pdpm for mds coordinators•orthopedic surgery •j2500, j2510, j2520, or j2530. •if none of these...

6/5/2019

PDPM For MDS Coordinators:making a successful transition to the new

payment model

Part 2

Speaker: Sarah Ragone, MSPT, RAC-CT, QCP

VP of Reimbursement & Education

PT and OT Clinical ComponentsBegins with a residents Clinical Category*Major Joint Replacement or Spinal Surgery*Other Orthopedic*Medical Management*Non-orthopedic surgery and Acute Neurologic

Further broken down by GG Functional Score

Both PT and OT components will always result in the same case mix group, however, they will differ in the case-mix adjustment indices.

SLP ComponentStarts with Dx: Acute Neurologic yes/noFurther broken down by-SLP comorbidities-sec I for dx or O-Cognitive Status- section C/BIMS-Mechanically Altered Diet yes/no (K0500C=2)-Evidence of a Swallowing Disorder (K0100A-D)

Non-Case Mix Component

This is a constant and does notchange but is factored in or added to

total rate calculation

Non-Therapy Ancillary (NTA) ComponentPoints are assigned for conditions and extensive servicesbased on MDS coding-i.e. 2 points assigned for: blood transfusion, active dx MS, active dx COPD/asthma/chronic lung disease-i.e. 1 point assigned for: dx morbid obesity, cystic fibrosis, Isolation while a resident, end stage liver disease-HIV/AIDS-point assigned based on coding of SNF claim, 8 points assigned for this

Nursing ComponentNo changes in the nursing component, factors are same as RUG’s IV to determine one of the following categories:-Extensive Services-Special Care High-Special Care Low-Clinically Complex-Behavior Symptoms-Cognition-Reduced Physical Function

Further broken down by RUG’s IV end splits and Section GG Function Score

PDPM Components

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Building the PDPM rate

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PT and OT Components: based on Clinical Category and Functional Status

• Determine the resident’s primary ICD-10-CM code for the SNF stay.

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Use ICD-10 Mapping file to determine

clinical category.

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• In addition to coding the ICD-10 CM code in I0020B, we must also code any major surgery the resident may have had during the preceding hospital stay• This additional item is needed to achieve one of the surgery related clinical

categories, but is not required with all Dx• Major Joint Replacement or Spinal Surgery

• Non-Orthopedic Surgery

• Orthopedic Surgery

• This category for surgical procedure will be coded using new MDS items in Section J.

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J2100- Gateway item for J2300-J5000

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This new MDS item will be used to indicate if major surgical procedure took place during

the prior hospitalizationand now requires active SNF care

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Step 1: Determine the patient’s primary diagnosis clinical category and enter in I0020B

-This will map to primary Dx clinical category

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html

• Some ICD-10 CM codes can map to a different clinical category from the default depending on a patient’s prior inpatient procedure history

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Step 1A:

• Major Joint Replacement or Spinal Surgery• J2300, J2310, J2320, J2330, J2400, J2410, or J2420.

• If none of these are checked, this will not map to that clinical category for the purposes of determinizing the PDPM classification.

• If checked, the primary diagnosis clinical category is Major Joint Replacement or Spinal Surgery.

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Step 1B

• Orthopedic Surgery• J2500, J2510, J2520, or J2530.


• If checked, the primary diagnosis clinical category is Orthopedic Surgery.

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Step 1C

• Non-Orthopedic Surgical Procedure • J2600, J2610, J2620, J2700, J2710, J2800, J2810, J2900, J2920, J2930, or

J2940.


• If checked, then Non-Orthopedic Surgical procedure will be the primary diagnosis clinical category.

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Step 1D:

• If a resident does not qualify for one of the surgical clinical categories, then select their default clinical category assigned to the primary diagnosis as recorded in MDS item I0020B.

• If the resident does qualify for one of the different clinical categories from the default, select the eligible surgical clinical category as determined in Steps 1A, 1B and 1C.

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• Next- determine the patient’s PT/OT clinical category based on the mapping shown here:

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PT and OT Components

• CMS provides a mapping tool on their website.

• https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html

• Return to Provider codes will not be paid unless corrected

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PT & OT Classification Groups and Case Mix Weights

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PT and OT Components- Functional Score

Use the scoring table shown here to assign points for each functional item in GG based on MDS coding instructions, see

below.

Admission Performance

(Column 1) =Function Score

05, 06 4

04 3

03 2

02 1

01, 07, 09, 10, 88, missing 0

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MDS 1.17.0 updates- Section GG Decision Tree

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PT/OT Component Functional Score

• Scores for each of the below items, or average of the items in a given section- will be summed to achieve the Functional Score.

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PT/OT Component- Functional ScoreDetermine the Functional Score from Section GG on the Admission assessment as follows:

Eating GG0130A1

Oral Hygiene GG0130B1

Toileting Hygiene GG0130C1

Average of Bed Mobility Scores(Sitting to Lying GG0170B1, Lying to Sitting GG0170C1)

Average of Transfer Scores: (Sit to Stand GG0170D1, Chair/Bed to Chair Transfer GG0170E1, and Toilet Transfer GG0170F1)

Average of Walking Scores: (Walk 50 ft with two turns GG0170J1 and Walk 150 ft. (GG0170K1)

= PT/OT Functional Score (0-24)20

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Let’s Meet Mrs. HYour patient is Mrs. H. She is 79 years old and has recentlybeen admitted to the SNF following a week long hospitalization related to multiple medical dx.

Hospital DC summary lists Dx as follows:1. Adult Failure to Thrive2. Acute on Chronic CHF3. Frequent falls

She is unable to stand due to significant weakness and therefore, staff are using a total mechanical lift with 2A.

Mrs. H has complications from diabetes including a diabetic ulcer on her right foot. She is also being treated with IV push Lasix For the CHF. Additional active dx include Inflammatory Bowel Disease (IBS).

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PT and OT Component: Functional Score-Case Study

•Eating: with staff oversight and encouragement

•Oral Care: has no natural teeth, performs all aspects of denture care and cleaning with Supervision and encouragement from Staff

•Toilet Hygiene: needs assist, CNA performs less than half the effort

•Bed Mob: one CNA is required and performs more than half the effort for sit to/from lying

•Transfers: requires a full mechanical lift for all transfers and 2 staff.

•Walking: She is unable to walk as she can not bear weight on her LE’s.

Functional Score Calculation

Task GG score Func. Score

Eating

Oral Hygiene

Toileting Hygiene

Ave. Bed Mob-Sit to Lying

-Lying to Sitting

Ave. Transfer Score-Sit > Stand

-Chair/Bed->Chair-Toilet Transfer

Ave. Walking Score-50 ft, 2 turns

-150 ft.

Total PT/OT Functional Score = 22

Practice

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PT and OT component case study, Mrs. H continued

• We already know Mrs. H’s PT/OT functional score = 09

• We now need to know the PT/OT clinical category to determine PT/OT case mix groups.

• Adult Failure to Thrive ICD-10 R62.7

• Acute on Chronic CHF ICD-10 I50.23

• Frequent Falls ICD-10 Z91.81

• Diabetes, Type II, with foot ulcer ICD-10 E11.621

• Urinary Incontinence: ICD-10 R32

• Chronic Bronchitis: ICD-10 J41.0

• IBS ICD-10 K58.9

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PT/OT Component-Mrs. H continuedAdult Failure to Thrive

“but it’s listed first on the hospital DC summary”

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PT/OT Component-Mrs. H continuedAcute on Chronic Congestive Heart Failure

Primary Diagnosis Clinical Category PT Clinical Category

Major Joint Replacement or Spinal Injury Major Joint Replacement or Spinal Surgery

Orthopedic Surgery (Except Major Joint Replacement or Spinal Surgery) Other Orthopedic

Non-Orthopedic Surgery Non-Orthopedic Surgery

Acute Infections Medical Management

Cardiovascular and Coagulations Medical Management

Pulmonary Medical Management

Non-Surgical Orthopedic/Musculoskeletal Other Orthopedic

Acute Neurologic Acute Neurologic

Cancer Medical Management

Medical Management Medical Management 25

PT and OT Case Mix

Classification Groups

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PT/OT Component:Mrs. H Continued- Determining PT/OT Case Mix Groups

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Clinical CategoryGG Function

ScorePT/OT Case Mix Group

PT Case Mix

Index

OT Case Mix

Index

Scoring Response for Section GG Items Score

05, 06 Set-up assistance, independent 4

04 Supervision or touching assistance 3

03 Partial/moderate assistance 2

02 Substantial/maximal assistance 1

01, 07, 09, 10, 88, [-]

Dependent, refused, not attempted, resident does not walk** 0

Section GG Items 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(avg. of

2 bed mobility items)GG0170C1 Mobility: Lying to sitting on side of bed

GG0170D1 Mobility: Sit to stand0-4

(avg. of 3 transfer items)

GG0170E1 Mobility: Chair/bed-to-chair transfer

GG0170F1 Mobility: Toilet transfer

GG0170J1 Mobility: Walk 50 feet with 2 turns 0-4(avg. of 2 walking

items)GG0170K1 Mobility: Walk 150 feet

Major Joint Replacement

orSpinal Surgery

Non-Orthopedic Surgery and

Acute Neurologic

Medical Management

Other Orthopedic

0-5

6-9

10-23

24

0-5

6-9

10-23

24

0-5

6-9

10-23

24

0-5

6-9

10-23

24

TA 1.53 1.49

TB 1.69 1.63

TC 1.88 1.68

TD 1.92 1.53

TE 1.42 1.41

TF 1.61 1.59

TG 1.67 1.64

TH 1.16 1.15

TI 1.13 1.17

TJ 1.42 1.44

TK 1.52 1.54

TL 1.09 1.11

TM 1.27 1.30

TN 1.48 1.49

TO 1.55 1.55

TP 1.08 1.09

PT Component and OT Component:PT and OT components will always result in the same case-mix group; however, the PT and OT case-mix indices/payment levels differ.

If a resident is coded as not attempted (07, 09, 10, or 88) for GG0170I1 (Walk 10 feet), then walking items for GG0170J1 (Walk 50 feet with 2 turns) and GG0170K1 (Walk 150 feet) will be scored as zero points.

PT/OT Component Practice

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Top 7 Categories for PT and OT Components

PT Component

CMI Clinical Category Sec. GGFunc. Score

1.92 Major jt. Repl. /Spinal Sx 24

1.88 Major jt. Repl. /Spinal Sx 10-23


1.67 Other orthopedic 10-23

1.55 Non-ortho sx, acute neuro 10-23


1.52 Medical Management 10-23

OT Component

CMI Clinical Category Sec. GG Func. Score


1.64 Other ortho. 10-23


1.59 Other ortho. 6-9

1.55 Non-ortho sx., acute neuro. 10-23

1.54 Med. Mgt. 10-23

1.53 Major jt. Repl. /Spinal Sx 24

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SLP Component

• Will be determined by:• Presence of an acute neurologic

condition based on primary dx clinical category

• SLP related comorbidities (Dx info from section I, or section O coding of trach or Vent)

• Cognitive status (BIMS and CPS, section C and B coding)

• Presence of a mechanically altered diet (K0510C2)

• Evidence of a swallowing disorder (K0100)

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SLP Component-Determine SLP Clinical Category

Primary Diagnosis Clinical Category SLP Clinical Category

Major Joint Replacement or Spinal Injury Non-Neurologic

Orthopedic Surgery (Except Major Joint Replacement or Spinal Surgery) Non-Neurologic

Non-Orthopedic Surgery Non-Neurologic

Acute Infections Non-Neurologic

Cardiovascular and Coagulations Non-Neurologic

Pulmonary Non-Neurologic

Non-Surgical Orthopedic/Musculoskeletal Non-Neurologic

Acute Neurologic Acute Neurologic

Cancer Non-Neurologic

Medical Management Non-Neurologic

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SLP ComponentDetermine if there are SLP related comorbidities• Review the clinical record and use either check box items in section I of the

MDS or enter ICD-10 codes under I8000 for the following conditions:• Aphasia (I4300)• CVA, TIA, or stroke (I4500)• Hemiplegia or hemiparesis (I4900)• TBI (I5500)• I8000, ICD-10 coding for:

• Apraxia• Dysphagia• ALS• Oral cancers• Laryngeal Cancers• Speech and Language Deficits

• Trach Care while a resident (O0100E2)• Ventilator or Respirator While a Resident (O0100F2)

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SLP Component- Determine Cognitive level

• Next, determine whether the resident has a cognitive impairment.

• The PDPM cognitive level assigns one of four cognitive performance levels based on the BIMS or the Cognitive Performance Scale/staff assessment

• If the BIMS is incomplete or not attempted, then the CPS is used.

PDPM Cognitive Level BIMS Score CPS Score

Cognitively Intact 13-15 0

Mildly Impaired 8-12 1-2

Moderately Impaired 0-7 3-4

Severely Impaired - 5-6

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Cognitive Performance Score (CPS)Used when BIMS is incomplete or not attempted

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Comatose (B0100=1) and

Eating (GG0170B1),

Toileting hygiene (GG0130C1),

Sit to lying (GG0170B1),

Sit to Stand (GG0170D1),

Lying to sitting (GG0170C1)

Chair/bed to Chair (GG0170E1)

Toilet Transfer (GG0170F1) = Dependent/Activity did no occur

Cognitive Skills for Daily Decision

Making (C1000) = 3, Severely Impaired

(never/rarely made decisions)

Severely Impaired Cognition

OR

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• Determine Basic Impairment Count

• Determine Severe Impairment Count

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Cognitive Skills for Daily Decision Making (C1000) 1 point if = 1 or 2

Makes Self Understood (B0700) 1 point if = 1,2, or 3

Short term Memory OK (C0700) 1 point if = 1

Cognitive Skills for Daily Decision Making (C1000) 1 point if = 2

Makes Self Understood (B0700) 1 point if = 2 or 3


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If the Basic Impairment Count is 2 or 3

AND

The Severe Impairment Count is 1 or 2

Moderately Impaired Cognition

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If the Basic Impairment Count is 1, 2 or 3

AND

The Severe Impairment Count is 0

Mildly Impaired Cognition

C00 Resident not interview-able

C1000 BIC= 1SIC=1

B0700 BIC=1SIC=1

C0700 BIC=1

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2

Total Count = 5Maps to – Severely Impaired

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SLP Component-Swallow Disorder (K0100)

Consider 7 Day Look Back when coding K0100• Interview the resident•Observe the resident • Interview staff all shifts• Review the medical record including notes from nursing,

physician, dietician, speech language pathologist and dental.

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SLP Component-Mechanically Altered Diet K0510C2• RAI definition: a diet specifically prepared to alter the texture or

consistency of food to facilitate oral intake. Examples include soft solids, pureed foods, ground meat and thickened liquids.

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SLP Component

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SLP Component -Mrs. H. , a closer look

• Acute neurologic condition: ?• dx is Cardiovascular/Coagulations

• SLP related comorbidities: ?• Mrs. H does not have any of the conditions checked in Section I (aphasia, CVA,

Dysphagia, Hemi, TBI, oral/laryngeal cancer, speech/language deficits) or O (trach or vent while a resident)

• SLP Cognitive Impairment:?• Scored 11 on BIMS= Mild Impairment

• Presence of a mechanically altered diet (K0510C2): ?• K0510C2 is NOT checked, resident is on a regular consistency diet

• Evidence of a swallowing disorder (K0100): ?• K0100 D is checked to indicate “complaints of difficulty or pain with swallowing”

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Practice

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Practice

SLP Component Presence of Acute Neurologic Condition, SLP-Related Comorbidity*, or Cognitive

Impairment**

Presence of: Swallowing Disorder (K0100A-D) OR Mechanically Altered Diet (K0510C2)

SLP Case-Mix Group

SLP Case Mix Index

All Three

Any Two

Any One

None

Neither

Either

Both

Neither

Either

Both

Neither

Either

Both

Neither

Either

Both

SA

SB

SC

SD

SE

SF

SG

SH

SI

SJ

SK

SL

SLP-Related Comorbidities:Aphasia (I4300); CVA, TIA, or Stroke (I4500); Hemiplegia or Hemiparesis (I4900); TBI (I5500); Tracheostomy (O0100E2); Ventilator (I0100F2); Laryngeal Cancer, Apraxia, Dysphagia, ALS, Oral Cancers, Speech and Language Deficits (I8000)

Cognitive Impairment:The PDPM cognitive level is based on the Brief Interview for Mental Status (BIMS) orstaff assessment. See the PDPM calculation worksheet provided by CMS for details.

0.68

1.82

2.66

1.46

2.33

2.97

2.04

2.85

3.51

2.98

3.69

4.19

Practice

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https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/therapyresearch.html

6/5/2019

Non Therapy Ancillary(NTA) Component-is a weighted count of comorbidities. These comorbidities are associated with high increases in NTA costs grouped into various point tiers. Points are assigned or each additional comorbidity present, with more points awarded for higher cost tiers.

Points are assigned based on MDS coding of various NTA-related

comorbidities. • HIV/AIDS (coded on SNF claim)

• Parenteral/IV feeding (MDS Section K)

• IV Meds (MDS section O)

• Use of Ventilator, Trach care, Radiation, Isolation- (MDS section O)

• Blood transfusion (MDS section O)

• Foot skin problems, Diabetic foot ulcers , Foot infection, open lesions on foot, Stage IV Pressure Ulcers(MDS section M)

• Coding of other diagnosis and conditions (MDS Section I8000)

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NTA Component

NTA Comorbidity Score NTA Case Mix Group CMI

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 0.7246

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Mrs. H- Case Study for NTA Component• Mrs. H. has been admitted to the SNF

following a week long hospitalization related to multiple medical dx including Adult Failure to Thrive, Acute on Chronic CHF and Frequent falls

• She has been given IV medication while a resident

• She has dx of Inflammatory Bowel Disease, DM and currently has a diabetic foot ulcer on her left foot.

IV Meds ___DM ___

IBS ___

Diabetic foot ulcer ______ points

NTA Component

NTA Comorbidity Score NTA Case Mix Group CMI

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

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Practice

Non-Therapy Ancillary (NTA) ComponentCondition/Extensive Service Source Points

HIV/AIDS SNF Claim 8

Parenteral IV Feeding: Level High MDS Item K0510A2, K0710A2 7

Special Treatments/Programs: Intravenous Medication Post-admit Code MDS Item O0100H2 5

Special Treatments/Programs: Ventilator or Respirator Post-admit Code MDS Item O0100F2 4

Parenteral IV Feeding: Level Low MDS Item K0510A2, K0710A2, K0710B2 3

Lung transplant Status MDS Item I8000 3

Special Treatments/Programs: Transfusion Post-admit Code MDS Item O0100I2 2

Major Organ Transplant Status, Except Lung MDS Item I8000 2

Active Diagnoses: Multiple Sclerosis Code MDS Item I5200 2

Opportunistic Infections MDS Item I8000 2

Active Diagnoses: Asthma COPD Chronic Lung Disease Code MDS Item I6200 2

Bone/Joint/Muscle Infections/Necrosis-Except Aseptic Necrosis of Bone MDS Item I8000 2

Chronic Myeloid Leukemia MDS Item I8000 2

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 Code MDS Item O0100E2 1

Active Diagnoses: Multi-Drug Resistant Organism (MDRO) Code MDS Item I1700 1

Special treatments/Programs: Isolation Post-admit Code MDS Items O0100M2 1

Specified Hereditary Metabolic/Immune Disorders MDS Item I8000 1

Morbid Obesity MDS Item I8000 1

NTA Score Range

NTA Case-Mix Group

CMI

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

*High level: K0710A2 = 3. 51% or more (while a resident)

** Low level: K0710A2 = 2. 26–50% (while a resident) and K0710B2 = 2. 501cc/day or more (while a resident)

Continued

Practice

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Non-Therapy Ancillary (NTA) Component, Cont.

Condition/Extensive Service Source Points

Special Treatments/Programs: Radiation Post-admit Code MDS Item O0100B2 1

Highest Stage of Unhealed Pressure Ulcer—Stage 4 MDS Item M0300D1 1

Psoriatic Arthropathy and Systemic Sclerosis MDS Item I8000 1

Chronic Pancreatitis MDS Item I8000 1

Proliferative Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1

Other Foot Skin Problems: Foot Infection Code, Other Open Lesion on Foot Code, Except Diabetic Foot Ulcer Code (M1040B)

MDS Item M1040A, M1040C 1

Complications of Specified Implanted Device or Graft MDS Item I8000 1

Bladder and Bowel Appliances: Intermittent Catheterization MDS Item H0100D 1

Inflammatory Bowel Disease MDS Item I8000 1

Aseptic Necrosis of Bone MDS Item I8000 1

Special Treatments/Programs: Suctioning Post-admit Code MDS Item O0100D2 1

Cardio-Respiratory Failure and Shock MDS Item I8000 1

Myelodysplastic Syndromes and Myelofibrosis MDS Item I8000 1

Systemic Lupus Erythematosus, Other Connective Tissue Disorders, and

Inflammatory Spondylopathies

MDS Item I8000 1

Diabetic Retinopathy—Except Proliferative Diabetic Retinopathy and

Vitreous Hemorrhage

MDS Item I8000 1

Nutritional Approaches While a Resident: Feeding Tube MDS Item K0510B2 1

Severe Skin Burn or Condition MDS Item I8000 1

Intractable Epilepsy MDS Item I8000 1

Active Diagnoses: Malnutrition Code MDS Item I5600 1

Disorders of Immunity—Except: RxCC97: Immune Disorders MDS Item I8000 1

Cirrhosis of Liver MDS Item I8000 1

Bladder and Bowel Appliances: Ostomy MDS Item H0100C 1

Respiratory Arrest MDS Item I8000 1

Pulmonary Fibrosis and Other Chronic Lung Disorders MDS Item I8000 1

NTA Score Range

NTA Case-Mix Group

CMI

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

Practice

Nursing Component

• PDPM uses the same basic nursing classification structure as RUG IV, with certain modifications:• Function score is based on Section GG• The number of nursing groups is recued from

43 to 25 by collapsing some functional groups

• RUG IV places residents into therapy RUG groups based on minutes of therapy, and a non-therapy RUG is assigned, based on certain patient characteristics• Only one of those RUG’s is used for payment• Therapy RUG’s are used to bill over 90% of

Part A days• Therapy RUG scores in RUG IV obscure

meaningful clinical differences in nursing characteristics between patients in the same therapy RUG.

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Nursing Component

• Determine the resident’s nursing case mix groups using the hierarchical classification used in RUG-IV.

• When using this approach, start at the top and work down through the PDPM nursing classification model until you find the first nursing category the resident classifies for.

Ext.Svc.

Special Care High

Special Care Low

Clinically Complex

Behavioral Symptoms and Cognitive Performance

Reduced Physical Function

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Nursing Category- Extensive Services

• Based on coding of extensive care services:• O0100E2 Tracheostomy care while a resident

• O0100F2 Ventilator or respirator while a resident

• O0100M2 Isolation or quarantine for active infectious disease while a resident

• If the resident does not receive these treatments or services, skip to Special Care High Category

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Nursing Category- Special Care High

• Based on coding of certain conditions or services:• Section B and GG Comatose and ADL dependent• Section I (ICD-10 Dx) Septicemia, DM with 7 days injections and 2

or more days Insulin order changes, Quadriplegia, COPD and SOB lying flat,

• Section J, and others Fever with pneumonia (sec I), vomiting (sec J), weight loss (sec K), or feeding tube (sec K)

• Section K Parenteral or IV Feedings• Section O Respiratory therapy for all 7 days

• If the resident does not have one of these conditions skip to the Special Care Low Category

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Nursing Category- Special Care Low

• Based on coding of the following:• Section I Cerebral Palsy, Multiple Sclerosis, Parkinson’s disease,

Respiratory Therapy and Oxygen use while a resident (sec O)

• Section K Feeding Tube• Section M Stage III or IV PU with treatments, Two Stage II Pressure Ulcers

with two or more skin treatments. One stage 2 and one venous/arterial ulcer with two or more selected skin treatments, Foot infection, diabetic foot ulcer or other open lesion of foot with application of dressings to the feet.

• Section O Radiation or Dialysis treatment while a resident

• If a resident does not have one of these conditions, skip to Clinically Complex Category

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Nursing Category- Clinically Complex

• Based on coding of:• Sec I (ICD-10 Dx) Pneumonia, Hemiplegia (with Nursing Function Score

≤ 11.

• Section M Burns

• Section O Chemotherapy, Oxygen Use, IV Meds or Transfusions while a resident

• If the resident does not have one of these condition, skip to the Behavioral Symptoms and Cognitive Performance Category

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Nursing Category- Behavioral Symptoms and Cognitive Performance

• Based on coding on presence of certain behavioral symptoms or the resident’s cognitive performance. • BIMS or Staff Assessment of Cognition in Section C• Presence of a coma and completely ADL dependent in section B and GG• Impaired cognitive skills for daily decision making in section C• Difficulty making self understood in Section B• Determine presence of behavioral symptoms in Section E

• Hallucinations• Delusions• Physical behavioral symptoms toward others• Verbal behavioral symptoms directed toward others• Other behavioral symptoms not directed toward others• Rejection of care• Wandering

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Nursing Category- Reduced Physical Function

• Residents who do not meet the conditions of any of the previous categories, including those who would meet the criteria for Behavioral Symptoms and Cognitive performance category but have a PDPM Nursing Function Score less than 11 are placed in this category.

• Further subdivided by Restorative Nursing Count

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Nursing Component-Nursing Functional Score

• Determine the Nursing Function Score• Similar to how PT/OT Function Score is determined (no oral hygiene or

walking in Nursing Function Score)

• Based on coding of section GG, using scoring criteria below

Eating: ___ +Toileting Hygiene: _____ +Average Bed Mobility Score(Sit to Lying and Lying to Sitting): _____ +

Average Transfer Score(Sit > Stand, Chair/Bed>Chair, Toilet Tx): _____

= Nursing Function Score

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Nursing Component-Nursing Functional Score

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Remember: Functional Score-Case Study

•Eating: with staff oversight and encouragement

•Oral Care: has no natural teeth, performs all aspects of denture care and cleaning with Supervision and encouragement from Staff

•Toilet Hygiene: needs assist, CNA performs less than half the effort

•Bed Mob: one CNA is required and performs more than half the effort for sit to/from lying

•Transfers: requires a full mechanical lift for all transfers and 2 staff.

•Walking: She is unable to walk as she can not bear enough weig

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Functional Score Calculation

Task GG score Func. Score

Eating

Toileting Hygiene

Ave. Bed Mob-Sit to Lying

-Lying to Sitting

Ave. Transfer Score-Sit > Stand

-Chair/Bed->Chair-Toilet Transfer

Total Nursing Functional Score = 6

Practice

Case Study- Mrs. H, Nursing Component

• Nursing Functional ScoreEat _ points

Toilet hygiene _ points

Ave Bed Mob _ point

Ave Transfers __point

Total = _ pts for Nursing Functional Score

• Special Care Low is assigned as the Nursing Category due to the coding of a diabetic foot ulcer and the absence of anything coded from the higher categories.

• She scores a 5 on the PHQ-9 Resident Interview, so does not qualify as Depressed

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Practice

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Nursing Component

CMI

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Nursing Component

RESIDENT

NO

NO

NO

NO

NO

3 TRACHEOSTOMY & VENTILATOR2 TRACHEOSTOMY OR VENTILATOR1 INFECTION ISOLATION

2 DEPRESSED1 NOT DEPRESSED


2 DEPRESSED

1 NOT DEPRESSED

2 NURSING REHAB 2+1 NURSING REHAB 0-1

2 NURSINGREHAB 2+

1 NURSINGREHAB 0-1

YES

YES

YES

YES

YES

YES

EXTENSIVE SERVICES

SPECIAL CARE HIGH

SPECIAL CARE LOW

CLINICALLY COMPLEX

BEHAVIOR SX CONDITION

REDUCED PHYSICAL FUNCTION

⚫

❖

GG-Based Function

Score0-140-140-14

ES3/4.04

ES1/2.91ES2/3.06

⚫

⚫ADL

ADL0-5

6-140-5

6-14

⚫

⚫

⚫⚫

HDE2/2.39HBC2/2.23

HDE1/1.99HBC1/1.85

ADL

ADL0-5

6-140-5

6-14

LDE2/2.07LBC2/1.71

LDE1/1.72LBC1/1.43

❖

❖

❖ ❖

❖❖

0-56-14

15-16

ADL

ADL

0-56-14

15-16

CDE2/1.86CBC2/1.54

CDE1/1.62CBC1/1.34

0-56-14

15-16

ADL

ADL

0-56-14

15-16

PDE2/1.57PBC2/1.21

PDE1/1.47PBC1/1.13

CA2/1.08

CA1/0.94

PA2/0.70

PA1/0.66

11-1611-16

BAB1/0.99

BAB2/1.04


05,06 Set-up assistance, independent 4




01, 07, 09, 10, 88, [-]

Dependent, refused, not attempted

0




GG0170B1 Mobility: Sit to lying 0-4(avg. of 2 bed

mobility items)GG0170C1 Mobility: Lying to sitting on

side of bed

GG0170D1 Mobility: Sit to stand

0-4(avg. of 3 transfer

items)



Nursing Component:See the CMS PDPM calculation worksheet for inclusion criteria for each nursing classification.

Practice

Constructing the PDPM rate

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=$/day

PT

$

OT

$

SLP

$

Nursing $

NTA

$

Non-Case-Mix

$

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Constructing the PDPM rate

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Applying the Variable Per-Diem to the PDPM Rate

There is a certain degree of variability in patient costs over the course of a stay.

To more accurately account for this, PDPM has applied an adjustment factor for certain components.

This adjustment factor changes the per diem rate over the course of the stay for PT, OT and the NTA components of the rate.

This variable per diem adjustment factor is multiplied by the case mix adjusted per diem rate following a schedule of adjustments for each day of the Medicare stay.

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Day in Stay PT/OT Adjustment Factor

1-20 1.00

21-27 0.98

28-34 0.96

35-41 0.94

42-48 0.92

49-55 0.90

56-62 0.88

63-69 0.86

70-76 0.84

77-83 0.82

84-90 0.80

91-97 0.78

98-100 0.76

Day in Stay NTA Adjustment Factor

1-3 3.0

4-100 1.00

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Day 1-3 of Medicare Stay--No variable reduction to PT/OT rate-NTA inflated x 3 for first three days of the stay

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Days 4-20 of Medicare Stay--No variable reduction to PT/OT rate-No variable adjustment to NTA

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Days 21-27 of Medicare Stay--PT/OT component reduced by 2%-No variable adjustment to NTA

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MDS and RAI Manual

Changes and Updates

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Changes by Chapter / Section

New Chapter 6 6.3 PDPM 6.3 PDPM calculation worksheet

Changed Chapter 2Chapter 5Section ASection CSection DSection GGSection I

Section JSection KSection OSection VSection XSection Z

No Changes Section BSection ESection FSection GSection H

Section LSection MSection NSection PSection Q

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Chapter 6

• Extensively revised for change in payment system

• Includes:• Changes to HIPPS codes

• Classification categories: Clinical and Functional based on section GG

• PDPM component tables for PT/OT, SLP, Nursing and NTA

• AI codes for the IPA and 5-Day

• Interrupted Stay Policy

• Non-compliance with the SNF PPS (late and missed assessments)

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Scheduled and Unscheduled Assessments

• Scheduled PPS Assessment• The PPS-required standard assessment is the 5-Day assessment.

• Has a predetermined time period for setting the ARD

• The SNF provider must set the ARD on days 1-8 to assure compliance with the SNF PPS PDPM requirements

• Unscheduled PPS Assessment• There are situations when a SNF provider may complete and assessment after

the 5-Day assessment, this is an unscheduled assessment called the InteriPayment Assessment (IPA).

• When deemed appropriate by the provider, the IPA may be completed to capture changes in the resident’s status and condition

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5-Day Assessment

• Must be the first PPS-required assessment to be completed when the resident is admitted to the facility for a Part A stay• When initially admitted to the facility, or

• Following a DC assessment – return not anticipated, or

• If the resident returns more than 30 days after a DC-return anticipated

• A 5-Day assessment is not required at the time a resident returns to a Part A covered stay following an interrupted stay, regardless of the reason for the interruption (DC from facility, resident no longer in need of skilled care, change in payer, etc.)

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5-Day Assessment

• If a resident were to change payer source, fro mMedicare Advantage to Medicare Part A, the SNF must complete a 5-Day assessment with the ARD set for one of the days 1 through 8 of the Medicare Part A stay• The resident’s first day covered by Medicare Part A would be day 1, unless it is

a case of an interrupted stay

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Interim Payment Assessment (IPA)-optional assessment

• ARD may be set for any day of the SNF PPS stay, beyond the ARD of the 5-day.

• Authorizes payment for the remainder of the PPS stay, beginning on the ARD

• Can not be combined with any other assessment (PPS or OBRA)

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Part A PPS Discharge

• The PPS Discharge assessment is completed when a resident’s Medicare part A stay ends, but the resident remains in the facility, unless it is an instance of an interrupted stay

• If the Med A stay ends and the resident returns to a skilled level of care and Med A benefits do not resume within 3 days, the PPS schedule starts again with the 5-day assessment.

• If the Med A stay does resume within the 3-day interruption window, then this is an interrupted stay

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Part A PPS Discharge

• If the resident leaves the facility fo ran interrupted stay, no Part A PPS discharge assessment is required when the resident leaves the building at the outset of the interrupted stay.

• However, an OBRA Discharge record is required.

• If the resident returns to the facility within the interruption window, an entry tracking form is required; however no new 5-Day assessment is required

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Combining PPS and OBRA Assessments

• The OBRA Admission assessment can still be combined with the 5-Day Assessment, however- keep in mind, when selecting the ARD• For OBRA Admission the ARD must be set between days 1- 14 counting the

day of admission as day 1

• For the 5-Day, the ARD must be set for days 1-8

• Tracking records 9entry and death in facility) and Interim Payment Assessment can never be combined with other assessments

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Combining PPS and OBRA Assessments

5-Day PPS Assessment may be combined with the

following assessment types:

OBRA Admission Assessment

OBRA Quarterly Assessment

Annual Assessment

Significant Change in Status Assessment

Significant Correction to Prior Comprehensive

Significant Correction to Prior Quarterly

OBRA DC Assessment

Part A PPS Discharge Assessment

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Factors Impacting the SNF PPS Assessment Scheduling• Res is sent out to hospital, not in SNF over midnight and is not

admitted• If res out less than 24 hours, and is not admitted, a new 5-day assessment is

not required, though an IPA may be completed

• The day preceding the midnight on which the resident was absent from the NH is not a covered Part A day pursuant to the “midnight rule”.

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Factors Impacting the SNF PPS Assessment Scheduling• Res takes a Leave of Absence from the SNF

• If res is out of the facility for LOA, there may be payment implications• For instance, if resident leaves at 6pm on Wednesday, which is day 29 of the resident’s

stay, and returns to the SNF on Thursday at 9am, then Wednesday becomes a non-billable day and Thursday becomes day 29 of the stay.

• Resident DC from Part A and from the facility and Returns to Part A skilled level:• If resident returns after the interruption window has closed, the OBRA DC and

Part A PPS Discharge must be completed an may be combined.

• On return, this is considered a new Part A stay, requiring a new 5-Day Assessment

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Factors Impacting the SNF PPS Assessment Scheduling• Non-Compliance with the PPS Assessment Schedule

• Frequent late assessment scheduling practices or missed assessments may result in additional review

• The default rate takes the place of the otherwise applicable Federal rate• This rate is equal to the rate paid for the HIPPS code reflecting the lowest

acuity level for each PDPM component, and will often be less than the Medicare rate payable if the SNF had submitted an assessment on time

• Late Assessments• The SNF will bill the default rate for the number of days the assessment is out

of compliance• The SNF would then bill the HIPPS code established by the late assessment for

the rest of the SNF stay, unless they opt to complete an IPA

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Special Considerations

• Significant differences between Section G and Section GG scoring methodology:• Using Section G, increasing scores are associated with increasing dependence

• Using Section GG, increasing scores are associated with decreasing dependence.

• Relationship to payment is • Under RUG IV, greater dependence in ADL’s -> higher payment

• Under PDPM, there is NOT a direct relationship between the two• i.e. for the PT and OT components, payment is highest for the mid-range functional

category, lower for most dependent and most independent as they are associated with a reduced need for therapy.

RUG IV & PDPM Functional Score Differences

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Restorative Nursing Programs- A Comeback?

A concept rooted in promoting a resident’s optimal physical, mental and psychosocial functioning.

Requirements of the Program:

• Measurable objectives and interventions as part of the care plan and in the medical record

• Periodic evaluation by the licensed nurse in medical record

• Training for certified nursing assistants in the techniques that promote resident involvement in the activity

• The program must be supervised by an RN

• A physicians order is NOT required

• Although therapists may participate in a restorative nursing program, members of the nursing staff are still responsible for overall coordination and supervision of restorative nursing programs.

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Nursing Component with Restorative Nursing

RESIDENT

NO

NO

NO

NO

NO

3 TRACHEOSTOMY & VENTILATOR2 TRACHEOSTOMY OR VENTILATOR1 INFECTION ISOLATION



2 DEPRESSED

1 NOT DEPRESSED

2 NURSING REHAB 2+1 NURSING REHAB 0-1

2 NURSINGREHAB 2+

1 NURSINGREHAB 0-1

YES

YES

YES

YES

YES

YES

EXTENSIVE SERVICES

SPECIAL CARE HIGH

SPECIAL CARE LOW

CLINICALLY COMPLEX

BEHAVIOR SX COGNITION

REDUCED PHYSICAL FUNCTION

⚫

❖

GG-Based Function

Score0-140-140-14

ES3/4.04

ES1/2.91ES2/3.06

⚫

⚫ADL

ADL0-5

6-140-5

6-14

⚫

⚫

⚫⚫

HDE2/2.39HBC2/2.23

HDE1/1.99HBC1/1.85

ADL

ADL0-5

6-140-5

6-14

LDE2/2.07LBC2/1.71

LDE1/1.72LBC1/1.43

❖

❖

❖ ❖

❖❖

0-56-14

15-16

ADL

ADL

0-56-14

15-16

CDE2/1.86CBC2/1.54

CDE1/1.62CBC1/1.34

0-56-14

15-16

ADL

ADL

0-56-14

15-16

PDE2/1.57PBC2/1.21

PDE1/1.47PBC1/1.13

CA2/1.08

CA1/0.94

PA2/0.70

PA1/0.66

11-1611-16

BAB1/0.99

BAB2/1.04


05,06 Set-up assistance, independent 4




01, 07, 09, 10, 88, [-]

Dependent, refused, not attempted

0




GG0170B1 Mobility: Sit to lying 0-4(avg. of 2 bed

mobility items)GG0170C1 Mobility: Lying to sitting on

side of bed

GG0170D1 Mobility: Sit to stand

0-4(avg. of 3 transfer

items)



Nursing Component:See the CMS PDPM calculation worksheet for inclusion criteria for each nursing classification.

Nursing Category Nursing Function Score (GG)

Case mix group/ CMI without 2 Restorative Nursing Programs/ Applied to base rate($103.46)

Case mix group/ MCI with 2 Restorative Nursing Programs/ Applied to base rate ($103.46)

Net Increase with 2 Restorative Nursing Programs

Behavior Sx/ Cognition 11-16 BAB1/.99/ $102.43 BAB2/1.04/ $107.60 + $5.17

Reduced Physical Function 0-5 PDE1/1.47/$152.09 PDE2/1.57/$162.43 + $10.34

6-14 PBC1/1.13/$116.91 PBC2/1.21/$125.19 + $8.28

15-16 PA1/.66/$68.28 PA2/.70/$72.42 + $4.14

Average increase $6.98/day

Restorative Nursing Programs- A Comeback?Consider your Return on Investment

• Restorative nursing programs can support a safe DC plan

• Can be beneficial to the residents after formalized rehab ends and before they are ready for DC from the facility

• Can be helpful in ensuring the resident is truly INDEPENDENT before they return to the community

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MDS Changes with PDPM-Schedule

• PDPM will continue to use MDS 3.0 as the basis for patient assessment (same as RUG’s IV)

• The assessment schedule with change a great deal as we move to PDPM.• RUG’s IV – need for frequent assessments, scheduled and unscheduled, several rules governing

timing and scheduling of assessments, etc. The high frequency of assessments being due to the need to closely track utilization of resources, aka therapy minutes primarily.

• PDPM-schedule more streamlined and less complex.

Medicare MDS Assessment Type ARD Applicable Standard Medicare Payment Days

5-day Scheduled PPS Assessment Days 1-8 All covered Med A days until PPS DC MDS (unless an IPA is completed

Interim Payment Assessment (IPA) Optional Assessment ARD of the IPA through PPS DC (unless another IPA is completed)

PPS Discharge Assessment PPS DC = End date of the most recent Medicare stay (A2400C) or End Date

N/A

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MDS Changes with PDPM-New Item Sets

• Interim Payment Assessment (IPA):

• Optional Assessment

• Can be used by providers to report a change in patients PDPM classification

• Will not impact the variable per diem rate

• ARD-Determined by provider

• Impact on payment- changes payment starting on the ARD of the IPA and continues until the end of the Part A stay or until another IPA is completed

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• Optional State Assessment (OSA):• This is the set of items that may be required by State Medicaid agency to

calculate the RUG III or RUG IV HIPPS code. This is not a federally required assessment; rather, it is required at the discretion of th State Agency for payment purposes (A0300A=1)

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• OSA is a standalone assessment and can not be combined with any other assessment

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CMS Updates FAQ’s on PDPM site - the below was updated 4/4/19

Originally, CMS indicated that it would allow providers in states using RUG-III or RUG-IV models as the basis for Medicaid payment to do so until 9/30/20. CMS will no longer support

RUG’s III or IV after that. Now- it is stating that after 9/30/20, states will be required to use the OSA.

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Additional Updates from CMS 4-4-19 on OSA


• SNF Primary Dx• I0020B – new item will be added to MDS

• Patient’s primary SNF Dx will be reported using ICD-10 code• What is the main reason for the skilled care in the SNF

• Coded when I0020 is coded with any response 1-13

• Surgical History• J2100-J5000 – new items will be added to MDS

• Providers will use these items to capture any major surgical procedure that occurred during the qualifying hospital stay

• Will be in the form of check boxes

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I0020B Primary ICD-10 Dx Code on MDS

CMS expects that I0020B Dx code and UB Dx will match, however there is no claim edit that will enforce this.

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• Section GG Functional Items- Interim Performance• A new column “5” will capture Section GG items on the IPA, capturing the

interim performance of the resident

• The look-back for this will be the three-day window leading up to and including the ARD of the IPA

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• Discharge Therapy Collection Items• O425A1-O425C5 –new items will be added to MDS

• The look-back period for these items will be the entire PPS stay.

• Providers will report, by discipline and mode of therapy (individual, concurrent and group) the amount of therapy time (in minutes) received by the patient

• The total amount of group/concurrent minutes should not exceed 25% of the total amount of therapy. If it does, a warning message will be issued on final validation report.

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What happens to Therapy?• PDPM is a change in our Revenue

Delivery System

• Not a chance in care delivery

• Rehab Dept- shift in thinking• No longer will rehab bring in

additional revenue (Med A) but will actually cost you money

• Residents will absolutely still need rehab/therapy services

• You may find that your IDT’s working together, can achieve the same outcomes with fewer minutes of therapy. Think: Efficiency103

Rehab Dept. Revenue

Generator

Rehab Dept. Cost Center

What happens to Therapy?• PDPM does not change the care

needs of the SNF patient.

• These needs remain the primary driver of care decisions, including the type , duration, and intensity of skilled therapies delivered.

• Patients are classified into a payment group for each of the therapy components, regardless of whether or not the patient is receiving services within that particular therapy discipline.

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PT?

OT?

ST?

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Concurrent and Group Therapy?

Concurrent Therapy- One therapist with 2 patients doing different things

Group Therapy- One therapist with up to four patients doing the same or similar activities (*potentially changing with ANPRM FY 2020)

Under current system, RUG IV- no > than 25% of therapy services delivered to SNF patients for each discipline, can be done in a group setting. However, there is no limit on concurrent therapy. (YIKES!)

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Concurrent and Group Therapy?

• Under PDPM, a combined limit of both concurrent and group therapy is set at no more than 25% of total therapy received by the resident, for each discipline.

• How will this be monitored?• New item O0425

• Will provide number of minutes, per mode and discipline for the entire Med A stay

• If the total concurrent and group is > 25% of total therapy minutes for any discipline, the provider will receive a warning message on final validation report.

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Concurrent and Group Therapy?Calculate:Step 1:

Total min. by discipline

(O0425X1 + O0455X2 + O0425X3)

Step 2:

Total Concurrent and Group min. by discipline

(O0425X2 + O0425X3)

Step 3:

Concurrent and Group Ratio/Total Minutes

(Step 2 result/Step 1 result)

Step 4:

If Step 3 result is > 0.25, then non-compliant

Example: Total PT Individual minutes (O0425C1)= 1,300Total PT Concurrent minutes (O0425C2)= 100Total PT Group minutes (O0425C3)=100

Step 1: Total PT minutes = 1,500Step 2: Total PT Concurrent and Group minutes = 200Step 3: C/G to Total Ratio: 200/1,500= 0.13Step 4: 0.13 is not greater than 0.25, this example is

in compliance

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MDS Coding of Part A Therapies: O0425 – Therapy MinutesA (Speech Therapy),

B (Occupational Therapy) and C (Physical Therapy)MDS 1.17.0 eff. 10/1/19

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MDS Coding of Part A Therapies: O0400- Therapy Start and End Dates A (Speech Therapy),

B (Occupational Therapy) and C (Physical Therapy)MDS 1.17.0 eff. 10/1/19

Interrupted Stay Policy

Background: • Potential for incentive for providers to discharge SNF patients back to the hospital

and then readmit in order to reset the variable per diem schedule- given the front loaded nature of the adjustment $$$

• On top of being a questionable ethical practice, frequent readmissions and transfers to the hospital comes with a significant risk to the well being of the patient, in addition to the added administrative burden on providers

• The interrupted stay policy is in place to address this potential incentive for the above, as it combines multiple SNF stays into a single stay in cases where the patient’s discharge and readmission occurs within a precise time window:

RESIDENT RETURNS TO THS SAME SNF WITHIN THREE DAYS OR LESS

• New MDS item, A0310G1, will be used on the discharge assessment to determine if it is an Interrupted Stay

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Interrupted Stay Policy

• Interrupted Stay Policy Applies:• Pt. is DC from a SNF and is readmitted to he same SNF within 3 consecutive

calendar days after DC.

• The assessment schedule continues from the point just prior to DC

• The variable per diem schedule continues from the point just prior to DC

• Interrupted Stay Policy Does Not Apply:• Pt. is DC from SNF & readmitted more than 3 consecutive calendar days after DC

• Pt. is admitted to another SNF (considered a new stay)

• The assessment schedule and variable per diem schedule reset to day 1

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Interrupted Stay Policy-Example

Example 1:• Mrs. A is admitted to the SNF on 10/7/19, admitted to hospital on

10/20/19, and returns to the same SNF on 10/25/19• Interrupted stay policy does NOT apply• This will be considered a new stay, beginning with a new 5 day assessment• The variable per diem will reset beginning on day 1 of the new stay

Example 2:• Mr. B is admitted to the SNF on 10/7/19, admitted to hospital on 10/20/19,

and returns to the same SNF on 10/22/19• Interrupted stay policy DOES apply• This will be a continuation of the previous stay• No PPS assessments are required (IPA is optional)• The variable per diem continues from day 14 (the day of the Part A DC)

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MDS Changes- A0310 Interrupted StayMDS 1.17 eff. 10/1/19

RUG’s IV A0310 Type of Assessment PDPM A0310 Type of Assessment

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Administrative Presumption

• Applies to a beneficiary who is assigned to one of the designated, more intensive case mix groups on the 5 day PPS assessment

• They are automatically classified as requiring an SNF level of care through the ARD of the 5 day MDS.

Ext. Svc.

Special Care High

Special Care Low

Clinically Complex

Behavioral Symptoms and Cognitive Performance

Reduced Physical Function

RUG IV Presumption of Care

Above the line- YesBelow the line- No

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Administrative Presumption in a PDPM World

Nursing Group-same as RUG IV

PT and OT GroupsSLP Group NTA Component

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Excluded from PDPM Presumption

HIPPS Coding

• 5 Character HIPPS code is identified through coding of the MDS and is used on Medicare claims

• RUG IV• Character 1-3: RUG code• Character 4-5: Assessment Indicator

• PDPM • Character 1: PT/OT Component• Character 2: SLP Component• Character 3: Nursing Component• Character 4: NTA Component• Character 5: Assessment Indicator

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HIPPS Coding

117

Step #1

Step #2

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119

Step #3



Step #4

120

Step #5

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HIPPS Coding Examples

Resident A:

• PT/OT-TN

• SLP-SH

• Nursing-CBC2

• NTA-NC

• Assessment-5 day

• HIPPS Code: _______

Mrs. H• PT/OT-TJ• SLP-SE• Nursing-LBC1• NTA-NB• Assessment-IPA • HIPPS Code: _______

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SNF billing practices related to the use of the HIPPS code and revenue codes remain the same under PDPM.

Practice

PDPM Case-Mix Group Conversion to HIPPS CharactersPT/OT Payment

GroupSLP Payment

GroupNursing Payment

GroupNTA Payment

GroupHIPPS Character

TA SA ES3 NA A

TB SB ES2 NB B

TC SC ES1 NC C

TD SD HDE2 ND D

TE SE HDE1 NE E

TF SF HBC2 NF F

TG SG HBC1 G

TH SH LDE2 H

TI SI LDE1 I

TJ SJ LBC2 J

TK SK LBC1 K

TL SL CDE2 L

TM CDE1 M

TN CBC2 N

TO CA2 O

TP CBC1 P

CA1 Q

BAB2 R

BAB1 S

PDE2 T

PDE1 U

PBC2 V

PA2 W

PBC1 X

PA1 Y

Assessment Type HIPPS Character

IPA 0

PPS 5-day 1

OBRA Assessment (not coded as a PPS assessment)

6

1st Character PT and OT payment group

2nd Character SLP payment group

3rd Character Nursing payment group

4th Character NTA payment group

5th Character Assessment Indicator

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PDPM Default Billing

• There are instances when providers must bill the “default” rate on a SNF claim (i.e. when an MDS assessment is late)• PDPM default code: ZZZZZ• RUG IV default code: AAA00

• Billing a ZZZZZ (PDPM default) is same as billing• PT/OT component-TP• SLP component-SA• Nursing component- PA1• NTA component- NF

PAYF^

• The variable per diem will be a factor of the default HIPPS code for as long as the default rate controls payment

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Transition to PDPM

• CMS has announced that there will be NO TRANSITION period between RUG IV and PDPM as this would present too large an administrative burden to both providers and CMS.• RUG IV billing ends 9/30/19• PDPM billing begins 10/1/19

• In order for all Med A covered residents to have a PDPM HIPPS code that can be used for billing, CMS will require all Part A residents to have an IPA completed with an ARD no later than 10/7/19.• The variable per diem count will begin with 10/1/19 considered day 1, even if

a Med A stay started sooner. • Any “transitional” IPA’s with ARD’s after 10/7/19 will be considered late and

applicable payment penalties will be applied.

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Example Resident- Mrs. HMrs. H• PT/OT-TJ, 1.42/1.44• SLP-SE, 2.33• Nursing-LBC1, 1.43• NTA-NB, 2.53• Assessment-5 day • HIPPS Code: JEKB1

Mrs. H admitted with CHF (acute on chronic)Has DM with diabetic foot ulcer, on IV Abx, Dx IBSSec G ADL score of 10Sec GG function score of 9, PT/OT and 5, nursing. Total therapy minutes 730, 6 calendar daysRUG IV score- RUB at $631/day

PDPM Days 1-3

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Example Resident- Mrs. H

PDPM Days 4-20

Mrs. H• PT/OT-TJ, 1.42/1.44• SLP-SE, 2.33• Nursing-LBC1, 1.43• NTA-NB, 2.53• Assessment-5 day • HIPPS Code: JEKB1

Mrs. H admitted with CHF (acute on chronic)Has DM with diabetic foot ulcer, on IV Abx, Dx IBSSec G ADL score of 10Sec GG function score of 9, PT/OT and 5, nursing. Total therapy minutes 730, 6 calendar daysRUG IV score- RUB at $631/day 126

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PDPM Days 21-27




PDPM Days 28-29, DC on day 30



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RUG IV, 29 day stay

• Day 1-14-> 14 @ $631 (RUB10)= $8,834

• Day 15-29-> 15 @ $631 (RUB20)= $9,465

PDPM, 29 day stay• Day 1-3 -> 3 days @ $1,048=$3,144 • Day 4-20 -> 17 days @ $653 = $11,101• Day 21-27-> 7 days @ $650 = $4,550• Day 28-29-> 2 days @ $646 = $1,292

Total = $20, 087

Total = $18,299

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PDPM Pit Falls!

• Missing MDS items or not accurately coding on MDS can have a big impact on your PDPM payment.

• Failing to code even one item can have a large impact.

• Failure to implement a discharge plan-> increased length of stay.

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Example Resident- Mrs. H with mis-coded NTA data on MDS

Days Per Diem Rate

RUG IVPDPM

Coded Accurately

PDPM with missing MDS data, DM not checked off

in Section I

1-3 $631 $1,048 $889

4-20 $631 $653 $600

21-27 $631 $650 $597

28-29 $631 $646 $593

Total for stay (29 days) $18,299 $20,087 $18, 232

One check box item missed on the 5 Day MDS costs $1,855.

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Example Resident- Mrs. HConsiderations for Length of Stay

• Daily PDPM rate for days 4-20 for Mrs. H is $653/day

• The daily rate is reduced to $614/day by day 100.

• Reminder- the initial rate days 1-3 was $1,048

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FY 2020 Proposed Rule Update

April 19, 2019 – CMS issued FY 2020 Proposed Rule

• Market Basket Update is projected at 2.5%

• Base rates for PDPM have been adjusted

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FY 2019 Unadjusted Federal Rate Per Diem -Urban

FY 2020 PROPOSED Unadjusted Federal Rate Per Diem-Urban


April 19, 2019 – CMS issued FY 2020 Proposed Rule

• “Group Therapy”- proposed change to definition, allowing 2-6 patients doing same or similar activities

• Reinforce that the IPA be performed at the discretion of the facility, CMS anticipates that IPA’s occur in only 4% of Med A stays.

• Propose that the phrase “the 5-day assessment” be replaced with “the initial patient assessment”

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April 19, 2019 – CMS issued FY 2020 Proposed Rule:

• Proposes to update two new QRP measures: Transfer of Health Information from the SNF to another Provider and Transfer of Health Information from the SNF to the Patient.

• CMS proposes to adopt a number of standardized patient assessment data elements.

• Proposing to expand data collection for SNF QRP QM’s to all SNF residents regardless of payer and to publicly display DRR QM.

• FY 2020 VBP is changing the name of its QM to “Skilled Nursing Facility Potentially Preventable Readmissions after Hospital Discharge” (SNFFPPR)

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Case StudiesTable Top Work Groups

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Practice Scenario- #1Resident is admitted to the NH for therapy services following hospitalization for acute coronary syndrome, which was Dx as an acute non-ST elevation MI (NSTEMI). Resident has BIMS of 5. Is on regular diet. Has comorbid Dx of DM.

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MDS Data- Coding Criteria

ICD-10/Primary Clinical Category I21.4 (NSTEMI)/ Med. Mgt.

PT/OT Function Score 9

Nursing Function Score 6

SLP Cognitive Impairment yes

SLP Comorbidities no

Swallow Disorder no

Mechanically Altered Diet no

NTA Comorbidity Score 2

Depression No

Nursing Case Mix Group Special Care High

PDPM Rate Break Down- Practice Scenario #1*using days 4-20 of Medicare A stay, and Federal Unadjusted Base Rates FY 2019

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TJ

TJ

SD

NE

HBC1

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Practice Scenario- #2Resident presents at hospital with slurred speech, facial droop and change in mental status. Is later Dx with an acute embolic cerebral infarction. Patient is also treated for HTN and hyperlipidemia, had a PEG tube placed. DC Dx lists embolic CVA with cognitive deficit, facial droop and oropharyngeal dysphagia, HTN, hyperlipidemia.

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MDS Data Coding Criteria

ICD-10/Primary Clinical Category I69.391 Dysphagia following Cerebral Infarction, Acute Neurologic




SLP Comorbidities yes

Swallow Disorder yes

Mechanically Altered Diet yes


Nursing Category Special Care High

Depression No


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M

HDE1

NC

SL

TM

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Practice Scenario- #3Resident is admitted to the hospital with generalized weakness, history of recent falls and failure to thrive. He has chronic renal failure that is contributing to his weakness. After a four night hospital stay, the patient is admitted to your facility for ongoing therapy to improve strength and function.

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ICD-10/Primary Clinical Category N18.9, Chronic Renal Failure, Medical Mgt.



SLP Cognitive Impairment no


Swallow Disorder no

Mechanically Altered Diet no


Nursing Category Reduced Physical Function

Depression No


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M

HDE1

NC

SL

TM

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Practice Scenario- #4Resident is admitted to SNF after 3 night stay in the hospital for fracture of the distal right radius and ulna related to fall at home. She has hx of CVA with hemiplegia.

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ICD-10/Primary Clinical Category S52.501D, Fx radius/ulna subsequent encounter/ Other Orthopedic



SLP Cognitive Impairment No

Swallow Disorder no

SLP Comorbidities yes



Nursing Category Clinically Complex

Depression No


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M

HDE1

NC

SL

TM

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Practice Scenario- #5Resident is admitted from the hospital after an elective THR right side for DJD. The patient is now on IV Vitamin K due to issues related to anticoagulation. She has BIMS of 9 and is complaining of pain with swallowing.

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ICD-10/Primary Clinical Category Z47.1, Aftercare following joint replacement surgery, Major Joint Replacement/Spinal Surgery




Swallow Disorder yes




Nursing Category Clinically Complex

Depression yes


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M

HDE1

NC

SL

TM

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Strategies for Success• ICD-10 Dx coding-

• What is your current process?• Who is responsible for to code your ICD-10 Dx

codes? Do they have a clinical background?• Often it is the facilities NAC that is responsible

for coding ICD-10 Dx. • While the primary ICD-10 Dx is receiving most of

the attention with PDPM, we must not lose sight of the other active dx that will impact the PDPM score: SLP comorbidities and the NTA score

• If we miss the ICD-10 Dx on the 5 day MDS, you may mis out on reimbursement for the entire Med A stay

• Are your coders adequately trained? Do they need additional education?

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Strategies for Success

• Fewer MDS’s to complete?• Don’t go down-sizing your MDS

department just yet• Where will you use them? On the

floor? Becoming more familiar with the residents may promote a more accurate assessment.

• Average length of stay Med A is 28.9 days. This is only one less MDS per stay, assuming a facility is currently not doing high frequency of unscheduled PPS and in PDPM will not have need to perform IPA.

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Strategies for Success• Nursing Component

• Most nursing categories fall into Reduced Physical Function or Clinically Complex

• Understanding your RUG IV categories and documentation to support higher levels will promote higher scores for PDPM Nursing Component

• Nursing and NTA Components make up 44% of the PDPM base rate.

• Are you confident in your skilled nursing documentation?

• What does it look like now?

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Strategies for SuccessSection GG

• Who is responsible for coding GG?

• Do you have a strategy?

• What does your timing look like for when you assess admission and discharge performance?

• Scores of 10-23 are most optimal for PT/OT component (mid-range)

• Scores of 0-5 are most optimal for Nursing component (most dependent)

• Remember, when coding “ usual performance”:

“The admission functional assessment, when possible, should be conducted prior to the person benefitting from treatment interventions in order to determine a true baseline functional status on admission. If treatment has started, for example, on the day of admission, a baseline functional status assessment can still be conducted. Treatment should not be withheld in order to conduct the functional assessment. “

RAI User’s manual Version 1.16, Oct. 2018

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• The evolving role of MDS staff

• Reduced work load???

• QRP

• VBP

• Monitoring QIES system

• PBJ, variety of useful reports

• QRP tools: Review and Correct Reports, Facility Level QM Reports, Provider Threshold Reports

• CASPER and Five Star Provider Rating reports

• Confidential Feedback Reports (Quarterly and Annual) on VBP

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Utilization Review Meetings:

• Will need to be restructured

• Should involve the IDT- not just the MDS coordinator

• Do you have an effective tracking tool?

• Work with you team to project HIPPS category and length of stay.

• Remain focused on your goals- both clinical/nursing and functional/rehab

• The resident should be the center of that care plan, along with their caregivers and family

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Thank You for Joining us!

Any Questions?

Sarah Ragone, MSPT, RAC-CT, QCP

VP of Reimbursement & Education

Coretactics Healthcare Consulting, Inc.

[email protected]

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pdpm for mds coordinators•orthopedic surgery •j2500, j2510, j2520, or j2530. •if none of these...

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