In today’s healthcare environment, achieving positive outcomes while maintaining revenue and managing costs is key to success. Beginning October 1, 2019 CMS will be replacing the current SNF PPS Resource Utilization Group (RUGs) payment model with a new per-diem payment model named the Patient-Driven Payment Model (PDPM). No longer will revenue be based on managing therapy minutes. Rather, PDPM will set reimbursement based on resident clinical profiles captured within various coding and assessment scoring factors from the interdisciplinary team. Since SNF’s will be getting paid based on the conditions of the residents in their care, there will be a specific focus on documentation and coding.
As part of the IDT, dietitians and dietary managers can play a critical role in helping achieve maximum reimbursement from CMS. While no new items will appear in Section K of the MDS, existing items will be getting a lot more attention:
K0100: Swallowing Disorder
- Alterations in the ability to swallow can lead to choking and aspiration placing the resident at risk for malnutrition, dehydration or aspiration pneumonia. When coding for a swallowing disorder, a resident does not need an actual diagnosis. Rather it is coded if the resident had the presence of signs and symptoms of a possible swallowing disorder in the seven-day look-back period. This means appropriate documentation must be in place during the look back period to support coding the disorder. Just because a resident has a diagnosis of dysphagia and is on a mechanically altered diet does not mean this section should automatically be coded.
K0200/K0300/310: Height & Weight/Significant Weight Change
- Height and weight measurements assist staff with assessing the resident’s nutrition and hydration status by providing a mechanism for monitoring stability of weight over a period of time. Morbid Obesity is a condition listed under non-therapy ancillary services that will receive one point towards the reimbursement rate.
- Weight loss may be an important indicator of a change in the resident’s health status. A physician-prescribed weight-loss regimen may include a diet plan specific for weight loss or expected weight loss related to physician prescribed diuretic. The expressed goal of the weight loss diet or the expected weight loss of edema through the use of diuretics must be documented.
- To code K0310 as 1, yes, the expressed goal of the weight gain diet must be documented.
K0510: Nutritional Approaches
- The resident’s clinical condition may potentially benefit from the various nutritional approaches included here. It is important to work with the resident and family members to establish nutritional support goals that balance the resident’s preferences and overall clinical goals.
- Parenteral IV feeding is listed as a non-therapy ancillary item with one of the highest point values. When coding Parenteral/IV feeding there must be supporting documentation that reflects the need for additional fluid intake specifically addressing a nutrition or hydration need.
- Enteral feeding formulas should only be coded as K0510D, Therapeutic Diet when the enteral formula is altered to manage problematic health conditions, e.g. enteral formulas specific to diabetics.
- Therapeutic diets provide the corresponding treatment that addresses a particular disease or clinical condition which is manifesting an altered nutritional status by providing the specific nutritional requirements to remedy the alteration. A nutritional supplement may be coded as a therapeutic diet if it is in place to manage problematic health conditions.
- The proportion of calories received through artificial routes should be monitored with periodic reassessment to ensure adequate nutrition and hydration. Calculate proportion of total calories received through these routes.
- If the resident took no food or fluids by mouth or took just sips of fluid, stop here and code 3, 51% or more.
- If the resident had more substantial oral intake than this, consult with the dietitian.
It’s crucial to pay close attention to any issues you may currently have with the processes and/or coding of these section K items and clean them up before transitioning to PDPM. The time is now to review your processes and establish a plan for improvement before these items have an even greater impact on reimbursement. Improvement in these areas can lead to better quality care outcomes and quality of life for the residents while also maximizing reimbursement.