Under PDPM, Providers Should Expect Close Scrutiny of Nursing Records

The new Medicare model for skilled nursing facilities more closely links reimbursements with resident conditions — and making sure that facilities completely document those conditions will soon be an essential step for success.

But because payment under the current Resource Utilization Group (RUG) system is driven primarily by therapy minutes, capturing those conditions on the Minimum Data Set (MDS) — part of the federally required process for assessing SNF residents — necessitates a change in some ingrained habits. After all, many conditions that will affect reimbursement under the Patient-Driven Payment Model (PDPM) aren’t currently making it to the MDS.

That means that providers have be ready for scrutiny of their documentation in some areas that haven’t been a focus before, Denise Gadomski, partner at the consulting firm Plante Moran, told Skilled Nursing News. That will particularly come into play for the non-therapy ancillary part of PDPM, where the services are often provided but not captured by providers, experts told SNN.


“If you’ve got that diagnosis and you’re indicating it, and you’re capturing that on the MDS, make sure you’ve got the appropriate documentation in the nursing note,” Gadomski said. “I do expect we will have audits as an industry with greater focus now on the nursing documentation, versus the therapy documentation that has been the focus in the past.”

The importance of nursing

At the Victoria, Texas-based Regency Integrated Health Services, the new reality has led to an extensive focus on documentation training for everyone from nurses to hospital partners.

The operator, which has 57 SNFs in the Lone Star State, is taking an in-depth look its hospital partners’ records to make sure they contain everything that the SNF needs to capture, Monica Walsh, senior vice president of clinical reimbursement at Regency, told SNN.


And like Gadomski, Walsh stressed the role that nursing documentation will play under PDPM, with a particular emphasis on instilling the importance of critical thinking among floor nurses, MDS coordinators, and directors of nursing.

“If you see a patient was on a medication in the hospital — or even if they’re currently still on it — but you don’t see a diagnosis to support that medication, it’s that critical thinking of really digging into it and trying to find out: Well, why were they on that?” Walsh said.

And if it’s because of a condition that isn’t documented, SNF staff should communicate with a physician to get the diagnosis added, she said.

But this process has to begin well before a patient is inside a SNF, both Walsh and Gadomski emphasized. The first step is the admission process and receiving all the information necessary from the hospitals. To make that task easier when PDPM comes into effect, Regency has reached out to all of its referring acute care providers and completed training with clinical liaisons so they know which data points SNFs will need after PDPM.

And once a patient makes it inside the SNF, the nurses will have to ensure that they’re communicating with everyone — including the patient and the patient’s family — because hospital documentation doesn’t always tell the whole story, Walsh noted. Instead, acute care providers typically focus only on why a patient was admitted to the hospital.

“The patient could have other diagnoses that just weren’t pertinent to that admission and what they were being treated for during their time in the hospital,” she said. “But it could be something that is really important from our perspective. So we’re even stressing the importance of, in those early days, talking to family members, getting a true holistic picture of the patient, and talking to the patient if they’re cognitively aware.”

Documenting for diagnoses

There are some concrete steps that providers can take to improve their documentation, particularly when it comes to conditions that might have been missed on the MDS in the past.

The Centers for Medicare & Medicaid Services (CMS) has indicated that officials will be monitoring the speech and language pathology components of PDPM for any suspicious increases, Gadomski noted. They’ll also be keeping an eye on increases in mechanically altered diet or swallowing disorders, she added.

But providers that actively capture such information are the exception, rather than the rule, at least in Gadomski’s experience.

“In the financial analyses we’re looking at based on MDS data, we are quite often seeing that providers have indicated in Section K of the MDS that literally no one in the facility will have a swallowing disorder or mechanically altered diet,” Gadomski said. “But in discussion with the whole interdisciplinary team, they’re quite surprised by those results, and they realized they do have individuals who have those conditions, and it just has not been captured on the MDS.”

That diagnosis-capture factor is yet another reason receiving complete information from the hospitals prior to and at admission is paramount. To capture and code a condition on the MDS, the SNF needs physician documentation that a patient has that condition — and it has to have been recorded in the past 60 days and active for seven days, Walsh said.

The nurse’s notes will be crucial to achieving seamless documentation, making it another area where SNFs have to start changing habits, Walsh told SNN. In the past, nursing could rely on therapy documentation, since that field had to improve its documentation practices over the years to withstand audits. Now nurses have to do the same, and that’s not a process that happens overnight, she said.

“A lot of training, which we’ve started, is teaching them … that as nurses, you now need to have a skilled note,” she explained. “You need to be able to demonstrate that it requires the skills of a nurse to provide that care, which is going to skill [the patient] for Medicare.”

Compliance with an eye to audits

SNF leaders will also have plan out how these procedural changes will affect their compliance programs, Gadomski said. Operators may need to look at training, for example, as well as implementing ongoing monitoring of their documentation processes.

CMS, for its part, did not answer specifically when asked multiple times by SNN if it would increase audits after PDPM takes effect. But a spokesperson said CMS plans to monitor implementation of the new model and will consider various steps to ensure that federal funds are being spent appropriately.

For Walsh, the need to have documentation is one of the key aspects of the new model — particularly for compliance success.

“It is on the part of the provider and the person that bills to know the rules and regulations — and for companies to have systems and processes in place to make sure that they do audits, that they don’t submit a bill to CMS that is not accurate,” she said. “It’s up to us, as providers, to make sure that we don’t do that.”

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