Historically, the Patient-Driven Payment Model (PDPM) was used primarily for Medicare Part A stays in the skilled nursing facility (SNF) and swing bed setting. However, states have or are in the process of converting their state Medicaid payment models to some variation of PDPM due to recent and future changes to the Minimum Data Set (MDS).
The PDPM is based on resident characteristics and conditions that must be documented accurately in the medical record to allow for appropriate reimbursement. If care provided to each resident, along with diagnosis information, is not documented in the medical record, then it cannot be coded on the MDS, and the provider reimbursement is often less than indicated.
There are five case-mix groups (CMGs) driven by the MDS and one non-case-mix, facility-specific component under PDPM for Medicare Part A stays. The dollar amounts of these six groups are added together to produce a specific Medicare daily rate for each MDS assessment completed. The PDPM components driven by the MDS assessment include physical therapy (PT), occupational therapy (OT), speech-language pathology (SLP), nursing, and non-therapy ancillary (NTA).
Under state Medicaid programs, there are numerous approaches detailed in current or proposed state plan amendments. Some states are using the nursing component only, while others have opted to use a blended component methodology. Regardless of the model chosen by individual states, it is critical that the MDS assessment captures each patient’s conditions and care appropriately.
Interdisciplinary participation in the MDS assessment process is vital to help warrant accurate capture of all patient characteristics and conditions. Team members directly involved in the PDPM process include the MDS personnel, physical and occupational therapists, and speech-language pathologists. These individuals work together to figure out the primary reason for each patient’s stay, which informs the primary clinical category for each MDS assessment. In addition, Section GG of the MDS requires that a team of qualified clinicians work together to decide each patient’s usual performance with specific functional tasks that calculate the PT/OT and nursing function scores. The function scores impact all of the case-mix groups for the PT, OT, and nursing components.
Other interdisciplinary team members that provide high-impact information for accurate MDS coding include:
Nursing assistants. Although they are not directly involved in the PDPM process, their observations and interactions with patients when appropriately captured through documentation provide valuable information to allow for MDS accuracy. Continued education to nursing assistants regarding definitions of functional tasks and the amount of assistance provided is critical to accurate MDS assessments.
Direct care nurses. They are responsible for providing the documentation regarding care given, along with assessments, monitoring details, and treatment of various conditions. Continued education to licensed nursing personnel is important to help ensure that the documentation contained in the medical record is appropriate, as that allows the information to be coded on the MDS assessment. Communication between the direct care nursing personnel and the MDS personnel is critical for timely determination of when a patient may be experiencing a change in condition that should result in completion of an updated MDS assessment. Some items that direct care nurses should report timely include fever, initiation of new orders for isolation, IV medications or fluids, and oxygen therapy. Other issues that should be communicated timely include new diagnoses, skin and wound issues, and physician-ordered treatments.
Social service personnel are often tasked with conducting the scripted interview sections of the MDS assessment. The Brief Interview for Mental Status (BIMS) and Patient Health Questionnaire (PHQ) interviews impact the final PDPM calculation. The BIMS influences the SLP component and the PHQ total severity score affects the nursing component. If these interviews are not conducted properly, then this can create inaccuracies within MDS data. Making sure these team members are educated on the importance of the interviews is important for PDPM success. In addition, it is vital that team members understand supporting documentation requirements once staff assessments are completed for the BIMS or PHQ. This knowledge can help prevent partial payment denials during medical review situations.
The administrator and director of nursing also play critical roles in the success of the PDPM. These leaders need a basic understanding of how to manage PDPM successfully and when to ask questions of their interdisciplinary team members. It is also their responsibility to make sure each team member receives appropriate education for this process. Lastly, these leaders should understand the meaning behind Health Insurance Prospective Payment System (HIPPS) codes for each individual MDS assessment and understand how to monitor these codes for both Medicare and Medicaid.
In addition, physicians and their extenders (nurse practitioners, clinical nurse specialists, and physician assistants) play a role in MDS accuracy under PDPM. They can help providers document accurate, specific diagnosis information, which can positively impact appropriate reimbursement under PDPM. Physicians and their extenders can also assist with reviewing diagnosis information routinely and providing documentation to support these diagnoses as active.
Providers who work with internal or external consultants may often include them by conducting routine reviews of MDS assessments and reading the supporting documentation to glean if appropriate reimbursement was obtained. These consultants can also assist with education, understanding data element criteria, and utilizing processes that may improve operations with Medicare and Medicaid under PDPM.
Many healthcare professionals regularly interact with the PDPM. This nuanced model requires attention to detail and deep knowledge to utilize and document information accurately. The healthcare team at Forvis Mazars can assist you with tools that break down the various components of the PDPM. For more information or to learn about successful management of PDPM for Medicare or Medicaid, please reach out to a professional at Forvis Mazars.