5 Commonly Overlooked Conditions in Skilled Nursing Patients That Impact Reimbursement

Skilled nursing facilities (SNFs) face the ongoing challenge of ensuring accurate and comprehensive patient documentation to optimize reimbursements. However, some conditions are frequently missed or underreported in patient files, leading to potential lost revenue. In this article, we'll discuss five commonly overlooked conditions that can significantly impact reimbursement rates for SNFs.

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1. MalnutritionMalnutrition is a prevalent issue among skilled nursing patients, with an estimated 20-50% of patients in long-term care facilities being malnourished (Wells & Dumbrell, 2006). Identifying and documenting malnutrition is crucial, as it can lead to higher reimbursement rates under the Patient-Driven Payment Model (PDPM) (CMS, 2021).
2. DepressionDepression is another condition that is often underdiagnosed in skilled nursing patients. According to a study by Gaboda et al. (2011), nearly 50% of nursing home residents with depression were not receiving treatment. Properly documenting depression can not only improve patient outcomes but also increase reimbursement rates (Levin et al., 2007).
3. Chronic PainChronic pain affects a significant portion of skilled nursing patients, with prevalence rates ranging from 45-80% (Hunnicutt et al., 2017). However, pain is often inadequately assessed and documented in patient files. Capturing the presence and severity of chronic pain can lead to more accurate reimbursement under PDPM (AAPACN, 2019).
4. Cognitive ImpairmentCognitive impairment, including conditions like dementia and delirium, is common among skilled nursing patients. A study by Magaziner et al. (2000) found that 43% of nursing home residents had dementia. Thoroughly documenting cognitive impairment is essential for ensuring appropriate care and reimbursement (AAPACN, 2019).
5. Pressure UlcersPressure ulcers are a significant concern in skilled nursing facilities, with prevalence rates ranging from 2.2-23.9% (Park-Lee & Caffrey, 2009). Accurately staging and documenting pressure ulcers can impact reimbursement rates under PDPM (CMS, 2021).

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By using software designed to identify these commonly overlooked conditions in patient files, skilled nursing facilities can improve documentation accuracy and optimize reimbursements. Investing in technology that streamlines this process can lead to significant financial benefits while ensuring patients receive the appropriate level of care.

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References:AAPACN. (2019). PDPM: What You Need to Know. https://www.aapacn.org/wp-content/uploads/2019/07/PDPM-What-You-Need-to-Know.pdf

CMS. (2021). Patient-Driven Payment Model. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM

Gaboda, D., Lucas, J., Siegel, M., Kalay, E., & Crystal, S. (2011). No longer undertreated? Depression diagnosis and antidepressant therapy in elderly long-stay nursing home residents, 1999 to 2007. Journal of the American Geriatrics Society, 59(4), 673-680. https://doi.org/10.1111/j.1532-5415.2011.03322.x

Hunnicutt, J. N., Ulbricht, C. M., Tjia, J., & Lapane, K. L. (2017). Pain and pharmacologic pain management in long-stay nursing home residents. Pain, 158(6), 1091-1099. https://doi.org/10.1097/j.pain.0000000000000887

Levin, C. A., Wei, W., Akincigil, A., Lucas, J. A., Bilder, S., & Crystal, S. (2007). Prevalence and treatment of diagnosed depression among elderly nursing home residents in Ohio. Journal of the American Medical Directors Association, 8(9), 585-594. https://doi.org/10.1016/j.jamda.2007.07.010

Magaziner, J., German, P., Zimmerman, S. I., Hebel, J. R., Burton, L., Gruber-Baldini, A. L., May, C., & Kittner, S. (2000). The prevalence of dementia in a statewide sample of new nursing home admissions aged 65 and older: diagnosis by expert panel. Epidemiology of Dementia in Nursing Homes Research Group. The Gerontologist, 40(6), 663-672. https://doi.org/10.1093/geront/40.6.663

Park-Lee, E., & Caffrey, C. (2009). Pressure ulcers among nursing home residents: United States, 2004. NCHS Data Brief, (14), 1-8.

Wells, J. L., & Dumbrell, A. C. (2006). Nutrition and aging: assessment and treatment of compromised nutritional status in frail elderly patients. Clinical Interventions in Aging, 1(1), 67-79. https://doi.org/10.2147/ciia.2006.1.1.67

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