PDPM and Condition Capture: What Gia Does and Does Not Do

Gia gets the assessments done and documented; the MDS coordinator and the clinician decide what is coded.

What does an AI co-clinician do for PDPM condition capture?

PDPM pays on what the assessment shows and the record supports. The MDS coordinator's problem is rarely the coding. It is getting the assessments done, on time, by someone who documents them.

The cost of a missed assessment is not a coding error. It is a window that closed with a blank, an MDS that understates what the staff were doing every day, and a record that cannot support what the coordinator knows to be true.

What PDPM asks of the chart

Cognitive status from the BIMS. Function from the ADL items. Conditions that are supported in the record, not just listed. All of it inside the assessment window, dated and attributed.

The coordinator can code what is there. The coordinator cannot code what was observed and never written down.

Timing is the pressure. The assessment window is short and the census does not wait. An assessment that was done but documented a week late is, for the coordinator's purposes, an assessment that was not done.

The record has to show who assessed and when. An assessment with a score and no name is an assessment an auditor can set aside. The coordinator's work depends on entries that carry both.

Where capture breaks down

The BIMS was due and the resident was asleep, and the window closed. The ADL review was done from memory at the end of a shift. Cognition was never assessed because nobody noticed the change. A condition was managed every day and documented nowhere.

Each of these is a staffing problem that shows up as a coding problem.

Language is part of it. A resident who answers in Mandarin or Farsi waits for an interpreter. The BIMS for that resident is the last one in the window, and the one most likely to be missed when the week goes wrong.

What Gia does

Gia administers the BIMS, a cognitive screening, or an ADL and IADL review in conversation, by phone or video, in the resident's language, when a clinician clicks Initiate Assessment. Results reach the clinician in under two minutes. If the resident does not answer, Gia retries.

Between assessments, Gia's scheduled check-ins and the 40-second speech check-in rank residents whose speech or answers have shifted, so the clinician knows who to assess before the window closes. After review, the scored assessment, the clinician's note and the follow-up write back to PointClickCare, Epic or your EHR.

Caregiver check-ins add the family's account of function at home or on visits. The clinician sees it beside the resident's own answers and the resident's speech over time.

What Gia does not do

Gia does not code the MDS. Gia does not assign a case-mix group. Gia makes no claim about your rate, your case mix or your margin, and neither does this post.

Every result comes with Proactive Decision Actions. Options, never orders. A check-in is a screening conversation. Gia is clinical decision support, not a diagnosis. The clinician decides what the assessment means. The coordinator decides what the record supports.

Gia does not promise a rate. Any vendor who does is making a claim about your population before seeing it. The honest version is this: the assessments that were being missed get done and documented, and the coordinator codes what the record now supports.

What to measure

Assessments completed inside the window. Assessments documented with a date and a name. Residents assessed for cognition who were not assessed the previous quarter. Clinician reviews recorded.

Those are the numbers the coordinator can defend in an audit. Start there.

Measure the window too. Days from the assessment due date to the date the scored assessment appears in the chart. A window that used to close with a blank should close with an entry, and the coordinator should be able to see that on one screen.

Where to start

Pull last quarter's late or missing BIMS and ADL assessments. That list is the pilot cohort. Have Gia administer the next window's assessments for it and compare completion and documentation.

See how post-acute and senior living operators use Gia, then book a working session with your MDS coordinator in the room.