Countdown to PDPM · 2019. 9. 16. · Countdown to PDPM Objectives •Describe the components of...

PDPM 2019

2019 Rehab Resources & Consulting, Inc. Do not copy or reproduce without written permission 1

PDPM: The Final Countdown

Ellen R. Strunk, PT, MS, GCS, CEEAA, CHC

Rehab Resources & Consulting, Inc.

www.RehabResourcesAndConsulting.com

1

Countdown to PDPM

Objectives

• Describe the components of the newly proposed Patient‐Driven Payment Model (PDPM).

• Understand the impact of self‐care, mobility, cognition, and swallowing in a value‐based world.

• Develop action steps to prepare for the implementation of a change in payment to insure quality of care is not sacrificed.

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How?

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Law Data

10/1/19 Therapy

What is Daily Skilled Need?

• Skilled nursing services or skilled rehabilitation services (or a combination of these services) must be needed and provided on a “daily basis,” i.e., on essentially a 7‐days‐aweek basis.

• A patient whose inpatient stay is based solely on the need for skilled rehabilitation services would meet the “daily basis” requirement when they need and receive those services on at least 5 days a week. – < 5 days a week? “Daily” requirement would not be met

– “…arbitrarily staggering the timing of various therapy modalities through the week, merely in order to have some type of therapy session occur each day, would not satisfy the SNF coverage requirement for skilled care to be needed on a “daily basis.””

5MBPM 100‐2; Chap 8; 30.6

What is Daily Skilled Need?

• As a “practical matter”, can the daily skilled services only be provided in the SNF?

• A reviewer would consider:– The individual’s physical condition – The availability and feasibility of using more economical alternative facilities or services. e.g. are they not available on an outpatient basis where the individual resides? OR is transportation to the closest facility: • An excessive physical hardship; • Less economical; or • Less efficient or effective than an inpatient institutional setting

– What is the availability of capable and willing family – What is the feasibility of obtaining other assistance for the patient at home?

6MBPM 100‐2; Chap 8; 30.6

PDPM 2019


Illustration of Payment Under PDPM

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What is Changing?What is Not Changing?

IS

Volume is out

Patient characteristics

are in

IS NOT

3‐night hospital stay

Daily skilled need

Physician Certification

8

Six Components of PDPM

PT OT ST SN NTANon‐

Therapy Case Mix

Federal Base Rate

Case‐Mix Adjusted

Special Adjustors

Variable Per Diem

Adjustment9

1. PT Case Mix2. OT Case Mix

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16 payment groups

PT and OT: Primary Reason for SNF Stay AVOID: Return to Provider

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F01.51 Vascular dementia with behavioral disturbance

F02.89 Dementia in other diseases classified elsewhere without behavioral disturbances.

I82.439 Acute embolism and thrombosis of unspecified popliteal vein

J69.8 Pneumonitis due to inhalation of other solids and liquids

J91.8 Pleural effusion in other conditions classified elsewhere

L89.324 Pressure ulcer of left buttock, stage 4

L89.510 Pressure ulcer of right ankle, unstageable

M62.81 Muscle weakness (generalized)

S70.02Xd Contusion of unspecified thigh, subsequent encounter

S72.009P Fracture of unspecified part of neck of unspecified femur, subsequent encounter for open fracture

PDPM 2019


PDPM Success with I0020B

Clinical Assessment Expertise

ICD‐10 Expertise

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1. PT Case Mix2. OT Case Mix

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16 payment groups

PDPM Changes Functional Scoring

x

x

15

RUG‐IV

PDPM

• Section G• 4 items• 7 day lookback• Most support at least 3 times• Higher Score = Less

Independent

• Section GG• 7 Nursing and 11 PT/OT items• Days 1‐3 before intervention• Usual performance• Higher Score = More Independent

Section GG: Rating Scale

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Code Score Description

6 Independent: If the resident completes the activity by him/herself with no assistance from a helper.

5Set‐Up or Clean‐Up Assistance: If the helper SETS UP or CLEANS UP; resident completes activity. Helper assists only prior to or following the activity, but not during the activity.

4Supervision or Touching Assistance: If the helper provides VERBAL CUES or TOUCHING/STEADYING assistance and/or CGA as resident completes activity. Assistance may be provided throughout the activity or intermittently.

3Partial / Moderate Assistance: If the helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.

2 Substantial / Maximal Assistance: If the helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.

1Dependent: If the helper does ALL of the effort. Resident does none of the effort to complete the activity, OR the assistance of two or more helpers is required for the resident to complete the activity.

Section GG: Rating Scale (If activity was not attempted, code the reason)

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Code Score Description

7 Resident refused: If the resident refused to complete the activity.

9 Not applicable: Not attempted and resident did not perform this activity prior to the current illness, exacerbation or injury.

10Not attempted due to environmental limitations: The item was unable to be

assessed due to outside influences, such as lack of equipment or weather constraints.

88 Not attempted due to medical condition or safety concerns: If the activity was not attempted due to medical condition or safety concerns.

PDPM Functional Scoring

Level of Assistance Score on MDS “Point Value” under PDPM

Independent 06 4

Set Up or Clean Up Assistance 05 4

Supervision or Touching Assistance 04 3

Partial / Moderate Assistance 03 2

Substantial / Maximal Assistance 02 1

Dependent 01 0

Resident Refused 07 0

Not applicable 09 0

Not attempted due to environmental limitations

10 0

Not attempted due to medical condition or safety concerns

88 0

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PDPM 2019


Who does this?

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“CMS anticipates that an interdisciplinary team of qualified clinicians is involved…”

Section GG: Definitions

• CMS considers Section GG to be an “Assessment” of the patient’s functional status. Therefore:– “Refer to facility, Federal, and State policies

and procedures to determine which staff members may complete an assessment.”

– “Facility staff who are direct employees and facility contracted employees”

• Does not include individuals hired (compensated or not) by persons outside of facility management and administration– Hospice, students, volunteers

20RAI manual v1.17, 3, GG‐10

Section GG: Steps for Assessment

1. Assess resident’s status based on– Direct observation, incorporating resident self‐reports and reports from qualified clinicians, care staff, or family documented in the resident’s medical record during the 3‐day period.

2. Residents should be allowed to perform activities as independently as possible, as long as they are safe.

3. If helper assistance is required because performance is unsafe or of poor quality, consider only facility staff when scoring amount provided

4. Activities may be completed with or without AD21

RAI manual v1.17, 3, GG‐10

Section GG: Steps for Assessment

5. 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.”


Section GG Admission: Steps for Assessment

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• “The admission function assessment, when possible, should be conducted prior to the resident benefitting from treatment interventions in order to reflect the resident’s true admission baseline functional status.

• If treatment has started, for example, on the day of admission, a baseline functional status assessment can still be conducted.

RAI manual v1.17, 3, GG‐10

RAI GG instructions

321

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PDPM 2019


PT and OT: Functional StatusItems Specific Section GG Score SN PT/OT

2 Bed Mobility items

GG0170B1: Sit to LyingGG0170C1: Lying to sitting on side of bed

0 to 4(Avg of 2) Y Y

3 Transfer items

GG9170D1: Sit to standGG0170E1: Chair/bed‐to‐chair transferGG0170F1: Toilet transfer

0 to 4(Avg of 3) Y Y

1 Eating item GG0130A1: Eating 0 to 4 Y Y

1 Toileting item

GG0130C1: Toileting Hygiene 0 to 4 Y Y

1 Oral Hygiene item

GG0130B1: Oral Hygiene 0 to 4 N Y

Gateway: GG0170H: Walk 10 feet NA NA NA

2 Walking items

GG0170J1: Walk 50 feet with 2 turnsGG0170K1: Walk 150 feet

0 to 4(Avg of 2) N Y

TOTAL POSSIBLE SCORE 16 2425

FINAL: 16 PT and OT categories

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Table 6: SNF 2020 PRClinical Category

Section GG Function Score

PT OT Case Mix Group

PT Case‐Mix Index

OT Case‐Mix Index

Major Joint Replacement or Spinal Surgery

0‐5 TA 1.53 1.49

6‐9 TB 1.70 1.63

10‐23 TC 1.88 1.69

24 TD 1.92 1.53

Other Orthopedic

0‐5 TE 1.42 1.41

6‐9 TF 1.61 1.60

10‐23 TG 1.67 1.64

24 TH 1.16 1.15

Medical Management

0‐5 TI 1.13 1.18

6‐9 TJ 1.42 1.45

10‐23 TK 1.52 1.54

24 TL 1.09 1.11

Non‐Orthopedic Surgery and Acute Neurological

0‐5 TM 1.27 1.30

6‐9 TN 1.48 1.50

10‐23 TO 1.55 1.55

24 TP 1.08 1.09CMI taken from SNF FR FY 2020

3. SLP Case Mix

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12 payment groups

FINAL: 12 SLP Categories

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Presence of Acute Neurologic Condition, SLP‐Related Comorbidity,

or Cognitive Impairment

Mechanically Altered Diet or Swallowing

Disorder

SLP Case‐Mix

Group

SLP Case‐Mix Index

None Neither SA 0.68

None Either SB 1.82

None Both SC 2.67

Any one Neither SD 1.46

Any one Either SE 2.34

Any one Both SF 2.98

Any two Neither SG 2.04

Any two Either SH 2.86

Any two Both SI 3.53

Any three Neither SJ 2.99

Any three Either SK 3.70

Any three Both SL 4.21

CMI taken from SNF PR FY 2020CMI taken from SNF FR FY 2020

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• Tracheostomy Care

• Invasive Mechanical Ventilator

• Isolation or QuarantineExtensive Services

• Comatose

• Septicemia

• Diabetes with daily injections and 2+ MD orders

• Quadriplegia; COPD+SOB when flat; Fever with...

• Parenteral/IV feeding

Special Care High

• CP, MS, Parkinson’s + Low functional score

• Respiratory failure + O2

• Pressure Injury, other wound care

• Radiation or Dialysis

Special Care Low

• Pneumonia

• Hemiplegia/hemiparesis + Low functional score

• Burns, Surgical wounds, Other open wounds

• Chemotherapy, O2, IV, Transfusions

Clinically Complex

• BIMS < 9 or staff assessment shows severe impairment

• Restorative count

Behavioral Sx & Cognitive

Performance

• Toileting program

• Restorative Nursing

Reduced Physical Function

GG

FUNCT I ONAL

L EVE L

Nursing Case Mix under PDPMNon Therapy Ancillary (NTA)

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M.D.S.

• Diagnoses• Appliances• Treatments• Conditions

50+*

* 1,540 ICD‐10 codes

PDPM 2019


What Did the Final Rule Say?

PT, OT

Group Therapy: 2‐6 persons doing same/similar

activity

PT, OT, SLP & NTA

ICD‐10 code changes

SubregulatoryOR

Rule‐Making

MDS Nomenclature

5‐day MDS is now known as

the Initial Medicare

Assessment

(IMA)

Rates

Unadjusted Federal Rates were revised from those posted in the Proposed Rule

Wage Indexes were revised from the

Proposed Rule

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What Did the Final Rule NOT Change?

PT, OT, ST

No change to how student services are recorded on the MDS.

Nursing

No changes

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To the PAC Provider

Process

Reconciled Med List

To the Patient

Process

Reconciled Med List

Final Rule: SNF QRP Measures for FY 2022

Tran

sfer of Health

Inform

ation

SNF VBP

• The SNF Potentially Preventable Readmission measure (SNF PPR)

To

• SNF Potentially Preventable Readmissions after Hospital Discharge

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SNF FY 2022 Performance Standards

Payment affects FY 2022

Performance Period FY 2020

Baseline Period FY 2018

10/1/17 ‐9/30/18

10/1/19 ‐9/30/20

10/1/21 ‐9/30/22

Achievement Threshold 0.79476 / 20.524%

Benchmark 0.83212/ 16.788%

WHAT MIGHT BE THE NEW DAY‐TO‐DAY REALITY?

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PDPM 2019


Illustration of Payment Under PDPM

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Key Compliance Areas

C BIMSK

DDepression I

GG FunctionO

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Active Dx

Swallowing

Special Services

Key Compliance Areas

39

Daily skill Section O

Uses of Quality Measures

Provide information on quality of care – To help choose a healthcare provider

– To inform those who already have a loved one receiving services from a healthcare provider

Facilitate communication between families/patients and the healthcare provider

Give data to the healthcare providers to help them with quality improvement activities

Quality Measures to W

atch

41 Quality Measures to W

atch

42

PDPM 2019


Goal of the IMPACT Act PPS and CB for SNF Final Rule

Final Specifications for

SNF QRP

• Measure description

• Purpose/Rationale

• Numerator / Denominator

• Exclusions

• Risk adjustors

• Time windows

• Calculation algorithm

Final Specifications for SNF QRP Measure IMPACT Domain Method SNF LTCH IRF HH

Functional Assmt & Care Plan

Functional Change

Assessment 10/1/16 10/1/16 10/1/16 1/1/19

Change in Self CareFunctional Change

Assessment 10/1/1810/1/16modi

10/1/16 ?

Change in MobilityFunctional Change

Assessment 10/1/1810/1/16modi

10/1/16 ?

Discharge in Self‐Care Score

Functional Change

Assessment 10/1/18 NA 10/1/16 ?

Discharge in Mobility Score

Functional Change

Assessment 10/1/18 NA 10/1/16 ?

Application of Measures in PAC

Support

• “SNF clinicians assess and document resident’s functional status at admission and discharge to evaluate the effectiveness of the rehabilitation care provided to individual residents and the SNF’s effectiveness.”

• “Examination of SNF data shows that SNF treatment practices directly influence resident outcomes.”

Federal Register/Vol. 82, No. 149; 8/4/2017; 36577

47

And….

• “Measuring residents’ functional improvement across all SNFs on an ongoing basis would permit identification of SNF characteristics, such as ownership types or locations, associated with better or worse resident risk‐adjusted outcomes and thus help SNF’s optimally target quality improvement efforts.”

• Supports communication in care transitions

• Helps consumers choose providers Federal Register/Vol. 82, No. 149; 8/4/2017; 36577

48

PDPM 2019


GG0130: Self‐CareSelf‐Care Comparison LTCH SNF IRF HH

Eating X X X X

Oral Hygiene X X X X

Toileting Hygiene X X X X

Wash Upper Body X

Shower / Bathe Self X X X

Upper body dressing X X X

Lower body dressing X X X

Putting on/taking off footwear X X X

GG0170: MobilityMobility Comparison LTCH SNF IRF HH

Roll left and right 2018 X 2019

Sit to lying X X X X

Lying to sitting on side of bed X X X 2019

Sit to stand X X X 2019

Chair/bed to chair transfer X X X 2019

Toilet transfer X X X 2019

Car transfer 2018 X 2019

Walk 10 feet X 2018 X 2019

Walk 50 feet with two turns X X X 2019

Walk 150 feet X X X 2019

Walk 10 feet on uneven surfaces 2018 X 2019

GG0170: Mobility (cont.)Mobility Comparison LTCH SNF IRF HH

1 step (curb) 2018 X 2019

4 steps 2018 X 2019

12 steps 2018 X 2019

Picking up object 2018 X 2019

Wheel 50’ with 2 turns X X X 2019

Type of WC X X X 2019

Wheel 150 feet X X X 2019

Type of WC X X X 2019

Self‐Care Functional Outcome Measures

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Mobility Functional Outcome Measures

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Exclusions

• Excluded residents are those with:– Incomplete stays– Independent with all self‐care or mobility activities at time of admission

– The following conditions: coma, persistent vegetative state, complete tetraplegia, locked‐in syndrome, severe anoxic brain damage, cerebral edema, compression of brain (as coded in B0100, or ICD‐10 codes)

– < 21 yo– Discharged to hospice– Not Med A beneficiaries– Do not receive PT or OT services

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PDPM 2019


UNDERSTANDING THE RISK ADJUSTORS

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Section GG

• GG0100 Prior Functioning: Everyday Activities

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• Bathing, dressing, using the toilet, eating

A. Self‐Care

•Walking from room to room

B. Indoor Mobility

• Internal

• ExternalC.

Stairs

• Planning regular tasks, shopping, remembering to take meds

D. Functional Cognition

Section GG: GG0100• “…prior to the current illness, exacerbation,

or injury.”• Only completed on Admission and PPS Discharge

– Interview patient or family– Review patient’s medical records– If no information is available after attempts are made, code 8. Unknown.

• Walker includes all types: Pickup walker; Hemi walker; Rolling walker; Platform walker; Four‐wheel walker; Rollator walker; Knee walker; Walkers for mobilizing while seated in walker

• Mechanical Lift includes: sit‐to‐stand, stand assist and full‐body style lifts

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Section I

• This item identifies the primary medical condition category that resulted in the resident’s admission to the facility and that influences the resident’s functional outcomes.

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J0200: Pain Assessment

• Attempt to conduct the interview with ALL residents• Completion is not contingent upon B0700, Makes Self Understood• If the resident interview should have been conducted, but was not

done within the look‐back period of the ARD, item J0200 should be coded 1, Yes, and a dash[‐] entered in J0300‐J0600– J0700, Should the Staff Assessment for Pain be Conducted is coded 0,

No, and J0800‐J0850 should not be completed– Exception‐1 When an interpreter is needed/requested and unavailable.

In this case, code J0200=0 and complete J0800, Staff Assessment of Pain– Exception‐2 Stand alone, unscheduled PPS assessments.

• Resident interview may be conducted up to 2 calendar days after the ARD; or• Previous interview responses may be used if obtained no >14 days prior to the

DATE of completion for the interview items

59RAI manual v1.16, 3, J‐5

J2000: Prior Surgery

• “Major surgery” is one that meets all 3 criteria:

– 1. Resident was an inpatient in an acute care hospital for at least 1 day in the 100 days prior to the admission to SNF; and

– 2. Resident had general anesthesia during the procedure, and

– 3. Surgery carried some degree of risk to the resident’s life or the potential for severe disability

60RAI manual v1.16, 3, J‐36

PDPM 2019


Change in Self Care: Risk Adjustors

Age Group;

Comorbidities using the HCCs

Admission SC function score

(continuous form; squared form)

Tube feeding or TPN

I0020: Primary medical condition

(neuro, SCI, progressive conditions,

amputation, ortho, medically complex)

Interactions between primary

medical condition category and SNF admission status

Prior surgery / Major surgery during the 100

days prior to the SNF

Prior Functioning –self-care; Indoor

ambulation

Presence of pressure ulcer at

admission (St 2); or severe PU/injury

at admit (St 3, 4, US)

Prior Device Use: Walker Use;

WC/Scooter use

Prior Device Use: Mechanical lift,

orthotics/prosthetics

Cognitive Abilities: BIMS; ability to

express ideas and wants;

understanding verbal and non-

verbal info

Urinary and Bowel continence

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Change in Mobility: Risk Adjustors

Age Group;

Comorbidities using the HCCs

Admission mobility score (continuous

form; squared form)Tube feeding or TPN

Primary medical condition (neuro, SCI,

progressive conditions,

amputation, ortho, medically complex)

Interactions between primary medical condition category and SNF admission

status

Prior surgery / Major surgery during the

100 days prior to the SNF

Prior Functioning; Indoor ambulation, stairs, functional

cognition

Presence of pressure ulcer at admission (St 2); or severe

PU/injury at admit (St 3, 4, US)

Prior Device Use: Walker Use;

WC/Scooter use, Mechanical lift, O/P

History of 1 or more falls in 6 months before admit

Cognitive Abilities: BIMS; ability to express ideas and

wants; understanding verbal and non‐verbal

info

Urinary and Bowel continence

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Change in SC/Mobility: Different Risk Adjustors

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Self Care Mobility

Major Infections: Septicemia, Sepsis, etc

Central Nervous System Infections; Other infectious diseases

Diabetes with/without complications Lymphomas and Other Cancers

Other significant endocrine and metabolic disorders

Other Major Cancers: colorectal, bladder, respiratory, heart, digestive and urinary, other

Delirium and Encephalopathy Mental health disorders

Parkinson’s and Huntington’s Diseases

Legally blind

Angina PectorisChronic Kidney Disease – Stages I through IV (and V)

Urinary Obstruction & RetentionMajor Fractures, except of skull, vertebrae or Hip

Section GG Discharge: Steps for Assessment


• Code the resident’s discharge functional status, based on a clinical assessment of the resident’s performance that occurs as close to the time of the resident’s discharge from Medicare Part A as possible.

• Must be completed within the last three calendar days of the resident’s Medicare Part A stay.

Final Checklist

Training of staff in important care areas that will improve/maintain quality of care metrics.

Clinical Programs: Group/Concurrent Therapy, Restorative, Activities

Case management

Documentation

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Questions?

• Thank you!

• [email protected]

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