Category Archives: Industry Insights/Hot Topics



Reimbursement QuickTIP: Get Paid for the Care and Services you Provide


During the COVID-19 pandemic, post-acute care leaders have had their days filled with sparse staffing, infection control surveys, sick residents and staff, and distraught families. Now that vaccines are rolling out to our residents and employees, we can begin to look beyond making it through the day and think about the overall health of our organization beyond COVID-19.

Now is the time to turn your focus to reimbursement as you prepare for the “new normal.” Although the CARES Act provided some financial support for extra costs during the Federal and State Public Health Emergencies (PHE), as of today, the PHE 1135 waiver is still in place, which supports changes for some Medicare procedural rules. While there are numerous waivers in place, the three-day hospital stay remains waived and the new benefit period rule is waived in some circumstances.

The clinical reimbursement processes in some skilled nursing facility (SNF) settings are not consistently optimizing residents’ access to the Medicare benefit under these waivers.

(See below for a complimentary checklist from Pathway Health to assist in identifying opportunities to advocate for your residents with Medicare to access their SNF benefit when appropriate.)

Tips on how to access Medicare during the PHE 1135 waiver:

  • Identify a change in condition or close exposure (from a COVID-19 positive staff or resident) for the resident.
  • Assess the change and decide if the resident meets one of the Medicare clinical criteria for coverage per the Medicare Benefit Policy Manual – Chapter 8 Coverage of Extended Care (SNF) Services under Hospital Insurance:
  • Skilled therapy
  • Skilled nursing
  • Observation and assessment
  • Management of a care plan
  • Teaching and training
  • Confirm that the resident has Medicare and has days available to use.
  • Obtain physician orders and certification for a skilled stay.
  • Begin discipline-specific assessments for Medicare stay (like a new admission).
  • Schedule a Significant Change/5-day MDS.

Another challenge is managing the residents’ diagnoses reimbursement coverage changes over the course of their stay. We are all aware that the resident’s primary diagnosis drives payment in many of the Patient Driven Payment Model (PDPM) components. During this PHE, staff may not have focused on effective diagnosis management. However, managing diagnoses is a key activity for PDPM and other payor success.

Leadership Considerations: Use a Best Practice Approach for Diagnosis Management

The diagnosis management process goes beyond identifying a primary diagnosis for PDPM. It also involves entering the correct diagnoses on the MDS and the billing claim for Medicare. Once a Medicare stay ends and a resident remains in the facility, the diagnoses need to be reviewed and potentially reorganized, which may impact your reimbursement. It is also important to note that the secondary payor must have correct codes on the claim as well. Consider the following:

  • Identify the correct diagnosis for the SNF admission. Validate that the primary diagnosis works for PDPM.
  • Clarify with the provider if needed.
  • Review all transfer documents and request documents from the hospital as needed to identify all active comorbidities, including:
  • Operative reports
  • Consult reports
  • Diagnostic test reports
  • Before completing the 5-day MDS, review notes from providers and discipline-specific assessments to identify all of the resident’s active conditions and interventions.
  • Clarify with the provider if documentation is needed.
  • Monitor provider documentation for changes in the diagnosis list over the course of the Medicare stay. Remember to sequence the remaining diagnoses based upon the primary diagnosis and severity of illness.
  • Consider an Interim Payment Assessment (IPA) MDS if the resident gets a new diagnosis or intervention that would increase PDPM payment.
  • Compare the provider-documented diagnoses to the MDS and Claim prior to billing to confirm that diagnosis codes are supported.


Complimentary Resource: Checklist for Medicare Reimbursement Systems
This complimentary Medicare Reimbursement QuickTIP is a great checklist designed for leaders! Use this with your team to review current Medicare processes during the COVID-19 pandemic, including your COVID-19 coding processes, billing and MDS outcomes.


Pathway Health’s reimbursement professionals are available to assist you in your reimbursement optimization journey. Contact us for details on the affordable Reimbursement SnapShot review which outlines areas of opportunity.


Karolee Alexander
Director of Reimbursement and Clinical Consulting


Coronavirus Disease 2019 (COVID-19): What You Need to Know

Proactive Planning and Preparation Strategies  

There has been a lot of information and news coverage of the Coronavirus Disease 2019 (COVID-19) outbreak. At this time, Pathway Health is preparing resources for long term care providers based upon the knowledge that is available through the Centers for Disease Control and Prevention (CDC), World Health Organization (WHO) and the Centers for Medicare and Medicaid Services (CMS). These sources provide trustworthy, transparent information as to what is and is not known about COVID-19.

The CDC has indicated that there has now been community transmission of COVID-19 in the United States, and it is anticipated there will be additional transmission in the near future. CDC recommends that all health care providers and health care professionals use this time to prepare, increase their knowledge and plan for potential community transmission.

Pathway Health is monitoring the situation and has prepared a set of resources including a complimentary resource: COVID-19 Policy and Procedure and Preparation checklist.


Leadership Preparation Strategies

Below are recommended strategies for leaders to use as a starting point for COVID-19 preparation.

    1. Review your Emergency Preparedness Plan and make revisions related to outbreak/pandemic requirements, if necessary
    2. Monitoring of CDC and WHO websites as information is evolving on a regular basis
    3. Review CDC Testing Guidelines for persons under investigation suspected of COVID-19
    4. Review all Infection Prevention and Control Policies and Procedures to ensure they are up-to-date, including:
    5. Re-educate all staff on the facility’s Infection Prevention and Control Policies and Procedures
    6. Review and implement the  Pathway Health’s COVID-19 Resource
    7. Identify local/state Public Health contacts and have contact numbers prepared
    8. Provide education for residents and their representatives regarding:
    9. Post signs at the entrance of the facility regarding:
    10. Make available at the entrance of the facility:
      • Alcohol-based Hand Rub (ABHR)
      • Masks
      • Tissues
      • Waste receptacles
    11. Identify outbreak management supply needs:
    Pathway Health will continue to monitor the evolving COVID-19 situation and will provide additional updates as they become available.

    Contact us for assistance with COVID-19 planning and other infection control assistance.


Susan LaGrange, RN, BSN, NHA, CDONA, FACDONA, CIMT, IP-BC – Director of Education



Five Days and Counting Until PDPM

As the industry anticipates the implementation of a completely new Medicare payment classification system, it is important to keep in mind a few fundamental concepts:

1) The basic Medicare program benefits and coverage criteria have not changed.
2) The MDS still follows a standard process for scheduling, data collection and interpretation.
3) An accurate and complete bill is the desired outcome of a billing process.

For the past few months, providers have been focusing on learning the new payment classification system. Clinical software systems will complete the calculations that staff has been learning to do manually; however, leaders will want and need to understand how the calculations work in order to determine if all the information needed is complete and have the information coded accurately on the MDS. PDPM uses the resident’s diagnoses, conditions and special treatments to calculate payment categories.

Leadership Considerations

Medicare Clinical Coverage Criteria: The PDPM classification system does not change the basic Medicare benefits and coverage criteria. The admission staff and the members of the facility’s interdisciplinary team (IDT) should be knowledgeable about identifying the technical and Clinical Coverage criteria for SNF Part A stay coverage. The RUGs classification system has been driven by therapy days and minutes, which also defined Medicare coverage for the SNF stay. The PDPM system does not provide a simple connection between payment classification and Medicare coverage.

The resident must meet technical eligibility criteria to be covered in a Medicare Part A SNF stay. A period of three consecutive midnights must be spent as an inpatient in an acute hospital to access the SNF Medicare benefit. In February 2019, the Office of Inspector General (OIG) completed a small claims review project that identified improper payments of approximately $481,000.00 because the dates of the qualifying hospital stays did not meet this technical criterion on sixty-five claims.1

For the past few years, the majority of SNF claims were billed for Rehab RUG categories and Medicare clinical coverage was easy to be determined by the amount of therapy provided. October 1 will usher in a new period when the specific Medicare Clinical Coverage criteria must be identified. There are five Clinical Coverage categories:

  • Skilled Therapy
  • Skilled Nursing
  • Assessment and Observation
  • Management of a Plan of Care
  • Teaching and Training

Therapy evaluation and treatment documentation does not have to change to support skilled therapy five days per week.


For all Clinical Coverage Criteria, the following medical record elements are needed:

  • A physician’s order for the skilled care.
  • An estimated length of coverage documented by the provider (physician or extender).
  • A description of the skilled need and the interventions planned to meet it, documented by the nurses of the facility. This can include a well-defined care plan problem statement and resident- specific interventions.


Nursing documentation for the clinical coverage categories beyond Skilled Therapy will be the responsibility of the nursing department. Daily skilled nursing is based on the skilled need that can only be met by the special skills of a licensed nurse, and the special treatment being provided to the resident, seven days per week, by a licensed nurse. This documentation is usually found on a flow sheet or treatment administration sheet. The need for and administration of the skilled nursing treatment is straight forward. Additional daily charting that reflects the resident’s status and response to treatment is needed beyond the flow sheet format.

Assessment and Observation is a less familiar coverage category. It is designed for the resident with a medically unstable condition(s). In addition to the required record elements described above, the unstable condition must be described, and all interventions and care plan changes need to be recorded. The condition of the resident and their response to treatment needs to be described at least daily. Medicare coverage under this criterion would end when the resident’s condition is stable. It is helpful to describe what “stable” looks like as the care plan goal.

Management of a Plan of Care is the coverage criteria for residents with multiple non-skilled needs that require a licensed nurse to develop a plan of care that prevents decline and complications and maintains the resident’s safety. Once the care plan is fully developed, and the resident is maintained in a steady state, the Medicare coverage would end. The care plan goals should describe the maintenance status of the resident.

Medicare coverage for Teaching and Training supports a resident’s education about a new medical condition or treatment that the residents and/or family care-giver will manage after discharge. Describe how you will know that the resident has learned what you have taught in order to know when Medicare coverage should end.

Without the RUG categories to help us determine when Medicare coverage ends, we will need to address each of the coverage categories applicable to the Medicare stay. Residents will likely qualify in more than one Clinical Coverage Criteria during a SNF stay. Identify each criterion that is met at admission and throughout the stay to recognize when a resident’s stay is no longer coverable by Medicare Part A.2

MDS Scheduling: There are far fewer MDS assessments to complete for the PDPM payment classification system. In many cases, the Medicare initial assessment, the 5-day MDS, will be the only payment MDS completed during the stay.

Identification of the Rehab RUG category will be used to drive the selection of the Assessment Reference Date (ARD). Remember that a 5-day MDS must be submitted, even if the resident leaves before Day 8 of the stay, in order to be paid above the default rate. The resident must be in a Medicare stay when the MDS is opened in the clinical software. If the Medicare stay has ended or the resident is discharged, the MDS cannot be opened and the facility must bill default. Consider teaching the admitting nurse to open the Medicare 5-day MDS with the ARD of the day of admission. The ARD can always be moved to a later date by the MDS Coordinator.

“The facility is required to set the ARD on the MDS Item Set or in the facility software within the required time frame of the assessment type being completed. This concept of setting the ARD is used for all assessment types (OBRA and PPS) and varies by assessment type and facility determination.”3

The Interrupted Stay policy requires that the OBRA assessment and the PPS assessment schedules be managed separately. The determination of the beginning and end of a Medicare Part A stay has nothing to do with the OBRA Discharge MDS schedule or need for an Entry tracker.

CMS has provided a Fact Sheet about the Interrupted Stay policy. Click to download.

Accurate and Complete Claim: The purpose of the PDPM payment classification system is to provide a structure for Medicare payment to the SNFs. The desired outcome is a bill that accurately reflects the resident, their clinical conditions and the type and amount of services provided to the resident during the Medicare Part A stay.

I strongly encourage you to spend time with the IDT to review the claim information, the MDS information and the supporting medical record documentation prior to billing PDPM for the first time. Use the claim form as the end point of the process and work your way backwards. Confirm the demographic information, the MDS coding and the daily skilled charting associated with the Part A stay. In this way, you will submit a claim without errors or missing information and be paid at the PDPM rate reflective of the resident’s needs and services provided.

Keep your focus on producing consistent, accurate medical record documentation that flows reliably to the claim for efficient claims processing.

Karolee Alexander
Director of Reimbursement and Clinical Consulting


Hot Topics: FINAL version of MDS 3.0 Data Specs Available

The Centers for Medicare & Medicaid (CMS) posted the FINAL version (V3.00.1) of the MDS 3.0 Data Specifications yesterday. This version is scheduled to become effective October 1, 2019.

Leadership Actions/Considerations:

  1. Please note that revisions since the errata can be identified by looking for “post-errata” in the version notes for the items and edits.
  2. The lookup file for the allowable ICD codes in item I0020B has been updated, and it is posted as a separate ZIP file.
  3. Download files directly from (see the downloads section)
  4. Quickly access the files by clicking on the links below:


MDS 3.0 Data Specs (V3.00.1) FINAL 04-22-2019 [ZIP, 13MB]

PDPM_ICD_Codes_for_I0020B_FY2020 [ZIP, 764KB]


Pathway Health experts are reviewing the FINAL revisions and resources, education and products to ensure their alignment with the changes. For further information, contact us.


Lisa Thomson
Chief Strategy and Marketing Officer




What Leaders Need to Know: The Final Rule – Impacts to the MDS Process

The Medicare payment classification system change to the Patient Driven Payment Model (PDPM) for SNFs is October 1, 2019. Medicare payments will be based on the PDPM classification system instead of the RUGS IV classification system.
Centers for Medicare & Medicaid Services (CMS) published Final Rule updates to the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs) for fiscal year (FY) 2020, making minor revisions to the regulation text to reflect the revised assessment schedule under PDPM. Additionally, there are revisions to the definition of group therapy under the SNF PPS, and the implementation of a sub-regulatory process for updating the code lists (ICD-10 codes) used under PDPM. Lastly, updated requirements for the SNF Quality Reporting Program (QRP) and the SNF Value-Based Purchasing (VBP) Program are also included. Click to download update from the Federal Register>

Below are a few “need to know” updates.

Q. What changes were made to the PDPM adjusted base rates?

A. Two major revisions were made:
1. The SNF Market Basket percentage increase was updated based on the second quarter 2019 forecast. The revised update is 2.8%.

2. PDPM Case-Mix indexes (CMI) and Adjusted Federal rates for each CMI for urban and rural facilities were updated and published.

Q. What are CMS’ clarifications to the Interim Payment Assessment (IPA)?

A. CMS clarified that the IPA is to be used as the SNF determines after the initial Medicare MDS (5-day) to address a resident’s clinical changes throughout the Medicare stay; “to provide excellent skilled nursing and rehabilitative care and continually monitor and document patient status. Moreover, the discussion of the IPA in the FY 2019 SNF PPS final rule (83 FR 39233) clearly envisions a role for this assessment that is not strictly limited to payment alone.”

Q. What are the SNF Quality Reporting Program (QRP) impacted areas?

A. Key updates were made to the following:
1. Transfer of Health Information to the PROVIDER – Post-Acute Care effective FY2022: The FY 2021 PPS assessments will be revised to collect data about the transfer of a reconciled medication list to the next post-acute care provider when a resident discharge from a SNF Medicare stay.

2. Transfer of Health Information to the PATIENT – Post-Acute Care effective FY2022: The FY 2021 PPS assessments will be revised to collect data about the transfer of a reconciled medication list to the resident at the time of discharge from a SNF Medicare stay.

3. The Discharge to COMMUNITY – Post-Acute Care:The Quality Measure for the SNF QRP will be adjusted for FY2020 to exclude residents of the SNF in 180 preceding their hospitalization and SNF stay.

4. Drug Regimen Review Conducted with Follow-Up for Identified Issues – Post-Acute Care: Will be posted to Nursing Home Compare for FY 2020.

5. Definition of the RAI Manual: The official definition of RAI Manual is the Manual instructions, the interpretive guidance and policy clarifications posted in the MDS website. Click here to view>

PDPM Insight, Expertise and Knowledge.

Pathway Health PDPM experts can assess your organization’s readiness and provide a detailed action plan for enhancing or improving these processes. Our PDPM consulting services and tools can support your busy leaders and staff to effect a smooth transition to the PDPM system. Pathway Health also offers expert PDPM training – classroom, onsite and web-based. Contact us to learn more.


Karolee Alexander
Director of Reimbursement and Clinical Consulting


Implementing Change and Making the S.H.I.F.T.

Everything we read about, hear about and talk about in post-acute care is change. Preparing for and managing change is about how we as leaders handle the complexity of the process.

Many leaders, like myself, have found that we are in a position of learning while leading. As post-acute care leaders we must evaluate, plan and implement tactics, strategies and operational processes to exceed the expectations of health care today and in the future – we need to S.H.I.F.T. to prepare for change.

Knowledge and clear understanding of the regulatory, reimbursement and quality measurement changes and their defined impact on our organization is key to determining the foundation for actions needed within our organization.

With your team, ask “How will this affect our organization?” to identify organization readiness for change. What systems, processes, services and resources will be needed, refined or changed due to the reimbursement, regulatory and quality measure changes coming in FY 2020 and beyond

Review current organization data and the confidential reports from CMS with your team. Align your current data outcomes with regulatory changes. Identify organization trends, variances, spikes in outcomes and the current impact to clinical, operational and financial outcomes.

Craft your vision and goals for change. Based upon your review of the regulatory changes, organization readiness and organization data, develop an action plan with your team. Determine priorities (immediate vs. important), what is immediate (which will have a serious and immediate negative impact) and what is important (that which needs to be accomplished, however, there are possibly a few more days to complete some of the tasks). Priorities may include financial analysis, education at all levels of the organization, as well as internal and external resources that will be needed to lead the organization to successful outcomes.

In today’s world – it takes a team. Track and trend outcomes to the strategies implemented in your action plan as well as your organization data outcomes. There are numerous changes and “to dos” that require yourself as a leader as well as various team members for input, skill sets and knowledge. You cannot do this alone – engage a team from all levels of your organization to review the changes, trend current and potential outcomes as well as solicit your team’s thoughts and ideas.

With the health care environment increasing in complexity, transforming the way we lead and how health care is delivered and managed within our organization and in collaboration with our partners is the key to success. The key competitive advantage today is the ability to change, adapt and evolve – SHIFT in order to achieve sustainable and successful outcomes.


Lisa Thomson
Chief Strategy and Marketing Officer


Celebrating Leaders in Clinical Excellence

National Nurses Week is a time for everyone – individuals, employers, other health care professionals, community leaders, and nurses – to recognize the vast contributions and positive impact of America’s 4 million registered nurses. Each year, the celebration ends on May 12, Florence Nightingale’s birthday.

As health care becomes more specialized with different types of provider types, higher acuity in various settings, increased technology, primary care physicians and specialists and interdisciplinary team members – one profession provides the continuity across the continuum – Nursing!

Nurses continue to play a pivotal role in quality patient care and outcomes. Nurses are the patient advocate, working with the patient, family and all health care professionals for smooth transitions of care.

The role of nursing is rapidly evolving as nursing professionals are tasked with an even wider range of responsibilities in the new health care environment. Nursing has become more complex in ways that couldn’t have been imagined a generation ago. Nurses are not only caregivers, but they are teachers, advocates and great innovators – utilizing their expertise and critical thinking abilities to assess and resolve complex situations. Nurses are innovators, influencing change in healthcare. With the change to a value-based approach to care, challenging organizations related to reimbursement and efficiencies, nursing leaders are reshaping care by enhancing clinical processes and competencies with their teams, fostering better outcomes. Empowering the capabilities of their teams unleashes a “gold mine” of talent, skills, and innovation amongst all nurses within an organization!

Every day, nurses continue to promote health and cater to the unique needs of individuals by providing safe and quality care. Many times in our complex health care world, we are wrapped up in day to day operations and complicated regulations and lose sight of the glue of our organization – our professional nurses. They are the heart of health care!

To all of the nurses across the nation, we thank you! Thank you for embracing the new health care environment and all of the changes it brings, reminding us every day why we do what we do – provide excellent care and services to those in need.

Happy Nurses Week!

Donna L. Webb, RN – Chief Operating Officer



Phase 3 Preparedness with Pharmascript

Pathway Health’s Leah Killian-Smith presents the webinar, titled, “Purposeful Preparedness for Phase 3,” hosted by Pharmascript. The event will provide participants with knowledge of the required elements of Phase 3 and their impact on LTC policies and procedures.


  • Understand the required elements of Phase 3 and how they affect long-term care’s current policies and practices.
  • Analyze the components of the regulations that are new and those that are in addition to what is already in place.
  • Gain knowledge to be able to prepare staff members for the next phase of regulatory guidance for long-term care

The webinar will take place May 16 from 10:30 – 11:30 a.m.

Check out more educational opportunities from Pathway Health »


Operational & Clinical Strategies for Success with OHCA

Pathway Health’s Sue LaGrange will be presenting at the event, titled, “Reducing Readmissions – Operational and Clinical Strategies for Success,” hosted by the Educational Foundation of the Ohio Health Care Association in Columbus, OH, on May 15. The event offers post-acute care leaders interactive discussions and practical resources they can implement immediately. Participants gain access to networks, mentorship possibilities, healthcare leaders and more.

The event will take place on May 15 from 8:30 a.m. to 3:45 p.m.

Schedule an appointment to connect with a Pathway Health expert.

Pathway Health leaders are traveling to many events in May for insights into the future of health care, in 2019 and beyond. Stay informed of their progress through social media and our blog.


Meet Pathway Health at MHCA 2019 in Duluth

Pathway Health will be exhibiting at the 2019 MHCA 49th Annual Meeting and Expo in Duluth, MN, on May 15. The Minnesota Home Care Association’s Annual Meeting offers unique opportunities for educational enhancement in the field of long term care alongside thousands of industry professionals. Participants gain access to networks, mentorship possibilities, healthcare leaders and more.

Attendees can connect with both of our team members at booth #33 during these times:

May 15:

  • 10:00 a.m. – 3:45 p.m.

Schedule an appointment to connect with a Pathway Health expert.

Pathway Health leaders are traveling to many events in May for insights into the future of health care, in 2019 and beyond. Stay informed of their progress through social media and our blog.