WHILE CLINICAL DOCUMENTATION hasn’t exactly been a
strength in many of today’s financially strapped skilled nursing
facilities (SNFs), this may soon change as SNFs shift to a new
payment methodology—the Patient-Driven Payment Model
(PDPM)—in which these facilities are paid based primarily on
each patient’s unique medical complexity. The biggest change?
Level of assistance with activities of daily living (ADL) and number (and type) of therapy minutes per week have minimal impact on reimbursement under the PDPM. Specificity of ICD-10-
CM diagnosis codes is what matters most, and those codes are
based entirely on clinical documentation. This is leading many
SNFs to turn to clinical documentation improvement (CDI) programs in order to rehab their documentation in advance of the
upcoming reimbursement changes.
“We definitely see an opportunity to increase our focus on
documentation now that SNFs are going to a diagnosis-related
payment methodology,” says Monica Baggio Tormey, BS, RHIA,
CHP, CHC, CHRC, chief compliance officer and director of
HIM/privacy officer at Spaulding Rehab Network, who plans to
launch a formal CDI program in its 123-bed SNF this fall.
Spaulding implemented a CDI program in its long-term care
hospital (LTCH) in 2011 and a similar program in its inpatient
rehab facilities (IRF) in 2015 primarily to ensure that documentation reflects patient acuity and drives accurate reimbursement. Baggio Tormey sees the PDPM as an opportunity to accomplish these same goals in the SNF realm.
However, as with all SNFs, Spaulding must address many challenges before it can proceed with formalizing a CDI program.
For example, who will perform the CDI function, and what additional training is necessary? How will individuals in the CDI
role pose and track queries to physicians? On what areas of documentation should a SNF CDI program focus?
Experts say the shift to PDPM is garnering attention from SNF
Seven High-Impact Areas of CDI in SNFs
administrators, many of whom want to ensure that the docu-
mentation recorded by the interdisciplinary team is consistent
with the MDS assessment to support accurate coding. A pri-
mary concern is that payers will scrutinize diagnosis codes and
potentially deny SNF services once PDPM goes into effect. The
Centers for Medicare and Medicaid Services provided the fol-
lowing reason for moving to the PDPM:
“Under RUG-IV, most patients are classified into a therapy pay-
ment group, which uses primarily the volume of therapy services
provided to the patient as the basis for payment classification. This
creates an incentive for SNF providers to furnish therapy to SNF
patients regardless of the patient’s unique characteristics, goals, or
needs. PDPM eliminates this incentive and improves the overall
accuracy and appropriateness of SNF payments by classifying pa-
tients into payment groups based on specific, data-driven patient
characteristics, while simultaneously reducing administrative
burden on SNF providers.”
“CDI will potentially explode into the SNFs because they’re
going to need this knowledge. There’s certainly an opportunity
for these programs,” says Deanna Peterson, MHA, RHIA, CHPS,
LNHA, vice president of health consulting services at First Class
Solutions, LLC, based in in Maryland Heights, MO. None of her
SNF clients have formal CDI programs, but they’ve already ex-
pressed interest in how to prepare documentation-wise for the
monumental shift to PDPM.
Under PDPM, the stakes are high. Documentation to support
ICD-10-CM diagnosis codes, medical necessity, and more is of
the utmost importance. Seven areas in which CDI can have an
1. Clarify specificity of all diagnoses, including the primary
diagnosis (why the resident is receiving skilled services)
and any comorbidities that exist on admission and/or develop throughout the duration of the resident’s stay.
2. Develop query templates, query tracking tools, CDI tip
sheets, physician education materials, and more.
3. Ensure that nursing documentation supports medical necessity of 24/7 skilled nursing care as well as all information reported on the MDS assessment.
4. Identify any major surgical procedures that occurred during the inpatient hospital stay that immediately preceded
the SNF admission.
5. Obtain copies of physician progress notes, which can be
omitted from the transfer/admission process.
6. Obtain copies of the complete hospital record, especially
the hospital discharge summary, operative report (when
relevant), and interfacility transfer report. These records
can also be omitted during the transfer/admission process, though in many cases a unit clerk would help assist
the CDI specialist with obtaining both physician progress
notes and the complete hospital record.
7. Work with acute care hospitals to clarify the date of the
preceding hospital admission.
Overcoming CDI Challenges in SNFs
Widespread adoption of CDI in today’s SNFs would represent a
significant departure from the status quo. Although SNFs generally provide some nursing education regarding documentation
requirements, these efforts don’t typically extend to physicians,
and there isn’t usually a formal (and compliant) process for
querying providers, Peterson says.
To date, there are many reasons why CDI programs haven’t
Three Best Practices for CDI in SNFs
1. Define SNF-specific CDI program goals and metrics. Acute care goals and metrics may not translate
directly to SNF programs because of the unique-ness of the workflow and MDS assessment that
2. Foster collaboration between coders (or individuals
performing the coding function), those serving in the
role of CDI specialist (or individuals trained to obtain
documentation specificity), and MDS coordinators.
3. Obtain buy-in from SNF medical directors who can
take the lead on physician communications.
Skilled Nursing Facilities
Eye CDI Programs