WHY IS SO MUCH SIGNIFICANCE BEING PUT ON NURSING DOCUMENTATION IN PREPARATION FOR PDPM?

Updated: Oct 9, 2019

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PDPM utilizes a different methodology for how payment will be calculated. Instead of determining the payment based on the days and amount of therapy provided in combination with the ADL score, payment will be generated based on the clinical complexities of a patient. The big factor will be a SNF provider’s ability to accurately capture the care provided and clinical complexities present so they can be reimbursed for the care delivered.


The biggest challenge to that is nursing documentation; or lack thereof. The rule of thumb has always been, “if it isn’t documented, it didn’t happen”. That will stay true with PDPM. The clinical record will need to justify key items indicated on the MDS assessment that will impact payment. Historically, over time providers have gotten really good at documenting section G, ADL delivery and substantiating therapy records. Under PDPM, multiple aspects of the MDS that will control payment will begin to be scrutinized. Many of the key areas are highlighted below and are summarized on our webinar - Nursing Documentation Considerations.


Brief Interview for Mental Status (BIMS) The presence of cognitive impairment in section C of the MDS impacts the ST component of PDPM. Specifically, if a score of 12 or less is generated, this will positively impact reimbursement. A facility should consider the following:

  • Most residents are able to attempt the BIMS interview. Review your facility interview process to be sure it’s being completed accurately.

  • Be sure you have the “right person” conducting the interview and that they are trained.

  • The medical record should demonstrate that the interview was completed timely; during the look-back period of the ARD.

  • Acknowledge that cognitive levels may fluctuate throughout the day and the BIMS interview should reflect the most care being provided to the resident.


PHQ-9 Mood Interview Responses to the PHQ-9 resident or staff mood interview can indicate possible depression. A score of greater than or equal to 10 can positively impact the Nursing component of PDPM. A facility should consider the following:

  • Most residents who are capable of communicating can answer questions about how they feel.

  • Mood disorders are common in nursing homes and are often under-diagnosed and under-treated.

  • Review your facility process for the PHQ-9. Ensure you have the “right person” completing the interview and that they are trained. The use of cue cards are encouraged to obtain accurate responses.

  • The medical record should demonstrate that the interview was completed timely; during the look-back period of the ARD.

GG: Functional Abilities and Goals Separate GG function scores will be determined for therapy (PT and OT) and Nursing components of PDPM. Therapy function score will range from 0-24 while the Nursing function score will range from 0-16. Consider the following:

  • GG uses a three-day data collection period, prior to therapeutic intervention.

  • Based on “usual performance”. Not the best and not the worst performance, but record the resident’s usual ability to perform each activity. Be sure to have justification in the medical record for the usual functioning determined.

  • Include direct observation, resident self-report, and reports from clinicians, care staff, or family is documented in the resident’s medical record.

  • Use an interdisciplinary approach; therapy is only a piece of the equation.

  • GG coding goes beyond PDPM. Data is currently being collected for QRP outcomes.


Primary Diagnosis in I0020B The diagnosis entered in I0020B will determine the clinical category under PDPM. This impacts the PT, OT and ST components of PDPM.

  • Evaluate and strengthen your facility process using an interdisciplinary approach for identifying and communicating the primary diagnosis code. This does not need to be the diagnosis code that the hospital used.

  • Validate the ICD-10 code maps to an appropriate clinical category. (Avoid return to provider codes).

  • Skilled documentation should support the primary diagnosis code chosen.


Diagnosis Coding in section I: The active diagnoses identified in section I of the MDS can significantly impact both the Nursing and NTA components of PDPM.

Swallowing Disorder The presence of signs or symptoms of a possible swallow disorder identified in K0100 can positively impact the ST component of PDPM.

  • Educate nurses, nursing assistants, IDT, and therapy staff on signs and symptoms to monitor and document.

  • Observe the resident, ask the resident if he/she had signs and symptoms, interview staff members on all shifts, and review the medical record including nursing, physician, dietician, and speech therapy notes.

Mechanically Altered Diet The delivery of a mechanically altered diet including “a diet specifically prepared to alter the texture or consistency of food to facilitate oral intake” can positively impact the ST component of PDPM.

  • This includes a 7-day look back period from the ARD.

  • The presence of documentation/evidence in the medical record must be present to support coding. This may be found in speech therapy diet trial notes and physician orders.


Nursing Categories Multiple items coded on the MDS can impact the Nursing Category identified in PDPM. This includes areas of the MDS such as sections B, C, D, E, H, I, J, M, N, O.

  • Nursing knowledge and education in assessing and monitoring for certain key conditions and complexities is essential.

  • Review the record during the observation period prior to the ARD to ensure all essential items are captured/documented.

  • Refer to our Nursing PDPM Category Guide.


The medical record documentation ultimately should support the skilled care delivered. If audited, the medical record should substantiate all items that were coded on the MDS assessment used for billing. Good, thorough documentation leads to accurate reimbursement and takes the collaboration of the entire interdisciplinary team.


For a more detailed review of these key areas that are essential to supporting the medical record under PDPM, please view the webinar and the full set of training materials.

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