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PDPM WORKSHOP
PDPM – Road Map for Success
PDPM WORKSHOP
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1 PDPM Overview
2 Components/Characteristics & Functional/Cognitive Scoring
3 MDS & Billing Changes
4 Strategies for Success
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PDPMOverviewBrian Hickman, CPA, Partner – BKD,
LLP
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Fun Facts
The Patient-Driven Payment Model (PDPM) is effective October 1, 2019
Specifications included in the SNF PPS Final Rule, published July 31, 2018
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From RUG-IV to PDPM
Payment Drives Culture
Brian Hickman, CPA
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*Spoiler Alert*
ICD-10 coding: from compliance issue to payment driver
Rehab minutes: from payment driver (minutes) to outcomes focus
ADL to functional scoring, capturing patient conditions – The song remains the same
The rise of patient-centered care
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PT PT Base Rate PT CMI PT Adjustment Factor
OT OT Base Rate OT CMI OT Adjustment Factor
SLP SLP Base Rate SLP CMI
Nursing Nursing Base Rate Nursing CMI
NTA NTA Base Rate NTA CMI NTA Adjustment Factor
Noncase Mix Noncase Mix Base Rate
PDPM Case Mix Adjusted Payment
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Patient-Driven Payment Model Rate Components
Urban Rural Low High Low High
Nursing 103.46$ 98.83$ 0.66 4.04 68.28$ 417.98$
NTA 78.05$ 74.56$ 0.72 3.25 56.20$ 253.66$
PT 59.33$ 67.63$ 1.08 1.92 64.08$ 113.91$
OT 55.23$ 62.11$ 1.09 1.68 60.20$ 92.79$
SLP 22.15$ 27.90$ 0.68 4.19 15.06$ 92.81$
Non‐Case Mix 92.63$ 94.34$ n/a n/a 92.63$ 92.63$
* Urban rates
Per‐Diem Base Rates Case‐Mix Index Base Rate Range*
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PDPM vs. RUG-IV Components
PDPM RUG‐IV Low High Low High
Nursing 103.46$ 0.66 4.04
NTA 78.05 0.72 3.25
Routine component 181.51 181.44 0.54 3.58
PT 59.33 1.08 1.92
OT 55.23 1.09 1.68
SLP 22.15 0.68 4.19
Rehab component 136.71 176.83 0.28 1.87
Non‐Case Mix 92.63 92.60 * Urban rates
Case‐Mix Index‐PDPM Case‐Mix Index‐RUG‐IV
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PDPM PT/OT Case Mix Classification Groups
Urban
Functional
Score PT CMI OT CMI Total CMI
CMI
Impact
Rate
Impact
0‐5 1.53 1.49 3.02
6‐9 1.69 1.63 3.32 0.30 17.23
10‐23 1.88 1.68 3.56 0.24 14.03
24 1.92 1.53 3.45 (0.11) (5.91)
0‐5 1.42 1.41 2.83
6‐9 1.61 1.59 3.20 0.37 21.21
10‐23 1.67 1.64 3.31 0.11 6.32
24 1.16 1.15 2.31 (1.00) (57.32)
Major Joint
Replacement or
Spinal Surgery
Other
Orthopedic
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PDPM PT/OT Case Mix Classification Groups
Urban
Functional
Score PT CMI OT CMI Total CMI
CMI
Impact
Rate
Impact
0‐5 1.13 1.17 2.30
6‐9 1.42 1.44 2.86 0.56 32.12
10‐23 1.52 1.54 3.06 0.20 11.46
24 1.09 1.11 2.20 (0.86) (49.26)
0‐5 1.27 1.30 2.57
6‐9 1.48 1.49 2.97 0.40 22.95
10‐23 1.55 1.55 3.10 0.13 7.47
24 1.08 1.09 2.17 (0.93) (53.29)
Medical
Man
agement
Non‐O
rtho
Surgery &
Acute
Neurologic
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PDPM SLP Case Mix Classification Groups
SLP Case Mix Index
Acute Neurologic
Condition, SLP‐Related
Comorbidity, or Cognitive
Impairment Neither Either Both Neither Either Both
None 0.68 1.82 2.66 15.06$ 40.31$ 58.92$
One 1.46 2.33 2.97 32.34$ 51.61$ 65.79$
Two 2.04 2.85 3.51 45.19$ 63.13$ 77.75$
Three 2.98 3.69 4.19 66.01$ 81.73$ 92.81$
Mechanically Altered
Diet/Swallowing Disorder
Mechanically Altered
Diet/Swallowing Disorder
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PDPMComponents & CharacteristicsSherri Robbins, Senior Managing
Consultant, RN, BSN, LNHA, RAC-CT, CLNC – BKD, LLP
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Clinical Categories Collapsed to 4 for PT & OT
PDPM Clinical Category Collapsed PT & OT Clinical Category
Major Joint Replacement or Spinal Surgery Major Joint Replacement or Spinal Surgery
Non‐Orthopedic SurgeryAcute Neurologic
Non‐Orthopedic Surgery & Acute Neurologic
Non‐Surgical Orthopedic/MusculoskeletalOrthopedic Surgery (Except Major Joint Replacement or Spinal Surgery)
Other Orthopedic
Medical ManagementAcute InfectionsCancerPulmonaryCardiovascular & Coagulations
Medical Management
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Section GG PT & OT Functional Score
Item Description Score Range
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 0‐4 (average of 2 items
GG0170D1 Mobility: Sit to stand 0‐4 (average of 3 items)
GG0170E1 Mobility: Chair/bed‐to‐chair transfer 0‐4 (average of 3 items)
GG0170F1 Mobility: Toilet transfer 0‐4 (average of 3 items)
GG0170J1 Mobility: Walk 50 feet with 2 turns 0‐4 (average of 2 items)
GG0170K1 Mobility: Walk 150 Feet 0‐4 (average of 2 items)
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PT & OT Case Mix Groups
Clinical CategorySection of GG
Function ScorePT 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 1.3
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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SLP Comorbidities
Section I Section I ICD‐10 Codes Section O
Aphasia Laryngeal Cancer Tracheostomy Care While a Resident
CVA, TIA or Stroke Apraxia Ventilator or Respirator While a Resident
Hemiplegia or Hemiparesis Dysphagia
Traumatic Brain Syndrome ALS
Oral Cancers
Speech & Language Deficits
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SLP Component
Presence of oMechanically Altered Diet (Section K)
oSwallowing Disorder (Section K)
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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 0.68None Either SB 1.82None Both SC 2.66
Any One Neither SD 1.46Any One Either SE 2.33Any One Both SF 2.97Any Two Neither SG 2.04Any Two Either SH 2.85Any Two Both SI 3.51All Three Neither SJ 2.98All Three Either SK 3.69All Three Both SL 4.19
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Nursing Component
Same RUG IV Major CategoriesoExtensive Services
oSpecial Care High
oSpecial Care Low
oClinically Complex
oBehavior Symptoms & Cognitive Impairment
oReduced Physical Function
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Nursing Functional Score
MDS Section GG – Functional Abilities & GoalsoAssessed during first three days of admission
oDocuments “usual performance”
oFunctional score ranges from zero to 16
Eating Average Bed Mobility
Toilet Hygiene Average Transfer
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NURSING CMINursing RUG Function Score CMI
ES3 0‐14 4.04
ES2 0‐14 3.06
ES1 0‐14 2.91
HDE2 0‐5 2.39
HDE1 0‐5 1.99
HBC2 6‐14 2.23
NBC1 6‐14 1.85
LDE2 0‐5 2.07
LDE1 0‐5 1.72
LBC2 6‐14 1.71
LBC1 6‐14 1.43
CDE2 0‐5 1.86
CDE1 0‐5 1.62
Nursing RUG Function Score CMI
CBC2 6‐14 1.54
CA2 15‐16 1.08
CBC1 6‐14 1.34
CA1 15‐16 0.94
BAB2 11‐16 1.04
BAB1 11‐16 0.99
PDE2 0‐5 1.57
PDE1 0‐5 1.47
PBC2 6‐14 1.21
PA2 15‐16 0.70
PBC1 6‐14 1.13
PA1 15‐16 0.66
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Nursing Component
Important to NoteoNursing component will be increased by 18% for residents with HIV/AIDS
o8 points into the NTA count
• B20 must be on SNF claim
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NTA Component
Calculated based on points assigned for 50 MDS items including diagnosis or extensive servicesoMany of the diagnoses will be based on ICD-10 codes
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Condition/Extensive Service Source Points
HIV/AIDS SNF Claim 8
Parental IV Feeding: Level High MDS Item K0510A2, K0710A2 7
Special Treatment Programs: Intravenous Medication Post-Admit Code MDS Item O0100H2 5
Special Treatment Programs: Ventilator or Respirator Post-admit Code MDS Item O0100F2 4
Parental IV Feeding: Level LowMDS 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: 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 I8000 1
Immune Disorders MDS I8000 1
End-Stage Liver Disease MDS 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 O00100E2 1
Active Diagnoses: Multi-Drug Resistant Organism (MDRO) Code MDS Item I1700 1
Special Treatments/Programs: Isolation Post-admit Code MDS Item O0100M2 1
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Condition/Extensive Service Source Points
Chronic Pancreatitis MDS Item I8000 1
Proliferated 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
MDS Item M1040A, M1040B, M1040C 1
Complications of Specified Implant Device or Graft MDS Item I8000 1
Bladder and Bowel Appliances: Intermittent Catheterization MDS Item H0100D 1
Inflammatory Bowel Disease MDS Item I1300 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 Hemorrhage 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 I560 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
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Condition/Extensive Service Source Points
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
Highest Stage of Unhealed Pressure Ulcer - Stage 4 MDS Item M0300D1 1
Psoriatic Arthropathy and Systemic Sclerosis MDS Item I8000 1
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NTA Case Mix Classification Groups
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
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• Case StudyCVA, PT/OT function score 7, hemiplegia dominant side, BIMS 10, mechanical soft diet, swallowing disorder, 2 stage III ulcers with daily treatment, PHQ-9 score of 10, Nursing Function score of 5, diabetic with daily insulin injections and retinopathy, 2 insulin change orders, IV meds days 1 and 2 after admission for UTI treated in the hospital and a diagnosis of malnutrition.
•Case Mix ClassificationsPT = TN CMI of 1.48OT = TN CMI of 1.49SLP = SL CMI of 4.19Nsg = HDE2 CMI of 2.39NTA = NC CMI of 1.85 Using the Urban base rates we will calculate the daily per diem for:Days 1-3Days 4-20Days 21-27
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Per Diem Days 1-3
PT- $59.33 x 1.48 = $87.81
OT- $55.23 x 1.49 = $82.29
SLP- $22.15 x 4.19 = $92.81
Nsg- $103.46 x 2.39 = $247.27
NTA- $78.05 x 1.85 x 3 = $433.18
Daily per diem for this patient for days 1-3 of the stay is $943.36
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Per Diem Days 4-20
PT- $87.81
OT- $82.29
SLP- $92.81
Nsg- $247.27
NTA- $144.39
Daily per diem for this patient for days 4-20 of the stay is $654.57
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Per Diem Days 21-27
PT- $87.81 less 2% = $86.05
OT- $82.29 less 2% = $80.65
SLP- $92.81 remains unchanged
Nsg- $247.27 remains unchanged
NTA- $144.39 remains unchanged
Daily per diem for this patient for days 21-27 of the stay is $651.17. This is $3.40 lower than days 4-20.
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Functional & Cognitive Scoring
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Section GG PT & OT Functional Score
Item Description Score RangeGG0130A1 Self-care: Eating 0-4GG0130B1 Self-care: Hygiene 0-4GG0130C1 Self-care: Toileting Hygiene 0-4GG0170B1 Mobility: Sit to lyingGG0170C1 Mobility: Lying to sitting on side of bedGG0130D1 Mobility: Sit to standGG0170E1 Mobility: Chair/bed-to-chair transferGG0170F1 Mobility Toilet transferGG0170J1 Mobility: Walk 50 Feet with 2 turnsGG0170K1 Mobility: Walk 150 Feet
0-4 (average of 2 items)
0-4 (average of 2 items)
0-4 (average of 3 items)
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Nursing Function Score
Item Description Score RangeGG0130A1 Self-care: Eating 0-4GG0130C1 Self-care: Toileting Hygiene 0-4GG0170B1 Mobility: Sit to lyingGG0170C1 Mobility: Lying to sitting on side of bedGG0170D1 Mobility: Sit to standGG0130E1 Mobility: Chair/bed-to-chair transferGG0170F1 Mobility: Chair/bed-to-chair transfer
0-4 (average of 2 items)
0-4 (average of 3 items)
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Cognitive Performance Scale
Cognitive Level BIMS Score CPS Score
Cognitivity Intact 13-15 0
Mildly Impaired 8-12 1-2
Moderately Impaired 0-7 3-4
Severely Impaired - 5-6
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PDPMMDS/Billing Changes
Julie Bilyeu, Managing Director – BKD, LLP
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Assessment Changes
Admission (Five‐Day)
• ARD – Days 1–8
• Covers entire stay unless IPA completed
Interim Payment Assessment (IPA)
• ARD can be no later than 14 days after change in first tier classification
• Pays from ARD until discharge except if another IPA is completed
• Does not change the variable payment schedule
PPS Discharge Assessment
• ARD equals end date of the most recent stay
• Not used for payment purposes
• Section O therapy days/minutes
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PDPM HIPPS CODING
1 •PT/OT PAYMENT GROUP
2 •SLP PAYMENT GROUP
3 •NURSING PAYMENT GROUP
4 •NTA PAYMENT GROUP
5 •ASSESSMENT INDICATOR
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ASSESSMENT INDICATORS
HIPPS CHARACTER ASSESSMENT TYPE
0 IPA
1 PPS 5 DAY
6 OBRA
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HIPPS CODE CROSSWALKNursing Group HIPPS Character Nursing Payment HIPPS
ES3 A CBC2 N
ES2 B CA2 O
ES1 C CBC1 P
HDE2 D CA1 Q
HDE1 E BAB2 R
HBC2 F BAB1 S
HBC1 G PDE2 T
LDE2 H PDE1 U
LDE1 I PBC2 V
LBC2 J PA2 W
LBC1 K PBC1 X
CDE2 L PA1 Y
CDE1 M
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HIPPS CODE CROSSWALK
PT/OT SLP NTA HIPPS
TA SA NA A
TB SB NB B
TC SC NC C
TD SD ND D
TE SE NE E
TF SF NF F
TG SG G
TH SH H
TI SI I
TJ SJ J
TK SK K
TL SL L
TM M
TN N
TO O
TP P
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PDPM Impact on OBRA Assessments
No changes to OBRA requirementsoAdmission/quarterly/annual/significant change
Optional state assessment (don’t expect this to impact Mo.)oUse of Medicare PPS MDS for case mix determination
oOnly supported through 9/30/2020
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Variable Per Diem Adjustment Factor – NTA
Medicare Payment Days Adjustment Factor
1‐3 3.0
4‐100 1.0
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Variable Per Diem Adjustment Factor – PT & OT
Medicare Payment Days 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
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Three-Day Interruption Window
Readmission within 3 days (by midnight
of day 3) is considered a
continuation versus a new stay.
Readmission after 3 days is considered a new stay. New MDS & variable payment
resets.
Admission from another SNF is
considered a new stay regardless of the timeframe.
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RUG IV/PDPM TRANSITION
RUG IV billing ends 9/30/19oMust have RUG with an ARD prior to 10/1/19 to bill
PDPM begins 10/1/19oTo establish PDPM payment an IPA with an ARD no later than 10/7/19 needs
completed for the transition
o10/1/19 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in
o If an IPA is completed with an ARD after 10/7/19 it will be considered late and the default penalty for days out of compliance will apply
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Don’t Let This Be You!Strategies for Success
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Diagnosis Coding
Assess staff competencies & provide education as needed
Include ALL ICD-10 codes on each applicable MDS
Review claims to ensure codes are pulling in the correct sequential order
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Minimum Data Set (MDS)
•Perform an MDS process assessment
• Provide education on section GG & start coding now as if payment depends on it
• Learn & implement strategies to improve ADL/functional scoring
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Therapy Service Model
•Assess data & identify best practices
•Develop “care paths” for specific patient conditions
•Discuss with contract therapy likely contract revisions
• Potential Pricing Options• Percent of PDPM
• Time Based
• Risk Based
• Hybrid
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Therapy-Nursing Communication
•Assess current communication system between nursing & therapy
• Evaluate current nursing restorative program & identify education needs for nursing staff
• Develop process for tracking therapy days & minutes for discharge assessment coding
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Length of Stay Management
•Assess length of stay data on current population by diagnosis/clinical condition
• Evaluate impact on PDPM payment
• Establish goals for length of stay management
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Financial
•Revise triple check to include PDPM elements
• Provide education to billing staff on changes under PDPM
•Perform PDPM financial analysis
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Tools to Help You Succeed
•Ask your BKD advisor for a complimentary PDPM impact analysis
• Subscribe to BKD Thoughtware
•Contact information• Brian Hickman [email protected]
• Sherri Robbins [email protected]
• Julie Bilyeu [email protected]
• 417.865.8701
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Questions?
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Thank You!
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The information contained in these slides is presented by professionals for your information only and is not to be considered as legal advice. Applying specific information to your situation requires careful consideration of facts & circumstances. Consult your BKD advisor or legal counsel before acting on any matters covered.