By Lisa A. Eramo, MA

It isn’t always easy to say goodbye, and for skilled nursing facilities (SNFs), parting with therapy minutes as the primary driver of payment has been easier for some facilities than others. Prior to October 1, 2019, SNFs received a per-diem payment rate along with additional reimbursement based on the number of therapy minutes and/or nursing services provided to each patient. However, under the new patient-driven payment model (PDPM), ICD-10-CM diagnosis codes take center stage, driving everything from admission to care planning to payment. This radical departure from how SNFs were paid previously is why many owners and operators are starting to lean on health information management (HIM) professionals for guidance.

SNFs are starting to realize that individuals assigning diagnosis codes must understand coding rules and regulations—particularly with a system as nuanced as ICD-10-CM, says Judy Wilhide Brandt, RN, BA, CPC, QCP, RAC-MT, DNS-CT, principal at Wilhide Consulting, which provides minimum data set (MDS) and prospective payment system (PPS) reimbursement consulting services to SNFs nationwide. The MDS is a comprehensive summary of each patient’s mental and physical issues. It also drives a diagnostic category similar to a diagnosis-related group that, in turn, drives a lump sum payment for all of the care the patient receives.

“We still have facilities that aren’t using an ICD-10 coding book because they use Google instead,” says Brandt. “There’s no nefarious intent, but I am really worried. I hope that our industry doesn’t wait until a facility has a huge takeback to start getting serious about documentation compliance.”

Medicare administrative contractor Novitas Solutions, Inc., for example, has already implemented prepay “targeted probe and educate” reviews for December 2019 claims, says Brandt. “It is extraordinary to be asking so soon,” she adds. Novitas is specifically requesting physician orders, progress notes, nurses’ notes, therapy notes, medication and treatment records, hospital transfer sheets, history and physical, discharge summary, surgical reports, and more.

PDPM Status Update

Now that SNFs have several months of the PDPM under their belts, we’ve asked experts to weigh in on how it’s been going during the transition to this new case-mix classification model that affects all SNF patients in a covered Part A stay.

Overall, SNFs are embracing the PDPM because it promotes more effective patient care, says Mike Cheek, senior vice president of reimbursement policy and legal affairs at the American Health Care Association (AHCA), an organization that represents more than 10,000 non-profit and for-profit assisted living centers, nursing facilities, facilities caring for developmentally disabled individuals, and subacute care providers.

“PDPM is patient-driven for a reason,” he says. “Clinical information allows the MDS nurses to drill down into each patient’s needs and better tailor a plan of care to a person’s unique clinical characteristics.”

Lacey Schnurpel, HFA, SNF administrator at Chase Center Rehabilitation and Nursing Services in Logansport, IN, agrees. “Since we have started PDPM, we are coming together as a team to develop a plan of care that is best for the resident,” she says. “I would say this is the biggest achievement of PDPM.”

SNFs that provided comprehensive training prior to the PDPM go-live are faring well so far with some even seeing as much as 10 percent more revenue than the same time last year, says Brandt. Others are starting to see signs of potential problems, though it may be too soon to identity the full financial impact, she adds.

“For us, the transition went better than expected; however, it’s difficult to capture specificity,” says Kelly Cooper, RHIA, CCS, health information corporate compliance officer at Solaris HealthCare that includes 15 SNFs and four assisted-living facilities throughout Florida. “We’re still tightening things up to make sure we’re getting credit for everything we do.”

Experts agree that the shift toward bundled payments has made this delicate balancing act more difficult. Uncomplicated patients frequently go home and receive home health services after discharge from an acute care hospital while only the most medically complex patients are admitted to a SNF. Without a thorough understanding of documentation and coding requirements under the PDPM, SNFs could quickly lose revenue.

Cheek agrees that capturing specificity will likely remain a challenge as facilities adapt to the PDPM. “I think most organizations understand how critical it is to provide PDPM training, but I think we have a ways to go in terms of skilled nursing facilities grasping the level of ICD-10 coding expertise at the level they need it,” he adds.

AHCA and AHIMA co-developed PDPM training to help SNFs prepare for the transition. Options include a 16-hour training for individuals who assign codes to SNF claims and/or the MDS assessment, as well as a four-hour training for those who need a more basic understanding of medical coding (e.g., administrators, directors of nursing, and regional managers for large multi-state companies).

Cheek says both trainings have been helpful in preparing SNFs for the PDPM but that facilities need to provide ongoing training to be successful. Those who have already attended the 16-hour training, for example, can take a two-hour refresher course annually that includes updates to the Centers for Medicare and Medicaid Services (CMS) case-mix group (CMG) mappings and other important information.

In addition to ramping up training efforts, SNFs are also starting to express an interest in hiring credentialed coders. However, there isn’t a coding credential specific to the SNF setting, making it difficult to find someone with the right expertise, says Nancy Bensen, RHIA, CHPS, RAC-CT, co-owner of Med-Rec Systems, a SNF consulting company in Indianapolis, IN.

At Solaris Healthcare, Cooper oversees a team of 36 HIM professionals, only one of whom has an RHIT credential. She’s encouraging other staff members to obtain the RHIT credential because it provides a solid HIM foundation; however, it’s not currently a requirement.

Overcoming Barriers to CDI

Given the newness of PDPM and the slim operating margins in many SNFs, experts agree that formalized clinical documentation integrity (CDI) programs may not be a reality in the immediate future. However, that shouldn’t stop facilities from laying the foundation, and HIM professionals can help lead the charge, says Cooper.

Marsha Bullock, RHIT, medical records specialist at Chase Center Rehabilitation and Nursing Services, for example, recently implemented a query process at her facility. More specifically, she faxes queries to physicians or asks them questions when they’re onsite. Her most common queries relate to cognitive ability. For example, she frequently asks physicians to clarify whether a resident has dementia (and if so, what kind) or Alzheimer’s disease. She also queries for morbid obesity and a variety of other comorbidities that can affect payment under the PDPM. Bullock, who was hired a year ago, says her formal HIM education has helped her identify potential coding errors.

Bullock says introducing queries was relatively easy because physicians are already accustomed to receiving them in the hospital. “Our experience has been that they don’t even ask what the query is. They just answer the questions and give it back to us,” she adds.

As the only credentialed HIM professional in the facility, Bullock also oversees documentation audits and requests hospital documentation (e.g., operative reports, discharge summaries, and labs) to support accurate code assignment. Each hospital is different in terms of what it requires for release of information (ROI), which is why she strives to build personal relationships with HIM staff at each facility. Sometimes she can call the hospital’s HIM department directly, and sometimes she sends a fax and must wait seven to 10 business days for a response before following up with her request.

Hospitals may also use a third-party ROI vendor, says Cooper, who tries to build relationships with these entities as well.

Moving Forward

CDI is uncharted territory for many SNFs, so creating a formalized program can seem daunting. However, with the PDPM, CDI programs will become increasingly important to ensure accurate reimbursement. “We absolutely need to establish a paper trail of compliant physician queries, and we need continuous documentation improvement to support compliant ICD-10 coding,” says Brandt.

The PDPM brings a whole host of opportunities for HIM professionals to lend their knowledge and expertise, says Cooper. “I think we are at a turning point in the skilled nursing industry,” she adds. “Facilities really should have someone with an RHIT or RHIA credential supporting the MDS nurses and providing guidance to them. This is a key time for HIM to come to the table.”

Experts provide the following advice for HIM professionals hoping to get involved with SNF CDI:

1. Obtain MDS nurse buy-in. Ensure nurses understand that coders are there to help them apply the coding guidelines and ensure compliance—not take their jobs away, says Cooper. “HIM professionals can provide additional expertise and can be someone the MDS nurses can lean on,” she adds.

2. Foster interdisciplinary communication. For example, at Solaris HealthCare, HIM professionals embedded within each SNF are part of a daily PDPM huddle to discuss code assignment on the MDS before finalizing it.

Therapists and nurses must agree on functional scores and the ICD-10 codes that drive them, says Cheek. “Coding isn’t sufficient. You need to have really well-integrated clinical communication with physicians, nurses, and therapists. The coding needs to happen as part of the dialogue with the assessment team,” he adds.

Cooper agrees. SNFs need to encourage dialogue regarding documentation discrepancies between nurses and therapists. What diagnosis codes were ultimately included on the MDS, and does all documentation support those codes?

3. Identify a champion. Look for a physician who embraces the PDPM and who can help spread the message about the importance of documentation specificity, says Cooper.

4. Prioritize efforts. The following are five high-ROI focus areas:

  • Primary diagnosis code for skilled care. This is the condition responsible for the resident’s admission to the facility—which may or may not be the same as the hospital principal diagnosis, says Bensen. She provides this example: A patient with Type 2 diabetes is admitted to the hospital with pneumonia. Although the patient’s pneumonia resolves with antibiotics, they subsequently develop a foot ulcer that requires skilled care. The diabetic foot ulcer therefore is the primary diagnosis for admission to the SNF.
  • Comorbidities. There are numerous diagnoses and comorbid conditions that affect payment under the PDPM. For example, there are 12 speech language pathology comorbidities that may drive higher payments because they are predictive of higher SLP costs: aphasia; CVA, TIA, or stroke; hemiplegia or hemiparesis; traumatic brain injury; tracheostomy (while resident); ventilator (while resident); laryngeal cancer; apraxia; dysphagia; ALS; oral cancers; and speech and language deficits. Likewise, there are 50 conditions related to increases in non-therapy ancillary (NTA) costs in the SNF that may drive higher payments. Diagnoses with the highest associated costs are HIV/AIDS, parental IV feeding (levels high and low), IV medication post-admit, ventilator or respirator post-admit, and lung transplant status.
  • Recent major procedures. Major procedures during the prior inpatient stay that impact the SNF care plan can make a big difference in terms of reimbursement, says Cooper. She provides this example: A patient with a fracture ultimately had a joint replacement before being admitted to the SNF post-discharge. If the SNF doesn’t receive the operative report and discharge summary, the skilled stay would move out of the major joint replacement CMG and into the nonsurgical orthopedic CMG.
  • Unspecified codes. Bensen suggests starting with long-term care residents. Address unspecified codes for these patients before moving to SNF residents. “Skilled patients may only be there another week,” she says. “Long-term care residents may fall and have an injury, be admitted to a hospital, and come back skilled. The documentation should be ready to go and as specified as possible.”
  • Upcoding. Some software systems auto-populate diagnoses in the MDS, potentially resulting in higher-than-warranted functional and cognitive scores that translate to higher payments, says Bensen. SNFs should address this with their vendor to prevent auto-population and provide education to MDS nurses and coders about the importance of clinical documentation that supports code assignment, she adds.

Brandt agrees. “There may be honest people who are just absolutely unknowingly noncompliant and taking money that doesn’t belong to them,” she adds.



Therapy is the dominant discipline Fosters a multi-disciplinary approach
Two case-mix adjusted payment components and two non-case mix adjusted components are used to derive payment Six payment components (five of which are case-mix adjusted) are used to derive payment
Patients are assigned to resource utilization groups (RUG) Patients are assigned to CMGs
Five scheduled PPS assessments One scheduled PPS assessment
Constant rates for length of stay Variable per diem rate over the course of the stay



Lisa Eramo ( is a freelance writer and editor in Cranston, RI, who specializes in healthcare regulatory topics, health information management, and medical coding.

Continuing Education Quiz

Review quiz questions and take the quiz based on this article, available online.

  • Quiz ID: Q2019104
  • Expiration Date: April 1, 2021
  • HIM Domain Area: Clinical Data Management