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THE PATIENT DRIVEN PAYMENT MODEL (PDPM)

CASE STUDIES

Presented by:RKL Senior Living Services Consulting

July 26, 2019

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• The information contained herein is of a general nature and is not intended to address the circumstances of any particular individual or entity. Although we endeavor to provide accurate and timely information, there can be no guarantee that such information is accurate as of the date it is received or that it will continue to be accurate in the future. No one should act upon such information without appropriate professional advice after a thorough examination of the particular situation.

Disclaimer

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PDPM OVERVIEW

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PDPM Components

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• PDPM consists of five case-mix adjusted components, all based on data-driven, stakeholder-vetted patient characteristics:

– Physical Therapy (PT)

– Occupational Therapy (OT)

– Speech Language Pathology (SLP)

– Non-Therapy Ancillary (NTA)

– Nursing Classification Groups

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• Each component utilizes different criteria as the basis for patient classification

PDPM Classification

Case Mix Components

Classifiers

PT • Clinical Category• Function Score

OT • Clinical Category• Function Score

SLP • Presence of Acute Neurologic Condition • SLP‐Related Comorbidity or Cognitive

Impairment• Mechanically‐altered Diet• Swallowing Disorder

Nursing • Same characteristics as under RUG‐IV• Function Score

NTA • NTA Comorbidity Score

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FUNCTION SCORE

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• The function score for the PT, OT and Nursing components is calculated as the sum of the scores on seven Section GG items:

• Two bed mobility items

• Three transfer items

• One eating item

• One toileting item

• In addition to the above seven items PT & OT function score also includes:

• Two walking items

• One oral hygiene item

Function Score

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Function Score: Item Response Crosswalk

• Function Score Determination

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Item Response FunctionScore

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 applicable, Not attempted due to environmental limitations, Not Attempted due to medical condition or safety concerns, Resident Cannot Walk (Coded based on response to GG0170I1)

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PT/OT COMPONENT

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PT & OT Clinical Categories• Primary Diagnosis in I0020B is Mapped to a Clinical

Category• The PT & OT components use four collapsed clinical

categories for patient classification

PDPM Clinical Categories PT & OT Clinical Categories

Major Joint Replacement or Spinal Surgery Major Joint Replacement or SpinalSurgery

Acute NeurologicNon-Orthopedic Surgery &

Acute NeurologicNon-Orthopedic Surgery

Non-Surgical Orthopedic/Musculoskeletal

Other OrthopedicOrthopedic Surgery (Except Major Joint Replacement or Spinal Surgery)Medical Management

Medical ManagementCancer

PulmonaryCardiovascular & Coagulations

Acute Infections

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• Prior surgery

‒ “Did the resident have a major surgical procedure during the prior inpatient hospital stay that requires active care during the SNF stay?” (New 10/1/2019)

‒ In order to capture surgical information which may be relevant to classify the patient into a PDPM clinical category, CMS is adding new items in Section J of the MDS. (10/1/2019)

• J2300‐J5000

Clinical Category- MDS 3.0: Section J

MDS Changes: Patient Surgical Categories

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Item Surgical Procedure Category Item Surgical Procedure CategoryJ2100 Recent Surgery Requiring Active SNF Care J2610 Neuro surgery - peripheral and autonomic nervous

system - open and percutaneousJ2300 Knee Replacement - partial or total J2620 Neuro surgery - insertion or removal of spinal and

brain neurostimulators, electrodes, catheters, andCSF drainage devices

J2310 Hip Replacement - partial or total J2699 Neuro surgery - otherJ2320 Ankle Replacement - partial or total J2700 Cardiopulmonary surgery - heart or major blood

vessels - open and percutaneous proceduresJ2330 Shoulder Replacement - partial or total J2710 Cardiopulmonary surgery - respiratory system,

including lungs, bronchi, trachea, larynx, or vocal cords - open and endoscopic

J2400 Spinal surgery - spinal cord or major spinal nerves J2799 Cardiopulmonary surgery - otherJ2410 Spinal surgery - fusion of spinal bones J2800 Genitourinary surgery - male or female organsJ2420 Spinal surgery - lamina, discs, or facets J2810 Genitourinary surgery - kidneys, ureter, adrenals,

and bladder - open, laparoscopicJ2499 Spinal surgery - other J2899 Genitourinary surgery - otherJ2500 Ortho surgery - repair fractures of shoulder or arm J2900 Major surgery - tendons, ligament, or musclesJ2510 Ortho surgery - repair fractures of pelvis, hip, leg,

knee, or ankleJ2910 Major surgery - GI tract and abdominal contents

from esophagus to anus, biliary tree, gall bladder, liver, pancreas, spleen - open, laparoscopic

J2520 Ortho surgery - repair but not replace joints J2920 Major surgery - endocrine organs (such as thyroid, parathyroid), neck, lymph nodes, and thymus - open

J2530 Ortho surgery - repair other bones J2930 Major surgery - breastJ2599 Ortho surgery - other J2940 Major surgery - deep ulcers, internal brachytherapy,

bone marrow, stem cell harvest/transplantJ2600 Neuro surgery - brain, surrounding tissue/blood

vesselsJ5000 Major surgery - other not listed above

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• PT and OT components will ALWAYS result in the same case‐mix group; however, the PT and OT case‐mix indices/payment levels will differ

PT & OT Components

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PT & OT Components: Payment Groups

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Clinical CategoryPT &OT

Function ScorePT &OT

Case Mix GroupPTCMI OTCMI

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

MedicalManagement 0‐5 TI 1.13 1.17

MedicalManagement 6‐9 TJ 1.42 1.44

MedicalManagement 10‐23 TK 1.52 1.54

MedicalManagement 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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SPEECH LANGUAGE COMPONENT

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• There are three conditions used to classify residents.‒ Clinical reasons for the SNF stay (acute neurologic

versus non-neurologic clinical category);‒ SLP-related comorbidities; and ‒ Presence of cognitive impairments

• Determine what above conditions are present then determine if there is a swallowing disorder or mechanically altered diet

SLP - Component

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• There are only two clinical categories used for classification in the SLP component:• Acute Neurologic• Non-Neurologic

Step 1 - Clinical Categories

Primary Diagnosis Clinical Category SLP Clinical Category

Major Joint Replacement or Spinal Surgery 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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• Comorbidities are determined utilizing Section I and O

Step 2 -SLP Related Comorbidities

MDS Item Description

I4300 Aphasia

I4500 CVA, TIA, or Stroke

I4900 Hemiplegia or Hemiparesis

I5500 Traumatic Brain Injury

I8000 Laryngeal Cancer

I8000 Apraxia

I8000 Dysphagia

I8000 ALS

I8000 Oral Cancers

I8000 Speech and Language Deficits

O0100E2 Tracheostomy Care While a Resident

O0100F2 Ventilator or Respirator While a Resident

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Step 3: Cognitive Performance

• PDPM Cognitive Measure Classification Methodology

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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• Determine how many of the following conditions are present: ‒ a. Based on Step 1, Is the resident classified in the

Acute Neurologic clinical category?‒ b. Based on Step 2, Does the resident have one or more

SLP-related comorbidities? ‒ c. Based on Step 3, Does the resident have a cognitive

impairment?

Step 4 - Conditions

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• Determine if there is a swallowing disorder present as coded on the MDS in section K0100A through K0100D (Swallowing Disorder)

• If any of the above items are present, then the resident has a swallowing disorder

Step 5 – Swallowing Disorder

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• Determine if the resident is receiving a mechanically altered diet as coded on the MDS in Section K0510C2 (Nutritional Approaches – while a resident)

Step 6 – Mechanically Altered Diet

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• Determine how many of the following conditions are present based on Steps 5 and 6: ‒ a. The resident has neither a swallowing disorder nor a

mechanically altered diet. ‒ b. The resident has either a swallowing disorder or a

mechanically altered diet. ‒ c. The resident has both a swallowing disorder and a

mechanically altered diet.

Presence of Mechanically Altered Diet or Swallowing Disorder? (Neither/Either/Both)

Step 7 – Conditions

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Step 8 - Resident 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 1.82

None Both SC 2.66Any one Neither SD 1.46

Any one Either SE 2.33

Any one Both SF 2.97Any two Neither SG 2.04

Any two Either SH 2.85

Any two Both SI 3.51All three Neither SJ 2.98

All three Either SK 3.69

All three Both SL 4.19

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NURSING COMPONENT

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• PDPM utilizes the same basic nursing classification structure as RUG-IV, with certain modifications.

– Function score based on Section GG of the MDS 3.0

– Collapsed functional groups, reducing the number of nursing groups from 43 to 25 (as compared to RUG-IV)

Nursing Component

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• Case‐Mix Methodology

• GG function score

• Qualifying services, conditions, and resources

• Indicators of depression

• Restorative programs

Nursing Component

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• The Classification Groups in this category are based on various services provided to the patient. (Hierarchical)

• Extensive Services

• Special Care High

• Special Care Low

• Clinically Complex

• Behavioral Symptoms and Cognitive Performance

• Reduced Physical Functioning

Nursing Component

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• Extensive Services:

*While as Resident

Nursing Component

Extensive Service Conditions

PDPM Nursing Classification

Nursing Case Mix

Tracheostomy care* andventilator/respirator*

ES3 4.04

Tracheostomy care* orventilator/respirator*

ES2 3.06

Isolation or quarantine for active infectious disease *without tracheostomy care*without ventilator/respirator*

ES1 2.91

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• Special Care High• Determine whether the resident is coded for one of the following conditions or

services: B0100, Section GG items Comatose and completely dependent or

activity did not occur at admission (GG0130A1, GG0130C1, GG0170B1, GG0170C1, GG0170D1, GG0170E1, and GG0170F1, all equal 01, 09, or 88)

I2100 Septicemia I2900, N0350A,B Diabetes with both of the following: Insulin

injections (N0350A) for all 7 days Insulin order changes on 2 or More days (N0350B)

I5100, Nursing Function Score Quadriplegia with Nursing Function Score <= 11

I6200, J1100C Chronic obstructive pulmonary disease and shortness of breath when lying flat

J1550A, others Fever and one of the following; I2000 Pneumonia J1550B Vomiting K0300 Weight loss (1 or 2) K0510B1 or K0510B2 Feeding tube*

K0510A1 or K0510A2 Parenteral/IV feedings O0400D2 Respiratory therapy for all 7 days

*Tube feeding classification requirements: (1) K0710A3 is 51% or more of total calories OR (2) K0710A3 is 26%

Nursing Component

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• Special Care High – Depression Split

• The resident qualifies for depression with a Total Severity Score of greater than or equal to 10, but not 99

Nursing Component

Resident Staff DescriptionD0200A D0500A Little interest or pleasure in doing thingsD0200B D0500B Feeling down, depressed, or hopelessD0200C D0500C Trouble falling or staying asleep, sleeping too muchD0200D D0500D Feeling tired or having little energyD0200E D0500E Poor appetite or overeatingD0200F D0500F Feeling bad about yourself- or that you are a failure or have let

yourself down or your family downD0200G D0500G Trouble concentrating on things, such as reading the

newspaper or watching televisionD0200H D0500H Moving or speaking so slowly that other people could have

noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual

D0200I D0500I Thoughts that you would be better off dead, or of hurting yourself in some way

- D0500J Being short-tempered, easily annoyed

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• Special Care High-

Nursing Component

Nursing Function Score

Depressed?PDPM Nursing Classification

Nursing Case-Mix

0-5 Yes HDE2 2.39

0-5 No HDE1 1.99

6-14 Yes HBC2 2.23

6-14 No HBC1 1.85

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Special Care Low:Determine whether the patient is coded for one of the following conditions or services:

I4400, Nursing Function Score Cerebral palsy, with Nursing Function Score <=11

I5200, Nursing Function Score Multiple sclerosis, with Nursing Function Score <=11

I5300, Nursing Function Score Parkinson’s disease, with Nursing Function Score <=11

I6300, O0100C2 Respiratory failure and oxygen therapy while a patient

K0510B1 or K0510B2 Feeding tube*

M0300B1 Two or more stage 2 pressure ulcers with two or more selected skin treatments**

M0300C1, D1, F1 Any stage 3 or 4 pressure ulcer with two or more selected skin treatments**

M1030 Two or more venous/arterial ulcers with two or more selected skin treatments**

M0300B1, M1030 1 stage 2 pressure ulcer and 1 venous/arterial ulcer with 2 or more selected skin treatments**

M1040A, B, C; M1200I Foot infection, diabetic foot ulcer or other open lesion of foot with application of dressings to the feet

O0100B2 Radiation treatment while a patient

O0100J2 Dialysis treatment while a patient

Nursing Component

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Special Care Low – Reminders:

*Tube feeding classification requirements:

(1) K0710A3 is 51% or more of total calories OR

(2) K0710A3 is 26% to 50% of total calories and K0710B3 is 501 cc or more per day fluid enteral intake in the last 7 days.

**Selected skin treatments:

M1200A, B Pressure relieving chair and/or bed M1200CTurning/repositioning

M1200D Nutrition or hydration intervention

M1200E Pressure ulcer care

M1200G Application of dressings (not to feet)

M1200H Application of ointments (not to feet)

#Count as one treatment even if both provided

Nursing Component

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• Special Care Low – Depression Split


Nursing Component







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• Special Care Low –

Nursing Component



Nursing Case Mix

0-5 Yes LDE2 2.07

0-5 No LDE1 1.72

6-14 Yes LBC2 1.71

6-14 No LBC1 1.43

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• Clinically Complex:

*Selected Skin Treatments: M1200F Surgical wound care, M1200G Application of nonsurgical dressing (other than to feet), M1200H Application of ointments/medications(other than to feet)

Nursing Component

MDS Item Condition or Service

I2000 Pneumonia

I4900, Nursing Function Score Hemiplegia/Hemiparesis with Nursing Function Score <=11

M1040D,E Open lesion (other than ulcers, rashes, and cuts) with any selected skin treatment* or surgical wound

M1040F Burns

O0100A2 Chemotherapy while a resident

O0100C2 Oxygen Therapy while a resident

O0100H2 IV Medications while a resident

O0100I2 Transfusions while a resident

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• Clinically Complex – Depression Split


Nursing Component







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• Clinically Complex –

Nursing Component



Nursing Case Mix

0-5 Yes CDE2 1.86

0-5 No CDE1 1.62

6-14 Yes CBC2 1.54

6-14 No CBC1 1.34

15-16 Yes CA2 1.08

15-16 No CA1 0.94

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• Behavioral Symptoms and Cognitive Performance:

• Determine the Function Score

• The total Nursing Function Score must be 11 or greater to classify into the Behavioral Symptoms and Cognitive Performance.

• If the score is less than 11, the resident would classify into the Reduced Physical Function Category.

• Determine Cognitive Performance

• BIMS/CPS

• Behavioral Symptoms?

• Restorative Programs?

Nursing Component

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Cognitive Performance

• PDPM Cognitive Measure Classification Methodology

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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Behavioral Symptoms and Cognitive Performance

Determine whether the patient presents with one of the following behavioral symptoms:

E0100A Hallucinations

E0100B Delusions

E0200A Physical behavioral symptoms directed toward others (2 or 3)

E0200B Verbal behavioral symptoms directed toward others (2 or 3)

E0200C Other behavioral symptoms not directed toward others (2 or 3)

E0800 Rejection of care (2 or 3)

E0900 Wandering (2 or 3)

Nursing Component

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• Behavioral Symptoms and Cognitive Performance

Nursing Component


Restorative Nursing


Nursing Case Mix

11-16 2 or more BAB2 1.04

11-16 0 or 1 BAB1 0.99

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• Reduced Physical Function –Determine Function Score and if there are Restorative Programs

Nursing Component


Restorative Nursing


Nursing Case Mix

0-5 2 or more PDE2 1.57

0-5 0 or 1 PDE1 1.47

6-14 2 or more PBC2 1.21

6-14 0 or 1 PBC1 1.13

15-16 2 or more PA2 0.70

15-16 0 or 1 PA1 0.66

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NON‐THERAPY ANCILLARIES (NTA) COMPONENT

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NTA Conditions/Services and assigned points

Condition/Extensive Service MDS Item Points

HIV/AIDS SNF claim 8

Parenteral IV Feeding: Level HighK0510A2, K0710A2

7

Special Treatments/Programs: Intravenous Medication Post-admit Code+

O0100H2 5

Special Treatments/Programs: Ventilator or Respirator Post-admit Code+

O0100F2 4

Parenteral IV feeding: Level LowK0510A2, K0710A2, K0710B2

3

Lung Transplant Status I8000 3

Special Treatments/Programs: Transfusion Post-admit Code+

O0100I2 2

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Major Organ Transplant Status, Except Lung

I8000 2

Active Diagnoses: Multiple Sclerosis Code+

I5200 2

Opportunistic Infections I8000 2

Active Diagnoses: Asthma COPD Chronic Lung Disease Code+

I6200 2

Bone/Joint/Muscle Infections/Necrosis -Except: Aseptic Necrosis of Bone

I8000 2

Chronic Myeloid Leukemia I8000 2

Wound Infection Code I2500 2

Active Diagnoses: Diabetes Mellitus (DM) Code+

I2900 2

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Endocarditis I8000 1

Immune Disorders I8000 1

End-Stage Liver Disease I8000 1

Other Foot Skin Problems: Diabetic Foot Ulcer Code+

M1040B 1

Narcolepsy and Cataplexy I8000 1

Cystic Fibrosis I8000 1

Special Treatments/Programs: Tracheostomy Care Post-admit Code+

O0100E2 1

Active Diagnoses: Multi-Drug Resistant Organism (MDRO) Code

I1700 1

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Special Treatments/Programs: Isolation Post-admit Code+

O0100M2 1

Specified Hereditary Metabolic/Immune Disorders

I8000 1

Morbid Obesity I8000 1

Special Treatments/Programs: Radiation Post-admit Code+

O0100B2 1

Stage 4 Unhealed Pressure Ulcer Currently Present *+

M0300D1 1

Psoriatic Arthropathy and Systemic Sclerosis

I8000 1

Chronic Pancreatitis I8000 1

Proliferative Diabetic Retinopathy and Vitreous Hemorrhage

I8000 1

* If the number of Stage 4 Unhealed Pressure Ulcers is recorded as greater than 0, it will add one point to the NTA comorbidity score calculation. Only the presence, not the count, of Stage 4 Unhealed pressure ulcers affects the PDPM NTA comorbidity score calculation.

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Other Foot Skin Problems: Foot Infection Code, Other Open Lesion on Foot Code, Except Diabetic Foot Ulcer Code+

M1040A, M1040C

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Complications of Specified Implanted Device or Graft

I8000 1

Bladder and Bowel Appliances: Intermittent catheterization

H0100D 1

Inflammatory Bowel Disease I1300 1

Aseptic Necrosis of Bone I8000 1

Special Treatments/Programs: Suctioning Post-admit Code

O0100D2 1

Cardio-Respiratory Failure and Shock I8000 1

Myelodysplastic Syndromes and Myelofibrosis

I8000 1

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Systemic Lupus Erythematosus, Other Connective Tissue Disorders, and Inflammatory Spondylopathies

I8000 1

Diabetic Retinopathy - Except : Proliferative Diabetic Retinopathy and Vitreous Hemorrhage

I8000 1

Nutritional Approaches While a Resident: Feeding Tube+

K0510B2 1

Severe Skin Burn or Condition I8000 1

Intractable Epilepsy I8000 1

Active Diagnoses: Malnutrition Code I5600 1

Disorders of Immunity - Except : RxCC97: Immune Disorders

I8000 1

Cirrhosis of Liver I8000 1

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Bladder and Bowel Appliances: Ostomy H0100C 1

Respiratory Arrest I8000 1

Pulmonary Fibrosis and Other Chronic Lung Disorders

I8000 1

• Utilizing the table and points value, determine the residents total NTA score.

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NTA Case-Mix Group and Index

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 3.259‐11 NB 2.536‐8 NC 1.853‐5 ND 1.341‐2 NE 0.960 NF 0.72

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CASE STUDIES

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• Ms. Shives is a 74 year old who was admitted to Happy Acres on November 30, 2019 from the acute care hospital with a CVA with left hemiparesis. She is left handed She is receiving PT/OT/ST. While in the hospital she developed a Stage 4 on her coccyx with a daily dressing change. She is on an air mattress. While in the hospital she developed an infection in her wound and was started on IV Rocephin, she will receive 3 more doses. She also has COPD and is receiving routine oxygen at 2L.

• The following information was coded on her Medicare 5‐Day Assessment:

Case Study #1

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MDS Item MDS Description MDS Coding

C0500 Brief Interview for Mental Status (BIMS) 8

GG0130A1 Self‐care: Eating 03‐Partial/moderate assistance

GG0130B1 Self‐care: Oral hygiene 03‐Partial/moderate assistance

GG0130C1 Self‐care: Toileting hygiene 02‐Substantial/maximal assistance

GG0170B1 Mobility: Sit to lying 02‐Substantial/maximal assistance

GG0170C1 Mobility: Lying to sitting on side of bed 02‐Substantial/maximal assistance

GG0170D1 Mobility: Sit to stand 88‐Not attempted due to medical condition or safety

concern

GG0170E1 Mobility: Chair/bed‐to‐chair transfer 01‐Dependent

GG0170F1 Mobility: Toilet transfer 01‐Dependent

GG0170J1 Mobility: Walk 50 feet with 2 turns 88‐Not attempted due to medical condition or safety

concern

GG0170K1 Mobility: Walk 150 feet 88‐Not attempted due to medical condition or safety

concern

I2500 Wound infection other than foot Checked

I4500 CVA Checked

I4900 Hemiparesis Checked

I6200 Asthma, COPD, chronic lung disease Checked

I0020 Indicate the resident’s primary medical condition category 01‐Stroke

I0020B Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side I69.352

M0300D Stage 4 Checked

M1200B Pressure reducing device for bed Checked

M1200E Pressure ulcer/injury care Checked

O0100C IV medication Checked

O0100H Oxygen Checked

O0400A1 Speech Therapy‐Individual Minutes 75

O0400A4 Speech Therapy‐Days 3

O0400B1 Occupational Therapy – Individual minutes 125

O0400B4 Occupational Therapy – Days 4

O0400C1 Physical Therapy – Individual minutes 250

O0400C4 Physical Therapy – Days 5

Case Study #1 Cont’d

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ComponentFunction

ScoreCase-Mix

GroupCase-Mix

IndexRationale

PT

OT

SLP

Nursing

NTA


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ComponentFunction

ScoreCase-Mix

GroupCase-Mix

IndexRationale

PT Clinical Category =Acute Neurologic

6 TN 1.48 Primary Diagnosis maps toAcute Neurologic which crosswalks to Non-OrthopedicSurgery and Acute Neurologicfor the PT/OT ClinicalCategory

OT Clinical Category =Acute Neurologic

6 TM 1.49

SLP Acute NeurologicCVA

Impaired Cognition

N/A SJ 2.98 BIMS = 8; No swallowing orMechanically altered diet

Nursing Special Care Low 4 LDE1 1.72 COPD but no mention of SOBwhile flat; No evidence ofdepression; Stage 4 withtreatments

NTA Total Points - 10 N/A ND 1.34 IV meds=5;Active Disease-COPD = 2;Wound Infection = 2;Stage 4 = 1

Case Study #1 Answers

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• Mr. Truax is a 74 year old who was admitted to Happy Acres on October 31, 2019 from the acute care hospital after a fall at his home. He has Pneumonia, dementia, depression, and diabetes. He has been requiring more assistance with his care. He is diabetic and receives insulin daily and was found to need dosage adjustment. He will receive PT and OT.

• The following information was coded on her Medicare 5‐Day Assessment:

Case Study #2

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MDS Item MDS Description MDS Coding

C0500 BIMS Summary Score 11

D0300 PHQ‐9 8

GG0130A1 Self‐care: Eating 05 – Setup or clean‐up assistance

GG0130B1 Self‐care: Oral hygiene 05 – Setup or clean‐up assistance

GG0130C1 Self‐care: Toileting hygiene 03 – Partial/moderate assistance

GG0170B1 Mobility: Sit to lying 03 – Partial/moderate assistance

GG0170C1 Mobility: Lying to sitting on side of bed 02– Substantial/maximal assistance

GG0170D1 Mobility: Sit to stand 03 – Substantial/maximal assistance

GG0170E1 Mobility: Chair/bed‐to‐ chair transfer 03 – Substantial/maximal assistance

GG0170F1 Mobility: Toilet transfer 02 – Substantial/maximal assistance

GG0170J1 Mobility: Walk 50 feet with 2 turns 03 – Partial/moderate assistance

GG0170K1 Mobility: Walk 150 feet 03 – Partial/moderate assistance

I0020 Indicate the resident’s primary medical condition category 06‐Progressive Neurological Conditions

I0200B Pneumonia

J15.1

I2900 Diabetes Mellitus Checked

I4800 Non‐Alzheimer’s dementia Checked

I5300 Pneumonia Checked

I5800 Depression Checked

K0510C Mechanically Altered Diet Checked

N0300 Record the number of days that injections of any type were received in the last 7 days 7

N0350A Insulin injections‐record the number of days that insulin injections were received in the

last 7 days

7

N0350B Orders for insulin‐Record the number of days the physician changes the resident’s

insulin orders

3

O0400B1 Occupational Therapy – Individual minutes 215

O0400B4 Occupational Therapy – Days 6

O0400C1 Physical Therapy – Individual minutes 325

O0400C4 Physical Therapy – Days 5

Cast Study #2 Cont’d

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ComponentFunction

Score

Case-Mix

Group

Case-Mix Index

Rationale

PT

OT

SLP

Nursing

NTA


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ComponentFunction

Score

Case-Mix

Group

Case-Mix Index

Rationale

PT Medical Management

15 TK 1.52 Pneumonia maps toPulmonary that crosswalksto Medical Management

OT Medical Management

15 TK 1.54

SLP One – Cognitively impairedMech Altered Diet

N/A SE 2.33 BIMS=11; Mechanicallyaltered Diet, no mention ofswallowing disorder

Nursing Special Care High 9 HBC2 2.23 DM with 7 days of injectionsand 3 insulin order changes

NTA Total Points = 2 N/A NE 0.96 Diabetes

Case Study #2 Answers

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PDPM HIPPS Coding

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• Based on responses on the MDS, patients are classified into payment groups, which are billed using a 5-character Health InsuranceProspective Payment System (HIPPS) code.

• The current RUG-IV HIPPS code follows a prescribed algorithm.

– Character 1-3: RUG Code

– Character 4-5: AssessmentIndicator• In order to accommodate the new payment groups, the PDPM

HIPPS algorithm is revised as follows:

– Character 1: PT/OT Payment Group

– Character 2: SLP Payment Group

– Character 3: Nursing Payment Group

– Character 4: NTA Payment Group

– Character 5: Assessment Indicator

63

PDPM HIPPS Coding Crosswalk: PT, OT, NTA

63

• PT/OT, SLP, NTA Payment Groups to HIPPS TranslationPT/OT

Payment GroupSLP

Payment GroupNTA

Payment GroupHIPPS

CharacterTA SA NA ATB SB NB BTC SC NC CTD SD ND DTE SE NE ETF SF NF FTG SG GTH SH HTI SI ITJ SJ JTK SK K

TL SL LTM MTN NTO OTP P

33

64

PDPM HIPPS Coding Crosswalk: Nursing

64

• Nursing Payment Group to HIPPS Translation

NursingPayment Group

HIPPSCharacter

NursingPayment Group

HIPPSCharacter

ES3 A CBC2 N

ES2 B CA2 OES1 C CBC1 P

HDE2 D CA1 QHDE1 E BAB2 RHBC2 F BAB1 SHBC1 G PDE2 TLDE2 H PDE1 ULDE1 I PBC2 VLBC2 J PA2 WLBC1 K PBC1 XCDE2 L PA1 YCDE1 M

65

PDPM HIPPS Coding Crosswalk:AI

65

• Assessment Indicator (AI) Crosswalk

HIPPS Character Assessment Type

0 IPA

1 PPS 5-day (Initial Patient Assessment)

34

66

• Case Study #1

• NJIB1

• Case Study #2

• KEFE1

HIPPS Codes

67

Stephanie Kessler, RAC‐CT, CHP

Partner

[email protected]

717.885.5724

Questions?

Tracy Montag, BSN, RN, RAC‐MT

Manager

[email protected]

717.885.5727

the patient driven payment model (pdpm) case … panac case studies ppfinalrev_0719-1.pdf1 the...

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