Harmony Healthcare Blog

Top 10 Things To Know About Triple Check PDPM Style

Posted by Pam Duchene on Tue, Aug 20, 2019

Edited by Kris Mastrangelo


Compliance • Audits/Analysis • Reimbursement/Regulatory/Rehab • Education/Efficiency

Business man pointing to transparent board with text Where do I Start?The triple check process is a long-standing system used at Skilled Nursing Facilities (SNFs) across the country to ensure compliance in Medicare billing.   Specifically, to assure that the RUG Level accurately billed for therapy minutes and that everything matches between the UB-04, the MDS and therapy logs.

The burning questions on everyone’s mind include: 

  • Will this process be needed October 1, 2019?
  • If therapy minutes matter less, and do not affect the HIPPS code, should the process change?

Yes, is the answer to both questions!

CMS is quite clear with their expectation that the way in which services are provided should not change with PDPM.  That is, patients who need rehabilitation should still receive therapy, and therapy minutes will continue to be coded on the MDS in Section O.  The minutes will not affect payment or the HIPPS billing code, yet they will continue to have a positive impact on patient outcomes and length of stay.  It is still critical that the MDS Section O therapy minutes match the therapy logs, although there is no financial impact for the intensity of minutes. 

  • If not minutes, what should the triple check include with PDPM, and when and how frequently should the PDPM triple check take place?

Following are the PDPM Top Ten Areas to review within 48 of admission:

  1. Baseline Care Plan: Review the key components of the baseline care plan that will be discussed with the patient and his or her representatives.  The baseline care plan should include the patient’s goals for the stay.
    One suggestion is to use the 48-hour interdisciplinary review and baseline care plan as the initial PDPM triple check.  Key members of the team should be the MDS Nurse Assessment Coordinator, the Billing Office Representative, and a Therapy Leader. 
  1. ICD-10 Coding for the Primary Reason for Admission: The ICD-10 code should be checked against the PDPM ICD-10 Mappings provided by CMS.  Since this document may change from time to time, it is essential that it be reviewed.
  2. Review of the Hospital History and Physician and Discharge Summary: The MDS Nurse Assessment Coordinator and Admission Liaison have likely reviewed these documents prior to admission.  They are a rich source for understanding the needs of the patients and for accurate coding in PDPM.

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  1. Swallowing and Dietary Needs: Accurate coding of swallowing concerns in Section K of the MDS and any risk for malnutrition or a modified diet should be identified very early in the patient’s stay.  Involving the CNAs in review of swallowing assessments will lead to a more comprehensive and accurate review of the patient’s needs. 
  1. Brief Interview of Mental Status (BIMS): According to the RAI User’s Manual, the BIMS interview should be done the day prior to or day of the Assessment Reference Date.  However, if the BIMS is not complete, no HIPPS code will be provided and no bill will be generated.  One strategy to prevent a miss in this area is to do a preliminary BIMS on admission and complete the official BIMS as expected with the ARD. 
  1. Restorative Nursing Needs: In order to capture Restorative Nursing as a component of PDPM, the program needs to start on Day 1 of the patient’s stay. Since Restorative Nursing is basically good nursing care with a focus on encouraging the patient to do for themselves what is possible, it make sense to do this Day 1.  Also, although Restorative Nursing has typically followed therapy, it makes more sense for Restorative Nursing and Therapy goals to coexist.  It has long been true, that great nursing care can reinforce the time of therapy repeatedly over the 24 hours of the day.  Restorative Nursing does this and should start without delay.
  1. Respiratory Therapy Needs: Similar to Restorative Nursing, Respiratory therapy should start on Day 1 of the patient’s stay.  Given that pulmonary concerns often contribute to rehospitalization risks, it makes sense that patients who require respiratory therapy, receive it on Day 1.
  1. Section GG (Function Score): How is Section GG being completed?  Who is providing input?  Does the GG section coding match with progress notes and the patient’s status as described in the Hospital discharge summary?  Section GG has a dramatic impact on overall rate of reimbursement.  Accurate assessment is essential! 
  1. Tentative Discharge Plan: What is the patient’s plan for discharge?  Does the patient have a safe place for the next level of care? 
  1. Clinically Anticipated Stay (Expected Length of Stay): How long does the interdisciplinary team expect the patient to require care in order to advance to the next level of care?  While the overall goal for skilled care remains to return to the Prior Level of Function, a focus on the next level of care should be part of the initial 48 hour assessment.

The PDPM Top Ten Areas should assure a solid framework to the patient’s plan of care.  Reviewing the list within the initial 48 hours of a stay enhance accurately coding the MDS and provide a process to safeguard for precise and appropriate HIPPS Coding. 

Most importantly, however, the PDPM Top Ten assures that the plan is patient-centered with a focus on early intervention, patient involvement and an eye toward discharge.

Many thanks for the creative input of Ellen Imperial, Clinical Services Director for the Presbyterian Communities of South Carolina.    

Harmony Healthcare International (HHI) is available to assist with any questions or concerns that you may have.  You can contact us by clicking here.  Looking to train your staff?  Join us in person at one of our our upcoming Competency/Certification Courses.  Click here to see the dates and locations. 

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Tags: PDPM, Triple Check

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