The blanket approach: Best practices for PDPM Success

August 23, 2019

Yet another glorious summer bites the dust, and fall colors are looming around the corner. Similarly, on October 1, SNFs, and their extended summer fling with RUGs, morph into the uncertainty of the Patient-Driven Payment Model.

The falling temperatures, and the absence of RUGs, will surely make SNFs reach for a warm blanket! Best practices can truly be SNFs’ security blanket as they cozy up to PDPM. Here are some tips.

  1. Admission and the Initial MDS Assessment: 
    Timeliness: The Initial MDS assessment (to be done between day 1-8) is the prime driver of reimbursement under PDPM. Therefore, accurate and comprehensive documentation of patient characteristics in the Initial MDS assessment is of paramount importance. 
    SNF patients are at their sickest upon discharge from hospitals, as they are being treated for acute illnesses, often requiring expensive medications and extensive nursing care and rehabilitation. The initial MDS assessment needs to happen as early as possible to capture the increased acuity and higher utilization of resources upon admission. An initial MDS assessment completed later in the window may not get credit for the higher NTA CMI that is usually afforded to IV infusions, medications, supplies and nursing care, if they are discontinued by that date. The cost of a missed opportunity is especially impactful as the NTA payments for the first three days of SNF stay are multiplied by a factor of three.
  2. Accuracy: While timing of the initial MDS assessment is critical, without an accurate capture of patient characteristics, SNF reimbursement will suffer under PDPM. 
    A thorough review of hospital records and outpatient records, performed by a clinical practitioner- who can verify and edit (if necessary) the ICD 10 diagnoses codes for each patient, goes a long way towards ensuring accuracy. Physicians are reimbursed by Medicare for the additional time spent in reviewing this information during the initial visit with a SNF patient, and SNFs should insist on, and facilitate, completion of initial visits at the earliest possible time. If non-physician practitioners spend time reviewing records or verifying orders, the prolonged visits are reimbursed based on medical necessity. Any administrative time spent by medical directors in this process, especially on patients who are not theirs to follow, needs to be factored into their monthly stipend.
  3. Relevance: There are many advertised ‘tools’ that scan documents for ICD 10 codes, or ‘group’ codes for efficiency, but they are generally poor substitutes for the much needed human intelligence in deciding which ICD codes and patient characteristics are relevant for each MDS assessment. Of particular import is the process of choosing ICD 10 codes to populate MDS fields based on their impact on case mix for each category. A ‘cheat sheet’, listing the high impact diagnoses for each category, will be very helpful at the outset. Special attention should be given to identifying acute neurological diagnoses, depression, dysphagia, altered diet, and cognitive deficits, as they significantly affect case mix indices under therapy categories.