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PDPM Coding Errors You Can Easily Avoid

November 11, 2020
Documentation, Billing, & Coding, Reimbursement By Rodney Farley, Director

LW Consulting, Inc. (LWCI) has identified multiple opportunities for facilities to improve coding under the Patient Driven Payment Model (PDPM) reimbursement model.

These opportunities are based on several chart reviews conducted as a partner with a facility’s compliance program and as an Independent Review Organization (IRO) for skilled nursing facilities (SNFs) under corporate integrity agreements (CIA).


Section GG—Functional Abilities

There are a lot of moving parts within Section GG. One primary cause of errors is lack of information on Section GG tasks collected within the assessment period. For the 5-Day assessment, we see, in our audits, that nursing staff relies on therapy staff to document Section GG tasks. Nursing staff is not using the form appropriately to capture the functional ability and goals. We often find nursing codes “09” which indicates that the functional ability and goal did not occur prior the hospitalization.

Baseline assessments are critical for identifying systemic issues. The primary purpose is to identify risk areas. Each organization has a different strategy. In our experience of partnering with chain organizations, standardized protocols vary from facility to facility. Even though a procedure might be outlined, the performance is not always operationally consistent.

Based on the results of the baseline findings, the strategy will vary significantly. Common strategies for improvement include education, reviewing systems and procedure, assessing Interdisciplinary Team (IDT) involvement, the effectiveness of the triple check process, and the biller’s communication with MDS coordinator of identified issues.

We also find high error rates when an Interim Payment Assessment (IPA) is completed. Section GG information is not captured in the time frame for the IPA.

During our audits, we have found that Section GG errors are mostly underpayment errors.


In our audits, we have also seen instances where there are a number of comorbidities documented in the clinical record that are not being captured on the MDS for payment.

Audits reveal missing documentation which impacts the Non-Therapy Ancillary (NTA) and /or nursing categories of the HIPPS code. Some examples, such as oxygen and insulin, are being provided per the medical record but are not marked on the Minimum Data Set (MDS). Wounds are marked on the MDS, but the medical record does not have the required wound and treatment interventions documented.

Many times, we see documentation where a resident has Chronic Obstructive Pulmonary Disease (COPD), but the documentation does not show shortness of breath while lying flat. Proper documentation showing the resident has shortness of breath while lying flat would show as a Special Care High category. Without the documentation, it may default down to Reduced Physical Function nursing category.

Brief Interview for Mental Status (BIMS)

The Resident Assessment Instrument (RAI) manual says that the BIMS must be signed on the Assessment Reference Date (ARD) or the day prior to the ARD. One common mistake is signing the MDS section ZO400 after the ARD and not including the interview in the medical record. When an IPA is completed, facilities are not going back to complete the BIMS coding. These errors impact the cognitive impairment scoring.

Section K—Speech Therapy 

When there are coding errors in Section K, often, the Speech-Language Pathology (SLP) evaluation supports coding but that documentation is not captured in the MDS. Sometimes this is because the person who inputs the information into the MDS in Section K does not have access to or does not understand what the SLP evaluation indicates.

Some Additional Thoughts

Primary diagnosis—The diagnosis coded is the primary reason for the skilled stay and largely determines the reimbursement for the entire Medicare stay. In our audits, there have been instances where the primary diagnosis is not representative of the primary reason for the stay and is not documented in the record. Many times, this changes the therapy Health Insurance Prospective Payment System (HIPPS) coding.

COVID-19 and isolation—Our audits have identified significant issues around the documentation supporting the coding of isolation. Isolation can only be coded when four factors are met: the resident has an active infection with highly transmissible or epidemiologically significant pathogens, precautions exceed standard precautions, the resident is in a room alone and all services are brought to the resident. Inadequate or inappropriate documentation poses significant risks to the organization.


For more information or to see if your organization can benefit from a PDPM accuracy review, contact Rodney Farley at 717-213-3123 or email

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