The transition to PDPM on October 1 brought forth a whole new reimbursement system centered around primary clinical characteristics of the patient that is dependent on five categories: PT, OT, SLP, NTA and Nursing. With the major shift from RUG-IV to PDPM, our post-acute care experts have received a multitude of questions revolving around diagnosis coding and how it greatly affects a SNF’s reimbursement under this new model. Our clinical and compliance experts, Jennifer Napier and Allen Johnson teamed up to provide tips and strategies to continually optimize accuracy under PDPM.
PRIMARY DIAGNOSIS CODING
Choosing the right diagnosis coding is necessary when completing the MDS in order to receive the most accurate reimbursement. The patient’s primary diagnosis greatly impacts three of the five PDPM components and in cases where a medically complex patient is admitted into a SNF, there may be several primary diagnoses that can be used. The code chosen and entered in I0020B influences the payment rate for PT, OT and SLP if there is an acute neurologic condition.
The Diagnosis Code entered into I0020B will determine the Clinical Category for PT/OT and ST as a major payment component. MDS nurses will need to ensure the diagnosis entered maps to a PDPM clinical category that impacts reimbursement (and not return to provider). When you have a patient who is medically complex and there are three possible codes that could be used as the primary diagnosis (two mapping to the medical management category and one mapping to acute neurologic), choosing acute neurologic will not only result in a higher case mix group for PT and OT, but will also result in a higher case mix group for the ST component as well. There is a significant difference from using an Acute Neurologic Code over Medical Management. Concept Rehab’s PT, OT and Speech Therapy Quick Guides along with our Crosswalk Tool can help determine the impact of these different codes that can greatly affect the SNF’s financial reimbursement.
CAPTURING IV FLUIDS FROM HOSPITAL STAY
Historically, it has always been a common occurrence for a SNF’s dietitian to fill out section K items on the MDS. Under PDPM, section K now has significant impact on a SNF’s reimbursement in several areas, specifically the question of K0510A. There are several services that can be captured from the hospital stay, even while the patient is not a resident at the facility that can affect the SNF’s reimbursement once they are admitted. Particularly, item K0510A1 on the MDS that focuses on Parenteral/IV Feeding—defined by CMS as the introduction of a nutritive substance into the body by means other than the intestinal tract. This specific question can categorize a patient who received IV fluids prior to becoming a resident within the SNF as a Special Care High category. This is one of the highest nursing categories for payment, just below extensive services. As we progress under PDPM, it is recommended to obtain these records along with any dietary and progress notes from the hospital. You may find that it may be beneficial to use Day 2 or 3 of the resident’s stay to set the 5-Day ARD Assessment so there is a full 7-day look back period into that hospitalization. Be sure that the person completing this MDS items is aware of the significance and impact of coding this particular question.
Section K0510A includes any and all nutrition and hydration received by the resident in the last 7 days either at the nursing home or in a hospital as an outpatient or inpatient, provided they were administered for nutrition or hydration. We have compiled a list of fluids that may be captured in the MDS when there is supporting documentation from the previous entity that reflects the need.
IV fluids for TPN purposes
Fluids to keep the vein open (KVO)
IV fluids contained in IV Piggybacks
Subcutaneous ports in hydration therapy
IV fluids can be coded in K0510A if they were needed to prevent dehydration if the additional fluid intake is specifically needed for nutrition and hydration
MORBID OBESITY DIAGNOSIS
Morbid obesity is diagnosed by determining the Body Mass Index and is categorized if an individual has a BMI of 40 or more. The facility’s dietitian is generally already gathering a patient’s height and weight to determine the BMI upon admission to the SNF. Anytime a resident has a BMI of 40 or more, and if they don’t have the established diagnosis of morbid obesity, it’s highly recommended to query the physician for a diagnosis clarification. This has to be a physician documented condition within the last 60 days in order to be captured in section I8000 on the MDS.
The diagnosis of morbid obesity results in 1 NTA point and can make a significant difference if captured. To get that NTA point, use one of the diagnoses seen on the chart to the right free-texted into item I8000 of the MDS. Coding morbid obesity into the MDS will add an additional point to your CMG that could greatly increase the financial reimbursement to the facility.
THE FINANCIAL IMPACT
Whether it’s capturing the primary diagnosis coding, documentation from the hospital or the extent of the patient’s medical complexity, it is necessary to have a plan in place when coding the MDS in order to not miss these financially crucial elements. Each of these tips explained above can have a financial effect on the state of the SNF under PDPM if not coded properly. It’s important to verify the credibility of each item of the MDS for the most accurate reimbursement. Concept Rehab’s Crosswalk Tool is an interactive tool designed to model PDPM reimbursement and allow you to practice different patient classifications in order to determine the financial impact different items of the MDS can have on your facility’s reimbursement over the course of a patient’s stay.
It is our commitment to continue to provide the necessary resources and solutions needed to meet your entire business strategy and allow for the most optimal financial reimbursement under PDPM. To help you create a financially impactful, seamless course of care, download our IDT Quick Guides and other PDPM resources here.