For the past three years, the Patient-Driven Payment Model (PDPM) has determined Medicare Part A reimbursement. Implemented October 1, 2019, providers have learned to manage the updated PDPM reimbursement system.
While many providers have successfully navigated the changes, several factors can potentially derail progress and negatively impact PDPM reimbursement. Staff turnover, new or inexperienced Minimum Data Set (MDS) staff, and changes to MDS coding rules are among the many reasons PDPM reimbursement may not accurately reflect the care and services provided to a resident.
We recommend that providers routinely review each of the four case mix group (CMG) Health Insurance Prospective Payment System (HIPPS) payment code items for accuracy to receive proper reimbursement. During such reviews, providers often identify items miscoded or missed on the MDS assessments.
Analysis of HIPPS component distribution for function scores and the distribution ratios of each of the four CMGs often give clues pointing to potential opportunities for training to help improve accuracy of the MDS coding. For example:
- Function Scores impact both the physical therapy/occupational therapy (PT/OT) and nursing components. Reviewing the function score distribution breakdowns can point to an accurate representation of the provider’s residents or identify areas of possible improvement.
- PT/OT Component distribution analysis may indicate a need to review ICD-10 diagnosis coding and verification of accurate coding of surgical procedures.
- SLP, Nursing, & Non-Therapy Ancillary Components distribution analysis may indicate a need to review ICD-10 diagnosis coding and verification of accurate and complete coding of clinical services.
Scheduling alternate PPS assessment reference dates and completion of the optional Interim Payment Assessment also can have a significant positive impact on reimbursement. Early identification of inaccurate coding and missed scheduling opportunities can help providers get back on track to accurate and appropriate Medicare Part A reimbursement.
If you have any questions or need assistance, please reach out to a professional at Forvis Mazars.