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The MDS nurse is responsible for PDPM reimbursement from the moment a resident steps into a facility to the day they are discharged. That means that the MDS nurse needs support and information from admissions, CNAs, nurses, physicians, and therapists, among others. In this blog, we will highlight some of things the MDS nurse must ask of other team members in order to best document care in a long term care software system. 

The Importance of Admissions In Getting PDPM Rates Right

It is of utmost importance that your MDS nurse knows how to get the information he or she needs during the admissions process, as the initial daily rate for PDPM rates for a resident could be impacted by a few dollars per day by something as simple as not supplying medications or not getting a bag of fluid. 

After the opportunity is missed upon the initial assessment, there is no longer the opportunity to return to the resident’s profile and document what was missed for the purposes of PDPM reimbursement. Thus, the daily rate determined during the admissions process will remain the same for the first week or two that a resident is first admitted. After this initial period, reimbursement is based on services provided, which is dictated by charting of ADLs, therapy, and modalities conducted by CNAs.

PDPM rates can be conveniently calculated in long term care software on the condition the MDS nurse receives the necessary information.

The initial assessment also sets the stage for the resident’s care and reflects on the care provided. A facility will want to show upward progress with the goal of the resident being discharged home or making progress and requiring less therapy. Meanwhile, the facility will not want the resident to appear to have become more complex or suffer a rapid decline. Thus, it is important that a complete picture of the resident is painted from the very start. 

It is, therefore, important that nurses and admissions must work in tandem to get the information needed to provide an accurate profile for new residents and document it in your long term care EHR or long term care software system. The MDS nurse will look to pick apart a newly-admitted resident’s medical history. To do so, the admissions coordinator must supply the MDS nurse with the information necessary to provide an accurate profile of each new resident. The MDS nurse will then review the admission information forwarded to the facility from the hospital, including the most recent documentation, as well as the results of testing and search for areas tied to reimbursement and comorbidities that result in a higher daily rate. 

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How Nurses Impact Medicare Skilled Nursing Facility Reimbursement Rates

In order to fill out their reports, your MDS nurse must ask nurses hundreds of questions about documentation in order to paint the most complete and complex picture of the resident possible in your long term care software system so as to maximize Medicare skilled nursing facility reimbursement rates. 

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PDPM rates must be justified and backed by documentation.

Many items documented in a nursing home software system for the purpose of PDPM reimbursement will be related to ADLs. For instance, how much help did a particular resident need getting out of bed over the last seven days? If a CNA did not have sufficient time to chart something, it will not get documented unless the administrator is informed of the issue. Once that day passes, the opportunity to capture something for reimbursement passes. This is because, if changes are repeatedly made after the fact, the government will get suspicious of what is filed as part of PDPM Medicare reimbursement. 

While the MDS nurse wants to maximize reimbursement, he or she does not want to include treatment codes that cannot be justified according to PDPM rates. The Centers for Medicare and Medicaid Services (CMS) closely monitors documentation and will look for inconsistencies during audits. So it is important to know how to use a PDPM rate calculator or similar tool. 

Some insurance companies, like Humana, also have teams of people who meticulously evaluate documentation in order to reduce a facility’s daily rate. In most cases, Humana will ask that the daily rate be adjusted. When nurses are not able to provide sufficient evidence, the facility will end up getting paid less. 

Getting Physicians to Do Their Part for PDPM Reimbursement

If physicians are complacent about care,  it will throw a wrench into the entire PDPM reimbursement system; if they are not properly documenting what they do, it will destroy the PDPM rate. They may say something was resolved when that is not actually the case. Or they may not be providing the diagnoses needed. Therefore, MDS nurses must also ask questions of physicians. Are they fully documenting history and physical examinations (H&P) and diagnoses? If so, are they updating diagnoses? 

pdpm reimbursement requires the support of physicians.
Medicare skilled nursing facility reimbursement means getting the diagnoses you need from physicians.

At times, MDS nurses will need to get a diagnosis from physicians, who spend far less time with residents than do nurses; while physicians may only see a resident once every 30 or 60 days, nurses will see that resident every day. 

An MDS nurse must know that physicians are generally open to suggestions about diagnoses. This is not just because they do not spend as much time with residents as CNAs and nurses but also because they are part of the larger picture, and they know that failing to help with PDPM will drive down admissions and rates. 

Therefore, nurses can approach a physician and point out that a particular resident seems to meet the criteria for a particular diagnosis that will affect the PDPM score. Upon being urged to observe eating habits or lifestyle limitations, a physician may decide to treat with medication or suggest a lifestyle change that can impact the PDPM score. 

Example: The MDS nurse might tell the physician that a particular resident has painful bowels or has complained of diarrhea. The physician then must decide whether the resident has IBS or digestive pulmonary disease, a condition that affects the PDPM score. 

The MDS nurse has a golden opportunity to approach physicians about potential diagnoses when the former requests the signature of the latter in a book of certification that justifies care. As the MDS nurse speaks with the physician about this matter, he or she can also briefly mention why the resident is being provided with a certain form of care. The MDS nurse can then say that the resident’s health is declining and request that the physician reevaluate him or her perhaps for the purpose of increasing their complexity. 

During a routine visit, a physician can be informed as to the issues that nurses have observed over the course of weeks or months, tendencies that are not documented but require the expert opinion of a physician. For instance, perhaps the resident is not eating as well, not chewing sufficiently, or pocketing their food. 

By simply leaving a sticky note in the physician’s review book, the MDS nurse can encourage the physician to take a look at the resident from the doorway, observe the resident consuming a meal, or draw labs. The outcome might be that the resident is malnourished, has a cognitive decline, or simply that they need a protein diet or supplement to gain back weight. Regardless of the treatment necessary, it must be documented for reimbursement purposes. 

The final step is to improve outcomes on account of these diagnoses and the PDPM reimbursement that follows. Doing so will help drive reimbursement rates for the facility in the future.

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