How well did you identify, document, and report conditions and services under RUG-IV?

With all the changes the Patient-Driven Payment Model (PDPM) brought in October, it was comforting to think that, at least, determinations for the Nursing Case-Mix Group (CMG) weren’t going to be that different from RUG-IV. This may have given some providers a false sense of security in terms of the nursing portion of the per diem. While it is true that the nursing component conditions and services are the same as before, you may want to ask, “how well were we identifying, documenting, and reporting these conditions and services under RUG-IV?” and you may find yourself answering “not that well.”

Now that the nursing case-mix group is a distinct part of the per diem rate, and not eclipsed by the “therapy RUG”, SNFs must refocus efforts on early assessment for and identification of conditions and services.

Under PDPM, the resident’s nursing case-mix group still uses a hierarchical classification of the following groups: Extensive Services, Special Care High, Special Care Low, Clinically Complex, Behavioral Symptoms and Cognitive Performance, and Reduced Physical Function. In the hierarchical approach, the assigned classification is the first group for which the resident qualifies.

If upon review you find your clients predominately fall into the Reduced Physical Function or Behavioral Symptoms and Cognitive Performance groups, you may be missing the mark in the nursing case-mix group.

  • Consider how accurate ICD-10-CM coding and assessment of Section GG usual performance is for newly admitted residents. As long as considered active per RAI Section I coding guidelines, certain diagnoses alone or with a Nursing Function Score (NFS) of 11 or less will qualify the resident for a higher CMG.
    *This list is not all-inclusive
  • Another important area of opportunity is early monitoring and accurate assessment of medically complex conditions. As seen in the table below, certain symptoms associated with specific conditions can qualify the resident for a nursing CMG of Special Care High. Consider facility practices for assessment of symptoms and how your documentation will support things like “shortness of breath when lying flat”; a specific symptom often overlooked (or under-documented) in conjunction with COPD.
    *This list is not all-inclusive
  • Similar thorough assessment processes should be applied to the early detection and identification of skin/wound issues. Understanding wound characteristics, appropriate staging, and seeking clarification when needed will assist in the determination of wound etiology and result in more appropriate resident care and accurate MDS coding.
    *This list is not all-inclusive
  • Additionally, consider the potential impact of the Restorative or Depression “end-splits”. Restorative Nursing Programs, when Medicare and RAI guidelines are met, will result in a slightly higher CMI for residents who qualify for one of the lower groups of Reduced Physical Function or Behavioral Symptoms and Cognitive Performance. Conversely, residents who qualify for one of the higher groups of Clinically Complex, Special Care Low, or Special Care High will receive a slightly higher CMI if indicators of depression are present as identified through the PHQ-9 or PHQ-9 OV.
  • Finally, don’t feel obligated to schedule every Initial Medicare (5-day) Assessment for day 8 of the stay. While in most cases this may still be prudent, we are no longer reliant on 5 days of therapy having to have been provided prior to the ARD. Given this flexibility, NACs should review hospital documentation as part of the ARD selection process for the opportunity to report certain conditions or services that fall within the assessment look-back period. For example, Parenteral/IV feedings administered for nutrition or hydration. Proactive has a PDPM Quick Reference Toolkit that contains tools and resources including a Nursing Case-Mix Group Classification and Nursing Case-Mix At-A-Glance Grouper Tool to help you navigate the intricacies of the Nursing Component. Contact us today for a PDPM focused MDS review to make sure you’re not missing the mark!

Proactive has a PDPM Quick Reference Toolkit that contains tools and resources including a Nursing Case-Mix Group Classification and Nursing Case-Mix At-A-Glance Grouper Tool to help you navigate the intricacies of the Nursing Component. Contact us today for a PDPM focused MDS review to make sure you’re not missing the mark!

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Blog by Eleisha Wilkes, RN, RAC-CT, RAC-CTA, Clinical Consultant, Proactive Medical Review

Click here to learn more about Eleisha and the rest of the Proactive team.