PDPM: Premature Celebration Could Be Your Costliest Mistake

Zimmet Healthcare recently wrote that PDPM is a “monumental improvement.” And, it is. For those of us who have spent hours, days, months, and even years prepping for PDPM, we’re satisfied with this new reimbursement model – even though there are plenty of concerns for the Centers for Medicare & Medicaid Services (CMS) to address. Early reporting suggests that the per patient day ($PPD) revenue has improved, but it is not clear whether the aggregate Medicare reimbursement has improved, stayed the same, or decreased. Length of Stay (LOS), alternative payment models, and hospital referrals must be calculated into PDPM’s overall success, and though early findings suggest most are optimistic, it seems premature to offer a safe conclusion by just about anyone.

PDPM is a Monumental Improvement.

Our optimism fades as we hear about CMS’ ability to perform a “clawback,” or rate reduction. CMS projected that PDPM would be revenue-neutral. They anticipated that 68.6% of nursing facilities would lose $PPD revenue while 31.4% would increase their $PPD revenue. The recent Zimmet Healthcare report suggests that this assumption is inverted: 32.6% are losing and 67.4% are improving with an overall increase of almost 6%. Some PDPM experts suggest a clawback could occur as early as this year.

Lessons Learned from Early PDPM Reports

Coding Oversight during Initial Assessment

In a recent Zimmet Healthcare webinar, it was suggested that one of the areas for improvement is in the “Special Care High” (SCH) category. For example, most skilled nursing facilities (SNFs) are missing when new admissions have had Intravenous Fluids (IV) fluids in the hospital, when they are short of breath while lying flat, and also have a diagnosis of pulmonary disease and other such comorbidities. Other coding items being missed are from the I8,000 of the MDS, as well as accurate GG assessment. This leads many SNFs underscoring and thus to underpayment.

Additionally, buildings are not accurately assessing and documenting signs of depression in the initial assessment. This is a $43 PPD item. A 20-day stay results in $860 of missed revenue if this is not captured. Lastly, the Non-Therapy Ancillary (NTA) capture is low. Buildings are missing the opportunity to capture malnutrition, multidrug-resistant organisms, morbid obesity, and acute and chronic respiratory distress diagnoses.

Why are we missing this documentation? The most common response is– human error.

Minimal/No Use of The Interim Payment Assessment

Early studies, executive interviews, and industry reports suggest that Interim Payment Assessments (IPAs) have also been a challenge for facilities. An IPA is difficult to identify and where a facility has strong IPA processes in place, they come at a heavy expense of staff time.

Declining Length of Stay

Length of Stay (LOS) is an impactful contributor to overall nursing facility revenue success. Even if $PPD increases in PDPM, if LOS drops too significantly a lower total reimbursement occurs. Recent data suggests that LOS is declining, thus there is increased pressure to have improved hospital referrals. Successful PDPM SNFs understand this dynamic and have improved relationships with their local hospitals.

Remain PDPM Optimistic with Real Time

Under PDPM, the potential for lost opportunities for reimbursement is exponentially greater than with the traditional therapy-driven reimbursement model. Within the electronic health record (EHR), nursing notes, orders, and point-of-care documentation hold the secret to your PDPM successes – all of which Real Time accesses. Without real-time access to this information, reimbursement will fall short of the care provided.

Optimizing Initial Assessment & Interim Payment Assessment Opportunities

Using Real Time, relevant PDPM data is always accessible and vital to classifying residents accurately. Real Time’s PDPM Complete solution currently supports over 1,000 SNFs. Zimmet Healthcare played an integral role in the development of our PDPM solution which was launched last June. Our PDPM solution exposes live data from the EHR which:

• Assists facilities in capturing “PDPM pertinent” information to complete a timely and more accurate Initial Assessment.
• Identifies an IPA and what the estimated reimbursement will be using the live data from your EHR.
• Captures shortness of breath when lying flat (a diagnosis of chronic obstructive pulmonary disease), nursing GG opportunities, depression, malnutrition, multi-drug resistant organisms, morbid obesity, and documentation of acute/chronic respiratory diagnoses—with no extra work.
• Provides timely, resident-specific details and reimbursement sensitive items to the user with no additional data entry or extra work by staff.

Considering the inevitable CMS “clawback” on the horizon, be sure that you are maximizing your Initial Assessment and IPA coding for maximum reimbursement. With PDPM Complete – get paid for the care you are providing in PDPM.

Successfully Manage Your LOS and Hospital Referrals

Real Time’s ProACT solution enables facilities to proactively identify resident’s potential risk for readmission to the hospital allowing the clinician to intervene early, therefore mitigating the risk of rehospitalization. It can also assist with improved, data-driven communications with referring hospitals, ACO’s, and health systems. Successful SNFs that use Real Time for PDPM are expanding their referral base to offset any LOS declines.

What Will Your Future Bring?

As we move through this first quarter of 2020, will we become more cautionary or more celebratory? What plans, partnerships, and actions are we about to embark on to further prepare? Data analytics should be a part of your formula for PDPM success, especially data analytics that integrates real-time resident data – we call that Interventional Analytics. realtimemed.com