powerpoint presentation · identify key operational, training and systems ... toileting hygiene...

11/2/2018

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Understanding PDPMDeveloping Your Facility Action Plan

Objectives

1. Review the components, MDS changes, and

key features that will impact payment under the

Patient Driven Payment Model (PDPM).

2. Identify key operational, training and systems

considerations for preparing to transition to

PDPM.

3. Review a framework for developing a facility

specific transition action plan.

© Proactive 2018

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Why PDPM?

• Therapy driven reimbursement -90% Rehab RUGs

• Scrutiny of RU/RV utilization

• Perceived financial considerations as impacting care

decisions

• Thresholding at minimum minutes

• Goal of patient characteristic focused reimbursement

rather than resource utilization

© Proactive 2018

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Final Rule

© Proactive 2018

• Final Rule/Federal Register :

https://www.federalregister.gov/documents/2018/08/08/2018-

16570/medicare-program-prospective-payment-system-and-

consolidated-billing-for-skilled-nursing-facilities

• Complete replacement of RUGs IV

• Effective Date October 1, 2019

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Acumen Study

RCS-1 PDPM

Re-allocation of Funds

© Proactive 2018

• Budget Neutral -not Intended to Reduce Medicare Spend

• Reallocates Funds from 2 “Buckets” into 5 “Buckets”

RUG-IV: PDPM:

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Nursing

Therapy

Nursing

PT OT SLP

NTA

RUGs IV vs PDPM

© Proactive 2018

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RUG IV PDPM

2 Case-mix Components (Therapy & Nursing)5 Case-mix Components (PT,OT, SLP, Nursing, Non-Therapy Ancillary)

5 Scheduled PPS Assessments

Plus: SOTs, EOTs, COTs2 Assessments: 5 Day & DC; Optional: IPA

Constant RUG Rates by assessment

across LOS

5 day sets payment for stay and there is a variable rate across LOS

Therapy minute thresholds for RUG levels &

Incentive for higher volume rehab

Therapy minutes are based on clinical need without specific volume tied to rates

Group and concurrent therapy restrictionsGroup and Concurrent Therapy Opportunities (75% is required to be 1:1)

Index maximizingCombination of classification components set payment

www.proactivemedicalreview.com Moving Mountains Series

https://www.federalregister.gov/documents/2018/08/08/2018-16570/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities

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Rate Components

PT*

OT*

SLPNursing

NTA*

+ Non-CaseMix

© Proactive 2018

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PDPM Rate Components

Total Rate

Nursing Base Rate x Nursing

CMI

NTA Base Rate x NTA CMI x Adjustment

Factor

PT Base Rate x PT CMI x

Adjustment Factor

OT Base Rate x OT CMI x

Adjustment Factor

SLP Base Rate x SLP CMI

Non-Case Mix Rate

© Proactive 2018

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Base Rate Components

© Proactive 2018

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FY 2019 PDPM Unadjusted Federal Rate per Diem --- Urban

Rate

componentNursing NTA PT OT SLP

Non-case-

mix

Per Diem

Amount$103.46 $78.05 $59.33 $55.23 $22.15 $92.63

FY 2019 PDPM Unadjusted Federal Rate per Diem --- Rural

Rate

componentNursing NTA PT OT SLP

Non-case-

mix

Per Diem

Amount$98.83 $74.56 $67.63 $62.11 $27.90 $94.34

Source: table 12-13 final rule Federal Register Vol. 83 No. 158 8/8/18

Variable Per Diem Adjustment Factor

© Proactive 2018

Applies to PT, OT & NTA Components

PT & OT Component:

• After day 20, 2% Reduction Every 7 Days

NTA Component:

• Multiplied x 3 X for Days 1-3

• Day 4 and Beyond — No Multiplier Applied

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PT & OT Variable

Per-Diem Adjustment

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

MDS Updates

© Proactive 2018

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PDPM MDS Assessments

PDPM Required Assessments

• 5-Day (ARD day 1-8*)

• Discharge

Optional Assessment

• IPA (Interim Payment

Assessment)

Eliminates:

➢ 14, 30, 60, 90 Day

Assessments

• SOTs, EOTs, COTs

OBRA Assessments

unchanged

• Admission, Quarterly,

Significant Change

© Proactive 2018

* Elimination of “grace days”


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Interim Payment Assessment (IPA)

© Proactive 2018

• Revise payment during the stay

based on condition changes when

significant enough to result in

payment change

• Optional assessment

• Providers set their own criteria for

determining if indicated

• Payment changes on the ARD

• Same MDS items as the 5-Day

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Discharge Assessment

© Proactive 2018

• Therapy Start & End Dates, Treatment Minutes by Mode

• Monitoring for:

• Significant decreases in therapy provided

• Group and/or concurrent in excess of allowable 25%

• Data for future rule-making / possible payment updates

• Potential Medical Review risks

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Interrupted Stay Rule

© Proactive 2018

• Applied when discharges from SNF, but out less than 3 midnights

• No New MDS required; “Interrupted Stay” continues, resumes prior

Case-Mix Components and payment

• The Variable Per Diem Adjustments do NOT re-set (NTA, PT, OT)

• If resident returns after 3 days, a new MDS completed and

everything starts over

• If patient admits to a different SNF, a new MDS is always

completed/everything starts over

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PDPM Case Mix Component Methodology

© Proactive 2018

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https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/SNFPPS/Downloads/MDS_Manual_Ch_6_PDPM_508.pdf

PT & OT Calculation

Clinical Category Functional Score

© Proactive 2018

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1. Major Joint Replacement

or Spinal Surgery

2. Non-Orthopedic Surgery

& Acute Neurologic

3. Other Orthopedic

4. Medical Management

Eating Sit-to-Stand

Oral HygieneChair/bed-to-chair

Transfer

Toileting Hygiene Toilet Transfer

Sitting-to-LyingWalk 50 feet with 2

Turns

Lying-to-sitting

on side of bedWalk 150 feet

Two Factors Determine the PT & OT Case Mix

The two bed mobility items are averaged; the three transfer items are averaged; & the

two walking items are averaged. This creates equal weighting for all six activities.

PT & OT

Function Scoring

© Proactive 2018

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Scoring Response for GG

Response 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, 88- Dependent,

Refused, N/A, Not

attempted, Res. Cannot

Walk 0

Section GG Items Included in PT /OT

Functional MeasuresScore

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 stand 0-4

(avg of 3

transfer

items)

GG0170E1 – Mobility: Chair/bed-to-chair

transfer

GG0170F1 – Mobility: Toilet transfer

GG0170J1 – Mobility: Walk 50 feet- 2 turns 0-4 (avg of 2

walking

items)GG0170K1 – Mobility: Walk 150 feet

• Uses 10 items

• Total score 0-24


https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/MDS_Manual_Ch_6_PDPM_508.pdf

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© Proactive 2018

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16 Possible Case-Mix Classification Groups for PT and OT

Clinical Category

Section GG

Function Score

PT-OT Case-

mix Group

PT Case-mix

Index

OT Case-mix

Index

Major Joint Replacement or Spinal

Surgery0-5 TA 1.53 1.49


Surgery6-9 TB 1.69 1.63


Surgery10-23 TC 1.88 1.68


Surgery24 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

Neurologic0-5 TM 1.27 1.30


Neurologic6-9 TN 1.48 1.49


Neurologic10-23 TO 1.55 1.55


Neurologic24 TP 1.08 1.09

Example: PT & OT Payment Calculation

© Proactive 2018

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Case-Mix Classification Groups for PT and OT

Clinical Category

Section GG

Function Score

PT-OT Case-

mix Group

PT Case-

mix Index

OT Case-mix

Index


Surgery6-9 TB 1.69 1.63

1st - Clinical Category Determined: (ICD-10 Code mapped into one of four

possible clinical categories)

2nd - Functional Score Determined:

(Sum of all GG items scores)

Major Joint Replacement

or Spinal Surgery

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Results in PT & OT Case-Mix Group: TB

PT Case-Mix Index: 1.69 OT Case-Mix Index: 1.63

Urban PT per diem: $59.33 Urban OT per diem: $55.23

PT: $59.33 x 1.69 = $100.26/day OT: $55.23 x 1.63 = $90.02/day

MDS Coding: PT/OT Calculation

© Proactive 2018

• Primary Diagnosis: I8000 (ICD-10)

• Surgical Procedure Codes

• Functional Score: Sec. GG

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MDS Coding Critical

© Proactive 2018

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Physical Therapy Per Diem

Highest Possible:

TD: 1.92 CMI

Base Rate X CMI = Per Diem Rate

$59.33 X 1.92 = $113.91/day

Lowest Possible:

TP: 1.08 CMI


$59.33 X 1.08 = $64.08/day

Difference: $49.83/day

Occupational Therapy Per Diem

Highest Possible:

TC: 1.68 CMI


$55.23 X 1.68 = $92.79/day

Lowest Possible:

TP: 1.09 CMI


$55.23 X 1.09 = $60.20/day


Speech Therapy Calculation

© Proactive 2018

Factors for Speech Therapy Case-Mix

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Presence of Acute

Neurologic

Condition

Presence of

Cognitive

Impairment

Presence of

SLP-Related

Comorbidity

Presence of

Mechanically Altered

Diet &/or Swallowing

Disorder

Source: table 12-13 final rule Federal Register Vol. 83 No. 158 8/8/18

SLP-Related Comorbidities

• Aphasia

• CVA, TIA, or Stroke

• Hemiplegia or Hemiparesis

• Traumatic Brain Injury

• Tracheostomy Care (while a

resident)

• Ventilator or Respirator

(while a resident)

• Laryngeal Cancer

• Apraxia

• Dysphagia

• ALS

• Oral Cancers

• Speech & Language

Deficits

© Proactive 2018

Source: table 22 final rule Federal Register Vol. 83 No. 158 8/8/18


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Cognitive Impairment

© Proactive 2018

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PDPM Cognitive Measure Classification Methodology

CFS Cognitive Scale 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


© Proactive 2018

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SLP Case-Mix Classification Group Calculation

Presence of Acute

Neurologic Condition,

SLP-related

Comorbidity, or

Cognitive Impairment

Mechanically Altered Diet

or Swallowing Disorder

SLP Case-mix

Group

SLP Case-mix

Index

None Neither SA 0.68

None Either SB 1.82

None Both SC 2.66

Any one Neither SD 1.46

Any one Either SE 2.33

Any one Both SF 2.97

Any two Neither SG 2.04

Any two Either SH 2.85

Any two Both SI 3.51

All three Neither SJ 2.98

All three Either SK 3.69

All three Both SL 4.19


Example: SLP Payment Calculation

© Proactive 2018

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1st - Identify Presence of Acute

Neurologic Condition

(Clinical Category Determined); SLP-Related

Comorbidities; Cognitive Impairment

2nd - Identify Presence of Swallowing

Disorder and/or Mechanically Altered Diet:

2 are Present

Both are Present

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

Any two Both SI 3.51

Results in SLP Case Mix Group: SI

ST Case-Mix Index: 3.51

Urban ST per diem: $22.15

ST: $22.15 X 3.51 = $77.74/day

MDS Coding: SLP Calculation

© Proactive 2018

Presence of…

• Acute Neurologic Diagnosis: I8000 (ICD-10)

• SLP-Related Comorbidities: Items I4300, I4500,

I4900, I5500, O0100E2, I0100F2, I8000

• Swallowing Disorder: Item K0100A-D

• Mechanically-Altered Diet: Item K0510C2

• Cognitive Impairment: BIMS or CPS Score

(PDPM Calculation)

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MDS Coding Critical

© Proactive 2018

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Speech-Language Pathology

Per Diem

Highest Possible:

SL: 4.19 CMI

Base rate X CMI = Per Diem Rate

$22.15 X 4.19 = $92.81/day

Lowest Possible:

SA: 0.68 CMI

Base rate X CMI = Per Diem Rate

$22.15 X .68 = $15.06/day


PDPM Group & Concurrent Therapy

© Proactive 2018

• Total of 25% of Therapy may be provided as

Group and/or Concurrent (discipline-specific)

• Group defined as up to 4 patients

• Penalties for Exceeding 25%:• Non-Fatal Error in QIES ASAP System

• Flag providers that consistently exceed—

possible medical review

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Nursing CMI

© Proactive 2018

• 25 Classifications

• Function Score Based on Sec. GG

• No tapering with LOS

• 57% of RUG IV Nursing Component

• 18% increase for HIV/AIDS on claim

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Nursing

Function

Score

© Proactive 2018

MDS Section GG Items Score

GG0130A1 Self Care: Eating 0-4

GG0130C1 Self care: Toilet Hygiene 0-4

GG0170B1

GG0170C1

Mobility: Sit to Lying; Lying to

sitting on Side of Bed

0-4 (avg of 2

items)

GG0170D1

GG0170E1

GG0170F1

Mobility: Sit to Stand;

Chair/bed-to-chair transfer;

Toilet Transfer

0-4 (avg of 3

items)

Source: table 24 -25 final rule Federal Register Vol. 83 No. 158 8/8/18

Scoring Response for GG Score

05

06Set up assistance

Independent

4

04 Supervision or

Touching Assist

3

03 Partial/Moderate

Assist

2

02 Substantial/Maximal

Assist

1

01,07,09,10,8

8,(-)Dependent, refused,

not attempted

0

• Uses 7 items

• Total score 0-16

© Proactive 2018

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Non-Therapy Ancillary (NTA)

© Proactive 2018

• 43% Current Nursing Component

(RUG-IV)

• Points System

• Points Based On Patient Conditions,

Specific Services

• 50 NTA Items

• Significant Per Diem Variable

Payment Adjustment

• Days 1-3 CMI 3X higher

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© Proactive 2018

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NTA Condition/Ext Service Points NTA Condition/Ext. Service Points

HIV/Aids 8 Active Dx: Diabetes Mellitus (DM) 2

Parenteral IV Feeding: Level High 7 Chronic Myeloid Leukemia 2

Special Treatments/Programs: Intravenous

Medication Post-Admit Code

5 Wound Infection Code 2

Special Treatments/programs: Vent or

Respirator Post-admit Code

4 End-Stage Liver Disease 1

Parenteral IV Feeding: Level Low 3 Other Foot Skin Problems: Diabetic

Foot Ulcer Code

1

Lung Transplant Status 3 Narcolepsy and Cataplexy 1

Special Treatments/Programs: Transfusion

Post-admit Code

2 Cystic Fibrosis 1

Major Organ Transplant Status, Except Lung 2 Special Treatments/Programs:

Tracheostomy Care Post-admit

1

Active Dx: Multiple Sclerosis Code 2 Active Dx: Multi-Drug Resistant

Organism Code

1

Opportunistic Infections 2 Special Treatments/Programs:

Isolation Post-Admit Code

1

Active Dx: Asthma COPD Chronic Lung Dis. 2 Specified Hereditary

Metabolic/Immune Disorders

1

Bone/Joint/Muscle Infections/Necrosis—

Except Aseptic Necrosis of Bone

2 Morbid Obesity 1

© Proactive 2018

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NTA Condition/Ext Service Points NTA Condition/Ext. Service Points

Unhealed Pressure Ulcer Stage 4 1 Special Treatments/Programs:

Radiation Post-admit Code

1

Endocarditis 1 Immune Disorders 1

Psoriatic Arthropathy & Systemic Sclerosis 1 Chronic Pancreatitis 1

Systemic Lupus Erythematosus, Other

Connective Tissue Disorders, & Inflammatory

Spondylopathies

1 Other Foot/Skin Problems: Foot

Infection Code, Other Open Lesion,

Except Diabetic Foot Ulcer Code

1

Complications of Specified Implanted Device

or Graft

1 Bladder & Bowel Appliances:

Intermittent Catheterization

1

Inflammatory Bowel Disease 1 Aseptic Necrosis of Bone 1

Special Treatments/Programs: Suctioning

Post-admit Code

1 Proliferative Diabetic Retinopathy &

Vitreous Hemmorrhage

1

Myelodysplastic Syndromes & Myelofibrosis 1 Cardio-Respiratory Failure & Shock 1

Diabetic Retinopathy-Except Proliferative

Diabetic Retinopathy & Vitreous Hemmorrhage

1 Nutritional Approaches While a

Resident-Feeding Tube

1

Severe Skin Burn or Condition 1 Intractable Epilepsy 1

Active Dx: Malnutrition Code 1 Disorders of Immunity-Except

RxCC97 Immune Disorders

1

Cirrhosis of Liver 1 Bladder & Bowel Appliance: Ostomy 1

Respiratory Arrest 1 Pulmonary Fibrosis & Other 1


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NTA Case-Mix Index

© Proactive 2018

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NTA Example: Total points = 4 NTA case-mix group ND (CMI: 1.34)

NTA Urban Base Rate CMI Per Diem

$78.05 1.34 $104.59/Day

NTA Score

Range

NTA Case Mix

Group

NTA 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

*Variable Per Diem Adjustment applies x 3 for days 1-3

Transition

Action Planning

© Proactive 2018

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Action Plan

© Proactive 2018

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1

22

3

4

5

6

Transition Team

Impact Analysis &

QAPI

Training Plan Stay Informed

Partner Collaboration

Clinical Operations &

MDS Accuracy

Skilled Level of Care Criteria

• All Existing Criteria for Eligibility and Access Remain

• Must require daily skilled service

• Qualifying hospital stay requirement

• Supportive Documentation

© Proactive 2018

Skilled Nursing Services

• Observation & Assessment

• Management & Evaluation of a

Care Plan

• Teaching & Training

• Direct Skilled Nursing Care

PDPM Transition Team

• Administrator

• DON

• MDS

• Business Office

• Therapy

• QAPI

• Marketing

• Admissions

• Case Manager

© Proactive 2018

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Strategic Planning

© Proactive 2018

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

• Critical Transition Considerations :

• MDS Coding Accuracy & Efficiency (5 day)

• Medicaid/Managed Care Payers are not required to

change to PDPM

• Market Opportunities for > Clinical Complexity


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

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General Projections

© Proactive 2018

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PDPM Winners PDPM Losers

Shorter Length of Stay Longer Length of Stay

Smaller Facilities Larger Facilities

Non-profits For-profits

Rural Facilities Urban Facilities

Higher Nursing Needs/Complexity

(Extensive Services)Low Nursing Needs

Conditions with high cost

medications

Conditions without costly

medications

Moderate-Level to Lower-level

Therapy Intensity Likely to

Remain Steady or See Increase

in Funding

Highest Therapy Intensity

(>70% Ultra High Category)

Likely to See Reduction in

Funding

Staffing Considerations

© Proactive 2018

• MDS Coordinators: Expanded Role and Duties

• Accurate GG Coding (floor observations and training)

• ICD10-Coding Experts

• Coding for NTA items

• Case Management Prepare to care for complex patients,

quality & outcomes focus

• Census Management

• LOS reduction incentives

• Rehab

• Utilization Monitored

• Outcomes Management

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Clinical Systems

• Admission Processes

• Care Planning & Case Management

• Clinical Meetings

• Clinical Pathways

• LOS/ Outcomes

• Restorative Nursing

• MDS Accuracy

• Coding Training Updates

• Supportive Documentation

© Proactive 2018

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Vendor/Partner Collaboration

© Proactive 2018

• Software Updates

• Medical Director/Physicians

• Hospital Partners

• Therapy Vendors

46

Understand Compliance Risks

© Proactive 2018

• Provider Behavior Changes

• Decreased therapy provided

• MDS coding

• Negligence/Professional Liability

• Plaintiff’s lawyers and Class Action suits

• Targeted Medical Reviews

• Current claims

• Historical claims (if can provide less therapy now,

potential to review old claims for over-providing)

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CMS ResourcesMedicare Benefit Policy Manual Ch. 8

https://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/downloads/bp102c08.pdf

PDPM Technical Report


Payment/SNFPPS/Downloads/PDPM_Technical_Report_508.pdf

PDPM Provider Impact Analysis Based on FY 2017 Actual Claims:


Payment/SNFPPS/therapyresearch.html

ICD.10-CM Clinical Category Mapping: www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/therapyresearch.html

© Proactive 2018

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https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c08.pdf

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/PDPM_Technical_Report_508.pdf

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

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

11/2/2018

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© Proactive 2018

Contact Information:[email protected]

www.proactivemedicalreview.com

Please join us in Dec. for: Phase 3 Implementing An Effective QAPI Program


mailto:[email protected]

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