Fact or Fiction - Common Myths Surrounding PDPM Component Capture



Through extensive PDPM analytics, QRM’s audit team has identified myths surrounding qualifiers for PDPM components, with a goal of improving accuracy with MDS condition reporting:


Myth 1:

  • Myth: Fluids used to reconstitute IV medications may be claimed toward provision of parenteral/IV feeding

  • Fact: IV fluids must be ordered for nutrition or hydration in order to claim toward the nursing component

  • Source: MDS 3.0 RAI Manual v1.17.1_October 2019, Ch. 3 MDS Items [K}, Coding Tips for K0510A


Myth 2:

  • Myth: Contributors to the SLP component may only be claimed for residents receiving speech therapy

  • Fact: Patients are classified into a payment group for each of the therapy components, regardless of whether or not the patient is receiving services within that particular [therapy discipline]

  • Source: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM#fact, PDPM FAQs (ZIP) (revision posted 8-30-19)


Myth 3:

  • Myth: In order to claim diabetes mellitus toward the NTA component, the resident must receive insulin injections for all 7 days (N0350A) and insulin order changes on 2 or more days (N0350B)

  • Fact: In order to claim diabetes mellitus toward the NTA component, the diagnosis must be active

  • Source: MDS 3.0 RAI Manual v1.17.1_October 2019, Ch. 3 MDS Items [I}, Definitions, Active Diagnoses


Myth 4:

  • Myth: Respiratory therapy may be claimed when only respiratory assessment is performed

  • Fact: Respiratory therapy claimed must include treatment

  • Sources: MDS 3.0 RAI Manual v1.17.1_October 2019, Appendix A: Glossary and Common Acronyms: Respiratory Therapy, MDS 3.0 RAI Manual v1.17.1_October 2019, Ch. 3 MDS Items [O}, Minutes of Therapy, Bullet 8


Myth 5:

  • Myth: Quarantine equates to isolation

  • Fact: Code for “single room isolation” only when all of the following conditions are met:

  1. The resident has active infection with highly transmissible or epidemiologically significant pathogens that have been acquired by physical contact or airborne or droplet transmission.

  2. Precautions are over and above standard precautions. That is, transmission-based precautions (contact, droplet, and/or airborne) must be in effect.

  3. The resident is in a room alone because of active infection and cannot have a roommate. This means that the resident must be in the room alone and not cohorted with a roommate regardless of whether the roommate has a similar active infection that requires isolation.

  4. The resident must remain in his/her room. This requires that all services be brought to the resident (e.g. rehabilitation, activities, dining, etc.).

  • Source: MDS 3.0 RAI Manual v1.17.1_October 2019, Ch. 3 MDS Items [O}, O0100M, Isolation for active infectious disease (does not include standard precautions)


Myth 6:

  • Myth: Consistent setting of the ARD on Day 8 provides time to ensure completion of all necessary assessments for optimal PDPM component capture

  • Fact: Consistent scheduling of Day 8 as the ARD does not lend itself to capture of hospital IV nutrition/hydration or diagnoses active during hospitalization

  • Source: MDS 3.0 RAI Manual v1.17.1_October 2019, Ch. 3 MDS Items [K}, K0510: Nutritional Approaches, Coding Instructions for Column 1


Myth 7:

  • Myth: In order to claim mechanically altered diet toward the SLP component, the diet must be documented as a new diet

  • Fact: All nutritional approaches performed after admission/entry or reentry to the facility and within the 7-day look-back period may be claimed

  • Source: MDS 3.0 RAI Manual v1.17.1_October 2019, Ch. 3 MDS Items [K}, K0510: Nutritional Approaches, Coding Instructions for Column 2


Myth 8:

  • Myth: Swallow disorder may not be claimed for residents dependent on tube feeding

  • Fact: Residents dependent on tube feeding may also receive pleasure feeding in presence of an order and documentation of consumption within the look back period

  • Source: MDS 3.0 RAI Manual v1.17.1_October 2019, Ch. 3 MDS Items [K}, K0510: Nutritional Approaches, Coding Instructions for Column 2


Myth 9:

  • Myth: Anyone may perform the BIMs and PHQ9 resident interviews

  • Best Practices: Only personnel trained in carrying out the BIMS and PHQ9 assessments and that have passed a related competency test should administer the interviews

  • CMS Tutorials:

  1. BIMs: https://pac.training/courses/snf_cognitive_course_2/#/

  2. PHQ9: https://pac.training/courses/snf_cognitive_course_4/#/


Myth 10:

  • Myth: 3 consecutive days of nursing or therapy documentation are required to substantiate MDS Section GG

  • Fact: CMS anticipates that an interdisciplinary team of qualified clinicians is involved in assessing the resident during the three-day assessment period

  • Sources: MDS 3.0 RAI Manual v1.17.1_October 2019, Ch. 3 MDS Items [GG}, GG0130: Self-Care (3-day assessment period) Admission/Interim/ Discharge (Start/Interim/End of Medicare Part A Stay), Steps for Assessment


Let's Get to the Point:

Go straight to the source documentation surrounding requirements for PDPM component capture to ensure accuracy. QRM is here to assist with your PDPM training initiatives