McKnight's Long-Term Care News, April 2019, page 53, Feature 2
Providers will see a drop in mandated resident assessments (from five to two, in most cases) under the new pay model.

As complex and daunting as the new Patient-Driven Payment Model seems, one change most providers have welcomed is the reduction in resident assessments for therapy.

RUG-IV mandated at least five assessments over a 90-day stay, but under PDPM many patients will need just two: an initial MDS completed within eight days of admission and a resident discharge assessment tied to the last day of stay.

“Under RUG, it was a lot of work,” says Elisa Bovee, vice president of clinical strategies for HealthPRO Heritage. “It’s intensive, and payment could be adjusted at those pre-set times based on therapy minutes or therapy type changing. Now, looking at skilled nursing, it makes more sense to provide a consistent rate that recognizes the level of skilled care and the consistency with which it is provided throughout the stay.”

It’s a logical shift when considering industry-wide pressure to decrease lengths of stay and the Centers for Medicare & Medicaid Services’ own proclamation that PDPM will improve the appropriateness of payments and reduce administrative burden.

While it may seem there’s less data to be collected, the opposite may be true.

Providers must be more accurate with the patient information they collect in the initial MDS and the medical record; more intentional about monitoring it internally; and more in-tune to changes that could precipitate additional communication with CMS to earn appropriate reimbursement.

“MDS now is going to basically allow you to paint a picture of the patient from a clinical perspective,” says Sherri Robbins, senior managing consultant with BKD’s healthcare group. “Every part is going to be more important than before, not just for Medicare reimbursement but for clinical outcomes. Under PDPM, leaving one thing off Section K or Section I, for example, it can really impact your ability to care for the patient.”

First look is key

The initial five-day assessment still hinges on the MDS, but providers who view the assessment tool the same as in the past are taking a risk.

“We have to step back,” says Mike Capstick, founder of Select Rehabilitation. “For 90 percent of patients, it’s been Section O or Section G that have driven payment … We’re going from roughly two sections to 11 or more.”

New MDS items under PDPM will include Section I for a primary SNF diagnosis, Section J for surgical history and a new column in Section GG to track interim performance. Other MDS items link specifically to payment for the first time, including Section K for swallowing disorders and other speech-related services and Section I’s addition of ulcerative colitis, Crohn’s and inflammatory bowel disease.

Staff also will need to be keyed into all the comorbidities and services that determine an individual’s case-mix. Once it’s set, there’s no way to add or adjust resident characteristics unless a resident has a significant change in status.

“Everybody agrees you will have to take your time, ensure that you have researched all diagnoses, all conditions, and be assured that the MDS is scored appropriately to ensure you get those monies that are due to you based on the services you will be providing,” says Nancy Losben, R.Ph., Omnicare’s senior director of quality.

Capturing the primary diagnosis likely will be difficult for many facilities, says Rosanna Benbow, RN, owner of Leading Transitions Post Acute Care Consultation and Staffing.

“Getting a comprehensive background on a patient is going to be the hardest part,” she says. “I think a lot of providers need to shift their pre-admission assessment process to clarify what they’ll be doing and who will be communicating with the hospital or the community physician.”

In some cases, two conditions, such as an elective knee surgery and an infectious complication,  may compete for the primary ICD-10 code. Working as a team, staff will have to determine which of those diagnoses would most accurately reflect the services needed by that resident and the resources that he or she will require.

Although CMS estimated in its proposed rule that a provider would save 183 MDS hours annually with fewer assessments, most MDS experts will take on new responsibilities, experts predict.

In addition to becoming puzzle-solvers, MDS coordinators could be assigned more time working directly with residents in a clinical capacity. Benbow predicts many buildings will ask MDS nurses and unit managers to perform hands-on assessments regularly, and some larger buildings should consider scheduling changes to ensure more MDS coverage.

“We’ve seen lost reimbursement before with agency nurses because of staffing shortages,” Benbow says. “Providers need to figure out now who is going to be doing all of the information gathering, coordinating with physicians to spot infection and hypertension issues, and making sure the coding and the documentation match.”

Interim opps

The Interim Payment Assessment remains the least understood new patient measure. Many providers said they were hoping the new Resident Assessment Instrument, expected by May, would put specific parameters around “optional” submissions.

“The premise of doing a significant change is a review of the patient because medically, something has happened, so they would have additional need for therapy,” Bovee says. “The trick of it comes into play when talking about who is monitoring patient information and how the case-mix works as far as using nursing and NTA [non-therapy ancillary] services.”

For now, providers are split on whether a status change will be tied to a resident’s primary diagnosis or whether the IPA could be completed if a resident needs more assistance with ADLs or new therapies.

Current language also doesn’t make clear whether providers should file for significant improvements in a resident’s condition.

“The word ‘optional’ from CMS always concerns me,” Capstick says.

He notes that under the RUG Change of Therapy policy, facilities that failed to report changes for patients not classified in a RUG-IV therapy group — a supposedly optional window — still sometimes found themselves paying back Medicare.

Staff given the responsibility to order IPAs need to know when they would be advantageous and to make sure any observed change in status is reflected on the corresponding MDS.

Although no one is certain how often IPAs will be justified, Benbow predicts filing more than the industry norm will bring scrutiny.

Discharge data

The fact that discharge assessments aren’t tied directly to payment shouldn’t influence how they are handled. Data will drive quality-reporting metrics and Five-Star ratings, and it will provide another opportunity for self-measurement.

Capturing how well your patients do — including functional and cognitive improvements and the prevention of decline for complex patients — will offer a competitive boon and be a tool for partners.

“PDPM doesn’t just exist in a vacuum,” says Scott Rifkin, owner of Real Time Medical Systems. “There are all of these market forces that hospitals are bringing to bear on every provider now.”

Discharge data also could eventually be used to inform a unified payment system. For the industry’s sake as well as that of individual operators, it’s important that providers accurately capture what works and what doesn’t.

“We want to make sure CMS has an accurate picture of what patients are doing and how we’re serving them,” Capstick said.


In response to the question posed in the title above, there is clearly a camp that says yes.

“There will be much greater pressure on providers to collaborate sooner about a patient’s needs and establish the care plan correctly from the start,” says Rita Cole, Optima Healthcare Solutions’ clinical director. “This will require software resources and business intelligence tools that can support greater communication between multidisciplinary team members and suggest the appropriate care plan for each individual patient.” 

Analytics will be increasingly important as SNFs try to spot diagnostic oversights, track patient conditions and attract new partners under PDPM.

“In the past, there was critical information in the medical chart that did not make it into the MDS,” says Mike Capstick, whose Select Rehabilitation has developed an online portal with optical scanning technology to read hospital, facility and therapy documentation to assist the MDS coordinator under PDPM. 

But how much of a voice should it be given in helping with actual MDS coding?

“Software can be useful in making sure an ICD-10 maps to a clinical category rather than return to provider,” says Sherri Robbins of BKD’s healthcare group. “That being said, the staff at the facility level are going to need to learn to code to the highest level of specificity for success under PDPM.”

As a one-time medical director and former owner of 21 skilled nursing centers, Scott Rifkin notes people play a powerful role in making software helpful. Make arrangements now to get physicians more involved so that they too can spot pathways to disease and add notes that other clinical staff might miss, he adds.

“If you can team them up with good data, mining the charts and the MDS, then you’ll be successful,” he explains. “It will pay for itself.”

Rifkin, owner of Real Time Medical Systems, says electronic medical systems and analytic capabilities will become more important once 14-, 30- and 60-day assessments end. Real Time, a Medline partner, runs automated keyword searches three times a day to warn of changes in status that could follow on the heels of chest pain or diarrhea.

“If you’re just using MDS-based data, and not accessing the data in your EMR, you’re literally leaving tens of thousands of dollars a month on the table,” Rifkin says.