Amy Stewart, RN, RAC-MT, DNS-CT

Under PDPM, how can we ensure accuracy of the Medicare Part A reimbursement rate?

The accuracy of the rates is based solely on the accuracy of the 5-Day PPS assessment and its supporting documentation, which will potentially set the rate for the entire Medicare stay. 

The exception to this is when an Interim Payment Assessment also is completed. You must have systems to ensure the accuracy and completion of ICD-10-CM diagnoses, clinical documentation, assessments and interviews during the look-back period. 

While some clinical characteristics or conditions will impact only one part of the Patient-Driven Payment Model overall rate, others have the potential to impact multiple areas. For example, the diagnosis of hemiplegia or hemiparesis (I4900) will impact the speech-language pathology-related comorbidities and could qualify for the nursing Clinically Complex group. 

However, the clinical service of intermittent catheterization (H0100D) will impact only the Non-Therapy Ancillary component. The accuracy of all items on the MDS is paramount, but it may help to start conducting accuracy checks on key items impacting multiple areas, such as ICD-10-CM coding, Section GG functional assessment, extensive services, wounds and infections.

Documentation to help support MDS coding may need to be secured from discharging providers. Often, the discharge summary is not readily available and may take several days or weeks to obtain. Despite that, providers still need to get diagnosis codes and surgical procedure history so that this information can support the coding of the 5-Day PPS assessment.

To plan for October 1, reach out to case managers. Start discussing the type of information that your facility will need from discharging providers. 

Please send your nursing-related questions to Amy Stewart at [email protected].