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MDS Nurse calculating pdpm reimbursement for nursing home
An MDS Nurse is responsible for calculating PDPM reimbursement.

MDS nurses directly impact reimbursement. They are the drivers of PDPM scores. They generate revenue for facilities by documenting ADLs in long term care software systems and all care that is administered, submitting assessments, and providing proof of clinical complexity. 

Their primary job is to code accurately and aggregate data in nursing home software or long term care EHR. But they are not accountants or secretaries. Rather, MDS nurses review all documentation in their long term care software and then use their knowledge and experience as nurses to put clues together, check the right boxes in an assessment, and help lead their team toward what residents need. They provide a depiction of residents that determines how much money the facility will receive to care for them. 

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The MDS Nurse Must Be Detective-Like

Under PDPM, long-term care facilities are now paid based on the burden of care that they provide. But if you do not claim that care properly, you stand to seriously damage the sustainability of your facility. That means that your MDS nurse must be meticulous in documenting care plans but also know when and how to rely upon other leaders at the facility

MDS Nurse in nursing home using kardex software
An MDS Coordinator must be detective-like to improve PDPM reimbursement

The MDS nurse will spend much of his or her day asking questions and interviewing anyone connected with residents in order to get assessments for the purpose of PDPM reimbursement. The MDS nurse will also look at residents’ BIMS scores and depression scale assessments in determining their care plans. 

After having gathered this data, the MDS nurse will try to put the clues together to figure out what steps need to be taken. For instance, suppose that the MDS nurse receives a report that a resident does not feel pain as much anymore and that their feet are less sensitive. The detective in the MDS nurse will realize that this individual is no longer aware of the pressure on their feet and thus needs heel protectors. 

It need not be said that the more efficient the systems at your facility, the more efficiently your MDS nurse can operate. That is why you will want to eliminate reliance upon outdated options for documenting care, like Microsoft Excel, and instead invest in more advanced technology, like a long term care EHR. This will increase the likelihood that your MDS nurse will be accurate in filling out assessments, pinpointing breakpoints, documenting KPIs, and catching mistakes. 

What an MDS Coordinator Must Do

  • See the bigger picture: Though it is physicians who look at patients and residents on an individual basis, it is the MDS coordinator who guides the care plan by taking the diagnosis or assessment that is submitted or the data collected and forming a picture of the resident as a whole for the purpose of PDPM reimbursement. The next step is to determine the strengths and weaknesses of the resident and what interventions are needed in order to obtain the best health status possible.

An MDS nurse cannot get too caught up in what is in front of him or her. Rather, they must think in terms of the various systems involved for PDPM Medicare or Medicaid reimbursement. It is the administrator’s job to help the MDS nurse in that regard and offer to help get him or her the documentation that they need

  • Come prepared for meetings: As soon as the MDS nurse enters the facility, he or she will look at the MDS assessments thoroughly. They will look at care plans and determine what is due today and tomorrow. They will then check their schedule to see what meetings are coming up and prepare accordingly.  
Nursing home CNA showing doctor point of care documentation software on a tablet
PDPM reimbursement requires meticulous documentation.

In morning meetings, the MDS nurse will ask and learn about any changes that have occurred since the previous morning meeting. He or she will then determine which residents are not receiving that which is demanded by their care plan as found in the facility’s long term care software. 

  • Report to the administrator: The MDS nurse must report things to the administrator, not the DON. This is because the work of an MDS nurse goes beyond the duties of other nurses; it is highly specialized and involves the operational side of things, such as surveys and financial accounting. 
  • Stay on top of quality measures: The MDS nurse must know what the facility’s outcomes are and why. If your facility is not performing as well as others in your peer group, the MDS nurse should be able to explain why that is. 

Example: Suppose, in a standup meeting, it is mentioned that one of your residents had a catheter added. A good MDS nurse will not simply move on. Rather, he or she will inquire as to what the diagnosis was. Then, he or she will set a 14-day timer in their head. This is because they know that there is a 14-day window in which the facility has the opportunity to determine if there is a medically-approved reason for the catheter to remain in place. For instance, the resident may have a large wound on his or her backside (sacrum) or may have recently had a stroke. A good MDS nurse will know that, if there is not a good justification, that catheter must be removed once the fourteen days are over. 

  • Refuse the urge to do other people’s work: As opposed to simply working extra hours, the MDS nurse should be urged by the DON to hold people accountable. That is because the MDS must focus on documenting care for the purpose of reimbursement. Of course, there will be situations where the MDS nurse will have to conduct extra assessments. But, in general, he or she should not be concerned with managing the systems except as it pertains to documentation and reimbursement.

PDPM Reimbursement Requires Careful Consideration

To maximize PDPM reimbursement, a facility needs its MDS nurse to not only stay on top of documentation in its long term care software system but also to hold others accountable and stay on top of the care plans of residents. If a facility hires a good MDS nurse, this will impact reimbursement tremendously. 

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Dr. Cameron Zargar