extended into the SNF setting. First, many SNFs don’t currently
employ certified HIM professionals, nor is HIM typically a dedicated role or department, says Carol Young, a recently retired
HIM professional who has extensive experience working in
skilled nursing facilities and helped AHIMA develop SNF CDI
tip sheets. Young says the quality of medical record documentation is usually a low priority because staff tasked with managing
records are also responsible for feeding residents, coordinating
transportation and supplies, creating staff schedules, and more.
Another challenge is that physicians aren’t employed directly
by the SNF. “This requires a very different engagement strategy
than on the acute care side,” says Staci LePage, RHI T, senior consultant at Anderson Health Information Systems in Santa Ana,
CA. Medical directors must play a key role in raising physician
awareness and explaining the purpose of the queries, she adds.
SNFs also frequently rely on documentation that’s outside of
their four walls—particularly the hospital record and physician
progress notes. The hospital record, for example, could drive the
entire SNF payment if the physician doesn’t see the resident by
the eighth day of the SNF stay (the day when the MDS assessment is due), Peterson says.
“Hospitals are just beginning to give SNFs access to their sys-
tems,” LePage says. “Some hospitals were reluctant to do this
unless they had a good relationship with the SNF and sent them
a lot of patients.”
Likewise, physician progress notes help SNFs identify specif-
ic diagnoses and comorbidities that affect payment under the
PDPM. However, physicians frequently document these notes
in the hospital electronic health record (EHR) system or their
own EHR. Copies may not be available to the SNF, making it dif-
ficult for SNF providers to obtain a complete clinical picture of
each resident and thus bill correctly.
A final challenge for SNFs looking to implement CDI programs
is that some SNFs don’t have an EHR. This means CDI in these
organizations is likely a manual and time-consuming process,
Baggio Tormey says. “If you don’t have an electronic medical
record, this change for SNFs is going to result in some facilities
having financial challenges,” she says. “There’s a lot of pressure
to figure out how they’re going to survive in this very new world.
Therapy isn’t the primary driver of revenue anymore.”
Emerging Opportunities for HIM Professionals
As SNF administrators consider the feasibility of CDI programs,
they must first address the question of who will perform the CDI
function. Spaulding Rehab Network hopes that MDS coordinators can take on some of the tasks. “MDS nurses work so closely
with attending physicians. They already have that relationship
established. Adding CDI to these conversations shouldn’t be a
heavy lift at all,” Baggio Tormey says.
Others agree. “The MDS nurse interviews the resident to com-
plete the MDS assessment, and they really know what’s going
on with the resident and what treatment they’re receiving,” Pe-
terson says. “They’re in an ideal position to be able to identify
Changes under PDPM also reduce the number of assessments
that MDS coordinators are required to perform. This could allow
them to invest time into CDI instead, LePage says. That’s what
Baggio Tormey hopes will happen. If it ends up being too much
for the SNF’s MDS coordinators to handle, she plans to recruit a
CDI professional to serve in a dedicated CDI specialist role.
Experts agree that regardless of who serves in the role of CDI specialist, this individual must work in tandem with a certified coder.
“PDPM is pushing everyone down the path of having a certified
coder assigning codes. Your acuity—and now your revenue—all
ties into ICD- 10 diagnosis codes,” says Baggio Tormey, adding that
Spaulding uses a centralized team of certified post-acute coders
who code all SNF services. Peterson agrees. “Even the facilities that
can’t afford to invest in a certified coder right now may start to look
for one just because there’s such a risk,” she says.
Large post-acute care networks are already beginning to create formal HIM departments, and smaller facilities likely won’t
be too far behind, Peterson says. “There absolutely is a need
for dedicated HIM personnel in long-term care. Facilities have
been reluctant to invest in these roles unless they have a reason,
and I think that PDPM is that reason,” she adds.
Experts agree that if larger SNFs begin to recruit HIM professionals to serve in a dedicated CDI capacity, these individuals
will likely report to corporate-level HIM directors or chief financial officers. In smaller facilities, HIM may report to the SNF administrator or director of nursing.
Developing a Physician Query Workflow
Physicians should have access to the SNF’s EHR so they can
clarify diagnoses on admission when they write and sign orders, says Rhonda Anderson, RHIA, QCP, president at Anderson
Health Information Services. Worst case scenario is that the facility uses a paper-based method to query physicians (i.e., cre-
Five Facts About the PDPM
CHECK OUT THESE important facts about the new payment model that will revolutionize the way in which SNFs
1. Takes effect October 1, 2019.
2. Replaces the current case-mix classification system,
the Resource Utilization Group, Version IV (RUG-IV).
3. Determines payment through a combination of six pay-
ment components, five of which are case-mix adjusted.
The case-mix adjusted components include speech
therapy, occupational therapy, physical therapy, nonther-
apy ancillary services, and nursing. The non-case-mix
adjusted component covers utilization of SNF resources
that do not vary according to patient characteristics.
4. Prioritizes clinically-relevant factors (i.e., individual resi-
dent conditions as represented by ICD-10-CM diagnosis
codes) to determine base rates and case-mix indices.
5. Includes an optional Interim Payment Assessment
(IPA) that allows providers to report a change in a resi-
dent’s PDPM classification.
To learn more about PDPM, visit www.cms.gov/Medicare/
Skilled Nursing Facilities