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Client Profile

A multi-facility skilled nursing organization dedicated to serving patients in the Southwest region.

Challenge

Since the implementation of the Patient Driven Payment Model (PDPM) in October of 2019, many skilled nursing organizations have employed a variety of strategies for grading their overall performance against this new reimbursement model. While an important key performance indicator (KPI) of well-oiled organizations is a consistent benchmark of projected revenue, another KPI that’s equally valuable, although often overlooked, is clinical documentation compliance. This specific KPI’ s importance is rooted in PDPM, as the Centers for Medicare & Medicaid Services (CMS) placed an emphasis on accurate and quality clinical documentation in support of active diagnosis being coded in the Minimum Data Set (MDS) and the treatment provided when the model was implemented.

This multi-facility skilled nursing organization faced challenges with clinical documentation compliance that prevented them from meeting their anticipated revenue goals. The organization recognized deficiencies in diagnosis coding and conflicting documentation of activities of daily living for section GG of the MDS. Additionally, the organization’s utilization of their EHR system added another challenge in meeting anticipated revenue, as the system was not being leveraged efficiently to support PDPM claims. Realizing there was opportunity in their quality assurance for improved revenue accuracy, the organization looked to McBee for solutions.

Solution

McBee deployed its expert PDPM clinical team to review the organization’s pre-admission records, interdisciplinary clinical documentation and coding methodology. Through this detailed analysis, McBee evaluated each of the five PDPM component scores and compared the results against the respective discipline’s supportive documentation.

McBee uncovered 15 specific areas for coding and documentation improvement. These findings included either unidentified diagnosis coding or miscoding, such as malnutrition, depression, shortness of breath lying flat and CVA. In addition, opportunities for more detailed coding that would qualify for MDS capture were identified.

The review extended beyond the component scores, additionally assessing the EHR system for optimization of capabilities in supporting PDPM claims. This evaluation included a review of the EHR workflow to identify gaps and target areas that could be leveraged more effectively. This review included ease of record document accessibility within the system, full utilization of user defined assessments (UDA), duplications of records, transferability of data to the MDS and underutilization of an MDS audit tool. McBee identified opportunities for improvement with UDA compliance, as the documentation did not accurately reflect the care that was provided and at times conflicted with narrative notes. With these findings, McBee identified individualized educational needs for each interdisciplinary team member to enhance understanding of PDPM and the supportive clinical documentation required for compliance and capture of relevant coding.

McBee also conducted staff training for the organization to gain competencies in understanding the intricacies of PDPM, how to document diagnosed conditions, as well as the assignment of the appropriate ICD-10 codes with the selection of the correct MDS medical conditions. With McBee’s insight, the organization prioritized working with their EHR provider on enhancing their UDAs, as well as using the MDS audit tool to assist with enhanced capture of clinical documentation.

Results

McBee’s PDPM clinical documentation compliance review, targeted education initiatives, and optimization of their EHR functionality enabled the organization to tackle PDPM process improvements. McBee’s PDPM clinical documentation compliance review identified opportunity for an average of 11% increase in reimbursement, equating to an average of $1031 increase in reimbursement for the duration of the Medicare Part A admission.

McBee’s education initiatives ensured the organization’s clinical staff enhanced their knowledge of PDPM and how it was impacting their organization, helping to achieve compliance with the model and engrain best practices within the organization’s culture for continued success with new CMS regulations. By working with McBee and their EHR vendor, the organization effectively utilized the MDS audit tool to achieve accurate, quality coding and clinical documentation.

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