Skilled Nursing Operators Should Focus on Current Practices to Avoid Costly Future PDPM Mistakes

Skilled nursing operators will be facing a complete overhaul of Medicare reimbursement from one day to the next when September ends. And to be ready, they need to examine their data collection practices now — from admission strategies to coding accuracy.

Providers still rushing to prepare for the coming sea change need to have a complete understanding of everything that they’re doing in their SNF today, so that when the Patient-Driven Payment Model takes effect, their team members and staff know how to adapt their behavior, according to Leah Klusch, the executive director at the Alliance Training Center.

“You cannot eliminate all the risk factors that you have with this change … but you can be proactive. You can do training,” Klusch said on a webinar presented by the long-term and post-acute pharmacy PharMerica and hosted by Skilled Nursing News. “You have to have policy development in this transition.”


Data and documentation

A crucial part of this strategy will be examining each facility’s data collection processes, she emphasized. Rather than jumping directly into PDPM, facilities have to examine their current databases an processes — then focus on changes.

That includes being aware of shifts in the October 1, 2019, Resident Assessment Instrument Manual, Klusch said.

Facilities have to make sure that their data formulation policies and procedures are appropriate for the rule, and that staff is compliant and competent for every aspect of the work the facility performs. Otherwise they could find themselves in “a very dangerous position,” she said.


“You want to look at the case management process in your facility or your company at the time of admission, to look at the accuracy of the diagnostic information — treatment, interventions, services, plans at the time of admission,” Klusch said on the webinar. “Then also be careful that you look back over your shoulder, and identify if you have any compliance issues with the assessment process, with transmissions, validations, the timeliness of your assessments.”

In addition, the utilization review process used under the current Resource Utilization Group (RUG) system will have to be “completely revised” to address PDPM, which will replace RUGs.

One of the most crucial parts of the process is related to the Minimum Data Set, the accuracy of which can be “very poor in some areas,” Klusch noted. Facilities need to look at who is responsible for MDS coding and accuracy, as well as training efforts for the data-gathering team — which should also be documented. If facilities are performing audits, leaders need to carefully document the process and record the outcomes.

It’s a point that’s been emphasized over and over again: the vital role of documentation under the new payment system. The Centers for Medicare & Medicaid Services (CMS) will scrutinize changes to payment that result from coding as opposed to changes in a facility’s case mix — making documentation paramount in case of audits.

And because PDPM shifts the payment driver to patient conditions rather than minutes of therapy, proper record-keeping will be essential, as audits are likely to fall on nursing documentation in a way that they haven’t before.

Gearing up for October 1

Provider preparations for the new model should be well underway, but there are some specific tasks they can work on now, Klusch noted on the webinar. For one thing, leaders will need to constantly record and monitor staff competencies so the SNF can demonstrate their abilities and qualifications. That means SNFs need to examine the new items on the MDS, as well as who’s responsible for properly recording them.

Accurate assessments will be essential, and facilities have to ensure all participants in assessments have the knowledge to complete them in compliance with the state operations manual on the MDS. This, according to Klusch, is a particularly difficult mandate.

And once again, data will be essential. There’s been an emphasis on the reproducability of the data on the MDS and medical record; Section GG information has to be supported with documentation from the nursing unit, therapy, and other available sources. SNFs will also need to have electronic processes and data collection tools to reproduce this information if asked by CMS.

“This is a very complex conversion,” Klusch said. “You have to start with your MDS data, and I believe that your MDS process should be documented with a policy and procedure.”

The data reported to the federal government has to be absolutely top-notch, both to secure timely payment and serve as a protection against future audits.

“With PDPM, if the data is wrong, is not logical or is incomplete, payment loss will be very high,” Klusch said.

With that in mind, SNFs have to look at the MDS 3.0 dataset content and examine what factors contribute to payment rates — a task that’s particularly important because of the increase in items that are going to affect reimbursements, she said.

And when it comes to being ready come October 1, there are two very focused areas that leadership, administrators, regional consultants and owners should be paying attention to: how to staff for the transition, and how much money is available to support the required staffing levels.

“It will require some extra staffing in most buildings, and .. extra hours. Extra duplicative assessments are going to require some extra budget,” Klusch said. “When we look at this, the scope of this change is enormous.”

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