AHCA PDPM Resident Classification Workbook – April 15, 2019 ….… · 2019-04-15 · code value into the column to the right. AHCA PDPM Academy Workshop Pre-Requisite Webinar Modules

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Copyright 2019 American Health Care Association. All Rights Reserved. PDPM Resident Classification Workbook_Template_4/15/19 Update

AHCA PDPM Resident Classification Workbook – April 15, 2019 Update Resident Name: Documents needed for this module when you simulate PDPM classification with your own residents:

• AHCA PDPM Resident Classification Workbook: Template • AHCA PDPM MDS Form Mock-Up: Template • CMS PDPM ICD-10 Mappings (Excel file on CMS and ahcancalED PDPM websites)

o https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html o https://educate.ahcancal.org/pdpmacademy

Primary Diagnosis Clinical Category Module (Steps 1-3) Step 1 – Identify ICD-10-CM Code on MDS that represents the Primary Reason for the SNF Stay

MDS Field/Value Action Primary Reason for the SNF Stay

ICD-10-CM Code (enter code value)

I0020 = 01-13 Go to MDS Field I0020B and enter the ICD-10-CM code value into the column to the right

AHCA PDPM Academy Workshop Pre-Requisite Webinar Modules

at ahcancalED Provide an Overview of PDPM - and

Guidance on How-To-Use the CMS ICD-10 Mappings Excel

Tables Necessary for Steps 2, 10, and 15 of this Workbook

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/PDPMClinicalCategoryMapping_Final.zip

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

https://educate.ahcancal.org/pdpmacademy

https://educate.ahcancal.org/products/payment-driven-payment-model-pdpm-workshop-pre-requisite-webinar-modules

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Step 2 – Identify the Default Primary Diagnosis Clinical Category from the CMS “CMS PDPM ICD-10 Mappings” Excel file tool”

cms.gov

Identify row in the Clinical Categories by Dx tab in the CMS PDPM ICD-10 Mappings Excel file that corresponds to the Primary reason for the SNF Stay ICD-10-CMS Code identified in Step 1 (remove the decimal when examining the Excel file).

Hint: If using a PC or MAC, highlight the entire page then use the “CTRL-F” function to search the CMS crosswalk file.

Download from ahcancalED: https://educate.ahcancal.org/pdpmacademy or

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

https://educate.ahcancal.org/pdpmacademy

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

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Step 3 – Identify Final Primary Diagnosis Clinical Category after considering if resident is eligible for a surgical adjustment

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Function Score Module (Steps 4-6)

Step 4 – Identify the PDPM Functional Score Points Applicable to Eating, Oral Hygiene, Toileting Hygiene, Bed Mobility and Transfers

Function Eating Oral Hygiene Toileting Hygiene

Bed Mobility Transfers

Sit to Lying Lying to

Sitting on Side of Bed

Sit to Stand Chair/Bed-to-Chair Transfer Toilet Transfer

MDS Field GG0130A1 GG0130B1 GG0130C1 GG0170B1 GG0170C1 GG0170D1 GG0170E1 GG0170F1

MDS Field Value

PDPM Functional

Score Points (circle 1)

PDPM Functional


PDPM Functional


PDPM Functional


PDPM Functional


PDPM Functional


PDPM Functional


PDPM Functional


05, 06 4 4 4 4 4 4 4 4

04 3 3 3 3 3 3 3 3

03 2 2 2 2 2 2 2 2

02 1 1 1 1 1 1 1 1 01, 07, 09, 10, 88,

missing 0 0 0 0 0 0 0 0

Average of circled GG0170B1 and GG0170C1

Functional Score Points (round to 2 decimals)

Average of circled GG0170D1 and GG0170E1 and GG0170F1

Functional Score Points (round to 2 decimals)

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Step 5 – Identify the PDPM Functional Score Points Applicable to Walking

Step 6 – Identify the PDPM Functional Score Points (Rounded sum) Attributed to the PT, OT and Nursing Components

Function PT and OT Component Function Score

Nursing Component Function Score

Eating Function Score (Step 4) Oral Hygiene Function Score (Step 4) Toileting Hygiene Function Score (Step 4) Average Bed Mobility Function Score (Step 4) Average Transfer Function Score (Step 4) Average Walking Function Score (Step 5)

PDPM Function Score (sum to 2 decimals)

PDPM Function Score (round to whole number) (range 0-24 for PT and OT, 0-16 for Nursing)

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PT and OT Component Module (Step 7) Step 7 – Identify the PDPM PT and OT Component Classification & Base PDPM PT and OT Component Per-Diem Rates

PT and OT Primary Diagnosis Clinical Category (see Steps 2 or 3)

PT and OT Clinical Category

Section GG Function Score

(see Step 6)

PT and OT Case- Mix

Group

FY 2019 PT Component Base Federal Per-Diem Rate

FY 2019 OT Component Base Federal Per-Diem Rate

Urban Rural Urban Rural

Major Joint Replacement

or Spinal Surgery

Major Joint Replacement or Spinal Surgery

0-5 TA $90.77 $103.47 $82.29 $92.54 6-9 TB $100.27 $114.29 $90.02 $101.24

10-23 TC $111.54 $127.14 $92.79 $104.34 24 TD $113.91 $129.85 $84.50 $95.03

Orthopedic Surgery (Except Major Joint

Replacement or Spinal Surgery)

Other Orthopedic

0-5 TE $84.25 $96.03 $77.87 $87.58 6-9 TF $95.52 $108.88 $87.82 $98.75

10-23 TG $99.08 $112.94 $90.58 $101.86 24 TH $68.82 $78.45 $63.51 $71.43

Medical Management, Acute Infections,

Cancer, Cardiovascular and

Coagulations, Pulmonary

Medical Management

0-5 TI $67.04 $76.42 $64.62 $72.67

6-9 TJ $84.25 $96.03 $79.53 $89.44

10-23 TK $90.18 $102.80 $85.05 $95.65

24 TL $64.67 $73.72 $61.31 $68.94

Non-Orthopedic Surgery,

Acute Neurologic

Non-Orthopedic Surgery and Acute

Neurologic

0-5 TM $75.35 $85.89 $71.80 $80.74 6-9 TN $87.81 $100.09 $82.29 $92.54

10-23 TO $91.96 $104.83 $85.61 $96.27 24 TP $64.08 $73.04 $60.20 $67.70

Note: The PDPM PT and OT component base rate is paid in days 1-20, and is reduced by 2% every seven days through the 100-day benefit period

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SLP Component Module (Steps 8-12) Step 8 – Identify the PDPM SLP Clinical Category

Step 9 – Identify the Presence of a Cognitive Impairment SLP Case-Mix Factor

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Step 10 – Identify the Presence of a SLP Comorbidity Case-Mix Factor (any row qualifies as a SLP comorbidity) Note: Identify Presence of SLP Comorbidity from the SLP Comorbidity Tab in the CMS “PDPM ICD-10 Mappings” Excel file tool

cms.gov

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Step 11 – Identify the Presence of SLP Swallowing Disorder and/or Mechanically Altered Diet Case-Mix Factors

Step 12 – Identify the PDPM SLP Component Classification & PDPM SLP Component Per-Diem Rate

SLP Level 1 Case-Mix Factors Acute Neurologic (Step 8)

Cognitive Impairment (Step 9) SLP Comorbidity (Step 10)

SLP Level 2 Case-Mix Factors Swallowing Disorder (Step 11)

Mechanically Altered Diet (Step 11)

SLP Case-Mix Group

FY 2019 SLP Component Federal Per-Diem Rate

Urban Rural

None Neither SA $15.06 $18.97 Either SB $40.31 $50.78 Both SC $58.92 $74.21

Any one Neither SD $32.34 $40.73 Either SE $51.61 $65.01 Both SF $65.79 $82.86

Any two Neither SG $45.19 $56.92 Either SH $63.13 $79.52 Both SI $77.75 $97.93

Any three Neither SJ $66.01 $83.14 Either SK $81.73 $102.95 Both SL $92.81 $116.90

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NTA Component Module (Steps 13-18) Step 13 – Identify the NTA Component “Points” from MDS Simple “Checklist” Items (evaluate all rows for NTA points eligibility)

Condition/Extensive Service (check all rows) MDS Field/Value NTA Points

Ostomy, Bladder and Bowel Appliances H0100C = Checked 1 Intermittent Catheterization, Bowel and Bladder Appliances H0100D = Checked 1 Ulcerative Colitis, Crohn’s Disease, or Inflammatory Bowel Disease I1300 = Checked 1 Multiple Drug Resistant Organisms I1700 = Checked 1 Wound Infection I2500 = Checked 2 Diabetes Mellitus I2900 = Checked 2 Multiple Sclerosis I5200 = Checked 2 Malnutrition Code I5600 = Checked 1 Asthma, COPD, Chronic Lung disease I6200 = Checked 2 Feeding Tube K0510B2 = Checked 1 Diabetic Foot Ulcer M1040B = Checked 1 Radiation O0100B2 = Checked 1 Suctioning O0100D2 = Checked 1 Tracheostomy Care O0100E2 = Checked 1 Ventilator/Respirator O0100F2 = Checked 4 IV Medications O0100H2 = Checked 5 Transfusions O0100I2 = Checked 2 Isolation O0100M2 = Checked 1 Sub-Total Points

Step 14 – Identify the NTA Component “Points” from MDS “Conditional” Items (evaluate all rows for NTA points eligibility) Condition/Extensive Service

(check all rows) MDS Field/Value NTA Points

Parenteral/IV Feeding (Level High) (K0510A2 = Checked) AND (K0710A2 = 3) 7

Parenteral/IV Feeding (Level Low) (K0510A2 = Checked) AND (K0710A2 = 2) AND (K0710B2 = 2) 3

Pressure Ulcer Stage 4 (M0300D1 = 1 or more) 1 Infection of foot or open lesions on foot (not diabetic foot ulcer) (M1040A OR M1040C = Checked) 1

Sub-Total Points

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Step 15 – Identify Presence of NTA Comorbidity from the NTA Comorbidity Tab in the CMS “PDPM ICD-10 Mappings” Excel file tool

Step 16 – Identify the NTA Component “Points” from MDS “ICD-10-CM” Items (evaluate all rows for NTA points eligibility)

Condition/Extensive Service (check all rows) MDS Field/Value NTA

Points Aseptic Necrosis of the Bone I8000 A-J = 1 Bone/Joint/ Muscle Infections /Necrosis (except Aseptic Necrosis of Bone) I8000 A-J = 2 Cardio-Respiratory Failure and Shock I8000 A-J = 1 Cirrhosis of Liver I8000 A-J = 1 Cystic Fibrosis I8000 A-J = 1 Diabetic Retinopathy and Vitreous Hemorrhage, Proliferative I8000 A-J = 1 Diabetic Retinopathy-except proliferative and vitreous hemorrhage I8000 A-J = 1 Disorders of Immunity (except RxCC97: Immune Disorders) I8000 A-J = 1 Endocarditis I8000 A-J = 1 End Stage Liver Disease I8000 A-J = 1 Epilepsy, Intractable I8000 A-J = 1 Implanted Device or Graft, complications I8000 A-J = 1 Immune Disorders I8000 A-J = 1 Leukemia, myeloid, chronic I8000 A-J = 2 Lung Transplant I8000 A-J = 3 Major Organ Transplant (except lung) I8000 A-J = 2 Metabolic/Immune Disorders, Heredity I8000 A-J = 1 Morbid Obesity I8000 A-J = 1 Myelodysplastic Syndromes and Myelofibrosis I8000 A-J = 1 Narcolepsy or Cataplexy I8000 A-J = 1 Opportunistic Infections I8000 A-J = 2 Pancreatitis, chronic I8000 A-J = 1 Psoriatic Arthopathy and Systemic Sclerosis I8000 A-J = 1 Pulmonary Fibrosis and Other Chronic Lung Disorders I8000 A-J = 1 Respiratory Arrest I8000 A-J = 1 Skin Burn (severe) or condition I8000 A-J = 1 Systemic Lupus Erythematosus, other connective tissue disorders, Inflammatory Spondylopathies I8000 A-J = 1 Sub-Total Points

cms.gov Look up all ICD-

10-CMS Codes in MDS Fields

I8000A-J

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Step 17– Identify the NTA Component “Points” from HIV/AIDS Comorbidity from Claim (circle appropriate NTA point value)

Condition/Extensive Service Claim Source/Value NTA Points

HIV/AIDS

FL 67 = ICD-10-CM Code B20 OR

FL 67 A-Q = ICD-10-CM Code B20 8

Neither 0

Step 18 – Identify the PDPM NTA Component Classification & Base PDPM NTA Component Per-Diem Rate

Note: The PDPM NTA component base rate is paid triple for days 1-3, and is reduced to the base rate days 3-100 of the benefit period

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Nursing Component Module (Steps 19-29) Step 19 – Identify Nursing Component Classification Start Point

Step 20 – Identify Nursing Component Extensive Services Case-Mix Group & Per-Diem Rate (if applicable)

If Step 20 Completed –

Proceed to Step 30

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Step 21 – Identify Nursing Component Special Care High Conditions/Services Eligibility & Depression Indicator

Step 22 – Identify Nursing Component Special Care High Case-Mix Group & Per-Diem Rate (if applicable)


Proceed to Step 30

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Step 23 – Identify Nursing Component Special Care Low Conditions/Services Eligibility & Depression Indicator

Step 24 – Identify Nursing Component Special Care Low Case-Mix Group & Per-Diem Rate (if applicable)


Proceed to Step 30

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Step 25 – Identify Nursing Component Clinically Complex Conditions/Services & Depression Indicator

Step 26– Identify Nursing Component Clinically Complex Case-Mix Group & Per-Diem Rate (if applicable)


Proceed to Step 30

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Step 27 – Identify Nursing Component Behavioral Symptoms & Cognitive Performance Eligibility & Restorative Nursing Count

Step 28 – Identify Nursing Component Behavioral Symptoms & Cognitive Performance Case-Mix Group & Per-Diem Rate (if applicable)


Proceed to Step 30

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Step 29 – Identify Nursing Component Reduced Physical Function Restorative Nursing Count, Case-Mix Group & Per-Diem Rate


Proceed to Step 30

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Federal Urban and Rural Per-Diem Payment Rate(s) at Different Points of Stay Module

Step 30 –PDPM Federal Urban and Rural Per-Diem Payment Rate(s) at Different Points of Stay Compared to RUG-IV Rates