patient-driven payment model (pdpm)clinical category section gg function score pt ot case-mix group...
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Patient-Driven Payment Model (PDPM)
Preparing for Payment Reform
Webinar Objectives
Learner will:
Identify key opportunities for
success at the site level for PDPM implementation
Identify key differences
between current and future payment
models for Medicare Part A patients in skilled nursing facilities
Understand key components of
payment that will not change in the PDPM payment
model
Identify effective strategies to
implement in order to be prepared for
October 1st
implementation of PDPM
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Understanding the CMS PDPM philosophy…
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Volume to
Value
Based on
Patient
Characteristics
Budget
Neutral
Implementation
Date:
October 1, 2019
Decrease in
Provider Burden PDPM model will
save providers
$200M per year or
$2B over 10 years
PPS pays for Volume PDPM attempts to pay for Value
Payment Model Comparison
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Payment = Diagnosis +
Clinical Complexities
+ ADL
PT CMI
OT CMI
NTA Payment
Non Case-Mix
Payment
SLP CMI
Nursing CMI
Payment = Therapy
Volume + Clinical
Complexities + ADL
NSG for Non-
Rehab RUG
Non Case Mix
PT Min
OT Min
SLP Min
ADL Score
It is important to stay focused on what hasn't changed...
Criteria for Skilled Services and Presumption of Coverage DOES NOT change
LTC Population Still Needs Therapy Services
Need to Stay Patient Centered
Need Comprehensive Nursing & Therapy Assessment
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What Can Go Wrong If You’re Not Prepared for PDPM?
If you deliver care that is not patient-
motivated or according to clinical needs =
AUDITS
If you do not enter MDS and claim
information correctly =
INCORRECT PAYMENT/
AUDITS
If you do not have appropriate staffing for
case mix =
LOWERQUALITY
OUTCOMES
If you do not optimize staffing and
contracting resources properly =
BUDGET ERRORS AND MARGIN SHORTFALLS
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1. Establish your PDPM Task Force
KEYS TO SUCCESS
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Financial Coding Quality
Performance Workforce Capability
Payer Mix Evaluation
Operational Requirements
Policies & Procedures
Referral Patterns
IT & Technology
Your workgroup must cover the following areas…
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Who are the members of your task force?
Administrator Director of Nursing CFO/Business OfficeDirector of
Quality/Compliance
Director of Therapy Director of EducationDirector of IT/Systems
Director of Admissions
Director of Reimbursement/Case
ManagementMDS Coordinator ?????
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2. Identify your gaps, and break the workload up into manageable pieces
KEYS TO SUCCESS
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You must have a structured, objective way to identify where you have gaps in process under today’s current payment structure and what
process changes need to occur to be successful under the new payment models. Consider:
How will the content of your meetings need
to change?
Are there different
reports that you will need
from your systems for meetings? Who will be
responsible for bringing them?
Are there different levels
of accountability that will need
to be in place?
Who is going to be responsible
for updating your
documentation, your clinical policies and procedures, your billing
SOPs?
Who is responsible for creating your
facility training plan?
How will you know where
you are at any point in time?
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One Example…Our Response
“THE ROADMAP TO PDPM MOMENTUM (RPM) ASSESSMENT”
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Roadmap To PDPM Momentum
To help support our partners, we have developed the Roadmap for PDPM Momentum (RPM) assessment to ensure they know exactly where they are in the PDPM transition journey.
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We complete the assessment together with our partners
How RPM Works
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RPM Assessment Results
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We use data analytics baked into our model to analyze results – on the spot!
ON-TRACKin your PDPM Preparedness
G R E E N
CAUTION-LAPmeaning work needs
to be done to getyour organization
back on-track
Y E L L O W
AT-RISKmeaning you need
to immediately stop,refocus and correctyour PDPM course
R E D
How RPM Works
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1 2 3
Step 4: We’ll take your results and develop an Action Plan to get you on-track for success
We educate your entire staff on the new
therapy requirements so you’re prepared to
deliver the highest quality outcomes, while
being reimbursed accurately for the care
your team delivers
We help you manage under PPS while we’re
getting you ready to “flip the switch” to
PDPM
We guide and support you, and even provide resources to ensure
you’re on-track
We outline areas of gaps or risk in terms of your PDPM readiness
How RPM Works
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3. Consider areas that you can focus on today that will drive success for your team today AND under PDPM
KEYS TO SUCCESS
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Determinants of Payment in PDPM
PT OT SLP Nursing NTA
• Primary reason for SNF
care
• Functional status
• Primary reason for SNF
care
• Functional status
• Primary reason for SNF
care
• Cognitive status
• Presence of swallowing
disorder or mechanically
altered diet
• Other SLP-related
comorbidities
• Clinical information from
SNF stay
• Functional status
• Extensive services
received
• Presence of depression
• Restorative nursing
services received
• Comorbidities present
• Extensive services
received
• Point in the stay
(variable per diem
adjustment)
• Point in the stay
(variable per diem
adjustment)
• Point in the stay
(variable per diem
adjustment)
Case Mix Components
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Clinical Condition of Stay
Extensive Services Special Care High Special Care Low
Clinically ComplexBehavioral Symptoms & Cognitive Performance
Reduced Physical Function
Nursing Classification Case Mix Groups
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RUG IV Based - Combined to 25 RUGS
Clinical Condition
of Stay
Functional Scores
Extensive Services
Depression
Restorative
Nursing
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Key Drivers | Nursing Category
Section I
Section GG
Section C
Section D
Restorative
• Special Care - Septicemia, Diabetes, COPD, Quadriplegia
• Function
• Nursing Behavioral Symptoms/ Cognitive Performance
• ST
• Impacts Special Care High/Low
• Clinically Complex
• Behavioral Symptoms/Cognitive Performance
• Reduced Physical Function
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NTA*
Condition/Extensive Service Source Points
HIV/AIDS SNF Claim 8
Parenteral IV Feeding: Level HighMDS Item K0510A2,
K0710A27
Special Treatments/Programs: Intravenous Medication
Post-admit CodeMDS Item O0100H2 5
Special Treatments/Programs: Ventilator or Respirator
Post-admit CodeMDS Item O0100F2 4
Parenteral IV feeding: Level LowMDS Item K0510A2,
K0710A2, K0710B23
Lung Transplant Status MDS Item I8000 3
Special Treatments/Programs: Transfusion Post-admit
CodeMDS Item O0100I2 2
Major Organ Transplant Status, Except Lung MDS Item I5200 2
Active Diagnoses: Multiple Sclerosis Code MDS Item I8000 2
Bone/Joint/Muscle Infections/Necrosis – Except Aseptic
Necrosis of BoneMDS Item I8000 2
Chronic Myeloid Leukemia MDS Item I8000 2
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*incomplete list
Condition/Extensive Service Source Points
Wound Infection Code MDS Item I2500 2
Active Diagnoses: Diabetes Mellitus (DM) Code MDS Item I2900 2
Endocarditis MDS Item I8000 1
Immune Disorders MDS Item I8000 1
End-Stage Liver Disease MDS Item I8000 1
Other Foot Skin Problems: Diabetic Foot Ulcer Code MDS Item M1040B 1
Narcolepsy and Cataplexy MDS Item I8000 1
Cystic Fibrosis MDS Item I8000 1
Special Treatments/Programs: Tracheostomy Care Post-
admit CodeMDS Item O0100E2 1
Active Diagnoses: Multi-Drug Resistant Organism
(MDRO) CodeMDS Item I1700 1
Special Treatments/Programs: Isolation Post-admit Code MDS Item O0100M2 1
Specified Hereditary Metabolic/Immune Disorders MDS Item I8000 1
Morbid Obesity MDS Item I8000 1
Special Treatments/Programs: Radiation Post-admit Code MDS Item O0100B2 1
NTA
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NTA NTA Base Rate NTA CMI NTA Adjustment Factor
NTA Score Range NTA Case-Mix Group NTA Case-Mix Index
12+ NA 3.25
9-11 NB 2.53
6-8 NC 1.85
3-5 ND 1.34
1-2 NE 0.96
0 NF 0.72
Days in Stay NTA Adjustment Factor
1-3 3.00
4-100 1.00
Step #2: Functional Score
Section GG ItemADL
Score
GG0130A1 Self-care: Eating 0 - 4
GG0130C1 Self-care: Toileting Hygiene 0 - 4
GG0170B1 Mobility: Sit to lying 0 - 4 (average of
2 items)GG0170C1 Mobility: Lying to sitting on side of bed
GG0170D1 Mobility: Sit to stand
0 - 4 (average of
3 items)
GG0170E1 Mobility: Chair/bed-to-chair transfer
GG0170F1 Mobility: Toilet transfer
Response Score
05 Set-up assistance, 06 Independent 4
04 Supervision or touching assistance 3
03 Partial/moderate assistance 2
02 Substantial/maximal assistance 1
01 Dependent, 07 Refused, 09 N/A, 88 Not Attempted 0
Nursing Functional Scoring
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Nursing Nursing Base Rate Nursing CMI
HE1/HD1Serious medical conditions e.g. comatose,
septicemia, respiratory therapyNo 0-5 HDE1 1.99
HC2/HB2Serious medical conditions e.g. comatose,
septicemia, respiratory therapyYes 6-14 HBC2 2.23
HC1/HB1Serious medical conditions e.g. comatose,
septicemia, respiratory therapyNo 0-5 HBC1 1.85
LE2/LD2Serious medical conditions e.g. radiation
therapy or dialysisYes 0-5 LDE2 2.07
LE1/LD1Serious medical conditions e.g. radiation
therapy or dialysisNo 0-5 LDE1 1.72
Nursing Example
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Nursing GG
Section GG ItemADL
Score
GG0130A1 Self-care: Eating 0 - 4
GG0130C1 Self-care: Toileting Hygiene 0 - 4
GG0170B1 Mobility: Sit to lying 0 - 4 (average of
2 items)GG0170C1 Mobility: Lying to sitting on side of bed
GG0170D1 Mobility: Sit to stand0 - 4
(average of
3 items)
GG0170E1 Mobility: Chair/bed-to-chair transfer
GG0170F1 Mobility: Toilet transfer
PT/OT GG
Nursing GG v PT/OT GG
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Section GG Item Score
GG0130A1 Self-care: Eating 0 - 4
GG0130B1 Self-care: Oral Hygiene 0 - 4
GG0130C1 Self-care: Toileting Hygiene 0 - 4
GG0170B1 Mobility: Sit to lying 0 - 4 (average of
2 items)GG0170C1 Mobility: Lying to sitting on side of bed
GG0170D1 Mobility: Sit to stand0 - 4
(average of
3 items)
GG0170E1 Mobility: Chair/bed-to-chair transfer
GG0170F1 Mobility: Toilet transfer
GG0170J1 Mobility: Walk 50 feet with 2 turns 0 - 4 (average of
2 items)GG0170K1 Mobility: Walk 150 feet3 Additional Areas for PT/OT
Nursing CMI moves inversely to therapy CMIs
Table 1: Determinants of Payment in PDPM
PT OT SLP Nursing NTA
• Primary reason for
SNF care
• Functional status
• Primary reason for
SNF care
• Functional status
• Primary reason for
SNF care
• Cognitive status
• Presence of
swallowing disorder
or mechanically
altered diet
• Other SLP-related
comorbidities
• Clinical information
from SNF stay
• Functional status
• Extensive services
received
• Presence of
depression
• Restorative nursing
services received
• Comorbidities
present
• Extensive services
received
• Point in the stay
(variable per diem
adjustment)
• Point in the stay
(variable per diem
adjustment)
• Point in the stay
(variable per diem
adjustment)
Case Mix Components
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PDPM Case-Mix Adjusted Payment
Per Diem Payment
Non-Case-Mix Non-Case-Mix Base Rate
Nursing Nursing Base Rate Nursing CMI
SLP SLP Base Rate SLP CMI
NTA NTA Base Rate NTA CMI NTA Adjustment Factor
OT OT Base Rate OT CMI OT Adjustment Factor
PTReduced by 2% every 7
days, starting at
day 21
PT Base Rate PT CMI PT Adjustment Factor
4. Have open discussions with your therapy team now
KEYS TO SUCCESS
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PDPM: Impact to Therapy
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Utilization Based System Patient Centered Payment
System
Outcomes Focused: Comprehensive plans
of care that allow patients to achieve
goals efficiently
Accuracy of GG Scoring
ICD-10 Coding accuracy
Clinical Flexibility with use of Group and Concurrent
Utilization of Therapy Based Services
Important and being tracked
Function is (still) an important driver
Documentation support to nursing
based on experience
PDPM total reimbursement declines with therapy CMI
Proposed PT and OT Case-mix Classification Groups
Clinical Category Section GG Function Score PT OT Case-Mix Group PT Case-Mix Index OT Case-Mix Index
Major Joint Replacement or Spinal Surgery 0-5 TA 1.53 1.49
Major Joint Replacement or Spinal Surgery 6-9 TB 1.69 1.63
Major Joint Replacement or Spinal Surgery 10-23 TC 1.88 1.68
Major Joint Replacement or Spinal Surgery 24 TD 1.92 1.53
Other Orthopedic 0-5 TE 1.42 1.41
Other Orthopedic 6-9 TF 1.61 1.59
Other Orthopedic 10-23 TG 1.67 1.64
Other Orthopedic 24 TH 1.16 1.15
Medical Management 0-5 TI 1.13 1.17
Medical Management 6-9 TJ 1.42 1.44
Medical Management 10-23 TK 1.52 1.54
Medical Management 24 TL 1.09 1.11
Non-Orthopedic Surgery and Acute Neurologic 0-5 TM 1.27 1.30
Non-Orthopedic Surgery and Acute Neurologic 6-9 TN 1.48 1.49
Non-Orthopedic Surgery and Acute Neurologic 10-23 TO 1.55 1.55
Non-Orthopedic Surgery and Acute Neurologic 24 TP 1.08 1.09
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TABLE 23: Proposed SLP Case-Mix Classification Groups
Presence of Acute Neurologic Condition,
SLP-Related Comorbidity, or Cognitive Impairment
Mechanically Altered Diet or
Swallowing Disorder
SLP Case-Mix
Group
SLP Case-Mix
Index
None Neither SA 0.68
None Either SB 1.82
None Both SC 2.66
Any one Neither SD 1.46
Any one Either SE 2.33
Any one Both SF 2.97
Any two Neither SG 2.04
Any two Either SH 2.85
Any two Both SI 3.51
All three Neither SJ 2.98
All three Either SK 3.69
All three Both SL 4.19
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Example
PT OT ST NSG NTA Non Case Mix
Case Mix Group TK TK SD CBC1 ND Xx
Case Mix Index 1.52 1.54 1.46 1.34 1.34 xx
Rural Base Rate 67.63 62.11 27.90 98.83 74.56 94.34
Subtotal102.79
(100.74)
95.64
(93.73)40.73 132.43
99.91
(299.73)94.34
DAYS
1-3 $765.66
4-20 $565.84
21-27 $561.88
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Therapy Medical Necessity
• Therefore, for these reasons, under the proposed PDPM, we propose to require that SNFs continue to complete the PPS Discharge Assessment, as appropriate, for each SNF Part A resident at the time of Part A or facility discharge. Under the current instructions in the MDS 3.0 RAI manual, the Part A PPS Discharge assessment is completed when a resident’s Medicare Part A stay ends, but the resident remains in the facility (MDS 3.0 RAI Manual Chapter 2.7). However, we are proposing to require this assessment to be completed at the time of facility discharge for Part A residents as well. Thus, we would continue to collect data on therapy provision as proposed in section V.F. of this proposed rule, to assure that residents are receiving therapy that is reasonable, necessary, and specifically tailored to meet their unique needs.
Final Rule:
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Clarifications?
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Feel Free to Email Me
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