By Liz Barlow, RN, CRRN, RAC-CT, DNS-CT
With the onset of the COVID-19 public health emergency (PHE), skilled nursing facilities (SNFs) have been focused on infection control, staffing, and heightened patient care. But as facilities settle into their new normal, they need to think about reengaging in Patient-Driven Payment Model (PDPM) reimbursement. In this article, Liz Barlow, RN, CRRN, RAC-CT, DNS-CT, AVP of clinical innovation for Paragon Rehabilitation and Jessie McGill, RN, RAC-MT, RAC-MT, curriculum development specialist for AAPACN, share some key strategies for nurse assessment coordinators (NACs) to get back on track with PDPM reimbursement and to improve collaboration between nursing, therapy, and the rest of the interdisciplinary team.
Involve the Therapy Team
Barlow says the first thing SNFs should do is engage the therapy team. “I have had many people ask me how therapy can really help with coding. All team members should be a part of care discussions, especially on admission, as we are all really learning about the resident. A therapist typically spends an hour or more on an evaluation on admission and then up to an hour every day after that with treatment. There is an opportunity that a resident may really open up and talk about his or her medical and personal history, or open up emotionally. For PDPM, this allows an opportunity to possibly capture diagnoses that weren’t listed on the discharge summary or in the medical record.”
Any time you are using an interdisciplinary team process, the therapy team should be included, agrees McGill: “The NACs should educate the therapy team on different areas where their documentation may help support MDS coding.”
While some areas of collaboration are obvious, such as functional status and rehabilitation potential, other MDS areas are subtler. McGill shares the following examples, “Consider that occupational therapy often evaluates the resident’s vision and perception—which could be used for both MDS coding and care planning; consider how physical therapy may be able to treat balance problems or other underlying issues that are currently addressed with a restraint; or consider how the speech language pathologist assesses cognition—this documentation may be used to code the Staff Assessment for Mental Status if the Brief Interview for Mental Status interview is incomplete.”
Bolster Section GG Coding
“Even though section GG has been around for several years, this section continues to be one of the biggest coding challenges on the MDS,” states Barlow. “It affects three case-mix groups for PDPM—physical therapy (PT), occupational therapy (OT), and nursing—so it has a big impact on reimbursement.”
Barlow cautions, “While the therapy evaluations scores are important, they may not reflect ‘usual performance.’ Be sure to use more than one source of information for your GG coding, as appropriate.”
McGill agrees that the team must consider how many times the activity occurred during the three-day performance window and collect data from all direct care staff assisting or observing these activities, as well as interviews with the resident and/or family, as appropriate. “Eating is a great example. Typically, the resident will have three meals a day for each of the three days, totaling nine meals. If therapy only observed one meal, the assessment of this meal may not represent how the resident usually completed eating across the entire three-day window.” For that reason, McGill emphasizes it is important to consider therapy’s documentation in the overall determination of usual performance, but often not as the sole determinant.
In addition to the resident’s admission performance in section GG, functional abilities, the IDT must collaborate to establish appropriate discharge goals and have a process to assess the resident’s discharge performance in these same activities. “In the facilities that I work with, there is often a greater focus on calculating admission GG scores, but less emphasis on discharge GG scores. Discharge GG scores are specifically important for showing the facility’s effectiveness in positive resident outcomes, and they also impact the SNF QRP Quality Measures,” says Barlow.
In the SNF QRP Measure Calculations and Reporting User’s Manual (v3.0), it clarifies how discharge GG scores affect outcome measures:
SNF Functional Outcome Measure: Discharge Self-Care Score for SNF residents
The total number of Medicare Part A SNF Stays (Type 1 SNF Stays only) in the denominator, except those that meet the exclusion criteria, with a discharge self-care score that is equal to or higher than the calculated expected discharge self-care score
SNF Functional Outcome Measure: Discharge Mobility Score for SNF residents
The total number of Medicare Part A SNF stays (Type 1 SNF Stays only) in the denominator, except those that meet the exclusion criteria, with a discharge mobility score that is equal to or higher than the calculated expected discharge mobility score.
SNF Functional Outcome Measure: Change in Self-Care Score for SNF residents
The measure does not have a simple form for the numerator and denominator. This measure estimates the risk adjusted change in self-care score between admission and discharge among Medicare Part A SNF stays, except those that meet the exclusion criteria. The change in self-care score is calculated as the difference between the discharge self-care score and the admission self-care score.
SNF Functional Outcome Measure: Change in Mobility Score for SNF residents
The measure does not have a simple form for the numerator and denominator. This measure estimates the risk adjusted change in mobility score between admission and discharge among Medicare Part A SNF stays, except those that meet the exclusion criteria. The change in mobility score is calculated as the difference between the discharge mobility score and the admission mobility score.
To revitalize a facility’s focus on GG discharge scores, Barlow suggests, “Review your process—if therapy has already discharged the patient prior to the three-day section GG discharge window, the NAC must ensure the direct care staff supply adequate documentation. If therapy is discharging during that three-day window and they have a much different score than what is reported by nursing, the interdisciplinary team should take that opportunity to discuss why there is a discrepancy. Discharge planning and communication regarding discrepancies must be ongoing throughout the stay, as it may indicate that the resident is not truly ready for discharge. This enables more education, training, and appropriate planning for the resident prior to discharge.”
“The biggest area of opportunity is to make sure there is a process in place to support section GG coding,” says Barlow. “There should be documentation to support the rationale behind the determination of usual performance.”
McGill agrees: “Unlike section G activities of daily living (ADLs), there is no definitive algorithm and there are no rules for section GG to authoritatively determine what the correct coding should be. This makes it even more critical that the rationale used to make your usual performance determination be well documented to withstand future audits.”
AAPACN has some outstanding tools for section GG documentation, including the Section GG Prior Function and Admission Performance Tool and the Section GG 3-Day Data Collection Tool.
Accurately Capturing Comorbid Conditions: NTA and SLP Case-Mix Groups
Admission to the SNF may be a very stressful transition for a resident—the admission paperwork, screenings, clinical assessments, and therapy evaluations can often be taxing, as well as acclimating to a new room and possibly new roommate. “The NAC should already be requesting hospital medical records, but also needs to talk to the resident about their medical history. This will help the NAC dig deeper into the medical record and try to identify all possible diagnoses, conditions, and comorbidities,” states McGill.
“Most facilities have not fully captured all pre-existing comorbidities. Capturing these conditions will improve reimbursement accuracy in the NTA and SLP categories,” adds Barlow. “Again, be sure to include therapy in this conversation. Did they identify a previous condition that may not have been in the medical record? Also, talk to the interdisciplinary team about section K0100, which impacts the SLP case-mix group. A diagnosis of dysphagia maynot impact the SLP case-mix group, but the symptom of dysphagia will have an impact. If a resident is given a glass of water during a break in therapy and he or she starts coughing and choking, that can be captured if it is documented. If a resident starts choking on their medication, this too can be captured during the look-back.”
Only the physician can diagnose, emphasizes McGill. “If the NAC identifies a suspected missing diagnosis, he or she must query the physician. An ICD-10-CM code cannot be added to the medical record or used on the MDS or Medicare claim if not supported by physician or physician extender documentation.”
Barlow agrees and adds, “If there is an unspecified code, be sure to reach out to the physician for clarification. This may allow a diagnosis to be captured under the NTA component, where most unspecified codes are not part of the diagnosis mappings.”
Pay Attention to Depression Capture
“Even with the impact of COVID-19 and social isolation, most facilities had low capture of depression through PHQ-9,” says Barlow. “This can impact the Nursing Special Care High, Special Care Low, and Clinically Complex categories. This alone can have an impact; up to 0.41 of a point for your case-mix index could equate to $44.34 a day in reimbursement.”
“The PHQ-9 is a scripted MDS interview that must be completed by a staff member who has competencies in the RAI User’s Manual requirements, as well as interview techniques,” explains McGill. “The interviewer needs to provide the proper setting, ensure that the resident can hear and see the interviewer, and have appropriate cue cards available. And while the interview itself is scripted, remember that the interviewer can use interview techniques such as disentangling, unfolding, and echoing to elicit resident responses.”
The RAI User’s Manual requires that the PHQ-9 resident interview be attempted with all residents, except those who are rarely or never understood (see page D-2). If it is attempted, but the resident is unable to complete the interview, then staff may proceed to the staff observation version (PHQ-9-OV©). However, McGill points out, “If the resident interview should have been conducted, but was not done, regardless of the reason, then staff are not able to complete the staff observation of mood and the interview items would be dashed.” Only if the resident is rarely/never understood, needed an interpreter and one was not available, or the resident interview was attempted but incomplete, can the facility utilize the observation version.
Barlow agrees and stresses, “If the PHQ-9-OV© is completed, have you included observations from the evening and night shift, including from CNAs? Sometimes residents open up or show overall mood changes at different times, and nighttime can be lonely for them.”
Make Sure to Have an Audit Plan
“There was a pause in additional documentation requests (ADRs) last year due to the PHE, but now they have resumed,” says Barlow. With this change, it’s important to always be “audit ready,” so here are a few tips Barlow offers to ensure facilities are prepared for an audit:
- While therapy doesn’t have as great an impact on reimbursement as it did under RUGs, therapy still skills the majority of residents in a SNF. Documentation must support that services were medically necessary and at a skilled level of care.
- Nursing documentation needs to be at its highest level. This is vital for capturing all of the complexities and comorbidities through PDPM. A simple diagnosis won’t be good enough; nursing documentation must reflect the assessment and skill of those diagnoses.
- A comprehensive review of admission information should be completed to support the 5-Day MDS assessment. Perform audits to validate what was scored, from diagnoses to section GG.
Review and understand your data. A facility should always know its billing patterns. Many electronic medical records systems allow a facility to compare billing to other facilities within its system. It’s important to take a look, at least monthly, at how your facility compares to others. Review and ask yourself: Am I an outlier? Is there an opportunity to better capture information on the MDS? What are my processes for capturing coding? Does this data really reflect my current resident population?
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