Nursing Documentation Requirements Under PDPM: What isn’t new

Written by Denise Wassenaar, RN, MS, LNHA, VP Clinical & Regulatory Affairs & CCO

Denise Wassenaar

Over the past 20 years, patients leaving an acute-care setting were presumed to be covered for skilled services through the need of rehabilitation services. Consequently, the burden of documentation demonstrating the need for skilled services was met by therapists.

Effective with the implementation of PDPM on October 1, 2019, the documentation burden will begin to shift to nursing as patients entering skilled nursing facilities from acute care are admitted with the presumption of coverage for skilled nursing services.

The Medicare Benefit Policy Manual “Coverage of Extended Care (SNF) Services” clearly outlines the requirements for coverage and subsequent documentation when a patient is admitted for skilled nursing services1. None of this is new because of PDPM, but as stated previously, this burden has been historically met by therapy.

When performing Medicare charting keep in mind the following:

  • Nursing documentation must reflect the need for the continuation of skilled care.
  • Nursing staff must document on Medicare A residents at least once every 24 hours and more often if warranted by a resident’s condition.
  • Documentation should include vital signs, why the resident is receiving skilled services and a detailed description of the resident’s condition at that time.
  • Documentation should be specific to the clinical reasons for coverage, services delivered, and response to care.

There are four principle skilled nursing services that require Medicare charting:

    1. Management and Evaluation of a Care Plan
      • The development, management, and evaluation of a patient care plan, based on the physician’s orders and supporting documentation, constitute skilled nursing services.
      • Nurses need to document the services that require the involvement of skilled nursing personnel to meet the patient’s medical needs, promote recovery, and ensure medical safety.
    2. Observation and Assessment of a Patient’s Condition
      • Documentation must reflect when the likelihood of change in a patient’s condition requires skilled nursing to identify and evaluate the patient’s need for possible modification of treatment or initiation of additional medical procedures, until the patient’s condition is essentially stabilized.
    3. Teaching and Training Activities
      • The documentation must thoroughly describe all efforts that have been made to educate the patient/caregiver and their responses to the training.
      • The medical record should also describe the reason for the failure of any educational attempts, if applicable.
      • Topics of teaching include colostomy care, insulin administration, prosthesis management, catheter care, G-tube feedings, IV access sites, and wound care.
    4. Direct Skilled Nursing Services to Patients
      • Nursing services are considered skilled when they are so inherently complex that they only can be safely and effectively performed by, or under the supervision of, a registered nurse or, when provided by regulation, a licensed practical (vocational) nurse.
      • Some examples of direct skilled nursing services are IV feeding (must meet criteria), IV meds, suctioning, tracheostomy care, rehabilitation nursing procedures, ulcer care, tube feedings, care for surgical wounds, and diabetes management with injections.

In preparation for the anticipated need for increased nursing documentation related to PDPM, the clinical leaders of MatrixCare are reviewing current documentation resources and identifying gaps. This will be a continuous improvement process in which we will seek your guidance to ensure we are developing in the right direction. Look for invitations from Kim Mulquin-Shumway, Senior Clinical Content Specialist, to participate in an upcoming CAB meeting related to clinical documentation.

1 30.3 Direct Skilled Nursing Services to Patients (Rev.179, Issued: 01-14-14, Effective: 01-07-04, Implementation: 01-07-14) A3-3132.2, SNF-214.2

PDPM Highlights from Directions in Nashville

Written by Amy Ostrem, VP Skilled Nursing Solution Strategy and Jessica Stagg, Product Manager

From “Everything Will Be Alright” with PDPM to “Guitars, Cadillacs, and PDPM” we had a blast sharing and discussing everything PDPM with you in Nashville during the education sessions! The panel discussions, client-led presentations, CEUs, and new feature sharing specific to MatrixCare was so well attended that some presentations ended up as standing room only. We’d like to highlight a few of the hottest topics discussed:

  • PDPM and Care Planning: It’s All About Outcomes! “Take Me Home, Country Roads” with Section GG. In this session, clients Cheryl Ahlberg and Christina Ray both with nearly two decades of nurse consulting experience, discussed section GG in detail. Since items from section GG will be used to calculate the functional score, and this score will replace the ADL score, all attendees were fully engaged. For section GG, in their facility, nursing, the resident, the family, and therapy participate in contributing to the initial three-day observation period. Emphasis was also placed on preparing for discharge: having the entire interdisciplinary team, as well as the resident and family, participate in determining the discharge goals, the date of discharge, and the goals that are most important. Then, throughout the stay, the care team can evaluate things like “are these goals and dates realistic for this resident?” During the session, we had a sneak peek at:
    • CareAssist versus the older Generation 1 Point of Care offering and how they differ around section GG (there is further improved workflow in CareAssist).
    • The NEW Discharge Summary feature in the MC SNF May/June 2019 R2 release.

    The key takeaway of the group discussion was around the CNAs and limiting the questions they are responsible for and limiting those through the configuration options. For example, facilities may want to consider having nursing or therapy evaluate car transfers, rather than aides. The same goes for evaluating capabilities with steps. To ensure the appropriately skilled clinicians are evaluating the resident’s functional status, MatrixCare offers Observations or Assessments that contain all Section GG questions. Taking those tasks off the aide’s plate with a configurable system like MatrixCare will help you maximize the results shared to the MDS, keep CNAs focused on their true daily tasks, and allow you the best possible outcomes.

  • Transformational Insights Preparing for PDPM. In this session, five clients participated in an interactive panel to share highlights of key things they are dealing with and recommending regarding PDPM.
    • It starts at the beginning with those first critical days and the 5-Day Assessment.
      • Share the ARD Date widely. Involve the interdisciplinary team. Work to train coders to navigate to the best ICD-10, and better yet, identify a Super Coder in your organization who people can go to with questions on selecting the best ICD-10.
      • Consider an interview sheet for the MDS coordinator to walk through with the CNAs. Since that initial 5-day assessment is so critical, a quick discussion rather than relying solely on POC tracking data could bring a world of clarity to maximize the MDS.
      • Consider requiring an Observation Assessment form for the first three days for each shift. Use the documentation captured to analyze and then discuss around the table to again maximize the highly critical, initial 5-day MDS.
    • Initiate changes to your daily medicare meeting. Since minutes no longer need to be tracked, think through the agenda and how your daily meetings should change.
    • Focus documentation on the clinical categories. Help and encourage floor staff nurses to understand that their documentation must relate to the leading clinical category for each resident.
    • Discuss daily changes as a team. Discuss when the time is right to do an IPA assessment for a potential increase in the reimbursement rate.
    • Use the data. Be sure you are reviewing clinical data at regular and frequent intervals starting at admission up until the resident’s planned discharge date to ensure they are progressing toward their goals.
    • Start evaluating charting for your organization now! Identify where you need more documentation and where you need less documentation. For example, decreased ADL charting and increased Functional Score charting.
    • Work with hospitals and strengthen your partnership. Educate them why the information is so critical to your organization and how you will work to prevent readmission. See if you can get a login to their system to look for ICD-10s and other data.
    • Restorative Nursing. Look into resurrecting restorative nursing. Be sure you are teaching residents how to do their injections. Emphasize the importance of collaboration between therapy and restorative folks.
    • Have your MDS Coordinator involved in the admission process more than ever before.
    • Make sure physicians and NP/PAs are trained on PDPM.

It was wonderful to see so many operators openly sharing and working together toward PDPM. MatrixCare will continue to encourage this through our thought leadership, educational webinars, focus groups, and providing early access to a prerelease environment where you can practice filling out IPA assessments in preparation for that critical first week of October. Your success is our success here at MatrixCare. We are always open to receiving your hard questions, expert ideas, and suggestions along the way; email them to us at

Thank You for Making MatrixCare Directions 2019 a Huge Success!

MatrixCare Directions 2019, which took place in Nashville, April 24th-26th—broke all company records in terms of client attendance, prospect attendance, partner sponsors, and programming content.

The event began with an exclusive invitation-only CIO Digital Health Summit on Tuesday, followed by two and a half days of programming, with multiple tracks and a total of 108 total sessions. More than 30 of these incorporated ways to succeed under PDPM. In addition, 29 partner organizations, including many Fortune 100 companies, participated in the MatrixCare Partner Pavilion.

Access the MatrixCare Client Community to view and download presentations across the various tracks. Our guest keynote speaker, Jerry Bridge, led a powerful session on dramatically reducing caregiver turnover, fatigue, and burnout. We encourage you to download his presentation Leadership, Culture, & Well-Being to review the actionable insights and best practices he shared. A recording of this presentation is also available in the Client Community.

Product News

ICD-10 Diagnosis Clinical Category Now Available

As part of the SigmaCare by MatrixCare 2018 R6 (22.2) release, you can now see the corresponding ICD-10 diagnosis’ clinical category, so you can properly select, rank, and bill for the resident’s correct diagnosis. When you add or edit an ICD-10, the Clinical Category now appears next to the Diagnosis description. This new feature will help you identify your skilled nursing resident’s with clinical categories that affect their PDPM score for Medicare Part A coverage, with MDS 3.0 assessment ARDs starting on October 1, 2019.

The following clinical diagnosis categories are identified:

  • Acute Infection
  • Acute Neurologic
  • Cancer
  • Cardiovascular and Coagulations
  • Major Joint Replacement or Spinal Surgery
  • Medical Management
  • Non-Surgical Orthopedic / Musculoskeletal
  • Non-Orthopedic Surgery
  • Orthopedic Surgery (Except Major Joint Replacement or Spinal Surgery)
  • Pulmonary

Upon upgrade, all active residents that have a primary diagnosis identified that falls into a Clinical Category will also be identified as the Primary Clinical Category.

For more information on the ICD-10 Diagnosis Clinical Category and other new enhancements, access the 2018 R6 (22.2) Release Tools available in the MatrixCare Client Community.

Frequently Asked Questions and Helpful Tips

In the 2018 R5 (22.1) release of SigmaCare by MatrixCare, we introduced an Outbound ADT Interface Error row to the General Dashboard Notification Box. This allows the facility to monitor the message status of any outbound ADT interfaces. The row displays a count of the errors for each corresponding interface type within the past five days.

Note: If your facility does not have an outbound ADT interface, this row will not appear.

Superior Interoperability with Best in KLAS Revenue Cycle Management Software

The MatrixCare platform allows for the sharing of information between your SigmaCare by MatrixCare Care Management (CM) and MatrixCare Revenue Cycle Management (MC RCM) solutions. At MatrixCare, we understand that the efficiencies provided by interoperability are no longer a luxury, time savings and information sharing are critical drivers of the quality of care delivered and the success of your business. The CM and the MC RCM solutions, when used together, can maximize your organization’s workflow and minimize data entry between your clinical, admissions, and billing staff, ensuring consistent information across the platform.

Census Synchronization

Preadmission information that is entered in CM, or generated from ReferralConnect, will create a face sheet for a resident in MC RCM. When the resident is admitted in CM, the attending physician will be automatically assigned, and the admission census event added in MC RCM.

To ensure the utmost synchronization of your census, the following events are managed in CM and will be reflected in MC RCM:

  • Room Changes
  • Attending Physician Changes
  • Hospital Transfers and Returns in CM will create Hospital Leave and Return events in MC RCM
  • Leave of Absence Start and Returns entered in CM can also be configured to create Therapeutic Leave and Return events in MC RCM

The hospital transfer turned discharge workflow is designed to support billing and clinical needs. When the resident is first sent to the hospital, the hospital transfer entered in SigmaCare will be reflected in MC RCM. Once the clinical staff learns of the admission to the hospital, a discharge with bed hold request is entered in CM but will not impact MC RCM. This gives billing the flexibility, based on payer and state bed payment policies, to leave the resident on Hospital transfer if the bed is being paid for, or to discharge the resident if or when the bed is no longer being paid for. If the bed is not being paid for and biller has entered a discharge in MC RCM, that discharge will release the bed hold in CM.

The seamless integration of these transactions ensures that the census in SigmaCare and MatrixCare match and the events in each resident’s history are the same, down to the minute, without any duplicate entry.

Sharing of Resident Information

Resident payer information is the primary focus of the billing team, while also playing a significant role in clinical workflows. A resident’s payer drives their drug formulary and MDS scheduling, to support these workflows, resident payer information entered by billing in MC will be automatically reflected in CM.

Resident diagnoses are initially assessed by the Provider and entered in CM, but billing needs a comprehensive record of the of the diagnoses to ensure the correct codes are applied to the claims. Resident diagnoses are managed in CM and will populate in MC RCM automatically. The sequencing of diagnoses is managed in each application separately to support accurate billing and clinical prioritization.
Resident demographics and contact updates can be made in both MC RCM and CM and will update the other application in real-time.

MDS information, specifically RUG scores, are critical to reimbursement. Manually importing MDS assessments is time-consuming and could lead to files being missed, putting reimbursement at risk. With the CM/MC RCM bidirectional integration, the MDS files automatically transmit from CM to MC during normal submission workflows, so there is no manual upload required.

Overall, information managed by the clinical team will be entered in CM and flow to MC RCM. Similarly, the information supplied by the billing team will be entered in MC RCM and flow to CM. You will find that the SC CM and the MC RCM solutions, when used together, will optimize your billing and clinical resources, avoid duplicate entry, and ensure consistency across a resident’s record.

Discover all the ways that Matrixcare Revenue Cycle Management can save time, increase revenue, and provide you with data to make sound, timely decisions. Learn about the business rules and regulations built into the system to give you improved results and reporting that allows you to dive into your data to analyze it from all angles. Contact your Account Manager to learn more!

Services News

Powerful Principles of a Competency Program to Manage Performance

Complimentary Teleforum

In partnership, MatrixCare and Conduit Coaching invite you to join Denise Wassenaar, VP Clinical & Regulatory Affairs & CCO at MatrixCare and Senior Care Leadership expert, Mary Ellen Sanajko of Conduit Coaching, for a 60-minute, complimentary thought-leadership teleforum.

Join us on Wednesday, June 26, 2019, at 11:00 AM CST as we get into the nuts and bolts of creating a Competency Program that will work for you and the essential leadership skills to make it stick.

During this session, we’ll discuss the points below plus field your specific questions:

  • What are the three big “whys” behind focusing on staff competency, aside from success under PDPM pretty much requiring it?
  • What are the three principles of a great competency program? And what’s an essential skill to make it happen?
  • How can you develop and implement a program that really fits your organization’s needs, without it becoming a full-time job?
  • Who should be part of your competency program? Is it only about your care team?

Learn what you can do to manage performance and help your community be more successful!


PDPM Readiness Webinars

The following webinars will help you prepare for upcoming changes related to the Patient-Driven Payment Model (PDPM). Access the MatrixCare Client Community to register for upcoming webinars or to view on-demand webinars.

Upcoming Webinars

  • Utilizing Restorative Nursing to Maximize Your Reimbursement in SigmaCare by MatrixCare | June 28, 2019 1:00-2:00 PM CST

On-Demand Webinars

  • PDPM Success with SigmaCare by MatrixCare
  • Developing a Successful Facility Action Plan for the Patient-Driven Payment Model
  • Get Ready for the Patient-Driven Payment Model (PDPM)
Partner News

Elevate Your MatrixCare Investment with Partner Product Integrations

Partner Webinar Series

As part of our commitment to being the most-connected LTPAC EHR solution, we have partnered with several leading technology providers to bring you a more robust tool-set that enhances your existing MatrixCare environment.

Join us on Wednesday, June 19, 2019, at 1:00 PM CST for an informative session led by a panel of our certified partners on products and solutions that help you simplify complicated administrative and clinical operations, support online bill pay, automate vitals documentation, and create better customer experiences through RetailTracker.


Guided by a mission to help, ABILITY, an Inovalon company, is a leading information technology company helping healthcare providers and payers simplify administrative and clinical complexity by enabling data-driven improvements in healthcare.

PayRight Health optimizes online bill pay capabilities in-home care and other post-acute operations. As an integrated MatrixCare partner, we drive payments through both Home Care and Care Community.

Medline is the largest privately held Medical manufacturer and distributor in the US. As the only supply source truly serving the continuum of care, we are uniquely positioned to help navigate change, improve patient care and control costs with products and solutions like CareConnection, Medline’s vitals integration solution.

PAR is a leading global provider of POS hardware and service solutions. Building on over 40 years of experience, PAR is recognized as the largest supplier of POS systems to the global Hospitality market, including RetailTracker.

Don’t miss this informative session. See what these technologies can do for you!


Regulatory News

CMS PDPM Resources Updated

CMS has a developed a PDPM page which offers a variety of educational and training resources to assist stakeholders in preparing for PDPM implementation. Some of the resources have been recently updated.

Updates include:

  • FAQs
    • Two versions are now available, labeled as final in the zip file. One includes the “redline” that identifies recent changes.
  • Training Presentation
    • Includes Changes to RAI Manual and MDS 3.0 Item Sets.
  • PDPM Resources
    • Updated PDPM Classification Walkthrough
    • Updated PDPM GROUPER Logic (SAS)
    • Updated PDPM ICD-10 Mappings

MDS 3.0 RAI Manual

CMS has published the MDS 3.0 RAI Manual v1.17 October 1, 2019. It can be found on the CMS page under the related links section.

Please note this early release is being provided in response to stakeholder feedback. The MDS 3.0 RAI Manual v1.17 contains many updates, including information related to the Patient Driven Payment Model. Please check back prior to October 1, 2019, for a final posting which may contain additional updates.

SNF Quality Reporting Program Training

Training materials for the 2-day Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Provider Training event on Tuesday, May 7th, and Wednesday, May 8th, are now available under the Downloads section at the bottom of the CMS webpage. Training materials include PowerPoint presentations, case studies, and other related materials to complete exercises that were used during the event.

Medicare Direct Entry (MDE) System Updates

CMS has posted a notice disclosing their plans to discontinue access to the Common Working File (CWF) queries through the shared system. The notice can be viewed on the CGS page.

Medicare providers and their agents that currently access the CWF queries through the shared system screens will need to modify their business processes to use HETS to access Medicare beneficiary eligibility information.

CMS has not provided a schedule for when CWF access will be removed. Change Healthcare is working on updating the Assurance Reimbursement Management product to accommodate these changes with minimal customer impact. We have identified enrollment requirements and have started completing enrollments on behalf of providers as required. As CMS releases more information, we will provide more details.

Action Required: Please be aware of upcoming system changes regarding Eligibility transactions on your Medicare Direct claims.

Industry Events

Upcoming Tradeshows & Meetings

We look forward to seeing you at the upcoming events. Be sure to visit with one of our representatives and learn more about all the MatrixCare solutions available to you.