👌 TOP FIVE CLAIM DENIAL AND RESOLUTIONS 👌

#5. Claim is being denied due to PDPM code being submitted is inconsistent with what was approved on the authorization.

PDPMpro response: “Facilities need to be sure they are reviewing all authorizations in their triple check meetings and confirming that the PDPM HIPPS code used on the claim for payment matches the authorization. This simple check & balance process will save time and money.”

#4. NTA not validated and claim is being revised to pay at a lower NTA score due to documentation not supporting active diagnoses of Diabetes Mellitus and Malnutrition.

PDPMpro response: “It is key that these diagnoses that earn NTA points are validated as an ‘active’ diagnosis. In your Medicare meeting, the team should review the documentation that supports these as active diagnoses. For these conditions, examples would include orders for insulin, or a recent weight loss of more than 5% in the last month or more than 10% in the last 6 months. The diagnoses are required to be active during the last 7 day look back period and have documentation by a physician (or by a nurse
practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) within the last 60 days.”

#3. Nursing CMG not supported, unable to validate the coding of parenteral/IV feeding.

PDPMpro response: “Per Section K of the RAI manual, in order to capture the Parenteral/IV feeding, it must include any and all nutrition and hydration received by the nursing home resident in the last 7 days either at the nursing home, at the hospital as an outpatient or an inpatient, provided they were administered for nutrition or hydration. The key here is that they were administered for nutrition or hydration. There must be supporting documentation that reflects the additional fluid intake is needed due to a nutrition or hydration need. Be sure to review the documentation of the nurses and dietician to support this need during the 7-day look-back period.

#2. Clinical documentation does not support the coding of a major surgery during the inpatient stay that immediately proceeded the members Part A admission.

PDPMpro response: “Due to the fact that a recent history of a major surgery can affect a resident’s recovery, PDPM added a new question to section J that accounts for any ‘major’ surgery immediately prior to the start of the Medicare stay. It’s critical to review the medical record before the ARD and look for any surgical procedure that 1) required at least one day in an acute care hospital in the 30 days prior to admission and 2) carried some degree of risk to the resident’s life or the potential for severe disability, according to the RAI manual. The surgery must be documented by a physician (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 30 days and must have occurred during the inpatient stay that immediately proceeded the resident’s part A admission. It must be determined whether the surgeries require active care during the SNF stay, thus they would have a direct relationship to the resident’s primary SNF diagnosis.

#1. Clinical documentation does not validate coding of Section GG.

PDPMpro response: “GG is a very important area to discuss and review in your Medicare meetings during the 72 hour look-back period. We should review both therapy documentation and nursing documentation to validate the coding of Section GG. Many of the charts we are auditing show discrepancies of function between nursing and therapy notes. It is critical that the interdisciplinary team members who are gathering the info for Section GG usual performance, are trained in the RAI rules for these areas. The fact is that not everyone understands how the coding works and the language in this area is quite different to what therapists are used to. Be sure your therapy team has been trained in the language of the RAI manual of Section GG. And if they have not been, your claims are at risk for denials. Let us know if your therapy team needs help. We can train them how to accurately code this area.

We are starting to see the many notices of remittance advice with adjustments to payment under PDPM. Here are the Top 5 most seen denials and the resolutions we are offering our clients.

We are starting to see the many notices of remittance advice with adjustments to payment under PDPM.

Here are the Top 5 most seen denials and the resolutions we are offering our clients.