Coding, Scoring, and Accuracy: Three Key Points of Attack for PDPM

With October 1 a few short months away, skilled nursing providers should be well into their preparations for the Patient-Driven Payment Model (PDPM), the overhaul of Medicare Part A reimbursement that’s set to take effect at the start of the new fiscal year.

The new requirements include a variety of new possibilities for payment, since SNFs will be getting paid based on the conditions of the residents in their care, and a specific focus on documentation and coding.

But because some aspects of care — and some of the paperwork — will carry more reimbursement weight under the new system, there are some crucial areas to monitor for the best outcomes.


Representatives from the accounting and advisory firm Blue & Co. discussed some of the most pressing issues that operators should focus on during a Wednesday webinar co-hosted with Skilled Nursing News, with a specific focus on accurate coding and scoring.

Keeping good score

Under PDPM, there are several areas where SNFs have the opportunity to receive payment for services that they’re already accustomed to providing, and under the current system, operators may not be recording all the data that could affect reimbursement.

“A lot of times, you will be giving care, and if you don’t have the right boxes marked, you’re not going to credit for it [under PDPM],” Nancy Hublar, senior manager at Blue & Co., said on the SNN webinar.


Part of the equation includes ICD-10 codes, specific diagnosis markers previously used primarily by hospitals — but which will now play a role in SNF reimbursements.

When it comes to physical therapy (PT) and occupational therapy (OT), major surgery that immediately precedes a hospital stay that requires active SNF care is a key factor. Depending on the SNF patient’s prior history, if any of the surgical procedures are checked on the Minimum Data Set (MDS) as being performed during the prior inpatient hospital stay, some of the ICD-10 codes could map to a different clinical category from the default, she explained — with the potential for serious reimbursement ramifications.

The major joint replacement or spinal surgery clinical category is one example.

“That clinical category — by raising it up from the major medical — would be about a $42 a day increase,” she explained. “So for a 20-day stay, you’re talking about an $840 increase in your claim. So you want to definitely pick up on any type of surgery. Make sure you check with the hospital; you may want to go prior to receiving the patient, do an onsite visit to the hospital — but have some type of way to make sure you’re picking up those claims.”

Scores on Section GG will also be crucial. For example, certain scores will bump the patient out of medical necessity for skilled nursing care, Hublar said, with a goal of making sure that patients are in the most appropriate setting.

“What Medicare is trying to do is tell you that they want them in a lower setting,” she said. “So if they’re that independent, then maybe they should be in home health or do outpatient therapy. Remember, when you want to discharge a patient, your discharge goal isn’t totally independent — it’s to go to the lowest level of care.”

Depression is another area that SNFs have to approach with an eye to accuracy in order to receive reimbursement for providing care. The symptoms, diagnosis, care plan for the condition doesn’t affect the case mix index category; what does is the PHQ-9 score, which has to be *at or above 10 to show depression on the MDS. A mistake in this area could lead to a $27 a day per patient loss, which translates to a loss of $540 for a 20-day stay.

Scores on the MDS Brief Interview for Mental Status (BIMS) and checking Section K on the MDS are also crucial for reimbursement for speech and language pathology (SLP), and capturing conditions relates to scores in the non-therapy ancillary (NTA) category as well.

Coding precision

SNFs should be very familiar with the ICD-10 codes identified as “Return to Provider,” which means they don’t map to any approved skilled nursing service.

Should a facility select one of these codes, the Centers for Medicare & Medicaid Services (CMS) will reject the claim, and SNFs will have to select a more specific code identified as acceptable for mapping to one of PDPM’s clinical categories, according to the American Health Care Association.

Some of these codes to nowhere include “Dementia in other diseases classified elsewhere without behavioral disturbance,” “Muscle weakness (generalized),” and “Gastronomy status.” CMS provides a variety of resources to show what approved codes might support those conditions, Blue & Co. senior consultant Nicole Cameron noted.

Cameron also noted that the primary diagnosis code must refer to the condition that sparked the transfer to the SNF, and the main motivation behind the patient’s SNF care.

“We know that the SNF patient may suffer from multiple conditions, but it is not appropriate for providers simply to report all conditions and be paid for the highest case mix index,” she noted.

Quality and assessments

A clinician must accurately perform the initial assessment of a resident to capture the correct coding for the right diagnosis in PDPM; if not, care and services — and by extension reimbursement — will be adversely affected, Jennifer Scott, also a senior manager at Blue & Co., observed.

But there’s another assessment that, on top of affecting safety, could also affect a SNF financially. The Drug Regimen Review (DRR) has to be completed by midnight the following calendar day each time a clinician finds a potentially significant medication issue, Scott said.

This is an assessment for safety, and it’s not the same as a federal requirement that has to be performed by a pharmacist, she noted — so SNFs don’t have to have a pharmacist complete it. That’s key, since noncompliance with the assessment can lead to a reimbursement penalty.

“The full impact of that quality measure is magnified by the fact that you can be noncompliant and receive a penalty, in payment, as well as receive an automatic regulatory violation, as a result of your MDS assessment noncompliance when the survey visit occurs,” Scott said.

*This article has been corrected to show that the PHQ-9 score for depression should be “at or above 10” rather than “above 10.” SNN regrets the error.

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