Cheat Sheets and Timely Visits: How SNFs Can Support Doctors’ Larger PDPM Role

Timely physician visits will play a central role in effectively capturing resident conditions — and reimbursements — under the new Medicare payment model. But with doctors seeing relatively few incentive changes amid the shift to the Patient-Driven Payment Model (PDPM), skilled nursing operators must find ways to make physician collaboration as easy as possible.

Medical directors and other physicians who work in skilled nursing facilities will become vital resources for accurate ICD-10 coding and Minimum Data Set (MDS) reporting, Rajeev Kumar wrote in a recent piece in Caring for the Ages, a journal published by AMDA — The Society for Post-Acute and Long-Term Care Medicine.

“ICD-10 coding education, training, and support for MDS clinicians falls on medical directors and all clinicians in the facility,” Kumar, chief medical officer for rehab and pharmacy provider Symbria, wrote. “External resources such as coding experts from professional associations and regional hospitals might be a great help as well.”


Under PDPM, set to take effect October 1, Medicare reimbursements for skilled nursing providers will be more closely tied to resident conditions — in general, operators will receive higher reimbursements for patients with more complex medical problems and co-morbidities.

As a result, leaders have begun preaching the importance of education on ICD-10 codes, a type of diagnostic classification more commonly used in hospitals. While the general consensus is that MDS coordinators won’t need to know the ICD-10 manual chapter and verse, a working knowledge of the most common diagnoses and their relation to Medicare reimbursements will be essential to success.

Geriatricians and other clinicians are natural choices for heading up ICD-10 awareness efforts, as they likely have more experience with the hospital setting to begin with. But many may be unaware that the new SNF payment model places a premium on their knowledge — and even if they do, they might not have a clear motivation to assume a leadership role on PDPM prep.


“It makes people believe that it’s just got to do with SNFs, and nothing to do with [physician] providers,” Kumar told SNN in an interview. “But without providers stepping in and helping, facilities will be at a significant handicap. Unfortunately, there’s no direct incentive for providers to do more — that’s the challenge. It’s a lot of work, but it doesn’t directly pay medical directors.”

Kumar, who also serves as secretary of AMDA, laid out a few ways that SNFs can entice medical directors, clinicians, and other partners — such as advanced practice registered nurses, or APRNs — to take a more active role in patient care in the SNF.

First, Kumar pointed to new billing codes from the Centers for Medicare & Medicaid Services (CMS), which allow doctors to receive compensation for reviewing patient documents and conditions outside of face-to-face visits. As long as a doctor accurately records the time spent on each resident, he or she can bill Medicare for care coordination efforts — an incentive designed to encourage physicians spend time really getting to know the SNF patients under their direct or indirect care.

The second key could rest in making physicians’ lives easier by narrowing down the list of ICD-10 codes they need to know for common skilled nursing resident conditions. Of the more than 70,000 potential ICD-10 options to choose from, about 23,000 do not map to reimbursable skilled nursing services, according to a recent analysis from consulting and accounting firm Wipfli. Should a provider select one of these codes to nowhere, CMS will kick the claim back as “return to provider,” or RTP, causing delays in timely payments.

That’s why Kumar recommends that nursing home staff develop a list of frequently used codes that physicians can then choose from.

“Coming up with a cheat sheet of commonly used ICD-10 codes, and then asking attending physicians to use that to pick the codes and document the initial visit — that will be very important and useful for everybody,” he said.

In addition, Kumar noted, CMS will require that a clinician sign off on any diagnosis codes, making their buy-in vital to securing the proper reimbursements — and potentially heading off compliance issues as officials look to combat wide swings in provider behavior during the PDPM roll-out.

“Not many people are anticipating the problem — but if CMS audits, and there’s no documentation from a clinician that this is the right code, how are you going to defend yourself?” he said.

Finally, providers need to ensure that residents receive an assessment from a physician as soon as possible. The law varies wildly on the issue: CMS only requires a doctor visit a SNF resident within 30 days of admission, though states often have much shorter timeframes, with Kumar pointing to Illinois’s 72-hour rule. A recent study hammered home the uneven nature of SNF doctor visits, finding that about 10% of all nursing home residents between 2012 and 2014 didn’t see a doctor at all, leading to significantly higher rates of hospital readmissions and death.

Regardless of a given state’s rules, Kumar stressed that in order to accurately assess resident conditions — thus ensuring proper care and reimbursement — nursing homes need to develop a strategy for going above and beyond the rules for physician-visit timing.

“How are you going to expect a clinical documentation, and how can the nursing staff and the facilities expect to gather all the information they need, if a patient is not even seen by a practitioner?” he asked.

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