A Glimpse into Medical Review Under the PDPM

While many providers are anxiously anticipating the receipt of their first additional development request (ADR) or denial under the Patient-Driven Payment Model (PDPM), other providers are gradually starting to receive requests. These requests are largely coming from managed care companies (primarily Humana) that also chose to adopt the new payment model on October 1, 2019.  While the documentation requests may look the same, the information being reviewed will differ.  Previously, the requests being received were solely focused on RUG reviews. With RUG levels no longer being the driver of payment, the reviews will shift to elements of support for qualifying hospital stays, medical necessity, and the strength of the skilled documentation supporting the services provided.

Qualifying factors for skilled services have not changed with the PDPM. It is our responsibility to document why skilled therapy is needed. Be mindful that not only does strong documentation affirm medical necessity for skilled therapy, but it also becomes part of the patient’s medical record and will be referred to for validation purposes if needed. Use of discipline specific clinical terminology and documentation of techniques, which can only be performed by a skilled clinician, are paramount to ensuring success.

 The most advantageous thing we can do to prepare for documentation review is to continue to ensure our documentation and coding is held to the highest standard.  By providing thorough documentation, a collaborative team approach, and the best care possible to all beneficiaries, we possess all the tools needed to produce the outcomes that will be necessary to succeed with these audits.

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