on an individual and person centric level.

I just want us all to consider new and refreshing alternatives. 

The intent of this piece is to promote increased awareness for having systems supporting a culture of ongoing prospective review process. This can be true for coding, clinical accuracy and trends which may begin, stick with me, even before individual patients enter our community. 

Like 2020! Let us leave the past behind us and consider how we can do better in the new year.

First, consider what review of medical records you are completing prior to admission to your skilled nursing facility from the primary care physician, specialists and potentially associated with acute-care Medicare Severity Diagnosis Related Groups trends in your community.

Of note, the Centers for Medicare & Medicaid Services has recently updated ICD-10 structure and published below as a guide to cross walk these diagnoses to MS-DRGs when considering care associated with COVID-19 noted in the table (right). 

On a broader sense, SNF providers who have a prospective understanding of what DRGs are trending in their unique communities will garner an appreciation of how to proactively develop plans of care to honor the clinical aims associated with PDPM and changes across the post-acute care spectrum.

Curious? The map below provides an overview of where we as a nation are trending in the three most recent quarters of data as provided by CMS Research Data Assistance Center (ResDAC).

Secondly, consider what methods for ongoing clinical review can be integrated into daily care, coding practice, and proactive clinical pathway development. 

These areas could include: proactive identification of risks for readmission; polypharmacy assessments; risk factors known to impact minority populations; physical, occupational, speech, and respiratory therapy evidence base considerations; broader appreciation for dialing in the person centeredness; education and training of protocols; known impacts of multiple comorbidities; and common sense use of  tools including pulse oximetry, natural diets and vitamins. 

2021 is here! Let us all learn from the challenges of 2020 but remember to steer forward with a clear vision to what stands in front of us for the year ahead.

Renee Kinder, MS, CCC-SLP, RAC-CT, is Executive Vice President of Clinical Services for Broad River Rehab and a 2019 APEX Award of Excellence winner in the Writing–Regular Departments & Columns category. Additionally, she serves as Gerontology Professional Development Manager for the American Speech Language Hearing Association’s (ASHA) gerontology special interest group, is a member of the University of Kentucky College of Medicine community faculty, and is an advisor to the American Medical Association’s Relative Value Update Committee (RUC) Health Care Professionals Advisory Committee (HCPAC).