Barriers Between Financial, Clinical Staff Must Come Down Under PDPM

Providers’ early reviews of the new Patient-Driven Payment Model (PDPM) have been largely positive, but operators also only have around 11 months to develop the kinds of internal protocols necessary to maximize reimbursements — and success could hinge on getting various players within a single facility to agree with each other.

In Leah Killian-Smith’s experience in nursing homes, each department in the building — from nursing to therapy to billing — has its own opinion on what’s important to note when filing Medicare claims. Under PDPM, which rewards the care of higher-acuity residents, correctly describing a patient’s condition will be essential, and there will generally be a right and a wrong way.

“To break those walls down and get rid of those barriers, when I teach coding, I say to people: You’re turning words into numbers to get paid,” Killian-Smith, director of quality assurance and government services at Pathway Health, said during a presentation at software provider PointClickCare’s annual summit in Nashville, Tenn. this week.


Killian-Smith suggested that providers start training certain staff members, including licensed practical nurses (LPNs), to serve as coding experts to prepare for the new rules, which place an increased emphasis on ICD-10 diagnosis codes.

“The bottom line is: That’s our paycheck,” she said. “The business office needs to have those codes in the right order, and we need to manage those appropriately.”

For instance, under current rules, Killian-Smith estimated that the typical nursing home loses about $3,000 per month due to inaccurate documentation of activities of daily living (ADLs). And while that figure might not sound that high, she noted, it works out to $36,000 per year — and since providers will no longer be able to generate revenue through pure therapy volume, operators will need to find every avenue necessary to make up for the difference.


Plus, there’s always the likelihood that the Centers for Medicare & Medicaid Services (CMS) adjusts reimbursement levels in the future once providers have time to work within the PDPM system.

“It’s supposed to be budget-neutral, but I have a hard time believing that the government would come up with a new payment system that wouldn’t benefit their pocket,” Killian-Smith said.

In a separate session, Maureen Hedrick of Richter Healthcare Consultants echoed the calls for creating in-house order in the waning months before PDPM takes effect in October 2019.

“PDPM is going to be very diagnoses-related,” Hedrick, who serves as Richter’s director of consulting services, said. “So if you know that you have diagnosis management issues, now is the time.”

Hedrick and Richter clinical consultant Jacklyn Brown stressed the importance of accurately documenting co-morbidities, each of which can boost the amount of money that a nursing home receives for services. Under PDPM, certain conditions that didn’t have an effect on reimbursements in the past will be crucial to record and report accurately, with Brown suggesting that providers analyze the Centers for Medicare & Medicaid Services’ (CMS) list of diagnoses and their associated scores.

“If you know your value and know what you do well and have some specialized services around those, that’s actually going to help you make money off PDPM,” Hedrick said. “PDPM isn’t a death sentence for the industry.”

Killian-Smith also stressed that it isn’t just about money. In her work for consulting and temporary-management firm Pathway, she’s heard nursing home staff debate whether to accept certain patients because they aren’t sure that nurses will code for the residents’ conditions accurately.

“If we are providing that level of services, the resident deserves to use that benefit, and we need to take credit for the work that we are doing,” she said.

Full disclosure: PointClickCare invited a team from SNN’s parent company, Aging Media Network, to attend their annual conference and covered the cost of accommodations. The Mississauga, Ontario-based firm did not have any influence on SNN’s coverage.

Written by Alex Spanko

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