VHCA PDPM One Day Training November 15, 2018 · of the model Then a deeper dive into each component and a look at where that data comes from ... Any three Either SK 3.69 Any three

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VHCA PDPM One‐Day TrainingNovember 15, 2018

MARK MCDAVID, OTR, RAC‐CT, CHC

Overview of the PDPM components and structure of the model

Then a deeper dive into each component and a look at where that data comes from

A few examples/case studies/tools

Industry changes

Contracting models

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Today

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5 case‐mix adjusted components and 1 non case‐mix adjusted component.

• Physical Therapy Component • Occupational Therapy Component • Speech‐Language Pathology Component • Nursing Component • Non‐Therapy Ancillary Component • Non Case‐mix Component (room and board, admin cost,

capital‐related costs) + wage adjustment

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PDPM – 6 Components

Patient Driven Payment Model

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OTComponent Non Case-Mix

Component

SLPComponent

Resident

PTComponent

Nursing Component

NTA Component

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Note:

All residents would be classified into PT, OT, and SLP classification regardless of whether they are on therapy case load (likely being assigned the lowest CMI for the these components).

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Patient Driven Payment Model

Physical and Occupational Therapy Case‐Mix Classification

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PT and OT Components

Unlike RCS‐I, in the PDPM the PT and OT Components are calculated together but paid separately based on the case‐mix.

Drivers of PT and OT component

• Primary reason for skilled stay

• Function score

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I8000 ICD‐10‐CM will classify the patient into one of the 4 Clinical Categories.

Multiple ICD‐10‐CM codes will point to more than one Clinical Category

In these cases, providers will select a surgical procedure category in a sub‐item within item J2000 which would identify the relevant surgical procedure that occurred during the patient’s preceding hospital stay and which would augment the patient’s PDPM clinical category• This is due to post‐surgical patient needs may be much

different than non‐surgical patients

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4 PT/OT Clinical Categories

Major Joint Replacement or Spinal Injury

Non‐Orthopedic Surgery and Acute Neurologic

Other Orthopedic

Medical Management

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PT and OT Functional Score

CMS will use 10 Section GG items to calculate the PT and OT Function Score. This includes 4 late loss ADLs and 2 early loss ADLs

• Two bed mobility items• Three transfer items• One eating items• One toileting item• One oral hygiene item• Two walking items

GG goes from a 6‐point scale (with 3 not attempted codes) to 0‐4 point scale for Function Score purposes

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PT and OT Functional Score Construction (Except walking)

Table 16 – CMS – 1696‐F

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Responses Score05, 06 Set-up assistance, Independent 404 Supervision or touching assistance 303 Partial/moderate assistance 202 Substantial/maximal assistance 101, 07, 09, 88 Dependent, Refused, N/A, Not

Attempted0 M

ore Care Needed

PT and OT Functional Score Construction for Walking Items

*Coded based on response to GG0170H1 (Does the resident walk?) – This item will be replaced with GG0170I1 (Walk 10 feet)

Table 17 – CMS – 1696‐F

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Responses Score05, 06 Set-up assistance, Independent 404 Supervision or touching assistance 303 Partial/moderate assistance 202 Substantial/maximal assistance 101, 07, 09, 10, 88

Dependent, Refused, N/A, Not Attempted, Resident Cannot Walk*

0

More Care Needed

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Finalized Section GG Items Included in PT and OT Function Measure

Table 18 – CMS – 1696‐F seagroverehab.com13

Section GG Item ScoreGG0130A1 Self-care: Eating 0-4GG0310B1 Self-care: Oral Hygiene 0-4GG0130C1 Self-care: Toileting Hygiene 0-4GG0170B1 Mobility: Sit to lying 0-4 (avg of

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

GG0170D1 Mobility: Sit to stand0-4 (avg of 3 items)GG0170E1 Mobility: chair/bed-to-chair transfer

GG0170F1 Mobility: Toilet transferGG0170J1 Mobility: Walk 50 feet with 2 turns 0-4 (avg of

2 items)GG0170K1 Mobility: Walk 150 feet

PT and OT Case‐mix Classification Groups

Partial Table 21 – CMS – 1696‐F seagroverehab.com14

ClinicalCategory

Section GG Function Score

PT OT Case-

MixGroup

PT Case-Mix

Index

OT Case-

Mix Index

Major Joint Replacement or

Spinal Surgery

0-5 TA 1.53 1.49

6-9 TB 1.69 1.63

10-23 TC 1.88 1.68

24 TD 1.92 1.53

Other Orthopedic

0-5 TE 1.42 1.41

6-9 TF 1.61 1.59

10-23 TG 1.67 1.64

24 TH 1.16 1.15

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ClinicalCategory


PT OT Case-

MixGroup

PT Case-Mix

Index

OT Case-

Mix Index

Medical Management

0-5 TI 1.13 1.17

6-9 Tj 1.42 1.44

10-23 TK 1.52 1.54

24 TL 1.09 1.11

Non-OrthopedicSurgery and

Acute Neurologic

0-5 TM 1.27 1.30

6-9 TN 1.48 1.49

10-23 TO 1.55 1.55

24 TP 1.08 1.09

Speech Language Pathology

Case‐Mix Classification

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SLP Component

5 Characteristics that will impact the SLP Component• Acute Neurologic or Non‐Neurologic

• SLP‐Related Comorbidity

• Cognitive Impairment

• Mechanically Altered Diet

• Swallowing Disorder

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SLP Component

Acute Neurologic or Non‐Neurologic

• Determined by I8000

SLP‐Related Comorbidity

• Determined by Section I (I4300, I4500, I4900, I5500, I8000)and Section O for ventilator and tracheostomy care (O0100E2, O0100F2)

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SLP‐Related Comorbidities

Table 22 – CMS – 1696‐F

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Aphasia Laryngeal CancerCVA, TIA, or Stroke Apraxia

Hemiplegia or Hemiparesis DysphagiaTraumatic Brain Injury ALS

Tracheostomy Care (while a resident) Oral CancersVentilator or Respirator (while a

resident)Speech and Language Deficits

CCognitive Functional Score (CFS)

CMS finalized blending BIMS and CPS to get a CFS score

Table 20 – CMS‐1696 ‐ F

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CFS Cognitive Scale BIMS Score CPS Score1. Cognitively Intact 13-15 02. Mildly Impaired 8-12 1-23. Moderately Impaired 0-7 3-44. Severely Impaired - 5-6

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SLP Component

Mechanically Altered Diet

• Determined by K0510C2

Swallowing Disorder

• Determined by K0100A‐D and K0100Z

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12 SLP Case‐Mix Groups

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Presence of Acute Neurologic Condition, SLP-Related

Comorbidity, or Cognitive Impairment

Mechanically Altered Diet or

Swallowing Disorder

Case-Mix Group

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 3.51Any three Neither SJ 2.98

Any three Either SK 3.69

Any three Both SL 4.19

Table 23 CMS‐1696‐F

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Nursing Case‐Mix Classification

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25 Nursing Indexes

CMS will use a modified version of the RUG‐IV Nursing Categories

CMS reduced the number of Nursing RUGs from 43 to 25.

This was accomplished by collapsing case‐mix groups that have contiguous ADL scores when those RUGs were defined by similar clinical traits

We will look at Table 26 in a few slides.

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25 Nursing Indexes


Nursing will also use Section GG to capture the Nursing Function Score

Using the same methodology as for the PT and OT component.

• 0‐4 point scale

• Average bed mobility and transfers

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Section GG items for Nursing

Table 25 – CMS – 1696‐F

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Section GG Item ScoreGG0130A1 Self-care: Eating 0-4GG0130C1 Self-care: Toileting Hygiene 0-4GG0170B1 Mobility: Sit to lying 0-4 (avg of



GG0170F1 Mobility: Toilet transfer

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PDPM Nursing Index – 25 Indexes

*e.g. septicemia, respiratory therapy and more – see full chartPartial Table 26 – CMS – 1696‐F

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RIG-IV Nursing

RUG

Extensive Services

Clinical Condition

Depression

# of RestorativeNursing Services

GG‐basedFunction Score

PDPMNursing Case‐Mix Group

Nursing Case-

Mix Index

ES3 Trach and Vent ‐‐‐ ‐‐‐ ‐‐‐ 0‐14 ES3 4.04

ES2 Trach or Vent ‐‐‐ ‐‐‐ ‐‐‐ 0‐14 ES2 3.06

ES1 Infection ‐‐‐ ‐‐‐ ‐‐‐ 0‐14 ES1 2.91

HE2/HD2 ----Seriousmedical

condition*Yes ‐‐‐ 0‐5 HDE2 2.39

HE1/HD1 --- same No ‐‐‐ 0‐5 HDE1 1.99

HC2/HB2 --- Same Yes ‐‐‐ 6‐14 HBC2 2.23

HC1/HB1 --- Same No ‐‐‐ 6‐14 HBC1 1.85

HIV/AIDS add‐on

Due to significant increase in nursing cost to care for HIV/AIDS pts, the facility will get an 18% increase in the Nursing Component

This would be applied based on the presence of ICD‐10‐CM code B20 on the SNF claim

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Non‐Therapy Ancillary


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50 Conditions & Extensive Services Used for NTA Classification

Partial Table 27 – CMS – 1696 ‐ F

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Condition/ExtensiveServices

Source Points

HIV/Aids SNF Claim 8Parenteral IV feeding: High MDS Item O0100H2 7Special Treatments/ Programs: IV Meds Post-admit

MDS Item O0100I2 5

Special Treatments/ Programs: Vent or RespPost-admit

MDS ItemO010F2 4

Endocarditis MDS Item I8000 1

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NTA Case‐Mix Classification Groups

Partial Table 28 – CMS – 1696‐F

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NTA Score Range NTA Group NTA Case-Mix Index12+ NA 3.259-11 NB 2.536-8 NC 1.853-5 ND 1.341-2 NE 0.960 NF 0.72

Non Case‐Mix Component

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Non Case‐Mix Component

Flat rate

Non case‐mix adjusted

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Variable Per Diem

Adjustment Factor

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Variable Per Diem Adjustment Factor

Adjustment Factor• PT and OT: After day 20, drop 2% every 7 days.• Of interest, if the patient is in the facility on days 98‐100,

the adjustment factor for PT and OT is 0.76.

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NTA Adjustment Factor

Table 31 – CMS – 1696‐F

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Medicare Payment Days Adjustment Factor1-3 3.0

4-100 1.0

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Assessments (MDS) to be completed

Only three types of assessments

• 5‐Day Scheduled Assessment

• Interim Payment Assessment (IPA)

• SNF Part A Discharge Assessment

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Assessments (MDS) to be completed

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Medicare MDS Assessment Type

Assessment Reference Date

Applicable Standard Medicare Payment

Days5-day Scheduled PPS

AssessmentDays 1-8 All covered Part A days until

Part A discharge (unless an IPA is completed)

Interim Payment Assessment (IPA)

No later than 14 days after change in

resident’s first tier classification criteria is

identified

ARD of the assessment through Part A discharge (unless another IPA is

completed)

PPS Discharge Assessment PPS Discharge: Equal to the End Date of the Most Recent Medicare Stay (A2400C) or End Date

N/A

Table 33 – CMS – 1696‐F

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5‐Day Scheduled Assessment

Grace Days• Remove the label “grace days” so that the 5‐day PPS

schedule will be days 1‐8 vs days 1‐5 with grace days of 6‐8.

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Interim Payment Assessment

Requirements

‐ The IPA is an optional assessment‐ The ARD for the IPA will be the date the

facility chooses to complete the assessment relative to the triggering event that cause the facility to choose the IPA.

‐ Payment for the IPA will begin on the same day as the ARD.

‐ The IPA is not susceptible to assessment penalties

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Proposed Interim Payment Assessment

Requirements(1) There is a change in the resident’s classification in at least one of the first tier classification criteria for any of the components under the proposed PDPM(which are those clinical or nursing payment criteria identified in the firstcolumn in Tables 21, 23, 26, and 27 – PT/OT, SLP, Nursing, NTA) such that the resident would be classified into a classification group for that component that differs from that provided by the 5‐day scheduled PPS assessment, and the change in classification group results in a change in payment either in one particular payment component or in the overall payment for the resident; and

(2) The change(s) are such that the resident would not be expected to return tohis or her original clinical status within a 14‐day period.

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Proposed Interim Payment Assessment

Requirements

‐ In addition, we propose that the Assessment Reference Date (ARD) for the IPA would be no later than 14 days after a change in a resident’s first tierclassification criteria is identified. The IPA is meant to capture substantialchanges to a resident’s clinical condition and not every day, frequent changes.We believe 14 days gives the facility an adequate amount of time to determinewhether the changes identified are in fact routine or substantial.

‐Missed or late IPAs will be treated as missed or late unscheduled assessments

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PPS Discharge Assessment

Must be completed on all PPS discharges

Adding a modified Section O to this assessment

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Modified Section O

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MDS Item Number

Item Name

O0400A5 Special Treatments, Procedures and Programs: Speech-Language Pathology and Audiology Services: Therapy Start Date

O0400A6 Special Treatments, Procedures and Programs: Speech-Language Pathology and Audiology Services: Therapy End Date

O0400A7 Special Treatments, Procedures and Programs: Speech-Language Pathology and Audiology Services: Total Individual Minutes

O0400A8 Special Treatments, Procedures and Programs: Speech-Language Pathology and Audiology Services: Total Concurrent Minutes

O0400A9 Special Treatments, Procedures and Programs: Speech-Language Pathology and Audiology Services: Total Group Minutes

O0400A10 Special Treatments, Procedures and Programs: Speech-Language Pathology and Audiology Services: Total Days

Partial Table 35 CMS‐1696‐F

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Decrease in Provider Burden

CMS Predicts• The PDPM model will save providers $200M per year or

$2B over 10 years

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PDPM Modes of Therapy

Group and Concurrent Therapy Limits to 25% combined Most services provided on an individual basis

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PDPM Modes of Therapy

Group and Concurrent minutes counted in full vs ¼ and ½ respectively

CMS will use the Discharge Assessment to monitor Group and Concurrent utilization.

• Should a provider exceed this limitation, a non‐fatal warning edit will appear on the validation report after submission to the QIES ASAP system

• CMS may consider future proposals to address abuses of this policy or flag providers for additional review

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PDPM Interrupted Stays

Payment calendar continues (using adjustment factors) if the resident is discharged from a SNF and returns to the same SNF within 3 midnights.

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Deeper Dive

Those are the basic components and structure of the PDMP model. Now, we will take a deeper dive into each component.

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PT and OT Component

Deep Dive

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Primary Reason for Skilled Stay

• I8000 from MDS

• Go to MDS Section I

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Primary Reason for Skilled Stay

• Clinical Category Mapping Spreadsheet1. Locate the ICD‐10 corresponding to primary reason

for skilled stay2. Column B shows the Default Clinical Category3. If the resident received a surgery during the prior

inpatient stay, then we will refer to J2000

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Function Score

• Section GG is extremely important• For QRP• For PDPM

• Go to Section GG on MDS

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Section GG refresher

• Usual Performance• A resident’s functional status can be impacted by the environment or

situations encountered at the facility. Observing the resident’s interactions with others in different locations and circumstances is important for a comprehensive understanding of the resident’s functional status. If the resident’s functional status varies, record the resident’s usual ability to perform each activity. Do not record the resident’s best performance and do not record the resident’s worst performance, but rather record the resident’s usual performance. RAI, page GG‐9

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Assessment Period: Admission This functional assessment must be completed within the first three days

(3 calendar days) of the Medicare Part A stay, starting with the date in A2400B, Start of Most Recent Medicare Stay, and the following two days, ending at 11:59 PM on day 3. The admission function scores are to reflect the resident’s admission baseline status and are to be based on an assessment. The scores should reflect the resident’s status prior to any benefit from interventions. The assessment should occur, when possible, prior to the resident benefitting from treatment interventions in order to determine the resident’s true admission baseline status. Even if treatment started 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 page GG‐36

*Underlined text is new language for FY 2019


Section GG refresher• Tips for Coding

• If the resident performs the activity more than once during the assessment period and the resident’s performance varies, coding in Section GG should be based on the resident’s “usual performance,” which is identified as the resident’s usual activity/performance for any of the Self‐Care or Mobility activities, not the most independent or dependent performance over the assessment period.

• Therefore, if the resident’s Self‐Care performance varies during the assessment period, report the resident’s usual performance, not the resident’s most independent performance and not the resident’s most dependent performance. A provider may need to use the entire three‐day assessment period to obtain the resident’s usual performance. RAI page GG‐13

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Definition: Qualified Clinician: Healthcare professionals practicing within their scope of practice and

consistent with Federal, State, and local law and regulations.

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Steps for Assessment1. Assess the resident’s self‐care performance based on direct observation,

as well as the resident’s self‐report and reports from qualified clinicians, care staff, or family documented in the resident’s medical record during the three‐day assessment period.

CMS anticipates that an interdisciplinary team of qualified clinicians is involved in assessing the resident during the three‐day assessment period. For Section GG, the admission assessment period is the first three days of the Part A stay starting with the date in A2400B, the Start of Most Recent Medicare Stay. On admission, these items are completed only when A0310B = 01 (5‐Day PPS assessment).

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Steps for Assessment2. Residents should be allowed to perform activities as independently as

possible, as long as they are safe.

3. For the purposes of completing Section GG, a “helper” is defined as facility staff who are direct employees and facility‐contracted employees (e.g., rehabilitation staff, nursing agency staff). Thus, “helper” does not include individuals hired, compensated or not, by individuals outside of the facility’s management and administration such as hospice staff, nursing/certified nursing assistant students, etc. Therefore, when helper assistance is required because a resident’s performance is unsafe or of poor quality, consider only facility staff when scoring according to theamount of assistance provided.

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Steps for Assessment4. Activities may be completed with or without assistive device(s). Use of

assistive device(s) to complete an activity should not affect coding of the activity.

5. 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.

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Steps for Assessment6. Refer to facility, Federal, and State policies and procedures to determine

which staff members may complete an assessment. Resident assessments are to be done in compliance with facility, Federal, and State requirements.

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Collaboration and Recommended Coding Process

Admission Data collection for Admission (Therapy and Nursing) Section GG meeting between therapy and nursing MDS Coordinator determines level to be coded on MDS

Planned Discharge Data collection by therapy and nursing for Discharge assessment (last 3

days of stay) Therapy and nursing meet to discuss Section GG findings MDS Coordinator determines level to be coded on MDS

Show AANAC GG data collection tools.

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Collaboration and Recommended Coding Process

This is important!

Currently, this impacts your annual QRP score

Post 10/1/2019 this will impact your daily per diem

Think about the post‐payment reviews related to PDPM payments.

Finalized Section GG Items Included in PT and OT Function Measure

Table 18 – CMS – 1696‐F seagroverehab.com64

Section GG Item ScoreGG0130A1 Self-care: Eating 0-4GG0310B1 Self-care: Oral Hygiene 0-4GG0130C1 Self-care: Toileting Hygiene 0-4GG0170B1 Mobility: Sit to lying 0-4 (avg of



GG0170F1 Mobility: Toilet transferGG0170J1 Mobility: Walk 50 feet with 2 turns 0-4 (avg of

2 items)GG0170K1 Mobility: Walk 150 feet

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ClinicalCategory


PT OT Case-

MixGroup

PT Case-Mix

Index

OT Case-

Mix Index

Major Joint Replacement or

Spinal Surgery

0-5 TA 1.53 1.49

6-9 TB 1.69 1.63

10-23 TC 1.88 1.68

24 TD 1.92 1.53

Other Orthopedic

0-5 TE 1.42 1.41

6-9 TF 1.61 1.59

10-23 TG 1.67 1.64

24 TH 1.16 1.15



ClinicalCategory


PT OT Case-

MixGroup

PT Case-Mix

Index

OT Case-

Mix Index

Medical Management

0-5 TI 1.13 1.17

6-9 Tj 1.42 1.44

10-23 TK 1.52 1.54

24 TL 1.09 1.11

Non-OrthopedicSurgery and

Acute Neurologic

0-5 TM 1.27 1.30

6-9 TN 1.48 1.49

10-23 TO 1.55 1.55

24 TP 1.08 1.09

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Speech Language Pathology


Deep Dive

67

SLP Component

5 Characteristics that will impact the SLP Component• Acute Neurologic or Non‐Neurologic

• SLP‐Related Comorbidity

• Cognitive Impairment

• Mechanically Altered Diet

• Swallowing Disorder

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SLP Component

Acute Neurologic or Non‐Neurologic

• Determined by I8000

• Same ICD‐10 Spreadsheet

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SLP Component

SLP‐Related Comorbidity• Determined by Section I (I4300, I4500, I4900, I5500,

I8000)and Section O for ventilator and tracheostomy care (O0100E2, O0100F2)

• Show Section I and O

Table 22 – CMS – 1696‐F

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Aphasia Laryngeal CancerCVA, TIA, or Stroke Apraxia

Hemiplegia or Hemiparesis DysphagiaTraumatic Brain Injury ALS

Tracheostomy Care (while a resident) Oral CancersVentilator or Respirator (while a

resident)Speech and Language Deficits

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CCognitive Functional Score (CFS)

CMS finalized using the BIMS and CPS to get a CFS score

Table 20 – CMS‐1696 – F

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CFS Cognitive Scale BIMS Score CPS Score1. Cognitively Intact 13-15 02. Mildly Impaired 8-12 1-23. Moderately Impaired 0-7 3-44. Severely Impaired - 5-6

Cognitive Function Score (CFS)

Will complete the BIMS or the CPS, but not both.

Brief Interview for Mental Status

• Show Section C ‐ BIMS

Cognitive Performance Scale

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SLP Component

Mechanically Altered Diet

• Determined by K0510C2

Swallowing Disorder

• Determined by K0100A‐D and K0100Z• Show Section K

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12 SLP Case‐Mix Groups

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Presence of Acute Neurologic Condition, SLP-Related

Comorbidity, or Cognitive Impairment

Mechanically Altered Diet or

Swallowing Disorder

Case-Mix Group

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 3.51Any three Neither SJ 2.98

Any three Either SK 3.69

Any three Both SL 4.19

Table 23 CMS‐1696‐F

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Nursing Case‐Mix Classification

Deep Dive

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25 Nursing Indexes


CMS reduced the number of Nursing RUGs from 43 to 25.• Extensive Services

• Clinical Conditions

• Depression

• Number of Restorative Nursing Services

• Section GG‐based Function Score

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25 Nursing Indexes


Extensive Services

• Tracheostomy care while a resident

• Ventilator or respirator while a resident

• Infection isolation while a resident

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25 Nursing Indexes

CMS will use a modified version of the RUG‐IV Nursing Categories Clinical Conditions*

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• Diabetic• Septicemia• COPD• Quadriplegia• Fever with pneumonia• Respiratory therapy• Parkinson’s• Cerebral Palsy• Multiple Sclerosis• Stage III or IV ulcers

• Hallucinations• Delusions• Behaviors towards others• Wandering• Burns• Oxygen• Transfusion• Parenteral feeding• Foot infections

*Truncated list

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25 Nursing Indexes


Depression – Yes or No

• Does the resident have signs/symptoms of depression as identified by the Resident Mood Interview (PHQ‐9) or the Staff Assessment of Resident Mood (PHQ‐9‐OV)

• Show Section D

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25 Nursing Indexes


# of Restorative Nursing Services – to be counted must have occurred for 15 minutes or more a day for 6 or more of the last 7 days.

In RUG‐IV, rarely does Restorative impact payment, however, in PDPM, it could impact payment on many more patients.

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25 Nursing Indexes


Restorative services include:• Urinary toileting program and/or bowel toileting program• Passive and/or active ROM• Splint or brace assistance• Bed mobility and/or walking training• Transfer training• Dressing and/or grooming training• Eating and/or swallowing training• Amputation/prosthesis care• Communication training

How does your restorative program compare today?• Pulling staff, post‐payment audits (documentation)• Restorative programming on admission? seagroverehab.com81

25 Nursing Indexes


Section GG‐based Function Score Go to Nursing Section GG from MDS

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PDPM Nursing Index – 25 Indexes

*e.g. septicemia, respiratory therapy and more – Show full chart Partial Table 26 – CMS – 1696‐F

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RIG-IV Nursing

RUG

Extensive Services

Clinical Condition

Depression

# of RestorativeNursing Services

GG‐basedFunction Score

PDPMNursing Case‐Mix Group

Nursing Case-

Mix Index

ES3 Trach and Vent ‐‐‐ ‐‐‐ ‐‐‐ 0‐14 ES3 4.04

ES2 Trach or Vent ‐‐‐ ‐‐‐ ‐‐‐ 0‐14 ES2 3.06

ES1 Infection ‐‐‐ ‐‐‐ ‐‐‐ 0‐14 ES1 2.91

HE2/HD2 ----Seriousmedical

condition*Yes ‐‐‐ 0‐5 HDE2 2.39

HE1/HD1 --- same No ‐‐‐ 0‐5 HDE1 1.99

HC2/HB2 --- Same Yes ‐‐‐ 6‐14 HBC2 2.23

HC1/HB1 --- Same No ‐‐‐ 6‐14 HBC1 1.85

HIV/AIDS add‐on

Due to significant increase in nursing cost to care for HIV/AIDS pts, the facility will get an 18% increase in the Nursing Component

This would be applied based on the presence of ICD‐10‐CM code B20 on the SNF claim

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Non‐Therapy Ancillary


Deeper Dive

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NTA Case‐Mix Classification Groups

Table 28 – CMS – 1696‐F

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NTA Score Range NTA Group NTA Case-Mix Index12+ NA 3.259-11 NB 2.536-8 NC 1.853-5 ND 1.341-2 NE 0.960 NF 0.72

Show Table 27, NTA

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PDPM Per Diem

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• Base Rate x PT and OT CMI x Adjustment FactorPT and OT Rate

• Base Rate x SLP CMISLP Rate• Nursing Rate x Nursing CMINursing Rate• Base Rate x NTA CMI x Adjustment

FactorNTA Rate

• Non-Case Mix RateNon-Case-Mix Rate

$$$

$$$

$$$

$$$

+

+

+

+

+

$$$

$$$

Total Per Diem

Case Study #1

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Mr. B had a hip replacement and was sent for rehab at our SNF. His case‐mix groups are as follows:

• PT and OT case‐mix group – TB

• SLP case‐mix group – SA

• Nursing PDPM case‐mix group – CDE2

• Non‐therapy ancillary – NE

• Non case‐mix flat rate

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Case Study #1

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Case-mix group TB TB SA CDE2 NE

Case-mix Index 1.69 1.63 0.68 1.86 0.96

Urban PT OT SLP Nursing NTA Non case-mix

Per diem $ 59.33 $ 55.23 $ 22.50 $ 103.46 $ 78.05x3 $ 92.63 Subtotal $ 100.27 $ 90.02 $ 15.30 $ 192.44 $ 224.78 $ 92.63

Days Per Diem

1-3 $715.44

4-20 $565.59

21-27 $561.78

‐ Urban‐ *Note: these rates are not wage index adjusted

Case Study #1

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Case-mix group TB TB SA CDE2 NE

Case-mix Index 1.69 1.63 0.68 1.86 0.96


Per diem $ 67.63 $ 62.11 $ 27.90 $ 98.83 $ 74.56x3 $ 94.34 Subtotal $ 114.30 $ 101.24 $ 18.97 $ 183.82 $ 214.73 $ 94.34

‐ Rural‐ *Note: these rates are not wage index adjusted

Days Per Diem

1-3 $727.40

4-20 $584.25

21-27 $579.94

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Case Study #2

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Extremely ill patient with multiple comorbidities (joint replacement, dysphagia and mech altered diet, septicemia, depressed, 0‐5 on GG, 12+ on NTA):• PT and OT case‐mix group – TB

• SLP case‐mix group – SC

• Nursing PDPM case‐mix group – HDE2

• Non‐therapy ancillary – NA

• Non case‐mix flat rate

Case Study #2

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Case-mix group TB TB SC HDE2 NA

Case-mix Index 1.69 1.63 2.66 2.39 3.25


Per diem $59.33 $55.23 $22.15 $103.46 $78.05 x3 $92.63Subtotal $100.27 $90.03 $58.91 $247.26 $760.98 $92.63

‐ Urban‐ *Note: these rates are not wage index adjusted‐ Show AANAC Handout

Days Per Diem

1-3 $1351.03

4-20 $843.70

21-27 $839.90

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Case Study #3

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Mrs. Smith was admitted from the hospital with acute onset of cerebrovascular accident. She is on a modified diet of ground meats and honey thick liquids and has left hemiplegia. Additionally, she is receiving parenteral feedings at a low intensity. She has a moderate cognitive impairment, is aphasic, and has Diabetes Mellitus. She needs partial/moderate assist with eating, oral hygiene, and sit to lying to sit. She needs substantial/maximum assist with toilet hygiene, all transfers, and walking 50’ with two turns. She cannot walk 150’. She is depressed.

Case Study #3

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PT and OT Case Mix Group Mrs. Smith was admitted from the hospital with acute onset of

cerebrovascular accident. She is on a modified diet of ground meats and honey thick liquids and has left hemiplegia. Additionally, she is receiving parenteral feedings at a low intensity. She has a moderate cognitive impairment, is aphasic, and has Diabetes Mellitus. She needs partial/moderate assist with eating, oral hygiene, and sit to lying to sit. She needs substantial/maximum assist with toilet hygiene, all transfers, and walking 50’ with two turns. She cannot walk 150’. She is depressed.

Clinical Category – Non‐ortho surgery and acute neuro Function Score – 8.5 PT/OT CMG – TN; 1.48 PT CMI and 1.49 OT CMI

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Case Study #3

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SLP Case Mix Group Mrs. Smith was admitted from the hospital with acute onset of


Column 1 – Acute neuro condition, SLP‐related co‐morbidity, Cognitive impairment –He has all 3.

Column 2 ‐Mechanically altered diet or swallowing disorder ‐ BOTH SLP CMG – SL; CMI of 4.19

Case Study #3

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Nursing Case Mix Group Mrs. Smith was admitted from the hospital with acute onset of


Nursing Category – Special Care High Clinical Services ‐ Depression Function Score – 6 NSG CMG – HBC2; CMI of 2.23

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Case Study #3

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NTA Mrs. Smith was admitted from the hospital with acute onset of


Parenteral Feedings Low – 3 points DM– 2 points NTA CMG – ND, CMI of 1.34

Case Study #3

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Case-mix group TN TN SL HBC2 ND

Case-mix Index 1.48 1.49 4.19 2.23 1.34




Days Per Diem

1-3 $901.48

4-20 $692.31

21-27 $688.91

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Case Study #4

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Mrs. Jones was admitted from the hospital with right femur fracture with ORIF. She has dysphagia and is on a modified diet. She is cognitively intact and has COPD. She is set‐up for eating, oral hygiene, and toilet hygiene. She is supervision with sit to lying, all transfers, walking 50’ with two turns, and walking 150’. She is partial/moderate assist with lying to sitting. She is not depressed.

Case Study #4

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PT and OT Case Mix Group Mrs. Jones was admitted from the hospital with right femur fracture with

ORIF. She has dysphagia and is on a modified diet. She is cognitively intact and has COPD. She is set‐up for eating, oral hygiene, and toilet hygiene. She is supervision with sit to lying, all transfers, walking 50’ with two turns, and walking 150’. She is partial/moderate assist with lying to sitting. She is not depressed.

Clinical Category – Other Orthopedic (not joint replacement) Function Score – 20.5 CMG – TG; CMI PT 1.67, OT 1.64

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Case Study #4


SLP Case Mix Group Mrs. Jones was admitted from the hospital with right femur fracture with


Column 1 – Non neuro condition, SLP‐related co‐morbidity, No cognitive impairment – She has 1

Column 2 ‐Mechanically altered diet or swallowing disorder ‐ BOTH SLP CMG – SF; CMI of 2.97

Case Study #4


Nursing Mrs. Jones was admitted from the hospital with right femur fracture with


Nursing Category – Special Care High Clinical Services – No depression, but does have COPD Function Score – 13.5 NSG CMG – HBC1; CMI of 1.85

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Case Study #4


NTA Mrs. Jones was admitted from the hospital with right femur fracture with


COPD – 2 points NTA CMG – NE, CMI of 0.96

Case Study #4


Case-mix group TG TG SF HBC1 NE

Case-mix Index 1.67 1.64 2.97 1.85 0.96




Days Per Diem

1-3 $765.30

4-20 $615.44

21-27 $611.65

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Available to you now!


Skilled Criteria

Benefit Policy Manual, chapter 8 is not changing based on PDPM payment rules.

Skilled for therapy is still 5+ days per week.

• Services must be skilled and medically necessary and require the skills of a licensed therapist.

• To count a day as a day of therapy must provide 15 minutes of therapy throughout the day.

Skilled for Nursing is requiring a nursing skilled service 7 days per week.


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Presumption of Coverage

Administrative Presumption effective October 1, 2019 will continue under PDPM The following case‐mix classifiers will qualify:

PT/OT CMG: TA, TB, TC, TD, TE, TF, TG, TJ, TK, TN, and TO

SLP CMG: SC, SE, SF, SH, SI, SJ, SK, and SL

Nursing: Extensive Services, Special Care High, Special Care Low, and Clinically Complex

NTA CMG: NA (12+)


Now What? Industry Changes?

Therapy utilization?• Assume that therapy utilization will decrease

May mean that there is a decreased demand for therapists nationwide.

Therapist salaries?

Is this “PPS lite” for the therapy portion of the industry?

Could “in‐house” therapy be an option or a reality for your facility?


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Some Concerns About the Model

Rationing of therapy.

Modified Section O on discharge assessment seen as helpful to the therapy community.

How will it be handled if one discipline misses a few days? (sick therapist, holiday, staffing issues)

Use of Section GG seen as a good thing, but “usual performance” to drive resource allocation?

Auditors may try to apply rules that do not apply to this model well after the fact (paid for SLP, but didn’t provide it to a specific patient, auditor may try to take those funds back)


CMS Oversight per Final Rule

CMS indicated that they would be monitoring provider behavior…

• Looking for drastic changes in volume of therapy as compared to RUG‐IV.

• Looking for compliance with group and concurrent therapy limit.

• Looking for an increase in mechanically altered diet in SNF population that may suggest beneficiaries are being prescribed such a diet based on facility financial considerations rather than clinical need.


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CMS Oversight per Final Rule

CMS indicated that they would be monitoring provider behavior…

• Use of Use of the interrupted‐stay policy to identify SNFs whose residents experience frequent readmission, particularly facilities where the readmissions occur just outside the 3‐day window used as part of the interrupted‐stay policy.

• Stroke and trauma patients, as well as those with chronic conditions, to identify any adverse trends from application of the variable per‐diem adjustment.

• Facilities whose beneficiaries experience inappropriate early discharge or provision of fewer services (e.g., due to the variable per‐diem adjustment).


Contract Models

The usual contract therapy contract will no longer “work”

Part B will continue “as is”


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Contract Models

New Contracting Models

• Contract should align incentives as much as possible• Diminish misalignment of incentives• There should be some sort of “value” piece included in

the contract • Built in compliance• Assist with capturing revenue where appropriate


Contract Models – 6 scenarios

1. Cost per Minute

• Simple model – SNF pays X amount for each minute of therapy provided, not based on per diem rate.

• No alignment of incentives – More therapy, more revenue for contractor but not for SNF.

• All risk on SNF to manage therapy volume against Medicare revenue.

• Unpredictable pricing model.• Incentives misaligned.


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2. Risk Share

• Contractor paid a percentage of the PT/OT/and ST component of the per diem.

• Risk is shared with contractor as they are only paid based on component and they must manage volume of therapy.

• Contractor participating in revenue capture for SNF means increased revenue for contractor.

• Contractor and SNF must manage and monitor outcomes to ensure adequate volume of therapy is being provided.

• May include a quality component.• SNF guaranteed margin for each type of patient.• Incentives mostly aligned.



3. Time on‐site

• Simple model where contractor is paid for every hour staff are on‐site.

• Risk is on SNF to manage contractor labor and ensure they are providing service while on‐site.

• No incentive for contractor to assist SNF with case management or revenue generation.

• Incentives are misaligned.


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4. Levels – capitated per diem

• Sets a certain number of therapy minutes for a certain type (or level) of patient. Much the same as the “level” Managed Care model

• Risk is on SNF to case manage, but therapy labor cost is set.

• This model has a lot of areas that are to be determined and could change per SNF.



5. Capitated per diem rate

• One flat rate for every patient day no matter various patient issues.

• Risk is shifted to contractor to manage therapy volume while achieving SNF‐expected outcomes.

• Lack of industry experience with PDPM makes this model hard to manage and may need to be adjusted more frequently than annually.

• Predictable cost to SNF.


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6. Percentage of overall per diem

• Contractor paid a percentage of the overall per diem.• Much like the risk‐share model, but based on overall patient

revenue vs PT, OT, and ST components.• Risk is shared with contractor as they are only paid based on per

diem and they must manage volume of therapy.• Contractor participating in revenue capture for SNF means

increased revenue for contractor.• Contractor and SNF must manage and monitor outcomes to ensure

adequate volume of therapy is being provided.• May include a quality component.• SNF guaranteed margin for each type of patient.

7. In‐house therapy is always an option for some


Now that we have opened Pandora’s box, what questions do you have about PDPM?

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20 Page synopsis on our website http://seagroverehab.com/articles/2018/8/3/understanding‐the‐impact‐of‐the‐finalized‐patient‐driven‐payment‐model

Mark McDavid, OTR/L RAC-CT, CHCSeagrove Rehab Partners

[email protected]

www.seagroverehab.com

Documents

VHCA PDPM One Day Training November 15, 2018 · of the model Then a deeper dive into each component and a look at where that data comes from ... Any three Either SK 3.69 Any three