The Centers for Medicaid & Medicare Services (CMS) recently announced the return of the Program for Evaluating Payment Patterns Electronic Report (PEPPER) after a three-year pause. During this pause, CMS reevaluated the metrics included and the quality of those metrics.
The PEPPER provides facilities with valuable insight into how frequently and to what extent they bill traditional Medicare for key nursing and therapy services. Using Medicare claims data, the report compares a facility’s billing patterns against state and national benchmarks in targeted areas identified as having a higher risk for improper payments.
The reports are returning just as CMS has voiced concerns about potential Patient-Driven Payment Model (PDPM) upcoding trends. As a result, these reports may serve as a roadmap for auditors, plaintiff attorneys, and regulatory agencies seeking to identify potential compliance risks within a facility.
However, proactive operators can use a PEPPER as a powerful compliance and quality assurance tool. By carefully analyzing the data and conducting focused medical record audits, facilities can identify opportunities for improvement before they become liabilities.
Areas to review may include:
- Accuracy of Section GG coding
- Physician documentation supporting ICD-10 diagnoses
- Completeness and consistency of nursing documentation
- Medical record support for billed services and reimbursement levels
Understanding your facility’s risk areas before an auditor, regulator, or attorney identifies them provides a valuable opportunity to correct issues, strengthen documentation practices, and reduce potential exposure.
A PEPPER is more than just a compliance measure—it is an opportunity to evaluate processes, validate documentation, and ensure reimbursement accurately reflects the care being provided.
Need assistance interpreting your PEPPER or evaluating potential risk areas? LW Consulting, Inc. (LWCI) can help! Our team can assist with data analysis, documentation reviews, coding audits, and compliance assessments to help your facility stay ahead of regulatory scrutiny and maintain reimbursement integrity.
LW Consulting, Inc. (LWCI) offers a comprehensive range of services that can assist your organization in maintaining compliance, identifying trends, providing education and training, or conducting documentation and coding audits. For more information, contact LWCI to connect with one of our experts!
