With overlooked reimbursement opportunities in the Payment-Driven Payment Model (PDPM) relatively common, nursing home operators can start to improve by focusing on some key areas where money is commonly left on the table.

Accurate documentation in the areas of speech, non-therapy ancillary services and nursing are top of the list for improving reimbursement through the model, according to experts who spoke on a recent webinar. Interim payment assessments, while optional, are another way to ensure appropriate reimbursement through PDPM.

Speech had the highest error by PDPM category at 38%, followed by non-therapy ancillary services at 31% and nursing at 27%, according to data collected by SimpleLTC for a webinar on PDPM opportunities. Error percentage dropped off steeply for PT and OT at 2%, and interim payment assessments also at 2%.

“This indicates an issue across the industry with communication and a documentation pause between inner disciplines … maybe some confusion around Section K,” Sarah Scott, senior client success coordinator for SimpleLTC, said of speech coding errors. Section K within the Minimum Data Set (MDS) assesses a resident’s nutritional status and ability to swallow, including information on height, weight and nutritional approaches.

Nhi Currie, director of clinical reimbursement with Palisades Care Coordination, said during the webinar that swallowing disorders are more prevalent than operators might realize and are often undocumented, which then leads to undercoding in the MDS.

“If a resident is on speech services, we can also interview staff and observe the resident during meals, snacks and medication pass,” said Currie. “Early nutritional assessment can also be very beneficial. It allows for quicker identification of issues, and in turn, a quicker intervention. We need to keep an eye on any condition changes that might warrant an interim payment assessment.”

Documentation and collaboration

Currie agreed that non-therapy ancillary services are often misunderstood and miscoded in PDPM.

PDPM “cheat sheets” for non-therapy services, Scott said, can help determine when certain sections related to these services need to be filled out in the MDS, and adding supportive documentation from the physician on a diagnosis code will help secure maximum reimbursement.

With Section GG dropping nursing categories, operators need to make sure there’s proper knowledge about where nursing notes would need to be transferred to the MDS, Scott added.

“Shortness of breath while lying flat was over half of the errors. A lot of times we’re seeing that these [observations] are in the nurse notes, but not on the MDS. Oxygen therapy is documented in the nurse notes, but not in the MDS,” said Scott.

Currie had one example of a resident with COPD whose shortness of breath while lying flat wasn’t documented, resulting in the loss of $81 per day. Better documentation was seen in another case, she said, involving a resident treated for sepsis. An order to finish out an IV antibiotic, daily notes on the resident’s wound and recording of the resident’s pain medication effectiveness secured an additional $130 per day for a special care, high acuity case mix group.

“Collaboration is key here,” Currie said. “Make sure that all active diagnoses are accurately coded. It is crucial to have supportive documentation for everything we code, to stand up to audits and ensure compliance.”

In terms of missed reimbursement opportunities with physical therapy and occupational therapy, the primary diagnosis often supported an uncaptured higher category with what would have been a higher reimbursement level.

Meetings with new patients to discuss their diagnosis, physical function and other relevant information can help appropriately determine higher acuity categories, Currie said. Reviewing the patient’s condition early on, including medications and labs, can allow for “more time to query” and in turn arrive at the correct category.

The IPA opportunity

While interim payment assessments only contribute to about 2% of errors, such assessments are a crucial way to capture higher acuity in the moment, and in turn higher reimbursement, said Currie.

Currie said an interim payment assessment should be completed if a resident is readmitted following an interrupted stay, if there’s a change in condition, new wounds, a change in orders or treatment, or new diagnosis.

In one example, nursing home staff completed an interim payment assessment for a resident who became ill with respiratory symptoms and a fever, leading to a $104 per day increase in reimbursement.

Staff opened an interim payment assessment for another resident, documenting a fever and diagnosis of acute kidney infection after being sent to the emergency room, with an additional $183 per day due to capturing higher nursing case mix and additional non-therapy ancillary points.

“Coding the diagnosis itself isn’t enough. We also have to satisfy the GG score of 11 or lower to get this nursing case mix group,” said Currie. “Interdisciplinary team (IDT) collaboration to code section GG is key … coding this section isn’t a solo task. It’s a team effort involving nursing, MDS coordinators, therapy staff and direct care staff. We need supportive documentation for the resident’s usual performance and also for the IDT decision making process as well.”