Refocus on capturing PDPM drivers to improve care, quality and reimbursement

April 13, 2021 | Written by: Jim Shearon, R.N., BSN, MHSA, Real Time Medical Systems, & Sheryl Rosenfield, R.N., BC, Zimmet Healthcare Services Group

With the prioritization of COVID-19 vaccinations in nursing facilities since late December, facilities nationwide have seen a significant decline in both new cases and deaths among resident populations.

Though the decline of COVID-19 cases is very encouraging, many skilled nursing facilities are now facing widespread systemic issues that the pandemic exposed.

Ongoing and dynamic infection prevention and control programs, along with strong facility policies and procedures for care, remain imperative for successful operations on many metric scales. Staffing ratios and lower occupancy rates also create business challenges that must be reviewed and quantified daily.

In light of the extreme pressures facilities are facing, SNFs and their clinical teams must understand the significant role that the Patient-Driven Payment Model for Medicare reimbursement has in addressing these systemic challenges. In more than 30 years of MDS required assessments, resident information on an individual and aggregate reporting identifies functional, quality of care, re-hospitalizations, staffing ratios, admissions and discharge analytics.

The importance of accurately completing and submitting the initial MDS assessment not only impacts financial outcomes, but it sets the  stage for establishing effective resident care plans, quality measures and survey results.

The initial MDS assessment is the basis for:

  • The functional assessment of an individual upon admission to a skilled nursing facility
  • The development of an individualized care plan, including goals for functional and quality-of-life concerns
  • Medicare payment utilizing PDPM
  • Medicaid reimbursement in individual state programs
  • Quality monitoring activities, such as quality measure and indicator trends for facility quality assessment and  performance improvement, or QAPI, programs
  • Individual resident and facility performance information necessary for federal and state data-driven survey and certification processes
  • The quality measures and Nursing Home Compare information used for public reporting metrics
  • Research and policy development by CMS and other entities

Collecting accurate data and determining appropriate clinical diagnoses and functional needs on admission is essential for improved resident outcomes. Yet, SNFs are still challenged with obtaining key information and data from the hospital upon admission to accurately complete the initial MDS assessment. Missing information can lead to incorrectly categorizing the patient care needs and prevent the clinical team from developing an accurate plan of care for the resident – resulting in lower reimbursement and negative patient outcomes.

Reviewing and analyzing information in the many fields on the UB-04 required for Medicare billing, through CORE Analytics, clinicians are guided to obtain and review missing data items that may not have been accessible from the hospital upon admission. Accuracy of the UB-04 information provides a timely source of clinical care drivers including diagnoses and PDPM item categories, in addition to facility profiles for analysis of trends and outcomes.

Utilizing individual resident information from the CORE reports helps to improve information workflow with improved identification of functional and other needs and allows for individualized and well-developed plans of care. From admission to discharge, clinical teams can improve the identification of all care needs, with appropriate reimbursement and accurate compliance.

The sheer complexity of ICD-10 coding and changing variables in resident conditions does not make PDPM easy to master – not even for the most skilled and knowledgeable MDS coordinators. In the fast-paced SNF environment, all facility staff must understand the intricacy of ICD-10 codes and recognize the importance of identifying as many clinical drivers of care as  possible, which impact resident outcomes and reimbursements.

Failing to recognize these commonly avoidable conditions, which can regularly plague new admissions and complex care residents, might also reduce facility quality measure  scores:

  • Falls and injuries
  • Pressure ulcers
  • Pneumonia and sepsis
  • Hospital and facility infections
  • Exacerbating comorbidities (COPD, congestive heart failure and diabetes)

Working collaboratively, strong communication between clinicians and MDS coordinators will also help to recognize  ongoing clinical changes in the patient. In some cases, these changes may warrant new treatments and/or diagnoses that may require an interim payment assessment to reflect the change in care and reimbursement levels. Yet, the  frequently used clinical narratives to communicate these changes make it nearly impossible to capture this time-sensitive information to alter the resident care plans and submit for an IPA.

Analyzing live data in the EHR and identifying keywords found within clinical documentation can help providers clinically prioritize resident care and improve IPA submissions by $35.59 per-patient, per-day, according to a review by Real Time Medical Systems. The depth of needed critical thinking with the review of clinical documentation provides a strong foundation of information about the patient based on factual evidence and not simply observational or anecdotal reports that would not allow for reasonable completion and submission of an IPA subject to review for reimbursement and care drivers.

What we have learned in the past and continue to navigate in the uncharted waters of the year ahead is that facilities need to evaluate tools and systems that can reduce unneeded burdens on the clinical team. Consideration and evaluation of your facility EHR must incorporate documentation and reporting systems for positive patient and facility outcomes. With higher patient acuity and costs of care, now is the time for clinical teams to identify new paths to improve care, reduce costs, and minimize administrative burdens. Is your EHR able to provide a broad range of needed data and analytics efficiently to effectively meet the clinical and reporting requirements in the years ahead?

In the words of C.S. Lewis, “You can’t go back and change the beginning, but you can start where you are and change the  ending.”

Jim Shearon, R.N., BSN, MHSA is a seasoned expert in Medicare and Medicaid reimbursements and quality improvement. He currently serves as the Vice President of Clinical Solutions with Real Time Medical Systems.

Sheryl Rosenfield, R.N., BC is Board Certified Gerontological Nurse and is an expert in state and federal protocols and policies impacting medical review and payment concerns. She is currently the Chief Clinical Officer with Zimmet Healthcare Services Group, LLC.

You may view this article on McKnight’s website, here.

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