Coding the MDS for PDPM · 3/9/2020 1 Coding the MDS for PDPM Success 2 Parts to Master 1.PDPM...
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3/9/2020 1 Coding the MDS for PDPM Success 2 Parts to Master 1. PDPM Structure 2. MDS Coding (with supportive documentation) A Quick Look at PDPM • Patient Driven Payment Model • Differentiates each patient in terms of their unique characteristic, comorbidities, and care needs. • All the components utilized for PDPM reimbursement come from a single MDS assessment LC1 1 2 3
Transcript of Coding the MDS for PDPM · 3/9/2020 1 Coding the MDS for PDPM Success 2 Parts to Master 1.PDPM...
3/9/2020
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Coding the MDS for PDPM Success
2 Parts to Master
1. PDPM Structure
2.MDS Coding (with supportive documentation)
A Quick Look at PDPM
• Patient Driven Payment Model
• Differentiates each patient in terms of their unique characteristic, comorbidities, and care needs.
• All the components utilized for PDPM reimbursement come from a single MDS assessment
LC1
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LC1 edicaLoni Collard, 2/22/2020
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Types of Resident information used in PDPM
Diagnoses The primary reason for admission to the SNF
Other diagnoses that represent comorbidities such as:
Diabetes COPDMDRO
Liver Cirrhosis Epilepsy Inflammatory Bowel Disease
Swallowing disorder
Cognitive Impairment
Wounds
Foot and Wound infections
Feeding Tube
Malnutrition
Morbid Obesity
Functional Abilities
Behavioral Symptoms
Shortness of breath when lying flat
Fever
Vomiting
Weight Loss
Burns
Resident Characteristics
For instance:
IV/SubQ fluids
IV medications
Isolation
Oxygen therapy
Tracheostomy Care
Wound dressing changes
TPN
Restorative Nursing
Dialysis
Transfusion
Chemotherapy
Radiation
Intermittent catheterization
Respiratory Therapy
Isolation
Care and Services Provided
For instance:
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A Quick Look at the MDS
• Stands for Minimum Data Set.
• A uniform instrument used in nursing homes.
• The MDS manifest function is foremost to assess resident condition and needs in order to improve quality of care.
• Serves the purposes of:• Collecting data to drive care plans
• Statistically describing the resident population
• Generating indicators of quality
• Acting as a data source for payment systems
• Currently there are over 1000 data elements collected on the MDS.
The RAI Manual
• The MDS “Bible”
• Created and published by CMS
• Revised at least 1 time a year
• The state purpose is to “offer clear guidance about how to use the Resident Assessment Instrument (RAI) correctly and effectively to help provide appropriate care”
• Chapter 3 contains item‐by‐item coding instructions
• Chapter 6
PDPM Structure and the MDS Coding
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Physical Therapy
Occupational Therapy
Speech‐Language Pathology (SLP)
Nursing
Non‐therapy Ancillary (NTA)
The 5 Case‐Mix Adjusted Components
Payment Components: PT and OT
Average Bed Mobility Score (2 tasks)
Average Transfer Score (3 tasks) Average Walking Score (2 tasks)
Eating Score
Oral Hygiene Score
Toileting Hygiene Score
– PT/OT Clinical Categories (determined from
Primary Diagnosis)
Major Joint Replacement or Spinal Surgery
Other Orthopedic
Non‐Orthopedic Surgery and Acute Neurologic
Medical Management
– PT/OT Function Score
Payment Component: SLP
5 Classification Components
Acute Neurologic clinical classification
Determined by the Primary Diagnosis
If the primary diagnosis maps to an Acute Neurologic clinical category, it qualifies for this component
Presence of cognitive impairment
Determined by a resident interview (the BIMS)
Mild to severe impairment qualifies
Certain SLP‐related comorbidities
Determined by specific diagnosis codes
For example: Oral cancers, dysphagia, speech deficits
Use of a Mechanically Altered Diet
Provided per physician order
Presence of a Swallowing Disorder
Determined by interview and assessment
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A combination of Classification Groups + Function Score + End‐split
The Nursing Classification Groups Extensive Services Special Care High Special Care Low
The Function Score is calculated using 7 self‐care and mobility Tasks
The End‐Splits Depression End‐Split Restorative End‐Split
Payment Component : Nursing
• Clinically Complex• Behavior Symptoms & Cognitive Performance• Reduced Physical Function
Nursing Classification Groups
Nursing Classification Groups
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Nursing Classification Groups
These include 34 diagnoses categories
The other 16 condition/services include things like; IV medications, Bladder/Bowel ostomy, Parenteral IV feeding, and Suctioning
50 Conditions and Services
Payment Component : NTA (Non‐Therapy Ancillary)
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MDS Coding
PDPM CMG
RAI Guidance
Look Back
ARD
Chapter 6
Chapter 3
What Really Makes PDPM Tick?
•Timing• Timing of ARD• Timing of hospital documentation• Timing of physician’s orders• Timing of care implementation• Timing of interviews
This Photo by Unknown Author is licensed under CC BY‐SA
Timing of ARD• Assessment Reference Date (ARD): Day 1‐8 of the SNF stay
• One assessment determines the daily rate for the entire stay
• Look‐back time‐frame for capturing information• 7 days (ARD minus 6 days) for most items• Some items have a longer look‐back• Certain items can be captured from the hospital stay
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Timing of hospital documentation
• Obtaining documentation at the time of, or prior, to admission
• Are there barriers?
Timing of physician’s orders
• All clarifications of diagnoses must be done prior to the ARD
Timing of care implementation
• Tests that lead to treatment or diagnosis
• Interventions to address conditions
• If a service is needed and implemented after the ARD, an IPA may not save you
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Timing of interviews
• If you want to maintain flexibility with the ARD, remember that the interview dates can bind you….
Hospitalization Captures
• IV Fluids• MDROs
• Infection diagnoses• Pneumonia
• Sepsis
• Acute episodes• Respiratory arrest/failure
• Pulmonary edema
Physician Support
• Timely response
• Understanding that ICD‐10 codes are highly specific
• Sometimes assessment leads to a probable diagnosis
• Proactive interventions
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A Patient Scenario
Patient Scenario
Mrs. Smith was admitted to the hospital for a severe pneumonia. She experienced respiratory failure and was placed on a ventilator for three days.
Once the acute stage of the infection had passed and the vent removed, she was ready for transfer to the SNF where she is expected to rehabilitate and return to her assisted living facility.
Mrs. Smith’s hospital H&P indicates elevated liver function values and the physician has noted this is as chronic liver disease.
It’s also noted that she is diabetic and has some diabetic‐related vision loss, and diabetic neuropathy.
Her H&P is additionally positive for a history of alcohol abuse, cerebral vascular disease, A‐fib, PAD, and COPD.
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During the initial SNF assessment, Mrs. Smith reports that she has lost around 15 pounds in the past 4 or 5 months, and it’s noted on admission to the SNF that her weight it 132 pounds.
When asked how her appetite is, she says that it’s “not what it used to be” over the last few years, but also her throat is sore and irritated, and she is having trouble swallowing meat and bread. She notices that she is coughing when she drinks liquids and is avoiding them because of the swallowing issue.
She has a confirmed diagnosis of COPD, and a prn O2 order is in place. Mrs. Smith reports that she has been on oxygen for the past 2 years, but only uses it at night.
She is also exhibiting some memory deficits and word‐finding problems.
Upon inspecting her skin, it’s found that she has 2 small open areas on underside of the tips of her middle two left toes.
It’s noted that the wound base is pinkish and there is a little bit of sanguineous drainage on the bed sheet.
There is also a colloid dressing on Mrs. Smith’s sacral area, dated for 4 days ago. Under the dressing a 3.4 cm circumference open area is found that is likely pressure‐related.
The edges are red and slightly edematous, and the wound bed is covered in slough.
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Face Value PDPM Picture
• Primary DX Pneumonia
• MDS PDPM captures = COPD, Diabetes, O2, swallowing disorder, arterial ulcers , impaired cognition
Assessment Item/Action PDPM Impact Financial
Physical Therapy Component Medical Management $86.27
Occupational Therapy Component Medical Management $82.00
SLP Component CMG SE $53.07
Nursing Component Special Care Low $183.24
NTA Component CMG ND $106.28
BASE RATE Urban $94.84
$605.70
Interdisciplinary Review
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Respiratory Failure
• Capture the appropriate ICD‐10 code• Set the assessment reference date to capture in the last 7‐days
• Impacts NTA points
Elevated Liver Functions/Chronic Liver Disease, Hx alcohol abuse
• Clarify whether liver disease is Cirrhosis or End Stage Liver Disease• Assign appropriate ICD‐10 code as needed
• Impacts NTA points
Diabetic with related vision loss
• Clarify whether vision loss is Diabetic Retinopathy• Assign appropriate Diabetes with complication ICD‐10 code as needed
• Impacts NTA points
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COPD – O2 use only at night
• Assign appropriate ICD‐10 code for COPD• Why O2 only at night? Is it due to shortness of breath when lying flat?
• Clarify O2 order to include “PRN for shortness of breath when lying flat”
• Impacts Nursing classification group
Weight loss, decreased appetite
• Complete nutritional assessment to determine malnutrition, or risk for malnutrition
• Query the MD for an appropriate malnutrition diagnosis code
• Impacts NTA points
Trouble swallowing, not drinking, CVD, memory issues
• Assess possible underlying causes• Document swallowing problems
• Assign ICD‐10 code for Dysphagia related to Cerebral Vascular disease as needed
• Order for mechanically altered diet and thickened liquids
• Impacts SLP component
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Wounds
• Differentiate Diabetic foot ulcer from arterial ulcer
• Wound debridement for accurate staging of sacral wound
• Document signs and symptoms of infection and assign ICD‐10 code for sacral wound
• Wound culture of sacral wound to determine MDRO organism
• Impacts NTA points and Nursing Classification group
Assessment Item/Action PDPM Impact Financial
Physical Therapy Component Medical Management $86.27
Occupational Therapy Component Medical Management $82.00
SLP Component CMG SE $53.07
Nursing Component Special Care Low $183.24
NTA Component CMG ND $106.28
BASE RATE Urban $94.84
$605.70
Assessment Item/Action PDPM Impact Financial
Physical Therapy Component Medical Management $86.27
Occupational Therapy Component Medical Management $82.00
SLP Component CMG SI $80.06
Nursing Component Special Care High $210.78
NTA Component CMG NC $147.09
BASE RATE Urban $94.84
$701.04+ 95.34/day
+40.81/day
+ 27.54/day
+ 26.99/day
In Conclusion…
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