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Nursing Documentation and PDPM:
Addressing the Crossroads for
ReimbursementJune 14, 2019
The information provided here is of a general nature and is not intended to address the specific circumstances of any individual or entity. In specific circumstances, the services of a professional should be sought.
Baker Tilly Virchow Krause, LLP trading as Baker Tilly is a member of the global network of Baker Tilly International Ltd., the members of which are separate and independent legal entities. © 2019 Baker Tilly Virchow Krause, LLP
Disclaimer
Baker Tilly Virchow Krause, LLP trading as Baker Tilly is a member of the global network of Baker Tilly International Ltd., the members of which are separate and independent legal entities. © 2019 Baker Tilly Virchow Krause, LLP
Facing the ChallengesNursing Documentation and PDPM
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Components of PDPM
Physical therapy
(PT)Occupational therapy (OT)
Speech language pathology
(SLP)
Nursing
Non-therapy ancillary
(NTA)
– Each of these is derived from the coding of the MDS assessment
– Coding of the MDS assessment results in a HIPPS code for billing
WHAT IS DIFFERENT FOR NURSING?• Not much will change from PPS RUG-IV• Number of classifications will decrease from 43 to 25• PDPM is applicable only to Medicare Fee For Services beneficiaries• Documentation is required to support MDS coding – as always• Documentation of some type required to support technical eligibility• Section G does not provide the functional level but GG does• Nursing documentation should also provide support for clinical
conditions of NTA
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Nursing Documentation and PDPM
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Nursing component: Payment groups (1)
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Nursing component: Payment groups (2)
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Nursing component: Payment groups (3)
Case mix component for nursing component includes the following:– Self-care: eating– Self-care: toilet hygiene– Mobility: sit to lying– Mobility: Lying to sitting– Mobility: sit to stand– Mobility: chair/bed to/from chair transfer– Mobility: toilet transfer
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• Determining the Case Mix Group (CMG) is not the role of nursing• Nursing MUST ensure that medical record documentation represents
the resident care delivered and supports the MDS item coding • Assessment nurses serve as gatekeepers to ensure that what they
hear/learn/know is documented to avoid leaving reimbursement• Educating nursing and reviewing documentation support with nurses
can be very helpful
Nursing Documentation and PDPM
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Facing The ChallengesNursing Documentation and PDPM
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Extensive Services (ES1, ES2 and ES3):• Tracheostomy care while a resident • Ventilator while a resident• Isolation for active infectious diseases while a resident
Nursing Documentation and PDPM
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SPECIAL CARE HIGH (HB, HC, HD, HE)• Comatose and completely dependent or activity did not occur at
admission for section GG • Septicemia• Diabetes Mellitus diagnosis with both
• Insulin injections on 7 days AND• Insulin orders on 2 or more days
• COPD diagnosis and SOB when lying flat• Parenteral/IV feeding
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SPECIAL CARE HIGH• Respiratory therapy x 7 days• Quadriplegia diagnosis with nursing function score < or = 11• Fever with one of these:
• Pneumonia• Vomiting• Weight loss• Feeding tube
Nursing Documentation and PDPM
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Depression End Split (used for both special care and clinically complex)• Uses the PHQ-9 in section D• Resident qualifies as depressed with signs and symptoms coded that
• Total Severity Score is greater than or equal to 10 but not 99 in resident interviewOR
• Total severity score is greater than or equal to 10 for staff assessment
Nursing Documentation and PDPM
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SPECIAL CARE LOW (LB, LC, LD, LE)• Complex clinical care and/or serious medical condition of these:
• Cerebral Palsy with nursing function score of < or = 11• Multiple Sclerosis with nursing function score of < or = 11• Parkinson’s Disease with nursing function score of < or = 11
• Respiratory Failure with oxygen while a resident• Foot infections or wounds with application of dressings• Radiation therapy while a resident• Dialysis while a resident
Nursing Documentation and PDPM
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SPECIAL CARE LOW• Tube feeding meeting the intake requirements• Two or more ulcer treatments for two or more ulcers including
• Venous• Arterial• Stage II pressure ulcers
• Two or more ulcer treatments for any one stage III or stage IV pressure ulcer
• Two or more ulcer treatments for one stage II pressure ulcer and one venous/arterial ulcer
Nursing Documentation and PDPM
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Clinically Complex (CA, CB, CC, CD, CE)• Hemiplegia/hemiparesis with nursing function score < or = 11• Open lesions with any treatment or surgical wound• Burns• Chemotherapy while a resident• Oxygen therapy while a resident• IV medications while a resident• Transfusions while a resident
Nursing Documentation and PDPM
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BEHAVIORAL SYMPTOMS AND COGNITIVE PERFORMANCE• Cognitive status from the resident interview for BIMS• Comatose and completely dependent or did not occur on admission• Severely impaired cognitive skills for daily decision making• Two or more of the following impairment indicators are present:
• Usually, sometimes, or rarely/never understood • Short-term memory problem • Impaired cognitive skills for daily decision making AND• One or more of the following severe impairment indicators are present: • Sometimes or rarely/never makes self understood • Moderately or severely impaired cognitive skills for daily decision making
Nursing Documentation and PDPM
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BEHAVIORAL SYMPTOMS AND COGNITIVE PERFORMANCEOne or more of the following behavioral symptoms• Hallucinations • Delusions• Physical behavioral symptoms directed toward others (2 or 3)• Verbal behavioral symptoms directed toward others (2 or 3)• Other behavioral symptoms not directed toward others (2 or 3)• Rejection of care (2 or 3) • Wandering (2 or 3)
Nursing Documentation and PDPM
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REDUCED PHYSICAL FUNCTION• Restorative Nursing Programs two programs for 6 of 7 days
1) Urinary toileting program and/or bowel toileting program
2) Passive and/or active range of motion
3) Splint or brace assistance
4) Bed mobility and/or walking training
5) Transfer training
6) Dressing and/or grooming training
7) Eating and/or swallowing training
8) Amputation/prostheses care
9) Communication training
Nursing Documentation and PDPM
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– Will not be altered with PDPM implementation
– Criteria must be achieved before PDPM components are evaluated
– Three day qualifying stay– Certification/recertification of skilled
services by the physician– Skilled services ordered by physician– Skilled services required on a daily
basis
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Medicare technical eligibility criteria
Documentation Guidelines• Clear, concise and comprehensive• Describe situations/treatments/care• Objective vs. subjective• Provide data not opinions• Medical record is about the resident not the staff• Reasonableness and necessity• Can be located anywhere in the medical record
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Non-therapy ancillary (NTA) component– NTA classification is based on the presence of
comorbidities
– Includes resident diagnoses which require understanding of ICD-10 coding and determination of the relevant comorbidities impacting resident care needs
– NTA component is based on a tiered system
– CMS has an ICD-10 mapping system available on the PDPM webpage
– Finding the relevant diagnoses and being able to correlate to ICD-10 coding is critical for NTA with support documentation in the medical record
– NTA items are derived from multiple sections of the MDS assessment
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NTA component: Condition listing (1)
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NTA component: Condition listing (2)
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NTA component: Condition listing (3)
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NTA component: Condition listing (4)
Facing The Challenges
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