Appeals & Compliance

Can Therapy Documentation be Effective in Overturning Unfavorable PDPM Medical Reviews?

Coding of Section GG and Section K on the MDS supports two of the main drivers of the PDPM payment – PT/OT CMG and ST CMG. Completion of the MDS must be supported by documentation in the Medical Record, which includes documentation completed by a PT, OT, or ST.

Therapy documentation can not only support the coding, but also be beneficial in the event the CMG reviewed, denied, and subsequently requires an appeal of non-covered services. Non-covered services may be a full denial of the CMG billed or partial denial or “downcode” of the CMG to a lower rate, such as a changing the PT/OT CMG from TK to TI. “Downcoding” or “re-coding” may occur if the medical record does not support the patient status recorded on the MDS.

Documentation that supports patient performance in daily notes or provides additional clarification of normal performance into the episode of care can be the information needed to overturn a modified PT/OT CMG.

Inclusion of a comprehensive diet assessment, interview with the patient, family, or staff, a standardized test, or documentation of a concern that develops outside of the initial treatment session can provide the information that may be the difference in a ST CMG of SF instead of a SD. Include examples such as food feeling “stuck,” feeling full, difficulty with specific types of foods or medication, or excessive heartburn to provide a clear picture of the impact of swallowing difficulties. Consider deficits that may be present but are managed by diet, have not changed, or do not require ST intervention during the current skilled stay.

Supporting Section GG and Section K coding goes beyond the plan of care and the computation of the CMG. Comprehensive, patient specific documentation can provide the needed support for the CMG in the event the claim becomes part of a medical review. That same documentation can overturn a “downcode” of the CMG during an appeal.

During an appeal, daily documentation may be highlighted if it includes the patient’s needed level of assistance for brushing their teeth during the second OT treatment session or the ability to ambulate 150 feet on day 3, when that item was coded “unable” during the evaluation. Support for Section K could be ST report that during a treatment session, significant residue was noted following the completion of a meal that contain mixed consistencies.

Look beyond the plan of care for ongoing support of the MDS, CMG, and Section GG and K coding. Document Section GG and K examples in progress notes, daily notes, updated plans of care, and discharge summaries to capture functional performance throughout the episode of care.

One statement included in the therapy documentation can be the support needed to ensure approval of the CMG, overturn denials, and allow payment for services at the appropriate rate.