The industry agrees: With the roll out of such a complex new system like PDPM…there are several risks and so much at stake. As such, here’s a question worth asking:
Does your facility have a proactive PDPM compliance, or verification process in place? If yes…good by you! But even a solid, well-functioning version of today’s process MUST be retooled in preparation for PDPM & Beyond!
MDS, coders, and billing specialists are laying awake at night worrying – with good reason – about the fiscal and compliance risks associated with the many, many details baked in to the new PDPM system. The implications of sub-optimal sequencing of ICD-10 codes or mistakenly using a return to provider (RTP) code will have weighty consequences. Coding and calculating rates under PDPM will be like learning a new language, as even HCPCS codes will be 10 digits instead of three digits. Facilities that don’t get the hang of it will be at risk for RAC and ZPIC audits, cash flow issues, as well as even suffer from the long-term impact of poor, publicly-reported data by CMS that effects QM and VBP performance metrics.
Yes, the IDT is under pressure, but standards for high expectations to code thoroughly, timely, accurately and with consistency (i.e.: Section X Modifications should = ZERO!) is a must. And that’s where the new PDPM compliance process comes in.
By the way, if you answered “No” to the question: “Does your facility have a proactive compliance process in place?” then please realize: Many SNFs that once considered it satisfactory to only have a retrospective process will soon learn than it will be as important as shelter, water, and food under PDPM. In other words, SNFs can’t live without it under PDPM and beyond!
Consider that your process today is a “look back” to reconcile RUGs scores. Under PDPM, HealthPRO® Heritage recommends that a much more proactive strategy will be required.
The foundation of the new compliance process starts with empowering the IDT (especially Nursing!) with documentation (re)training to reinforce how important it is to capture clinical care early and often in a resident's stay. The focus must be on documentation practices that align to what will drive successful coding practices.
To keep it simple and to the point: SNFs’ new compliance process should include:
- Regular review of residents’ status and changes
- Regular review of supportive documentation and related coding
- Pre-transmission reviews of MDS and bills
- Post-billing reconciliation
Warning! There are no short cuts here. But IDTs can make the necessary changes easier by investing time and resources NOW to facilitate this shift in culture, processes, and expectations.
Don’t wait until month’s end for the final traditional triple check meeting. SNFs that invest the time and resources TODAY to build an internal self-auditing system to regularly include MDS compliance checks into existing meetings (or create new meetings) can take comfort in knowing they will be CMS compliant and receive optimal reimbursement.
Tools You Can Use
FYI: HealthPRO® Heritage is rolling out The New Clinical Meeting – a redesigned IDT meeting to support compliance processes. Additionally, HealthPRO® Heritage will utilize a proprietary tool to make this process seamless. The PDPM Profiler will – among other important functions – guide necessary workflow processes and track/optimize coding & outcomes. .
HealthPRO® Heritage Supports PDPM Compliance Process ReDesign for Oct 1 & Beyond!
As PDPM and therapy experts, HealthPRO® Heritage helps our current SNF clients to execute on revamping proactive compliance processes. Consider the value of a therapy provider with extensive reimbursement and clinical strategy expertise. Inquiries: firstname.lastname@example.org.