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How does Patient-Driven Payment Model (PDPM) affect nurse practitioners, physician assistants, and doctors in Nursing homes


PDPM in nursing home

How does Patient-Driven Payment Model (PDPM) affect nurse practitioners, physician assistants, and doctors in Nursing homes? With the payment models changing in nursing homes, the main question from medical providers in nursing homes is, “How does this affect me?”

The truth is that there isn’t a significant impact on medical providers. Doctors, APRNs, and PAs, are already doing most of the things that are needed to help the facilities meet their goals. 

Medical providers are needed to order skilled nursing services for illnesses or conditions that required a hospital stay requiring follow-up skilled nursing care.

The doctors, advanced nurse practitioners, and physician assistants continue providing the same great medical care to the residents of the facilities. 

They now need to improve their ICD 10 coding abilities and properly document the diagnosis codes for the patient. 

The provider will need to identify any missed ICD 10s upon admittance to the facility. Chart reviews will require more time spent on the evaluation of paperwork from the hospital. 

The history of present illness may be more time-consuming as you comb through the discharge summary and W10 to capture data points needed for the diagnosis codes.   

It’s not known if the new payment model will mean less or more revenue for the medical providers. The increased time spent on documentation could be offset by the increased reimbursement from higher acuity patients, including higher complexity visits.

As a provider in the nursing home, you shouldn’t look at PDPM as a “facility issue.” PDPM is a team issue that includes providers, nursing, and physical therapy. Therefore, you will need to improve communication among members of the team and families.

Physical Therapy

PDPM is having a significant impact on nursing homes in the United States. The shift away from physical therapy as the primary driver of revenue has affected many people in this industry. 

Many physical therapy companies are laying off staff or cutting back on hours for their employees. They are also shifting how they will provide care and the number of hours for patients. 

Nursing Homes

PDPM is focusing on the patient rather than the volume of services provided to the patient. Nursing homes will start to receive improved reimbursements for patients with more medical problems and higher complexity.

Predictions are that nursing homes are going to be taking on sicker and higher acuity patients due to the potential for higher reimbursement. Doctors, APRNs, and PAs, are going to be needed to care for these ill residents.

What happens when the nursing documentation doesn’t justify the level of acuity? 

We have all heard the phrase, “if it isn’t documented, it isn’t done.” This saying will have a direct impact on reimbursement for nursing homes. 

The nurses in the facilities are pressed for time to properly document the information needed for MDS. There is a shortage of nurses in many parts of the country, making it even more challenging to get the nurses to document at a higher level of detail as required. If they spend more time on documentation, that means less time providing direct patient care. 

Due to the nurses, not potentially documenting enough for reporting, the facilities are going to rely on the provider’s notes more than ever before. The facilities need documentation to back up the level of care provided to patients in the nursing home.

Providers can help nurses by providing coaching on proper documentation. Many times it is just clarifying the importance of what needs documentation. 

Some nursing staff feels they either have to document long notes or nothing at all. When in reality, a short note on what is occurring can meet the need of the facility.

The benefit to the provider for helping facility with PDPM success

Unfortunately, with the new PDPM model, there isn’t any extra money or reimbursements involved in helping the facilities succeed with the new payment model. 

The new model does not affect the reimbursement for CPT codes other than increasing the potential level of complexity.

Your chances of doing better in the nursing home are directly related to the success of the nursing home. If the nursing home is fully occupied, you will have more patients on your nursing home panel. Increased panel size may potentially result in more patients needing medical evaluations.

By helping the facilities, you help solidify your role as a team player. They need your help to provide the required diagnosis codes and proper documentation ethically.

With the new PDPM model, the doctor and the nurse practitioners have become a more integral part of the team and not just a third party coming in to see the residents. 

What are some of the things you can do as a provider to help the staff and facility succeed with PDPM?

Helping out the nursing home in their PDPM journey often starts with the basics of proper documentations and ICD 10 coding. It is vital that you are coding the ICD 10 to the farthest point while avoiding “unspecified” diagnosis codes.

You will also want to familiarize yourself with ICD 10 codes that “Map” to codes that will provide reimbursement to the nursing homes. 

Sometimes attending basic ICD 10 training can make all the difference in the world. Many classes offer coding and post-acute care nursing home training. 

As a medical provider, ask yourself after completing your note, have you:

  1. Identified and captured all the diagnosis codes in your progress note?
    • Make sure your selected ICD 10 codes don’t lack the specificity required for billing. 
    • Try to avoid any diagnosis with “unspecified.”
    • Be sure to code the ICD level to the highest specificity.
  2. Did you properly document a complete progress note to back up these diagnosis codes?
  3. History of Present Illness (HPI)
  4. Physical Exam (PI)
  5. Review of Systems (ROS)
  6. Assessment and plan (A&P) to back up these diagnosis codes? 
  7. Lastly, did you develop a level of care via your assessment and plan?

Acuity of Patient

It will be essential to the skilled nursing facility to make sure the providers document the acuity and severity of the patient.  

Capturing acuity is done by recording the diagnoses and providing a good history on the patient. 

Documenting the acuity of the patient:

  • The medical providers will need to capture the conditions and all their comorbidities in a timely fashion.
  • Request thorough discharge information from the hospital when not available. Providers will need the W10 and discharge summary information to obtain the diagnosis list for the patient.
  • Utilize the discharge summary to provide surgery information, which may help provide a patient medical history, which is required by the facility.

Providers will be tasked with documenting a complete history, physical exam, including all the medical issues your patient may be experiencing upon arrival to the nursing home. 

The timing of your medical assessments will also play a role. The patients will need to be evaluated upon arrival to the facility as soon as possible. 

Timeliness of visits will help the facility obtain the required documentation to support the admitting diagnoses. 

Make sure to document BMI on all overweight patients. If there BMI is higher than 40, it will have a positive effect on the revenue of the facility. 

The facilities will have to make sure they are documenting the heights on the residents and the weight upon arrival.

Proper documentation for PDPM

There will be diagnosis codes that will have more impact on the reimbursements for the nursing homes. Therefore, the providers will need to make sure their documentation captures these ICD 10 codes.

Principal diagnosis to include in Diagnosis list:

  1. HIV
  2. Liver disease
  3. Diabetes with complications
  4. Surgical conditions
  5. Orthopedic conditions
  6. Prosthetic devices
  7. Major cardiac arrhythmias
  8. Major pulmonary illnesses
  9. Epilepsy/Seizures
  10. Obesity
  11. Document on all infections the patient may have, including chronic infections.
  12. Psychiatric Diagnoses

Capture the comorbidities when possible. Document swallowing problems, speech and language deficits, cognitive impairment, and mood changes.

With the PDPM model, you can include the surgery diagnosis if it occurred within 100 days before nursing home arrival. Even though this diagnosis may not be one you usually include, you should include it for the facility documentation.

 Of course, the list of diagnoses that can map to billable PDPM categories is much longer than discussed and will help give a starting point in ICD 10 identification.

Capture complex medical interventions:

  1. Chemotherapy/radiation
  2. Ventilator/respirator
  3. IV meds/hydration
  4. TPN
  5. Tube feeding
  6. Anticoagulants
  7. Insulins
  8. Burn care

PDPM Clinical Categories

  • Major Joint Replacement or Spinal Surgery
  • Non-Surgical Orthopedic/Musculoskeletal
  • Orthopedic Surgery
  • Acute Infections
  • Medical Management
  • Cancer
  • Pulmonary
  • Cardiovascular and Coagulation
  • Acute Neurologic
  • Non-Orthopedic Surgery

Some facilities will supply the medical providers with a “cheat sheet” or chart to assist them in picking ICD 10 codes that the facilities can use to bill for their patients. You can utilize this basic list of ICD 10 codes to assist you in the documentation of ICD 10 for the patient.

 Conclusion

When you look at PDPM as a provider, you will most likely nod your head and move on. However, if you can take on the role of PDPM expert, you will be appreciated by the facility more than you know.

The MDS nurses will come to you will issues and concerns affecting the patient which will require follow-up visits. You will learn how to properly document and capture diagnosis codes that will hopefully increase the level of the visit though increase complexity.

References

Background & Finalized Changes to the Skilled Nursing Facility (SNF) Prospective Payment System (PPS). Patient-Driven Payment Model. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/PDPM-101_Final.pdf Retrieved October 14, 2019

Jennifer Gross, BSN, RN-BC, RAC-CT, CPHIMS, Is Your Documentation PDPM-Ready? https://pointright.com/is-your-documentation-pdpm-ready/ Retrieved October 12, 2019

McKnight’s Long-Term Care News. PDPM will reduce clinical requirements but demands more attention to detail. https://www.mcknights.com/print-news/pdpm-will-reduce-clinical-requirements-but-demands-more-attention-to-detail/ Retrieved October 4, 2019

Medicare Program; Prospective Payment System and …. https://regulations.vlex.com/vid/medicare-program-prospective-payment-716195001

sjeske001

I am a Family Nurse Practitioner working in the post acute setting which includes Nursing homes, Assisted living facilities. I have worked for two other companies that provided APRNs to the nursing homes and now run a company providing APRNs in this setting. I have experience with clinical, operations, and general nursing home topics. This blog is a hobby that I use to relax after a long day working in the post acute world.

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