The new PPDM (Patient Driven Payment Model) was implemented in October 2019. As the COVID-19 pandemic hit the United States in March 2020, skilled nursing operators were relieved to have this new payment model. Operators claimed that the new model helped them survive the unprecedented crisis. Now as skilled nursing facilities are able to manage the crisis more effectively, it is expected that CMS (Centers for Medicare and Medicaid Services) will start auditing with scrutiny.
There are five categories that providers receive reimbursement for under PDPM. These categories are physical therapy, occupational therapy, speech language pathology, non-therapy ancillary (NTA) and skilled nursing. CMS will resume audits and it is necessary for skilled nursing facilities to have the appropriate documentation and records for services provided in these categories.
One possible target area could be physical and occupational therapy provided to patients of non-orthopedic surgery or those who fall under the acute neurologic subcomponent. Skilled nursing facilities should have clear records for patients that are recorded under the acute neurologic primary diagnosis code, impaired cognition, and speech related comorbidities. There should be clear policies and procedures listed on how Brief Interview for Mental Status (BIMS) assessments are conducted. An area of concern for operators could be if they have a high percentage of impaired cognition capture for staff assessments versus resident interviews. Another target area for the PDPM audit for the PT/OT component could be the primary diagnosis code. According to Sciacca, good documentation for this should include why the diagnosis was the primary reason for skilled nursing care. The documentation should also include why the patient receiving Medicare needs to stay in the skilled nursing facility. The reasoning should be recorded in details by the physicians and the interdisciplinary team. Documentation should include what the patient is being cared for and which treatments they are receiving and for what purpose.
The end goal is to assess where skilled nursing providers stand for compliance risk. This is achieved through the SALT tool. A facility would be considered an outlier if they fall above the 80th percentile or below the 20th percentile.
CMS has not yet commented on the documentations they will be auditing. However, it is highly recommended that skilled nursing providers prepare for these audits and have the proper documentation ready.