Post on 22-Mar-2022
10/15/2020
1
Collaborative IDT Approach to PDPM
By Julie Moore & Jennifer Napier
TABLE OF CONTENTS
PDPM Audits
• Types of audits• Responding to audits• Ensuring complete
records
IDT COLLABORATION IN MDS PROCESS
• MDS interview process• Holding IDT accountable• Ensuring IDT is trained to complete
sections
PDPM OPTIMIZING ACCURACY
• Pre-admission records• Primary diagnosis• Predicting CMGs at time of
admission• Tools to predict CMGs/payment• Interim Payment Assessment
(IPA)• Documentation compliance• Huddle meetings• Triple Check
10/15/2020
2
MDS ACCURACY
MDS touches many parts of the SNF organization:
• Reimbursement
• Case Mix
• Staffing expectations (star rating)
• Quality Measures
• 5-star rating
• State Surveys
MDS Assessments should be completed with an IDT approach and use multiple sources of information:
• Review the medical record
• Communicate with and observe the resident
• Communicate with direct care staff from all shifts
• Communicate with other disciplines who have recently had contact with the resident.
• Communicate with the resident’s physician
• Communicate with the resident’s family if applicable
Establish Quarterly Assurances practices:
• Review of the MDS Prior to submission
• Read and respond to validation reports
• Triple Check
PDPM QUICK GUIDES
https://www.conceptrehab.com/quickguides
10/15/2020
3
PDPM ANALYZER
https://www.conceptrehab.com/pdpmanalyzerform
COMPLETE ADMISSION RECORDS
Accuracy and Optimization starts with complete and accurate hospital admission records
• Extra effort makes a difference• IV hospital flow records• Hospital dietician records• Hospital labs – need for hydration• Diabetes + glasses – look for diabetic
retinopathy
10/15/2020
4
PRIMARY DIAGNOSIS (I0020B)
PDPM Impact
The diagnosis entered in I0020B will determine the clinical category under PDPM. This impacts the PT, OT, and ST component of PDPM.
Documentation Considerations
• Strengthen facility process for identifying primary diagnosis
• Validate that ICD-10 code maps to clinical category.
• Primary reason for SNF stay (not necessarily hospital diagnosis)
• IDT process
• Skilled documentation should support primary diagnosis.
• Use CMS mapping file to find optimal diagnoses
• Example: Metabolic encephalopathy -> Acute neurologic
PT/OT Clinical Categories
Major Joint Replacement or Spinal Surgery
Non-Orthopedic Surgery and Acute Neurologic
Other Orthopedic
Medical Management
PRIMARY DIAGNOSIS (I0020B)
CMS Mapping File: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM
10/15/2020
5
SECTION GG: FUNCTIONAL ABILITIES & GOALS
PDPM Impact
Separate GG function scores determined for therapy (PT and OT) and Nursing
component of PDPM. Therapy function score ranges from 0-24 and Nursing function
score ranges from 0-16.
Documentation Considerations
• Three day data collection period
• Usual Functioning
• Interdisciplinary approach (Therapy is only a piece to the equation)
• Outcome data being collected for QRP
• What if therapy isn’t involved?
• What to do with discrepancies?
Direct observation, resident self-report, reports from clinicians, care staff, or family that is documented
in the resident’s medical record during the three-day assessment period.
SECTION GG: FUNCTIONAL ABILITIES & GOALS
10/15/2020
6
BRIEF INTERVIEW FOR MENTAL STATUS (BIMS)
PDPM Impact & PHQ9
Presence of cognitive impairment impacts ST. Clinical indicators of depression impact Nursing.
Documentation Considerations
• Most residents are able to attempt interviews
• Review interview process
• Right person completing interview
• Interview during look-back period of ARD
• Medical record demonstrate timely interview
• Cognitive levels fluctuate throughout day
• Mood may fluctuate
• Can be completed more than once
PDPM Cognitive Level BIMS CPS
Cognitively Intact 13-15 0Mildly Impaired* 8-12 1-2Moderately Impaired* 0-7 3-4Severely Impaired* - 5-6
Total Mood Severity Score
Minimal depression 1-4
Mild depression 5-9
Moderate depression 10-14
Moderately severe depression 15-19
Severe depression 20-27
SPEECH COMORBIDITIES
I8000 Codes: • Check CMS Mapping File
10/15/2020
7
SWALLOWING DISORDER
PDPM Impact
The presence of signs or symptoms of possible swallowing disorders identified in section K0100 impacts the ST Component of PDPM.
Documentation Considerations
• 7 day look-back period from 5-day or IPA ARD.
• Education of Nurses, Nursing Assistants, IDT, and therapy staff on signs and symptoms to monitor and document.
• Ask resident if he/she had symptoms
• Observe resident
• Interview staff members on all shifts
• Review medical record (nursing, physician, dietician, Speech Therapy notes)
MECHANICALLY ALTERED DIET
PDPM Impact
The delivery of a mechanically altered diet including “a diet specifically prepared to alter the texture or consistency of food to facilitate oral intake” can impact the ST Component of PDPM.
Documentation Considerations
• 7 day look-back period from 5-day or IPA ARD
• Presence of documentation/evidence in the medical record
• Speech therapy trials
• Physician orders
• Even if it only happened once
10/15/2020
8
PDPM Impact
Multiple items coded on the MDS impact the Nursing Category of PDPM. This includes but is not limited to sections: B, C, D, E, H, I, J, M, N, O.
Documentation Considerations
• Nursing knowledge and education in assessing and monitoring for certain conditions and complexities
• Role of Clinical Documentation Specialist
• Reviewing documentation prior to ARD
• Refer to Nursing PDPM Category Guide
NURSING CATEGORIES
NURSING CATEGORIES
10/15/2020
9
LOOK-BACK PERIOD OF ARD
MDS items look-back period into the hospital stay
• Section I- Active condition in the last 7 days• Respiratory Failure (with oxygen) -> Special Care High• Septicemia -> Special Care High • Wound Infection -> NTA• Cardio-respiratory failure and shock -> NTA• Respiratory arrest -> NTA• Multi-drug resistant organism -> NTA
• K05101A- Parenteral/IV feeding while NOT a resident (in the last 7 days)• IV Fluids for hydration -> Special Care High
Hospital records should impact how you choose your 5-day ARD.
PARENTERAL/IV FEEDING
10/15/2020
10
NON-THERAPY ANCILLARY
• Use CMS Mapping file to search for NTAs
• Mostly diagnosis driven
• Query physician for clarification
• Research Article: Prevalence of Diabetic Retinopathy
• Click here to review
NON-THERAPY ANCILLARY (NTA)
Commonly missed NTA’s
• Morbid obesity
• Risk for malnutrition
• T84.84xa- pain r/t internal device
• Updates to mapping file allow “d”‐ subsequent encounter codes
• Respiratory failure (It’s possible to code 3 times in section I)
• J99- Respiratory conditions and diseases classified elsewhere -> NTA point for pulmonary fibrosis and other chronic lung conditions
• Infections- MRSA, ESBL-> multidrug resistant organism (I1700)
ICD 10 Code Description
E66.01 Morbid (severe) obesity due to excess calories
E662 Morbid (severe) obesity withalveolar hypoventilation
Z6841 Body mass index (BMI) 40.0‐44.9, adult
Z6842 Body mass index (BMI) 45.0‐49.9, adult
Z6843 Body mass index (BMI) 50‐59.9 , adult
Z6844 Body mass index (BMI) 60.0‐69.9, adult
Z6845 Body mass index (BMI) 70 or greater, adult
10/15/2020
11
3-DAY HUDDLE MEETING
• Skilled Residents
• Completed day 2-3 after admission (day 1 too soon)
• Predicting PDPM HIPPS Score based on info collected
• Information gathering for MDS process
• Opportunity- complete additional interviews, talk with physician for clarification on diagnoses, start triple check process
• Most important meeting you can have for skilled residents
As a result of this meeting:
• Additional measures put in place to collect data (ex: SOB while lying flat)
• Additional interviews conducted
• Additional clarification from hospital records and physician
• Discussion with resident/family (ex: diabetic retinopathy)
MDS ACCURACY CONSIDERATIONS
• Who completes each section of the MDS? • Dietary- Section K
• Are they in all of your meetings where you discuss residents before ARD?
• Do they know when a patient exhibited sign/sx of swallowing in Nurses notes?
• Do they know they can code IV fluids for hydration from hospital stay?
• Do you as the MDS nurse verify accuracy?
• Do you compare your actual CMGs with what you predicted?
• No longer can you wait until after the ARD to gather information
• Preventative “documentation compliance” is key
10/15/2020
12
To IPA or not to IPA - that is the question
• Must have PDPM calculator
• If reimbursement increases = complete IPA
• If reimbursement decreases = don’t complete IPA
INTERIM PAYMENT ASSESSMENT
PDPM CODING SCENARIOS
10/15/2020
13
Tips
• Set ground rules as an IDT
• Get IDT buy-in
• Keeping administrator updated if problems
• Keeping line of communication up to date• MDS Schedule updates
HOLDING IDT ACCOUNTABLE
TRIPLE CHECK
Purpose
All facilities are responsible for submitting complete and accurate claims in accordance with applicable Medicare requirements. The purpose of holding a triple check meeting is to ensure that Medicare is billed accurately and in a timely manner. The process requires claims to be reviewed for accuracy by the clinical team, therapy and the business office prior to transmission.
Procedure and Process
The facility is responsible for implementing an effective monthly triple-check process to verify claims are accurate to submission to the FI. The facility will verify each Medicare (Part A and B) claim prior to submission.
Recommended Individuals to AttendAdministratorDONMDS CoordinatorTherapy Program ManagerBusiness Office ManagerMedical Records
AdministratorResponsible for ensuring that the meeting takes place monthly and that everyone required to attend is present, on time and prepared.
10/15/2020
14
TRIPLE CHECK FORM
AUDIT & APPEALS
CMS definition of Medical Review
Collection of information and clinical review of medical records by Medicare Contractors to ensure that payment is made only for services that meet all Medicare coverage, coding, and medical necessity requirements.
Goal of Medical Review
To determine whether the services are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation.
Focus
Medicare contractors focus on the unique, individualized needs, characteristics and goals of each patient, in conjunction with CMS payment policies, to determine the appropriateness of the case-mix classifier billed.
10/15/2020
15
MEDICAL REVIEW FOCUS
Under RUG:
-Validating medical necessity of SNF Skilled Level of care
-Validating level of therapy intensity provided (volume of therapy)
-Validating section G ADL coding (rule of 3)
Under PDPM:
- Validating patient characteristics and clinical service needso Coding compliance based on RAI guidelines for each item impacting reimbursement
o Maintain charting that validates each payment‐impacting MDS item.
- Validating medical necessity of SNF Skilled Level of Care (unchanged)
SNF SKILLED LEVEL OF CARE (unchanged)
Interdisciplinary documentation to support these 4 criteria is as important as ever with the SHIFT toward patient-specific characteristics and clinical needs.
SNF level of care is covered if ALL of the following four factors are met:
1. The patient requires skilled nursing services or skilled rehabilitation services;
2. The patient requires these skilled services on a daily basis; and
3. As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in the SNF.
4. The services delivered are reasonable and necessary for the treatment of a patient’s illness or injury.
Chapter 8, Section 30 of the Medicare Benefit Policy Manual (Pub. 100–02), to be covered, the services provided to a SNF resident must be ‘‘reasonable and necessary for the treatment of a patient’s illness or injury, that is, are consistent with the nature and severity of the individual’s illness or injury, the individual’s particular medical needs, and accepted standards of medical practice.’’
10/15/2020
16
PREPARING FOR PDPM AUDITS
Activity Indicators• Provider behavior• Patterns of therapy provision• Outcomes
CMS clearly specifies intent to examine
Medicare Contractors:MAC – Medicare Administrative ContractorRAC – Recovery Audit ContractorCERT – Comprehensive Error Rate TestingUPIC – Unified Program Integrity ContractorOIG – Office of Inspector General
ADDITIONAL DOCUMENTATION REQUEST (ADR)
• Time sensitive: if provider fails to respond to a Medicare contractor’s ADR within the prescribed time frame, the Medicare contractor shall deny the claim, in full or in part, as not reasonable and necessary.
• Within 45 calendar days for MACs, RACs and CERTs after the date of the request (or within a reasonable time following an extension)
• 30 calendar days for UPICs after the date of the request (or within a reasonable time following an extension)
• Send complete records to support a claim: If the provider furnishes documentation that is incomplete/insufficient to support medical necessity, the claim will be adjusted.
GOAL:
No findings at initial review prevent denials/appeals process
10/15/2020
17
TARGETED PROBE EDUCATION (TPE)
TARGETED PROBE EDUCATE (TPE)
10/15/2020
18
To support look back period:
• hospital discharge summaries and transfer forms;
• physician orders and progress notes;
• patient care plans;
• nursing and rehabilitation therapy notes;
• treatment and flow charts and vital sign records, weight charts and medication records.
To support medical necessity:
• physician orders for care and treatments,
• medical diagnoses and rehabilitation diagnosis (as appropriate),
• past medical history,
• progress notes that describe the beneficiary’s response to treatments and his/her physical/mental status,
• lab and other test results,
• other documentation supporting the beneficiary’s need for the skilled services being provided in the SNF.
SUPPORTIVE CLINICAL DOCUMENTATION
COMMON DENIAL REASONS
#1 - Insufficient Documentation: element required as a condition of payment is missing
• Certification/Recertification statement was missing or insufficient
• Signature of the certifying physician was not included
• Physician Signature requirement not met – not dated
• Physician Signature requirement not met – untimely
Other reasons for denied claims:
• No documentation received
• Medical necessity not supported
• Incorrect coding
10/15/2020
19
PROVIDERS NEED TO MONITOR TRENDS
Audit coding – identify supportive documentation for all MDS items that impact reimbursement
Monitor coding trends and assess changes that indicate a shift in coding of services from pre-PDPM to post-PDPM (such as, a distinct increase in coding modified diets)
Update approach and systems to meet PDPM requirements GG impacts 3 of the 5 components of the PDPM rate. GG requires combined assessment of multiple disciplines between days 1-3 to
determine usual performance of function; cannot just rely on nursing or therapy alone.
MDS coding must correspond to what’s charted in the medical record. Focus on accurate MDS coding and supportive documentation. Analyze your decision making practices so they relate to optimal patient care and
outcomes.
SUPPORTIVE DOCUMENTATION
Documentation must clearly support HIPPS codes billed.
Emphasize clinical decision-making process for establishing documented therapy plan (including modes of therapy).
Monitor resident outcomes and make adjustments as needed to meet individual resident needs.
Nursing care plans need to be effectively documented, treatments and services must support active coded conditions
Nursing documentation must support skilled daily services are provided.
GG Function Score: the process for determining ‘usual performance’ must be collaborative. Documentation must clearly support MDS coding from a therapy and nursing perspective. GG impacts 5‐Star rating, QMs and SNF QRP – not only PDPM payment rates.
Documentation must support coding in K0100A-K0100D and K0500C (Swallowing and Mechanically Altered Diets). ST involvement must support utilization of higher SLP CMGs.
10/15/2020
20
ACCURACY – THOROUGHNESS – PREPARATION
Accuracy of coding, documentation and monitoring is vital in preparation for PDPM medical review audits.
Provider data will trigger audits and anything that drives payment or supports skilled services coded on the MDS will potentially be reviewed.
Inadequate documentation will result in denied claims.
MEDICAL REVIEW RESOURCES
Skilled Nursing Facilities in Publication 100-08 Medicare Program Integrity, Transmittal 924 https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R924PI.pdf
Medicare Benefit Policy Manual Ch. 8
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c08.pdf
10/15/2020
21
Thank You!
JENNIFER NAPIERBSN, RN, RAC-CT, RAC-CTA, QCPDirector of Clinical Reimbursement
jennifern@conceptrehab.com
JULIE MOOREOTR/L, CMC, CMCOCompliance Officer
juliem@conceptrehab.com
www.conceptrehab.com
ObtainedSignificance: Obtaining diagnoses, medical history, surgical history, vaccination history, and care planning
Significance: Obtaining diagnoses, medical history, infection control planning, wound etiology, discharge planning, and care planning
Significance: Obtaining diagnoses and care planning
Significance: Discharge planning and care planningPhysical Therapy records
Occupational Therapy recordsSpeech Language Pathology records
Significance: Necessary look-back for IV fluids/nutrition provided in hospital, medication reconciliation, obtaining diagnoses, obtaining needed equipment and supplies, and care planning
All lab reports
Scheduled and PRN medication recordsRespiratory recordsTransfusion records
IV Medication/fluids/TPN/Tube feeding records
Consultation reports and progress from specialists
Physician progress notesNurses notes
www.conceptrehab.comCopyright © 2019 Concept Rehab, Inc. All rights reserved.
Hospital Admission Date
PATIENT NAME
Primary Reason for SNF Stay
Payor Type
Therapy Records
Medication Records
Consultation and Progress Reports
Laboratory Reports
Radiology Reports (including MRI/PET/CAT/Nuclear/Pathology)
Social service notes
Infectious disease reports
Wound care notes
Follow-Up Comments
Surgical reports and consults from current stay and last 100 days
Surgical RecordsSignificance: Determining primary clinical category
SNF PRE-ADMISSION CHECKLISTPURPOSE
History and Physical - emergency roomHistory and Physical - hospital admission
Discharge summaryComprehensive diagnosis listing, surgical and immunization history
Physician orders for SNF care
HOSPITAL RECORDS
Under PDPM, it is becoming increasingly significant to ensure you have accurate, complete and comprehensive medical records prior to and at the time of admission from an acute care entity. The below list helps ensure the right records are gathered to ensure a more seamless transition of care and to be able to have all information needed for PDPM.
Estimated SNF Admission Date
Reports
Admit Date ARD
5 Day IPA
descriptor Clinical Category Mapping
Section GGSelf Care
Mobility
Eating
Oral Hygiene
Toilet Hygiene
Sit to lying
Lying-sit side of bed
Sit to stand
Chair/Bed-chair txfr
Toilet txfr
Walk 50' 2 turns
Walk 150'
GG Score PT/OT Nursing
Totals
avg
avg
avg
PDPM fx score
Scoring Response for Section GG PDPM fx score
01,07,09,88
05,06
04
03
02
Set-up, Independent
Supervision/Touch Assist
Partial/Moderate Assist
Substantial/Max Assist
Dep, Ref, N/A, Not Attempt
4
3
2
1
0
None, any one, any two, or all three
Acute Neuro Condition
SLP Related Comorbidity
Cognitive Impairment
Yes NoNeither, either, or both
Swallowing Disorder
Mechanically Altered Diet
Yes No
Extensive Services Infection isolationTrach and Vent Trach or Vent
Depressed Not Depressed
Depressed Not Depressed
Depressed Not Depressed
Restorative Nursing 2+ Restorative Nursing 0-1
Restorative Nursing 2+ Restorative Nursing 0-1
Special Care High
Special Care Low
Clinically Complex
Behavior/Cognition
Reduced Phys Function
PDPM CLASSIFICATION CHECKLIST
Patient Name
Primary Medical ICDcode
PT/OT Clinical Category(check applicable category)
Maj Joint Replacement or Spinal Surgery
Other Orthopedic
Medical Management
Non-Ortho Surgery and Acute Neuro
Speech Component(check yes or no as applicable)
Nursing Category Non-Therapy AncillaryCondition/Extensive Service Points
Total NTA Points:
(check category and category descriptor)
Projected PDPM Case-Mix GroupPT OT ST Nursing NTA
Actual PDPM Case-Mix Group
HIPPS Code
Date Verified PT OT ST Nursing NTA
MDS
Med Records/Coder
Therapy Manager
Adminstrator
Signatures
Powering Potentialbeyond the walls of therapy.Copyright © 2020 Concept Rehab, Inc. All rights reserved.
www.conceptrehab.com
Powering Potentialbeyond the walls of therapy.
www.conceptrehab.comCopyright © 2019 Concept Rehab, Inc. All rights reserved.
TRIPLE CHECK VALIDATION FORMMedicare A PDPM
PURPOSEAll facilities are responsible for submitting complete and accurate claims in accordance with applicable Medicarerequirements. The purpose of holding a triple check meeting is to ensure that Medicare is billed accurately and in a timelymanner. The process requires claims to be reviewed for accuracy by the clinical team, therapy, and the business office prior totransmission. PROCEDURE AND PROCESSThe facility is responsible for implementing an effective monthly triple-check process to verify claims are accurate prior tosubmission to the FI. The facility will verify each Medicare (Part A and B) claim prior to submission. RECOMMENDED INDIVIDUALS TO ATTEND
AdministratorDONMDS CoordinatorTherapy Program ManagerBusiness Office ManagerMedical Records
ADMINISTRATORResponsible for ensuring that the meeting takes place monthy and that everyonerequired to attend is present, on time and prepared. TRIPLE-CHECK FORMThe following checklist identifies the areas that need to be verified as accurate on the UB-04 prior to claim submission. Claimshould not be submitted until all areas have been verified and signed off as complete and accurate.
TRIPLE CHECK VALIDATION FORMMedicare A PDPM
PATIENT NAME Month/Year
Dates of Service
Beneficiary Name, Medicare #, DOB, eligibility and days remaining verified per CWF 8, 10, 60 BOM to validate, CWF
Admission date is correct 12 Nursing notes, MDS
Statement form and through date correct 6 Medical record
Type of bill and patient code status correct 4, 17 BOM to confirm
Qualifying hospital stay correct 35 Hospital/medical record
ARD within assessment scheduled window and indicated on UB04 with appropriatereason for assessment 31-34, 44 MDS, Therapy
Correct CMG and HIPPS Code on Claim assessment 44 MDS, Medical record, Therapy
If applicable, IPA assessments present in MDS and on claim with correct ARD(s) andHIPPS 44 MDS, Medical record, Therapy
Ancillary charges included (pharmacy, laboratory, DME, therapy, radiology) 42-47 Invoice and medical record
Therapy number of days match therapy records 46 Therapy logs
Diagnosis - principal, admission, sequencing all correct. Therapy diagnoses areincluded for each discipline 66-69 MDS, Therapy log, Medical record
Attending Physician and NPI correct 76 Medical record
Physician certification is complete, signed and dated timely — Medical record
Physician order to admit to skilled signed/dated — Medical record
Therapy orders and certifications are signed/dated timely — Medical record
Physician orders present and signed to support skilled services — Medical record
Documentation present to support skilled services — Medical record
Verify all MDS assessments listed have been transmitted and accepted — Validation report
ITEM/AREA REVIEWED UB04 FIELD LOCATOR SOURCE RECORD
Powering Potentialbeyond the walls of therapy.
www.conceptrehab.comCopyright © 2019 Concept Rehab, Inc. All rights reserved.
KEY
√ or XItem Complete
Blank Item not Complete
N/ANot Applicable
DATE APPROVEDFOR BILLING
SIGNATURE OF ATTENDEES:
Business Office
MDS
Therapy
Additional
STATUS