We all say we want compliance, but do we strive for it? My philosophy professor in college used to emphasize that you must define what you are discussing so that you can discuss it intelligently. So let’s define “compliance” in medical record documentation. For this blog we will define compliant documentation as “accurately recording the care you have provided per the rules and regulations that govern us” In skilled nursing facilities we are regulated and governed in large part by CMS and the RAI manual. Let’s narrow our scope here to being compliant with the MDS. For MDS purposes we must document per the rules of the RAI manual. I talk to many facilities about their ADL documentation and they readily admit their CNAs consistently inaccurately code the care they have provided per Section G of the RAI manual. So not only do they not get paid appropriately, they are out of compliance by definition, AND ITS ACCEPTED! Is it better to be compliant and get paid more OR be non-compliant and get paid less? That sounds absurd, but I meet many MDS coordinators, DONs, Administrators, and Owners that accept inaccurate (read: out of compliance) Section G coding for multiple reasons….. “It too hard to teach” or “They have always coded this way” or “We have all new staff” etc….
PDPM is coming and now striving for compliance is becoming a BIGGER issue. Medicare Part A just got much more complicated with hundreds of items now contributing to our reimbursement in Section GG, Section K, Section I, Section H, Section , Section M, Section O Section D Section J, and MORE!!! I believe some will continue to accept inaccurate and non-compliant documentation and get paid less and struggle more. I also believe some will “strive” for compliance and accurately code the MDS per the rules/definitions in the RAI manual and will thrive under PDPM