Getting Paid for the Care You Provide: Why MDS Accuracy Is a Leadership Priority

Insights from Scott Heichel, RN, RAC-MT, RAC-CTA, DNS-CT, IPCO, QCP, ICC – Director of Reimbursement and Education, Pathway Health

In today’s post-acute care environment, the Minimum Data Set is more than a required assessment. It is a reflection of resident acuity, care delivery, compliance performance, and reimbursement integrity. When the MDS does not accurately capture the care being provided, organizations can experience more than missed revenue. They may face audit exposure, claim denials, recoupment risk, operational inefficiencies, and a growing disconnect between clinical documentation and financial outcomes.

Some of the most common MDS mistakes occur when documentation, coding, and billing processes are not fully aligned. Examples include:

• Coding diagnoses that are not clearly supported by physician or qualified practitioner documentation
• Missing or incomplete documentation to support skilled services, treatments, or resident conditions
• Inaccurate lookback periods or assessment timing errors
• Coding services that were provided but not consistently documented in the medical record
• Gaps between the MDS, care plan, therapy notes, nursing documentation, and billing records
• Missed case mix opportunities due to incomplete clinical review or lack of interdisciplinary communication
• Billing practices that do not fully align with the assessment, documentation, or payer requirements

These issues can directly affect case mix, Medicare reimbursement, Medicaid payment, quality measures, and survey readiness. For leaders, the question is not simply whether the MDS was completed. The more important question is whether the assessment accurately tells the resident’s story and supports payment for the care your team is already providing.

Three Key Leadership Strategies for Success

• Create a culture of documentation accuracy. Leaders should reinforce that documentation is not just a task; it is the foundation for compliance, reimbursement, quality reporting, and resident-centered care. Every coded item should be timely, accurate, and supported in the medical record.
• Invest in ongoing MDS education and mentoring. MDS requirements continue to evolve, and teams need consistent education, coaching, and support to remain confident and current. Mentoring helps strengthen critical thinking, improve coding accuracy, and build consistency across the interdisciplinary team.
• Review reimbursement and billing processes before problems occur. Proactive case mix reviews, Medicare and Medicaid billing reviews, and internal audits help identify missed opportunities, documentation gaps, and compliance risks before they affect revenue or result in recoupment.

How Pathway Can Help
Pathway Health partners with organizations to provide customized support based on your team, systems, payer mix, and operational goals. Our solutions include:

• MDS Baseline Assessment to evaluate current MDS practices, identify risk areas, and uncover opportunities for improvement. Download Overview >
• MDS Education to strengthen staff knowledge, coding accuracy, documentation practices, and regulatory understanding
• MDS Mentoring to provide hands-on support for MDS coordinators, clinical leaders, and interdisciplinary teams
• ADR Leadership Checklist for leaders to review and understand CMS Skilled Nursing Facility 5 Claim Probe and Educate Review. Learn more >
• Managing Medicare in Post-Acute Care Virtual Class includes the rules and regulations for beneficiary access to the program and the best practices for internal processes to manage Medicare and receive the appropriate reimbursement for services. Learn more >
• Case Mix Review to help ensure resident acuity is accurately captured, and reimbursement opportunities are not missed
• Medicare/Medicaid Billing Review to assess alignment between documentation, assessments, claims, and payer expectations
• Customized Organizational Support designed around your facility’s needs, workflows, and goals

The goal is simple: help your organization optimize revenue, reduce risk, and get paid accurately for the care you provide. With the right leadership focus and the right support, MDS accuracy becomes more than a compliance requirement. It becomes a strategic advantage.

For more information, connect with Scott at Scott.Heichel@pathwayhealth.com