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PDPM and Section K—Three Processes to Shore Up Now

By AANAC - March 19, 2019

While no new items in section K of the MDS are expected this October, the Patient-Driven Payment Model (PDPM) is a game changer and some of the existing section K items are going to get a lot more attention. While swallowing and nutritional status have always been important for care areas and care planning, starting October 1, section K steps into the reimbursement spotlight for the speech-language pathology (SLP) component of PDPM. Not to mention, other key MDS items, like parenteral/IV feedings, tube feeding, and intake by artificial route, which currently impact reimbursement, will have even more pull under PDPM.

1)      Assessing for signs and symptoms of swallowing disorders

There may be some misconceptions when it comes to the requirements for coding a swallowing disorder under the SLP component of PDPM, which states that if the resident has a swallowing disorder at K0100, then the criteria for one item of the second tier of either, neither, or both is met. However, item K0100 does not require that the resident actually have a diagnosed swallowing disorder; rather, it is coded if the resident had the presence of signs and symptoms of a possible swallowing disorder in the seven-day look-back period.

This means that the documentation of these potential signs and symptoms prior to the ARD of the 5-day MDS is key. However, it is also important to note that these symptoms are coded only if they are actually present during the look-back period. If the resident has interventions in place, such as thickened liquids to prevent coughing or choking on liquids, and had no symptoms during the look-back period, then it is not coded.

According to Jessie McGill, RN, RAC-MT, RAC-MTA, and a curriculum development specialist for AANAC, “The barrier to collecting this information on the 5-day is that documentation has to be in place for it to be captured within the seven-day look-back period. This requires nurses to have an increased focus on any problems that the resident has while eating or drinking, as well as to assess for any pain or difficulty with swallowing.” All shifts should be aware of how the resident is handling liquids—this is not just a mealtime observation, but should be a focus anytime the resident is swallowing liquids or food.


2)      Supporting documentation of mechanically altered diets

The other items that impact the second tier of the SLP component under PDPM is mechanically altered diet, which is defined by CMS as “a diet specifically prepared to alter the texture or consistency of food to facilitate oral intake. Examples include soft solids, puréed foods, ground meat, and thickened liquids. A mechanically altered diet should not automatically be considered a therapeutic diet.” The RAI User’s Manual further clarifies that enteral feeding formulas cannot be coded as mechanically altered diet.

McGill cautions, “When using a mechanically altered diet for the resident, the purpose must be to facilitate the resident’s oral intake. This means that an altered diet should not be offered to residents who are able to eat without alterations to their diet. Keep in mind that a physician’s order is required to alter the resident’s diet.”



3)      Accurate calculations of percent by artificial route

While most NACs are familiar with how parenteral/IV feedings, tube feedings, and the percent by artificial route impact RUG-IV today, it is important to note the increased focus added under PDPM. While the nursing component of PDPM will continue to have the same requirements for parenteral/IV feedings for Special Care High and tube feeding for Special Care Low as exist today, these criteria are also used under the non-therapy ancillary (NTA) component for PDPM.

The NTA component awards the second highest number of points—seven—for capturing parenteral/IV feedings at a high level. This looks at the presence of parenteral/IV feedings at K0510A while a resident and also the percent of artificial intake at K0710A while a resident. In order to qualify, the resident must receive 51% or more of total calories by artificial route. If the resident receives 26–50% and 501cc/day at K0710A and K0710B, then the resident would qualify for low-intensity parenteral/IV feedings for three points.

A key component to this NTA qualifier is accurate calculation by the dietitian during the seven-day look-back period. The steps for assessment are to first review the intake records to determine actual intake through parenteral/IV or tube-feeding routes, then to calculate the portion of total calories received through artificial routes, requiring a calculation of total calories by mouth and artificial route.

McGill states, “An important thing to remember is that the percent of intake by artificial route is compared to the total caloric intake throughout the seven-day look-back period. This requires not only detailed documentation of the parenteral/IV feedings or tube-feeding calories, but also a detailed record of all oral intake, including snacks. If a resident has a high-calorie snack every day that’s not accounted for, it can change the accuracy of the percentage of total calories.”



It’s vitally important to pay close attention to any problems you may currently have with the processes and/or coding of these section K items and shore them up before you transition to PDPM. Review your processes and establish a plan for improvement before these items have an even greater impact on reimbursement. Improving these areas can lead to better quality care outcomes and quality of life for the residents.

“Not only will early identification of any issues with swallowing and nutrition help to establish a more comprehensive care plan, but it can also lead to an appropriate and timelier referral to speech therapy,” states McGill.


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