MDS Alert

If you don’t feel like your ICD-10 knowledge is up to snuff now, seek training now so you’re ready for PDPM’s immense impact.

Nurse assessment coordinators (NACs) are frequently acting as ICD-10 sleuths, figuring out how a resident’s diagnosis should be portrayed in the MDS and beyond. With the arrival of the Patient-Driven Payment Model (PDPM) and consequent replacement of RUG-IV, nursing facilities and staff must be ready to adjust documentation and even clinical practices in order to shore up crucial reimbursement.

One of the most important tips to get off on the right foot for PDPM? “Become an expert on the qualifiers for the clinical categories,” says Judy W. Brandt, RN, Ba, QCP, CPC, RAC-MT, DNS-CT, principal at Wilhide Consulting inc. in Virginia Beach, Virginia.

Bolster Nursing Over Therapy?

With RUG-IV, facilities depended on therapy hours for reimbursement — sometimes letting the delivery of other care fall by the wayside, in reality or in documentation.

Ideally, PDPM will be a big push in bringing individualized, high-quality, patient-centered care to every facility and every resident. But the long-term care industry is still waiting to see whether PDPM will live up its name and reflect policymakers’ intent.

Much of the significance facilities face in the adoption of PDPM versus the current RUG-IV is the narrowed focus on “patient characteristics” instead of “caregiver resources,” says Kris Mastrangelo, president and CEO of Harmony Healthcare International in Topsfield, Massachusetts. Facilities will have to look beyond therapy minutes for reimbursement, and that means a greater shift to evaluating nursing.

As facilities adjust to this major change, there could be some light at the end of the tunnel. “While the primary diagnosis and the physical therapy/occupational therapy (PT/OT) function score will be the determinant for case mix index (CMI) for the PT and OT categories, the nursing category can be huge, and does not decline over time,” Brandt says.

For NACs in particular, this could mean a lot more legwork. This is a great moment to re-evaluate your communication processes within your team and make sure that your documentation workflow is watertight.

“Learn the nursing function score, master the nursing categories, and begin refining processes to collect the nursing information. I know the nursing categories are not new, but, in the past, if you had the therapy and ADL score, it wasn’t worth it to dig for hours getting the ‘shortness of breath lying flat’ with COPD. Now it’s going to be crucial,” Brandt says.

Conquer the ICD-10 Frontier

One aspect of bolstering documentation and communication within your team and for each individual resident’s clinical record is really diving into ICD-10 and getting to know it inside and out. In the past, skilled nursing staff have been able to do their jobs without needing complete fluency in the ICD-10 landscape.

PDPM — specifically the move away from therapy minutes determining reimbursement and the greater focus on nursing — essentially requires that facility staff responsible for coding the MDS understand and utilize ICD-10 to ensure reimbursement.

“Refine your ICD-10 coding skills. I’m a CPC and I can tell you there is no such thing as a certification by AHIMA or AAPC in ‘SNF coding.’ It does not exist because our reimbursement has not hinged on the code. Now, some of it will. The general and chapter specific coding guidelines must be followed to get an accurate diagnosis,” Brandt says.

If you are a NAC who feels unsure of your ICD-10 footing, now is a great time to go to your superior and ask for the time and support in pursuing further training. One option: the American Association of Nurse Assessment Coordinators (AANAC) will be offering a virtual workshop on ICD-10 coding for nursing facilities later this year.

Know What to Expect on the MDS, Too

Active diagnoses as recorded in Section I (Active Diagnoses) in the MDS — which must be documented by a physician in the past 60 days and active during the seven-day lookback period — will become a lot more meaningful with PDPM.

Once PDPM is implemented, Section I (Active Diagnoses) will play a huge role in evaluating whether a resident is receiving appropriate, patient-centered care at the facility — including PT, OT, and speech language pathology (SLP).

ICD-10 diagnoses coded in item I8000 (Additional Active Diagnoses) will be jump-off point for evaluating other components of care for reimbursement.

“PDPM will use the ICD-10 code used in the first line of I8000 to determine the primary clinical category for the PT, OT, and SLP components,” says Jessie McGill, RN, RAC-MT, curriculum development specialist at AANAC in Denver, Colorado.