PDPM Corner: Mastering Medical Records

By Lori O’Hara, CCC-SLP, Skilled Reimbursement Resource

In general, we rightly focus heavily on what we are doing and how things are working. After all, we care for people, not paper! Yet the reality is the only way we can prove our work is through our medical records. And yes, this also includes being able to show why we deserve to get reimbursed for what we billed. For PDPM, where there are so many components that support the reimbursement calculation, the records become even more important.

The MDS itself is almost never the actual source of information — it mostly reports information from the medical record itself. So, almost everything that goes into it comes from somewhere else — such as a doctor’s note, a nursing assessment, a therapy document, or a hospital record. And when the claim is being reviewed (for any reason!), we absolutely must be able to show how and why the MDS entry is accurate, and we do that with the medical record.

A lot of the source documentation comes from our own electronic health records — PCC, POC and Nethealth — so we know that it’s secure and can be accessed later. But what about things that come from somewhere else?

Hospital Documents

Many things that support our patient’s care (and PDPM calculations) come from the acute hospital. Make sure that in addition to whatever records the hospital sends, you routinely obtain the following:

● I/V MAR/TAR and I/O records: The IV MAR/TAR shows if/when the patient received IV hydration or other nutritional support, and the I/O records can sometimes support that those interventions were given for the purpose of nutrition/hydration. It is almost never enough that a note says that the patient was receiving an IV; we must have clear documentation of exactly when it was given.

● All labs and Culture and Sensitivity reports: Drug-resistant infections are on the rise, but we must have evidence that this is true. These documents assist with that coding as well as help guide clinical management for ongoing infections.

● Consultation Reports: The hospital H&P and ongoing progress documents tend to focus on the principal reason for the hospitalization, but it’s often the consultation reports that talk about other underlying diagnoses (retinopathy, malnutrition, immunocompromised status) that we need to know about and manage.

● Discharge Summaries: This takes a little planning, as they’re often not ready at the time of discharge, but they often have helpful information and can confirm the existence of conditions that may not have been clear in the original H&P. Additionally, the timing of the MD confirmed diagnosis is often supported in this document, as it is closer in time to the ARD.

It is highly recommended that a few people in the facility obtain portal/electronic access to the upstream provider’s EHR when it’s available. Self-serve documentation is often more efficient than HIM requests. But if HIM requests to the acute are all you have, then make sure you know the hospital’s process and have a solid internal system for getting those requests made.

Paper Documents in the Facility

While we love our electronic systems, some things just happen on paper. Whenever you have a paper document, scan it into the MISC tab in PCC STAT! Paper grows feet and walks away with startling regularity, so you have to plan ahead for:

● Any documents from the hospital that came in paper form

● The MD certification document and the NOMNC/ABN (not PDPM items, but critical documents that are prone to vanishing)

● Any paper version of an assessment (the BIMS, PHQ2-9, Eat-10, etc.)

● Anything signed by a physician (fax orders, recap orders, query documents, progress notes, signed labs, consultation reports, etc.)

● All third-party documents (labs, dialysis notes, wound nurse notes, etc.)

Develop an Upload Cadence

A pile of documents that need to be scanned can get really big really fast. To avoid getting overwhelmed by the stack, it is essential that you have systems for uploading as often as you can.

This is also very important for MDS accuracy. For example, if the MDS coordinator doesn’t know that a physician has confirmed a diagnosis, they can’t code it. But if the doctor’s confirmation has been received, but it’s tucked in a stack of items waiting to be scanned, then the MDS is now inaccurate and the facility has missed out on reimbursement for a condition they’re actually caring for.

As a reminder, the Triple Check document asks the team to affirm that all PDPM supporting documentation has been uploaded — don’t say yes if it hasn’t happened yet!

Perfecting the Process

A few system tweaks can make a big difference, so here are a few suggestions:

● Get IDT support for Medical Records personnel so they develop a good sense of what documents are helpful and what they look like for fast organization.

● Create a process for organizing hospital documents for the attending MD to review.

● Rely on an IDT knowledgeable in what the timing and documentation requirements of the different sections are (reach out to your MDS and Therapy Resources for help here!).

● Use the Notes report in the MDS to create a map to where supportive documentation can be found. The Notes report cannot be a source document itself (it is neither signed nor dated), but it’s sure a time-saver when it details where to find that one page from the hospital that said the patient has diabetic retinopathy!

Finally, reach out to your Medical Records Resources if you need help dialing in processes for any of your medical records systems. An extra brain can go a long way toward helping you problem-solve and streamline.