Category Archives: Perspectives


What Leaders Need to Know: MDS Updates

In December, the Centers for Medicare and Medicaid Services (CMS) posted a new DRAFT version of the 2020 MDS item sets (v1.18.0). This version is scheduled to become effective October 1, 2020.

Click here to review and download recent MDS updates from CMS.

In FY 2020, CMS implemented PDPM for Medicare Part A along with the MDS item set changes associated with this change. There are now specific MDS item sets that will calculate a 38 or 48-RUG category and specific item sets that only calculate PDPM payments.

For FY 2021 there will only be one item set that can calculate a 38 or 48-RUG category. All other item sets will not contain the Section G ADL data used for RUGs category calculations. The 5-day MDS became the MDS to set the payment rate for an entire Medicare Part A stay.

What follows are a few insights from our Reimbursement and Clinical Consulting team experts.

What MDS changes happened in December 2019?

CMS announced federal MDS assessments would no longer have Section G as of October 1, 2020. CMS released draft item sets, however, Pathway Health experts will review the RAI Manual’s final instructions to know what will happen for certain.

Currently, the following is what we can determine from the draft item sets:

  • No Section G for the following:
    • Any OBRA assessments – Admission, quarterly, annual, significant change in status, significant correction to prior comprehensive, or significant change to prior quarterly
    • Any PPS assessments – 5-day, interim payment assessment, or PPS discharge assessment
    • Any Tracking forms – entry, death in facility (Section G has not been a part of these “non-assessments.”)
  • Section G will continue to be part of the Optional State Assessment, however, G0110 Activities of Daily Living (ADL) Assistance for resident self-performance and staff support for only the four late loss ADLs (bed mobility, transfer, eating, and toilet use) will be included.
  • Two Section G items will be moved to Section GG on federal assessments:
    • G0400 Functional Limits in Range of Motion will become GG0115.
    • G0600 Mobility Devices will become GG0120.
  • Two Section G items will be eliminated on federal assessments:
    • G0300 Balance During Transitions and Walking.
    • G0900 Functional Rehabilitation.
  • The lookback period for Section GG items on OBRA federal assessments will be seven days.
  • Two Section GG items have been added to OBRA federal assessments:
    • GG0130I Personal Hygiene has been added to Self-Care.
    • GG0170FF Tub/Shower transfer has been added to Mobility.
  • Six Section GG Mobility items have been eliminated on OBRA federal assessments:
    • GG0170G Car transfer.
    • GG0170L Walking 10 feet on uneven surfaces.
    • GG0170M 1 step (curb).
    • GG0170N 4 steps.
    • GG0170O 12 steps.
    • GG0170P Picking up an object.


How does this impact skilled nursing providers?

The entire data collection process for the 5-day MDS is now “front-loaded.” LTC facilities need to collect and clarify all resident diagnoses and comorbidity information as well as obtain provider clarification as necessary to optimize PDPM reimbursement. Therapy time treating the resident no longer affects the Medicare payment rate.

The 2021 changes to the MDS item sets mean that State Medicaid agencies that use RUG reimbursement categories for Medicaid payments will need to make significant changes to their software or require providers to complete two MDSs each time an OBRA MDS is required, the OBRA assessment and the Optional State Assessment.

States that use RUG-III or RUG-IV Medicaid reimbursement systems will still need to code Section G on the Optional State Assessment (or other state-designated form) at the state-designated times to receive appropriate Medicaid reimbursement.

  • The OSA requires coding only for the four late-loss ADLs (bed mobility, transfers, eating, and toilet use). Individual states may require coding for additional ADLs.
  • Facilities will no longer need to code nor to obtain supporting documentation for any early-loss, mid-loss, or late-loss ADLs found in G0110 for any federal assessments beginning October 1, 2020. This will significantly reduce the documentation time for CNAs and staff nurses and the coding time for MDS nurses.
  • Facilities will need to code and obtain supporting documentation for Section GG Self-Care and Mobility for OBRA assessments beginning October 1, 2020. This will not only offset the time reductions related to Section G noted above but will also increase the coding time for MDS nurses.
  • Since introducing Section GG to the MDS 3.0, CMS’ intent has been that the coding would be based on the usual performance of the resident that would be assessed by an interdisciplinary team of qualified clinicians using direct observation as well as resident self-reports and reports from qualified clinicians, care staff, or family documented in the resident’s medical record during the three-day assessment period.
  • The RAI Manual defines a “qualified clinician” as a healthcare professional practicing within their scope of practice and consistent with Federal, State, and local law and regulations.
  • Self-care and mobility definitions and performance coding for Section GG differ greatly from Section G.
    • There will be a steep learning curve for CNAs and staff nurses if they are not already providing supporting documentation.
    • The MDS nurse will need to provide additional education and auditing.


How will the changes impact quality measures?

Quality measures will not be impacted by the FY 2020 changes to MDS data elements but the elimination of Section G for FY 2021 will have a significant impact on CASPER quality measures as the ADL items in Section G are the primary topic of or a risk adjustment factor for many quality measures.

There are five SNF Quality Measure programs – MDS 3.0 Quality Measures, Nursing Home Compare Quality Measures, SNF Quality Reporting Program (QRP) Measures, SNF Value-Based Purchasing (VBP) program measures, and the Five Star Quality Rating program on Nursing Home Compare.

Section G currently provides numerators, covariates, high-risk determinations, and exclusions for ten Quality Measures in three of the five quality measure programs. (See chart below.)

In calculating Quality Measures after October 1, 2020, CMS may substitute certain Section GG items for Section G items when possible, may place a one-quarter or longer “hold” on calculating some or all of the measures until sufficient data is available, may remove some measures, may introduce new measures.


QMs that Use
Section G ADLs
How Section G Is Used in the QM
QM Program
Percent of Residents or Patients With Pressure Ulcers That Are New or Worsened (Short Stay)
NQF #0678
MDS 3.0 QM
Five-Star Quality Rating System
Percent of Residents Who Made Improvements in Function (Short Stay)
NQF: None
Numerator and covariate
MDS 3.0 QM
Five-Star Quality Rating System
Percent of High-Risk Residents With Pressure Ulcers (Long Stay)
NQF: 0679
High-risk determination
MDS 3.0 QM
Five-Star Quality Rating System
Percent of Low Risk Residents Who Lose Control of Their Bowel or Bladder (Long Stay)
NQF #0685
MDS 3.0 QM
Percent of Residents Whose Need for Help with Activities of Daily Living Has Increased (Long Stay)
NQF #0688
MDS 3.0 QM
Five-Star Quality Rating System
Percent of Residents Whose Ability to Move Independently Worsened (Long Stay)
NQF: None
Numerator and covariates
MDS 3.0 QM
Five-Star Quality Rating System
Number of Hospitalizations per 1,000 Long-Stay Resident Days
NHC Claims-Based QM Five-Star Quality Rating System
Number of Outpatient Emergency Department Visits per 1,000 Long-Stay Resident Days
NHC Claims-Based QM Five-Star Quality Rating System
Percentage of Short-Stay Residents Who Have had an Outpatient Emergency Department Visit
NHC Claims-Based QM Five-Star Quality Rating System
Percentage of Short-Stay Residents Who Were Re-Hospitalized after a Nursing Home Admission
NHC Claims-Based QM, Five-Star Quality Rating System


Leadership Considerations:

For now, facilities need to focus on diagnosis coding, and following the various rules that affect diagnosis sequencing and management, such as the RAI manual, the Medicare Claims processing manual, The Medicare benefit Policy manual and the ICD-10 CM Official Coding Guidelines.

  1. In states that use RUG-III or RUG-IV for Medicaid reimbursement, pay close attention for announcements from the state Medicaid agency and the state RAI Coordinator regarding any changes.
  2. Look at current supporting documentation systems for Sections G and GG and use a QAPI process for identifying strengths, weaknesses, and opportunities for improvements.
  3. The Interdisciplinary Team should be fluent regarding MDS coding instructions, documentation requirements, quality measure impact, and reimbursement. Invest in the education of the staff.
  4. The Leadership Team should be fluent regarding federal and state regulatory requirements associated with assessments and care planning as well as the provider and public QMs and their data sources.
  5. Follow the news for your State with your local nursing home professional organization. Feel free to reach out to your State MDS Coordinator with your questions.
  6.  Stay tuned to Pathway Health communication for educational opportunities as CMS releases more information about the coming changes.

NOTE: When CMS released the DRAFT version of the 2020 MDS item sets on December 20, 2019, they also stated the MDS 3.0 Item Set Change History for October 2020 report would be posted to their website shortly.  On January 23, 2020, a CMS press release announced the 43-page DRAFT document was ready.

Providers can download the sets and the change history at keeping in mind both are DRAFT documents.

Pathway Health consulting services provide your organization the expertise to enhance reimbursement, minimize risk and ensure quality clinical outcomes to reach your desired goals.

Visit or 877-777-5463. 


Karolee Alexander
Director of Reimbursement and Clinical Consulting

Louann A. Lawson
BA, RN, RAC-CT Clinical Reimbursement Team Leader/Clinical Educator



Pathway Perspectives: 2020 Leadershifts


Change. A new decade…new reality! Everything we read, hear and talk about in post-acute care is change. So how does a leader do more than just hang on and survive in this ever-changing, fast-moving environment? The key is to learn how to make ongoing leadershifts.”1

“You cannot be the same, think the same and act the same if you hope to be successful in a world that does not remain the same.”-John C. Maxwell.

Maxwell identifies the following leadershifts to achieve personal and organizational growth:

The Focus Shift – Soloist to Conductor: Great leaders used to be top producers. Tomorrow’s leaders need to orchestrate groups.

The Personal Development Shift – Goals to Growth: Goals help you do better but growth lets you become better. Leaders are growth oriented.

The Cost Shift – Perks to Price: Great leaders don’t think about what they can get. They’re focused on what they can give.

The Relational Shift – Pleasing People to Challenging People: You cannot lead people if you need them. Great leaders challenge their teams to do better all the time.

The Abundance Shift – Maintaining toCreating: Have the mindset you want to move things forward rather than standing still. Be a creator.

The Reproduction Shift – Ladder Climbing to Ladder Building: Forget about ladder climbing. Help others build and ascend their own ladders. Be an equipper.

The Communication Shift – Directing to Connecting: Great leaders don’t order people around. They connect, influence and help people.

The Improvement Shift – Team Uniformity to Team Diversity: Great leaders value diversity highly. Do everything you can to bring people into your teams who are different.

The Influence Shift – Positional Authority to Moral Authority: A leadership position does not give you leadership authority. You have to earn moral authority.

The Impact Shift – Trained Leaders to Transformational Leaders: Don’t settle for being a trained leader. Become a transformational leader who inspires change.

The Passion Shift – Career to Calling: Don’t look at leadership as a career. Make it your calling. Find your purpose and you’ll never look back.



What is your leadershift vision for 2020? As health care leaders we must evaluate, plan and implement strategies and operational processes to exceed the expectations of today’s environment and position for the future. We need to leadershift in order to positively enhance personal and organizational growth. Consider the following:

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

How – Consider how an initiative will move our organization forward. Challenge your team to determine the systems, processes, services, and resources needed, refined or changed due to the reimbursement, regulatory and quality changes throughout 2020, and beyond.

Information – In order to inspire change, arm your team with information. Review current organization data and the confidential reports from CMS. Align your current data outcomes with the proposed changes. Additionally, identify organization trends, variances, spikes in outcomes and the current impact to clinical, operational and financial outcomes.

Formulate – Based upon your review of the upcoming changes, organization readiness and key data insights, develop an action plan with your team. Determine priorities that immediate (which will have a serious and immediate negative impact) vs. important (that which needs to be accomplished to support personal and organizational success).

Team – Be a transformational leader who challenges your team. Make an impact by bringing together people who have different perspectives. Equip others to find purpose in all they do.


With the health care environment increasing in complexity and transforming the way we implement leadershifts is the key to ongoing success in 2020, and beyond.

1. Leadershift: The 11 Essential Changes Every Leader Must Embrace. John C. Maxwell. 2019

Lisa Thomson
Chief Strategy and Marketing Office

Pathway Health provides the insight, expertise and knowledge to keep your organization on the right path.  

Visit or 877-777-5463. 


International Infection Prevention Week

October 13-19 marks International Infection Prevention Week. This year’s tagline, “Vaccines are Everybody’s Business,” underscores the importance of re-evaluating your systems on Infection Prevention and Control AND the importance of vaccines.

Also, Infection Prevention and Control (F880) continues to be the #1 most frequently cited F-tag across the U.S.

It is estimated that 90 percent of seasonal influenza-related deaths and more than 60 percent of seasonal influenza-related hospitalizations in the United States each year occur in people 65 years and older.[1] Hospitalizations also are often sentinel events in this population group, precipitating disability and potentially resulting in loss of the ability to live independently.


Did You Know?

  • 1 to 3 million serious infections occur every year in SNFs.
  • Infections include urinary tract infection, diarrheal diseases, antibiotic-resistant staph infections and many others.
  • Infections are a major cause of hospitalization and death; as many as 380,000 people die of these infections each year.[2]

As clinical leaders, it is vital to keep up-to-date on the latest infection prevention and control resources in order to achieve positive outcomes for those we serve. What follows are a few of my suggested resources as you prepare for the upcoming influenza season:


Immunization Guidance Resources:


Infection Prevention and Control Resources:


Hand Hygiene Resources:


Other Resources:

Leadership Considerations

Having a well-written and effective infection prevention and control plan is key to success. Consider the following:

  • Review the new guidance areas for infection prevention and control.
  • Determine facility updates to policies, procedures and protocols.
  • Meet with your Medical Director to discuss updates.
  • Good hand hygiene continues to be instrumental in the spread of infection, especially as we are entering the cold and influenza season. This is a perfect time to re-educate all residents, employees, volunteers and visitors on hand hygiene.
  • Educate employees, residents, resident representatives and visitors on the updates to facility system.


Pathway Health can assist facilities with education and resources for your Infection Prevention and Control Program to include:


Need assistance with infection control processes, systems and training?
Pathway Health’s team of experts and trainers are ready to assist.
Contact us today.


Director of Education


Are You Ready? PDPM is on the Horizon

PDPM will become effective in a little more than three weeks, on October 1, 2019. Is your team ready for this substantial change?

Below are a few leadership considerations as providers transition to this new payment model:

1. Identify the Medicare coverage criteria are met throughout the Resident’s Stay.

Providers can no longer rely upon the RUGs categories as a guide in determining the Medicare coverage criteria met by the resident’s stay. The Centers for Medicare and Medicaid Services (CMS) has provided information surrounding PDPM components that meet the Administrative Presumption of Coverage rules in the recently released Fact Sheet. The Administrative Presumption of Coverage is effective until the Assessment Reference Date (ARD) of the first Medicare MDS. Learn more: Download the Fact Sheet.

Because most Medicare stays have been billed at Rehab RUGS categories, providers are not accustomed to thinking about all five of the Medicare Clinical Coverage Criteria (Skilled Rehab, Skilled Nursing, Assessment and Observation, Management of a Plan of Care and Teaching and Training). Consider the following:

  • Identify ALL of the clinical coverage criteria met at admission.
  • Review that coverage criteria met at each weekly Medicare meeting.
  • When a resident’s stay no longer meets any coverage criteria, issue a beneficiary notice of non-coverage.
  • The clinical coverage criteria are described in detail in the Medicare Benefit Policy Manual, Chapter 8. Review by clicking here.

2. Understand the ICD 10-CM Official Coding Guidelines.

The entire interdisciplinary team (IDT) needs to have a working knowledge of the coding guidelines to understand the selection of the Primary Diagnosis, which impacts three of the five case-mix adjusted PDPM components. Download the 2020 ICD 10-CM Official Coding Guidelines.

There are specific diagnosis codes that are allowed for Speech-Language Pathology (SLP) co-morbidities and Non-therapy Ancillary (NTA) items.

Download information CMS published regarding the diagnosis code mapping for Clinical Condition Categories, SLP co-morbidities, and NTA.

3. Identify the Primary Diagnosis and Co-Morbidities.

The most effective identification of the Primary Diagnosis is made through collaboration by the IDT. It is possible that more than one condition treated in the proximal hospital stay will meet the definition from the Official Coding Guidelines for Primary Diagnosis. The IDT can discuss the reason for the resident’s Medicare stay and agree upon the appropriate Primary Diagnosis. The Primary Diagnosis and active co-morbid conditions should be integrated into admission assessments, care plans, and daily skilled charting to support Medicare billing. There are definitions for these terms in the Official Coding Guidelines.

4. Understand the new Interrupted Stay Policy.

With the implementation of the PDPM classification system, CMS will also implement a new Interrupted Stay policy. Under this policy, a resident who ends their Medicare stay, either by a non-coverage notice or by discharging from the SNF, and resumes care in the same SNF before midnight of the third non-covered day, will restart their stay where they left Medicare coverage. Read the below examples:

  • If a resident is admitted to the SNF, goes to the hospital on Day 3 for two midnights, and returns to the SNF before midnight of the third day, the resident will have a continuation of the prior Medicare stay. There will not be a new 5-day MDS completed, and the Variable Per Diem Adjustment calendar continues from Day 5.
  • If a resident is admitted to the SNF and goes to the hospital on Day 3 for four midnights, and returns to the SNF on Day 5, this will be a new Medicare stay upon return. A new 5-day MDS will be completed after re-entry and the Variable Per Diem Adjustment calendar will reset to Day 1.

CMS provided clarification of the Interrupted Stay Policy in a revised Fact Sheet. Download the Fact Sheet from CMS

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


Staff Competency Starts with Knowing Your KSAs

The complexity of the health care environment requires that staff in the facility participate in educational programs that ensure they have the knowledge, skills and abilities (KSAs) to provide individualized care promoting the health, safety and welfare of the resident population.

There are competencies required by federal nursing home regulations, state nursing home regulations and other governing institutions for persons working in healthcare organizations. Some of the organizations overseeing rules and laws that apply to staff and leaders include the Occupational Health and Safety Administration, the U.S. Equal Employment Opportunity Commission, the Medicare and Medicaid Integrity Program, State and Federal labor laws, State and Federal Building codes, and practice rules for licensed, certified and registered professionals.

The Requirements of Participation outline specific competencies needed by nursing and all staff within a facility. The Implementation Checklist outlines the specific F Tags in which nursing staff and all staff competencies are described. Designing training and education programs, that coordinate with resident population needs, facility requirements, state and federal regulations and standards of practice, is expected. The overall premise is that staff have the knowledge, skills and resources to provide care and services to the resident population.

Need to Know Definitions:

Competency – is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. This is not dependent solely upon qualifications or licensure.[1]

Knowledge, Skills and Abilities (KSAs) – KSAs are knowledge, skills, and abilities that a staff member needs to possess in order to perform the duties of their position, aligning with their respective roles and responsibilities.

Knowledge – the understanding of concepts, the subjects, topics, and items of information that a staff member should know at the time of employment, annually or as determined necessary.

Skills – capabilities or proficiencies developed through training or hands-on experience. Skills should be measurable and observable.

Abilities – traits or talents that a person brings to their role or the facility or the job position.

All personnel who work in a long-term care facility are required to have specific knowledge and demonstrate their understanding of specific topics. There are many types of competencies expected of health care team members. While research indicates numerous functional and core competencies, skilled nursing facilities have specific competencies that are:

  • Mandatory for all Staff – These include the mandatory competencies from the Requirements of Participation
    • Preventing and reporting abuse, neglect, and exploitation
    • Change of Condition identification and notification
    • Dementia management
    • Infection Control
    • Resident rights
    • Person-centered care
    • Communication
    • Cultural competency
    • Other areas as identified through the Facility Assessment
    • HIPAA
    • QAPI
    • Emergency response (Fires, etc.)
    • Fall Prevention
    • Operation of exit alarms
    • Reporting changes in residents’ conditions
    • Competencies identified by the assessment of residents’ needs
    • OSHA
  • Mandatory for Nursing Staff – In addition to the mandatory competencies for all staff, the RoP outlines other nursing competencies
    • Competencies related to an approved nurse aide training and evaluation program
    • Medication management
    • Basic nursing skills
    • Basic restorative services
    • Skin and wound care
    • Pain management
  • Clinical Knowledge – Standards of Practice
  • Core Clinical Competencies
    • Clinical systems
    • Incident/Accident
    • Dialysis
    • Nutrition
    • Physical Assessment
    • MDS Process and Care Planning
    • Respiratory care
    • Other areas as identified through the Facility Assessment
  • Annual Training Requirements and Competencies – Per federal, state and job specific requirements
  • Facility Identified Competencies
    • Other areas as identified through the Facility Assessment
    • Facility Mission and Strategic Goals
    • Market place needs
    • Partnership requirements and expectations
    • Quality outcomes
    • QAPI outcomes and PIPs
  • State-Specific Requirements, as applicable

Leadership Considerations

The above is not an all-encompassing list; rather, providers must review its served resident population, clinical systems, technology, resources and standards of practice to develop the competency requirements for licensed and non-licensed staff.

  1. Providers must identify the residents’ needs and determine, beyond the required topics, what knowledge, skills, abilities, behaviors and other characteristics are needed.
  2. For each job category, determine the mandatory and core competencies necessary for optimal performance and quality outcomes. These competencies need to align with the respective job description.
  3. To determine competency levels and needs for staff, facility leaders may follow the below general process to target specific competencies and training needs, including:
    • Based upon the facility assessment and mandatory requirements
    • Competencies are related to your facility mission
    • Current policies and procedures for resident care and quality outcomes
    • Utilize policies and procedures as a foundation for competency development
    • Follow the KSA approach needed for individual performance and improvement needs
    • Incorporate competency process into your overall training plan
    • Align competencies with staff job descriptions
    • Incorporate competency review and monitoring process per the facility Quality Assurance and Performance Improvement Plan

Competence is a complex concept, especially in health care. At the very least, competency in health care requires evaluation of both an employee’s ability to meet job expectations and subsequently to deliver continuous, effective care and quality outcomes for your residents.


Director of Education


[1]Centers for Medicare & Medicaid Services State Operations Manual, Appendix PP – Guidance to Surveyors for Long Term Care Facilities (Rev. 173, 11-22-17):


Pathway Health provides your organization the insight, expertise and knowledge to help ensure quality clinical outcomes to reach your desired goals.

Visit or 877-777-5463.




Tick, Tock…PDPM is Fast Approaching!

The Medicare payment classification system change to 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.

There will be no transition period to PDPM. Nursing facilities need to perfect their systems that impact PDPM now. Help your team prepare with the following 90-day plan:

Click to download tool>

July 2019: Educate and Review

  • Complete staff education about the PDPM classification system and ICD10 CM Official Coding Guidelines for admissions staff, billing staff, MDS staff, social workers, nurse leaders, HIM staff, Case management staff and Administrative staff.
  • Review Medicare technical and clinical coverage criteria, as they have not changed.
  • List changes to make to standard clinical document:
    • Update the pre-admission intake forms to collect primary diagnosis and other co-morbidities.
    • Identify a PDPM estimator for use with pre-admission reviews.
    • Update discipline-specific Admission assessments to refer to the clinical conditions used in the PDPM classification system.
    • Update daily skilled nursing charting format to refer to the clinical conditions used in the PDPM classification system.
    • Revise the Medicare meeting agenda to review the skilled residents’ progress toward goals related to their clinical conditions.

August 2019: Identify and Revise

  • Determine changes needed to the E.H.R. care plan library to capture the monitoring and treatment provided for residents’ clinical conditions.
  • Review Medicare Advantage contracts to validate payment structures and confirm the internal processes for calculating RUG categories, if relevant for Medicare Advantage plan billing.
  • Identify the mechanisms to monitor and decide about completing an Interim Payment Assessment.
  • Write and revise policies and procedures for managing the PDPM system:
    • Interim Payment Assessment criteria and process
    • Use of the Other State Assessment item set
  • Review and revise as needed, the assignments of MDS section completion (e.g., Section I, Section K, and Section O).
  • Review diagnosis codes and sequencing for Medicare Part A stays.

September 2019: Monitor and Implement

  • Begin to estimate PDPM payments for new Medicare Part A admissions.
  • Monitor the number of Medicare Part A admissions to plan for transition IPA scheduling.
  • On September 25, identify the residents expected to still be in the facility on October 1, 2019. Review their diagnosis codes and sequencing. Review Section GG coding and each resident’s current status.
  • On September 28, schedule Interim IPA assessments with ARD between October 1 and October 8.

Click here to download and print the complementary tool.

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


Trauma-Informed Care with LeadingAge Kansas

Pathway Health’s Leah Killian-Smith presents the first installation of the new 4-part webinar series hosted by LeadingAge Kansas on trauma-informed care. The webinar, titled, “Overview of Behavioral Health Services,” will provide participants with information on the new requirements for behavioral health services.

The information provided will give providers the definitions of behavioral health disorders and ways to help the resident attain or maintain the highest practicable mental and psychosocial well-being.


  • Describe and clarify terminology related to behavioral health services
  • Identify how to determine if a resident needs specialized services for behavioral health
  • Learn three leadership strategies for providing behavioral health services for residents

The webinar will take place on April 4 starting at 2 p.m.

Check out more educational opportunities from Pathway Health »


The Heart of Health Care: The Many Roles of Nursing Leaders in Post-Acute Care

In today’s vastly changing health care environment, the role of nursing leadership is one thing that remains consistent. It is and always will be the heart of health care.

My role as an operational leader was to set the strategic direction of the organization while working side-by-side with my nursing leader. I found organizational success unattainable without the contributions of my nursing leader and her team.

Nursing leaders focus on setting standards, setting policy, dealing with compliance, and overseeing quality measures and clinical outcomes. They spearhead innovation and transformation within their teams and the organization as a whole.

As I reflect on my career, and the dynamic nurse leaders that I have had the opportunity to work with, I note the following are the cornerstones of successful nursing leaders:


Nursing leaders provide direction for their department while holding staff accountable. Nursing leaders oversee many responsibilities, including:

  • resident care delivery
  • customer and staff satisfaction
  • clinical processes
  • compliance
  • financial outcomes


Nursing leaders continually expand their knowledge and understanding of industry changes. Their main goal is caring for our residents. Staying on top of the changes that affect the organization can challenge nursing leaders. It is important that nursing leaders continue accessing education, tools and outside resources. Education provides a level of support for their organizations’ priorities, as well as expected outcomes.

Translating the information and knowledge into organizational best practice is another responsibility. Aligning industry changes with facility and department goals helps to relieve some of the pressure felt by nursing leaders. Implementing best practices allow nursing leaders to focus on targeted, high-level priorities and clinical processes for successful outcomes.

Align Talent and Clinical Success

Nursing leaders continue to work with their team at all levels. They identify the knowledge, skills and abilities of their team. Then, they align those talents with the clinical priorities of their organization. This allows for ongoing mentorship and development of future nursing leaders. Successful nursing leaders help build upon their success by surrounding themselves with an amazing team. Team building is essential to leading a diverse group of people with distinct personalities and skills. Fostering an environment of collaboration and professional growth is a key strategy for successful nursing leaders.

Motivate and Innovate

Given all the changes faced by nursing leaders, they possess a unique ability to motivate staff, especially in times of challenge. They know when to talk and when to listen. They are often confident and optimistic while inspiring enthusiasm in those around them. Today’s nursing leaders also spark and support innovation, knowing change is necessary to succeed in the new health care environment.


Being a leader is an amazing journey. It continues to provide opportunities for innovation, as well as personal and professional growth. Working next to dynamic nursing leaders in post-acute care is an honor and a privilege. Thank you for being at the center of our organizations, and for being the heart of health care.


Happy Valentine’s Day!


Lisa Thomson

Chief Strategy and Marketing Officer


Contact Pathway Health for more information on how we can expand the education and expertise of your long term care staff.


A Case Study for Quality Outcomes with LeadingAge KS

Don’t miss the webinar presented by Pathway Health’s Leah Killian-Smith on culturally competent actions and procedures within nursing facilities.

The event, titled “QAPI– A Case Study for Quality Outcomes,” is part of a series hosted by LeadingAge Kansas that breaks down new regulations in order to prepare nursing facilities for changes that go into effect November 28, 2019.

Tune in on February 19 from 2:00-3:00 p.m., and gain the following insight:

  • Build upon lessons from earlier event titled, “5 Elements of QAPI Interactive Workshop,” presented in January 2019
  • Perform a root cause analysis of your existing procedures in quality assurance and performance standards
  • Identify an area of deficient practice and work through systems review and improvement.

Register for the event here.



What Do You Really Need to Do Now to Prepare for PDPM?

When the Medicare payment model changes for nursing homes on October 1, 2019, the drivers of reimbursement will be dramatically changed. Under the current payment model, the amount of therapy provided to the resident in a seven-day period is the major determinant of the amount of daily payment the nursing home will receive from Medicare. Additionally, the resident’s level of dependence in activities of daily living (ADL) impacts the final payment category and amount. The higher the level of ADL dependence, the higher the payment rate. The nursing assistant staff documents the supporting charting of each resident’s ADL dependence level.

The new payment model, Patient-Driven Payment Model (PDPM), uses the resident’s clinical conditions as the main determinant of payment. The resident’s ADL dependence score is derived from an area of the Minimum Data Set (MDS) that is assessed and documented by the professional staff. There is no impact on the payment rate from the amount of therapy services provided. Payment is higher in the Physical Therapy (PT) and Occupational Therapy (OT) components of PDPM for residents who require some ADL help but are not totally dependent. These residents are more likely to be able to participate in and benefit from therapy services.

The PDPM system is comprised of six components:

  1. Non-Case-Mix Base Rate
  2. Physical Therapy
  3. Occupational Therapy
  4. Speech therapy
  5. Skilled Nursing
  6. Non-therapy Ancillary

Each component is scored separately and has federally established rates for each Case-Mix category in the component. The Case-Mix rates for each component are summed to establish the overall daily payment rate for the resident’s skilled stay under Medicare Part A.

There will be no transition period to PDPM. On September 30, 2019, Medicare payment will be from the RUG-IV classification system. On October 1, 2019, Medicare payment will be determined by a new MDS that established the PDPM payment rate. Because there will be no transition, nursing facilities need to perfect their systems that impact PDPM now.

The triad of systems, or M-I-P, that support PDPM are highlighted below:

  • MDS coding accuracy, especially in Section GG, functional performance and Section I, diagnoses
  • ICD-10 diagnosis coding accuracy and management
  • Pre-bill claim check review

MDS Coding – 

Section GG of the MDS was added in October 2017. Confusion remains about the best process for obtaining an accurate assessment of the resident’s USUAL performance in the first three days and last three days of their Medicare stay. The most effective approach is to have the nursing and therapy staff collaborate on coding Section GG. If the resident only performs the activity in therapy, that is the resident’s usual performance. If the resident performs the activity multiple times per day with nursing staff and only once with therapy, the resident’s performance with nursing staff best represents their usual performance.

ICD-10 Diagnosis Coding – 

Section I of the MDS is dependent upon accurate ICD-10 diagnosis coding and management so that the MDS and the Medicare claim contain the same information in the same order. There are few resources for staff education for ICD-10 coding for nursing homes. Most nursing facilities do not have a professionally certified medical coder on staff. Ensure that the staff responsible for coding understands the Official Coding Guidelines as published by the CMS and NCHS.

Download here.


Most clinical software used in nursing homes automatically enters the diagnosis codes onto the bill. There must be processes in place to ensure that the admitting and primary diagnoses are entered in the correct location on the bill and the coded conditions entered on the bill provide the clinical “story” that supports the amount being billed.

Pre-bill Claim Review – 

Pre-bill Claim Review involves an interdisciplinary team process that starts with the draft bill or claim and validates the information on the bill as well as the supporting documentation in the resident’s medical record. When this process is conducted effectively, the facility submits a “clean claim” that is a much lower risk for audit or medical review, thus is paid quickly and accurately.

PDPM Solutions to Start Preparing Now

Pathway Health PDPM experts can assess your facility’s M-I-P systems 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.

 PDPM Solutions

New! Complimentary PDPM Resource

Non-Therapy Ancillary Condition/Extensive Services Tool – PDPM – DOWNLOADABLE

The Non-Therapy Ancillary (NTA) component of PDPM presents an opportunity to capture reimbursement for resident comorbidities and special treatments. This one-page tool is a quick reference to those items that qualify in the NTA component of PDPM. Download now>


Karolee Alexander,
Director of Reimbursement and Clinical Consulting,
Pathway Health