Why Part 2? Because PDPM Medicaid Is Won—or Lost—in the Details
If Part 1 outlined the “what,” this article covers the “how.” Under PDPM Medicaid, your reimbursement hinges on timely, defensible documentation and interdisciplinary coordination—not therapy minutes. Facilities that still operate on a RUGs mindset are seeing the impact in their case-mix index (CMI) and daily rates.
This companion article focuses on five levers you can pull now:
- supportive documentation that survives audit,
- respiratory therapy protocols that hold up in the look-back,
- psychological services that fix the PHQ-2/9 gap,
- PDPM-trained physician partners (physiatry, cardio, nephro, pulmo), and
- the MDS coordinator’s new role as the chief orchestrator of ARD timing and IDT workflow.
Supportive Documentation: What “Counts” Under Scrutiny
PDPM Medicaid compresses your margin of error. Items like shortness of breath while lying flat (COPD), wounds, infections, malnutrition, and oxygen status require recent, relevant, and corroborated documentation—checkboxes on a TAR (Treatment Administration Record) often aren’t enough.
Action steps
- Build a supportive documentation grid for the top 50 nursing and NTA drivers in your state (requirements vary).
- For each item, list: acceptable sources (RT eval, MD note, psych eval), recency expectations, and where it must appear (progress note vs. flowsheet vs. MDS).
- Train staff to re-document ongoing conditions at reasonable intervals. “Captured once last year” won’t survive a Medicaid audit.
Pro tip: Post a “What counts?” cheat sheet inside your nurses’ station and morning-meeting deck. If your team can’t say where and when something must be documented, you’ll miss it.
Respiratory Therapy (RT): A Small Investment That Pays for Itself
Long-term care residents often qualify for RT-related services beyond nebulizers—incentive spirometry, education, and monitoring included. What matters is a protocol and timing that places the evaluation inside the seven-day look-back window before your ARD.
Minimum viable RT protocol
- Baseline pulmonary function to establish need (and repeat per protocol).
- Quarterly (or monthly) RT assessments scheduled to land inside look-back windows.
- On-campus presence at least 2 days/week for evals, check-ins, and documentation.
- MDS ↔ RT shared calendar (3+ weeks out) to ensure RT touches occur in the window.
Why it matters: An RT eval carries more weight than a daily checkbox. It’s also the documentation trail auditors expect for certain nursing/NTA drivers tied to respiratory conditions.
Psychological Services: Fixing the PHQ-2/9 Blind Spot
If your PHQ-2/9 capture rate is near 0%, that’s a red flag—not a victory. Typical, properly conducted screening yields ~10–12% residents with signs/symptoms of depression across LTC and short-stay.
What’s going wrong
Rushed, transactional screenings; leading questions; no rapport; wrong setting. Residents won’t disclose sensitive info on a drive-by questionnaire.
The fix
- Schedule psychiatry/psychology visits within the ARD look-back.
- Let psych conduct PHQ-2 (and expand to PHQ-9 as indicated).
- Have MDS shadow 5–10 screenings to recalibrate how social work runs them.
- Retrain social workers on setup, rapport, and neutral phrasing.
Result: Accurate capture of behavioral health needs improves care and supports appropriate nursing/NTA classification.
PDPM-Trained Physician Partners: Build Your On-Campus Panel
Generic “down-the-street” specialists may not understand PDPM documentation. Seek PDPM-trained partners: physiatry, cardiology, nephrology, pulmonology, wound care.
How to make it work
- Contract for monthly or quarterly campus days.
- Share the ARD calendar so notes fall inside look-back windows.
- Create a PDPM one-pager per specialty: what to document, where it lives, and how it maps to nursing/NTA drivers.
- Align with your medical billing and coding teams so ICD-10 “I” vs. “R” codes reflect real charting and maximize accuracy.
The MDS Coordinator as Chief Orchestrator (Not a Scheduler Every 92 Days)
The MDS coordinator now drives timing and team alignment. “Quarterlies every 92 days” is a recipe for leakage.
Your new playbook
- Own a rolling ARD calendar visible to RT, psych, dietitian, therapy, and visiting MDs.
- Run a clinical-only standup (separate from regular ops) to track: new diagnoses, meds, wounds, oxygen, infections, weight changes, psych flags.
- Use 24-hour report sweeps to query providers and close documentation gaps in real time.
- Keep a Top-50 PDPM Drivers list at every workstation; update in-services monthly.
In PDPM Medicaid, “coordinator” isn’t a title—it’s the job.
For Rate-Freeze States: Why You Must Act Now
Many states froze rates during their PDPM transition. Don’t let that lull you into complacency. We’re seeing states emerge from freezes and retroactively apply previous MDS periods to set initial PDPM rates. If your documentation wasn’t ready, you can’t fix the past—and daily rates can drop for a quarter or two.
What to do
- Operate as if PDPM is live today.
- Tighten your documentation, RT/psych cadence, and ARD timing.
- Audit 60–90 days of recent MDSs against state-specific PDPM Medicaid rules.
- Build a remediation list and fix forward.
Readiness Checklist (Part 2 Focus)
- ☐ Publish a supportive documentation grid for top nursing/NTA drivers in your state.
- ☐ Stand up a campus RT program with scheduled assessments inside look-back windows.
- ☐ Add psych campus days; have MDS coordinate PHQ-2/9 timing with ARDs.
- ☐ Formalize a PDPM-trained specialist panel (physiatry, cardio, nephro, pulmo, wound).
- ☐ Replace “every 92 days” with an ARD-by-indicator approach (dynamic rescheduling).
- ☐ Run 24-hour clinical sweeps and provider queries to close charting gaps.
- ☐ Align ICD-10 coding with real documentation (especially “I” vs. “R” codes).
- ☐ Conduct a 30-chart audit for PHQ-2/9 accuracy and retrain if <10–12% capture.
Common Mistakes We’re Seeing (And Quick Corrections)
- Mistake: TAR checkboxes used as primary evidence.
Fix: Replace with evaluative notes (RT, psych, MD) inside look-back windows. - Mistake: PHQ-2/9 at 0% capture.
Fix: Psych-led screenings; MDS observes/retrains social work. - Mistake: Static “every 92 days” mindset.
Fix: ARD timing set by clinical indicators, not the calendar. - Mistake: Specialists without PDPM awareness.
Fix: Onboard PDPM-trained panel; provide documentation one-pagers. - Mistake: Late therapy/RT notes missing look-back.
Fix: Shared ARD calendar; 3-week forecast reminders to all partners.
FAQs
Q1: We’re a nursing-only state. Does NTA still matter?
Yes. Even if your current rate set is nursing-only, states can—and do—update methodologies. Building NTA-ready documentation (e.g., RT, psych, wound) protects you for future phases and improves care now.
Q2: How often should RT reassess?
Follow clinical need and your protocol, but quarterly at minimum—and schedule to land inside the seven-day look-back prior to ARD.
Q3: What’s a healthy PHQ-2/9 capture range?
Facilities with proper screening usually see ~10–12% residents with signs/symptoms of depression (across LTC and short-stay). Near-zero implies process failure.
Q4: Do we need new software?
Not necessarily. Most EHRs (e.g., PCC) can support PDPM Medicaid; the gap is usually workflow, timing, and training—not tech.
How Gravity Consulting Can Help
We help facilities operationalize PDPM Medicaid:
- State-specific documentation grids and MDS/NTA playbooks
- RT and psych program design tied to ARD timing
- PDPM-trained specialist onboarding and one-pagers
- Section GG, ICD-10, and PHQ-2/9 staff training
- Rapid audits to recover missed CMI
Resulting, not consulting. When you need measurable lift—not just a slide deck—we’re your team.
▶ Download: State-by-State PDPM Medicaid Guide
▶ Talk to us: Gravity Consulting (844-899-6883)
