Indiana Medicaid Reimbursement Update - cmcglobalfiles.cmcglobal.com/AdamsLake.pdf · Indiana...

1

Indiana Medicaid Reimbursement Update

Tysen Adams, CPADeborah Lake, RN, RAC-CT

Senior Managing ConsultantsBKD, LLP

Agenda

• 5 To 8 Year Long-Term Care Plan• Value Based Purchasing Issues• Proposed Report Card Score Changes• Compliance Reviews• Intergovernmental Transfers/Upper Payment Limits• Transition to RUGS IV 48 Grouper Strategies

• Indiana Case-Mix Level of Care Audits• Special Care Unit2

5 to 8 Year Long-Term Care Plan

• State is in discussions with Indiana Health Care Associations for a 5 to 8 year plan to modify Long-Term Care Possible reimbursement changes Continued shift to Home & Community-Based

Services (HCBS) Review of entire process from Admission to

Discharge Setting up Work Groups to discuss issues in more

detail3

2

Value Based Purchasing (VBP) Issues

• Clinical Expert Panel (CEP) to reconvene Includes 18 members – Health Care Association

representatives, OMPP, State Department of Health, Myers & Stauffer & Education

Develop Phase III of the Nursing Home VBP Program Determine if satisfaction survey data will be incorporated

into the Quality Add-On Determine if Quality Indicators will be incorporated into

the Quality Add-On Proposed changes to report card score

4

Proposed Report Card Score Changes

• Proposed Revised System Simplified Scoring System Higher score reflects better performance All surveys and tags will be included More current – revised system would be current

through the biweekly update of the consumer reports and would include all surveys going back 30 months

5

Proposed Report Card Score Changes

• Revised scoring system Score is a rolling score based on all surveys in past

30 months Scoring is based on severity level

• Substantial compliance: 0 points• No actual harm: 3 deduction points• Actual harm: 20 deduction points• Immediate jeopardy: 25 deduction points

Maximum (best) score is 300 points6

3

Compliance Reviews

• Myers and Stauffer recently posted an announcement to their website addressing compliance review requests Marked increase in the number of providers

failing to submit requested records prior to fieldwork Failure to comply with records request in a timely

manner could result in the following:• Payment denials• Termination of provider agreement

7

Compliance Reviews

• Additional requests for non-state government owned/operated (NSGO) nursing facilities participating in the Upper Payment Limit (UPL) program Bank statements for the applicable period showing that

UPL funding was deposited into the operating account of the nursing facility

Written policy detailing procedures for handling UPL payments

Bank statements and supporting documentation for the applicable period for the check requests showing that IGT payments are made by the NSGO entity

NSGO entity audited financial statements8

Intergovernmental Transfer (IGT)/Upper Payment Limit (UPL)

• As of March 31, 2015, there were 394 nursing facilities in the IGT/UPL Program

• 25 County Hospitals now own nursing facilities in the Program

• $111.50 was the average facility-specific UPL amount last quarter

9

4

Upper Payment Limit

• The April 1, 2015 through June 30, 2015 quarterly UPL payment is currently being finalized and notification letters should be mailed to the County Hospitals in the near future

10

Upper Payment Limit Calculations

• Partnership with a county hospital

• UPL = Monetary difference between the Medicare rate that would have been paid if the resident had been covered less the facility’s Medicaid rate for the time period

11

Upper Payment Limit Calculations

• Identifies all Medicaid residents on the last day of the quarter from the Time Weighted Report (TWR) March 31 June 30 September 30 December 31

• Uses latest OBRA assessment• Converts the RUGS-III scores from the TWR to the RUGS-IV

(66 grouper)• “Low Need” scores do not impact

12

5

8 Major RUG-IV Classifications

• Rehab Plus Extensive Services• Rehabilitation• Extensive Services• Special Care High• Special Care Low• Clinically Complex • Behavioral Symptoms and Cognitive Performance• Reduced Physical Function

Strategies for IGT/UPL

• Remember your strategies for RUGS-III • Know the differences between RUGS-III and RUGS-IV

categories Components Index maximizing ADL scores and end-splits End-splits for depression and restorative

• Be aware of snap-shot dates and timing of assessments March 31 June 30 September 30 December 31


• Capture isolation as appropriate• Assess COPD residents for shortness of breath when

lying down during reference periods• Respiratory failure and oxygen• Alter Physician Order/Visit log to reflect insulin order

changes• Monitor ADL’s• Parkinson Disease residents and ADL documentation

15

6


• Plan therapy minutes and days of treatment 5 days and 150 minutes = RM Remember distinct day requirement for RM and RL

16

Indiana Transition to RUGS IV

• Effective July 1, 2016• Indiana Nursing Facility rates will be calculated using RUGs IV

– 48 grouper For a one year period Further extension depends on discussion and progress on

5-8 year plan• $6.9 million more than RUGs III Unspent money from Quality Assessment Fee

• Therapy scores will not be re-RUGed at this time• Index maximizing

17

Indiana Transition to RUGs IV

• ADL Score Calculation ADL score 0-16 vs. 4-18

• RUGS III range of 4-16• RUGS IV range of 0-16

RUGS IV only• Most commonly coded score of “2” (Limited Assist) has

been devalued• Tube feeding/IV fluid component removed• Weight given to staff support with feeding

7

RUG-III Late Loss ADLs

Bed Mobility, Transfer, Toileting, & Eating

RUG-IV Late Loss ADLs

Bed Mobility, Transfer, Toileting, & Eating

Limited vs Extensive Assistance

• Limited Assist (2) = Resident highly involved in activity Guided maneuvering – No weight bearing

• Staff uses hands to guide – no use of muscles• No bearing of weight of any part of the resident• Contact guard

Physical directing of the resident – “Mothers gentle touch” Hands on top – palm down

8

Limited vs Extensive Assistance

• Extensive Assist (3) = Resident performs part of activity Staff performs a component of the ADL Hands on bottom – palm up Staff provides weight bearing assistance

• Giving resident a “boost”• Staff uses hands and muscles• Weight bearing some or any of the resident’s weight• Weight bearing is determined by who is supporting the

weight of the resident or extremity


• Extensive Services (ADL = 2-16) 48 Grouper

• Ventilator and trach (ES3)• Trach or ventilator (ES2)• Isolation (ES1)• Services while a resident• ADL score of 0-1 classifies as Clinically Complex

23


• Isolation or Quarantine 4 criteria must be met

• Active infection with highly transmissible pathogen(s)• Precautions over and above standard precautions

(contact, droplet and/or airborne)• In a room alone because of infection and cannot have a

roommate• Resident must remain in his/her room – requires all

services be brought to the resident Does not apply for

• UTIs, encapsulated pneumonia, wound infections24

9


• 48-Grouper Rehab 150 minutes or more and 5 distinct days of any

combination of ST, OT or PT OR

45 minutes or more and 3 distinct days of any combination of ST, PT and OP and 2 or more restorative services (6 or more days)

25


• Restorative Nursing Programs• Administered during 7-day look-back period• Specific program must have been administered at least

15 minutes during the 24 hour period• Measurable objectives and interventions outlined in a

plan of care• Supervision by a licensed nurse (RN or LPN)• Evidence of periodic evaluation by a licensed nurse –

note can be written by a restorative aide and co-signed by a licensed nurse

• Nursing assistants/aides skilled in the techniques that promote resident involvement in the activity

• No more than 4 residents per supervising caregiver26


• Restorative Nursing Programs Urinary toileting program and/or bowel toileting

program** Passive and/or active ROM** Bed mobility and/or walking training** Splint or brace assistance Transfer training Dressing and/or grooming Eating and/or swallowing Amputation/prosthesis care Communication training

**Count as one service27

10


• 48 Grouper Rehab ADL Dependent

• RAA = 0 -1• RAB = 2 - 5• RAC = 6 - 10• RAD = 11 - 14• RAE = 15 -16

28


• RUGS IV – 48 Grouper Rehab

29


• RUGS III Rehab

30

11

Special Care HighADL Score 2-16

ADL Score 0-1 = Clinically Complex

HE2 (15-16)

HE1 (15-16)

HD2 (11-14)

HD1 (11-14)

HC2 (6-10)

HC1 (6-10)

HB2 (2-5)

HB1 (2-5)

• Quadriplegia ADL>5• Fever +

Pneumonia, Feeding Tube, Vomiting OR Weight Loss

• Respiratory Therapy x 7 Days• Coma / ADL Dependent• Septicemia• DM / INSULIN Injections x7 days / 2 days

INSULIN order changes• COPD and SOB when flat• Parenteral IV feedings or fluids

Special Care LowADL Score 2-16

ADL Score 0-1 = Clinically Complex

LE2 (15-16)

LE1 (15-16)

LD2 (11-14)

LD1 (11-14)

LC2 (6-10)

LC1 (6-10)

LB2 (2-5)

LB1 (2-5)

• Cerebral Palsy ADL>5• Multiple Sclerosis ADL>5• Ulcers * (See next slide)• Radiation – While a resident• Feeding Tube with intake requirement• Foot Infections / Open Foot Lesions with

dressings• Diabetic Foot Ulcer with dressings• Dialysis – while a resident• Parkinson’s ADL > 5• Respiratory Failure and O2

Special Care Low - Ulcers

Ulcer Combinations

• 2 or more stage 2 pressure ulcers

• Any # stage 3 or 4 pressure ulcer

• 2 or more venous/arterial ulcers

• 1 stage 2 pressure ulcer and 1 venous/arterial ulcer

Treatments – 2 or more• Pressure relieving chair

and/or bed **• Turning/repositioning • Nutrition or hydration

intervention • Ulcer care • Application of dressings

(not to feet) • Application of ointments

(not to feet)

***Count as one treatment even if both provided

12


• Special Care High and Low (ADL = 2-16) 48 Grouper Use of depressive end-split U Use of

34


• Special Care RUGS III

35


• Considerations: Special Care High

• COPD and SOB when lying down• Diabetes with insulin injections (7 days) and 2 or more

days of insulin order changes• Parenteral/ IV feedings (Extensive Service RUG III)

Special Care Low• Dialysis (Clinically Complex in RUGS III)• Parkinson’s Disease with ADL of at least 5• Respiratory failure and oxygen administration• Foot infection (Clinically Complex in RUGS III)• Feeding Tubes (Clinically Complex in RUGS III)36

13

Clinically Complex

CE2 (15-16)CE1 (15-16)CD2 (11-14)CD1 (11-14)CC2 (6-10)CC1 (6-10)CB2 (2-5)CB1 (2-5)CA2 (0-1)CA1 (0-1)

• Burns – 2nd or 3rd Degree• Pneumonia• Hemiplegia ADL>5• Oxygen (while a resident)• Chemotherapy (while a resident)• Transfusions (while a resident)• Surgical wounds / open lesions with

treatment Surgical Wound Care Application of dressing (not to feet) Application of ointments (not to feet)

• IV Medications (while a resident)


• Clinically Complex 48 Grouper

38


• Clinically Complex RUGS III

39

14


• Considerations for Clinically Complex Surgical wounds and open lesions with skin

treatments (Special Care with RUGS III) IV medications (Extensive Service with RUGS III) Dehydration and Internal Bleeding eliminated Physician orders/visits eliminated

40

Behavior Symptoms and Cognitive Performance

BB2 (2-5)BB1 (2-5)BA2 (0-1)BA1 (0-1)

• Impaired Cognition and Behavior RUG categories combined – removal of 4 categories

• Uses the Restorative End Split • Cognition scores based on MDS interview BIMS or CPS

• Behavior symptoms defined by MDS 3.0 definitions

• ADL Score 0-5

Behavior Symptoms and Cognitive Performance ADL score = 5 or less

Cognitive Interview – BIMS <=9Staff Observation - Difficulty in making self understood, Short

Term memory or decision making (CPS >=3) HallucinationsDelusions

Coded 2 or 3 (4-6 days or daily)Physical behavioral symptoms toward othersVerbal behavioral symptoms toward othersOther behavioral symptomsRejection of careWandering

15


• Behavior Symptoms and Cognitive Performance 48 Grouper

43


• Impaired Cognition and Behavior Problems RUGS III

44

Reduced Physical Function

PE2 (15-16)PE1 (15-16)PD2 (11-14)PD1 (11-14)PC2 (6-10)PC1 (6-10)PB2 (2-5)PB1 (2-5)PA2 (0-1)PA1 (0-1)

Needs are primarily ADL support and general supervision

Uses Restorative End-Split

16


• Reduced Physical Function (ADL = 0-16) 48 Grouper

46


• Reduced Physical Functioning RUGS III

47

RUGS IV Additions/Deletions

• Added Conditions: Parkinson’s Disease COPD and SOB while lying flat Respiratory failure with oxygen use O2 Isolation for active infectious diseases

• Removed: Aphasia with tube feedings Dehydration Internal bleeding Suctioning Physician orders and visits

17


• Moved: IV/Parenteral Feedings to Special Care High IV medications to Clinically Complex Comatose to Special Care High Septicemia to Special Care High DM with both daily insulin injections and 2 days of insulin

order changes to Special Care High Tube feeding alone will be Special Care Low Tube feeding with fever will be Special Care High Dialysis moved to Special Care Low Foot infection moved to Special Care Low Surgical wounds to Clinically Complex Pressure, arterial or venous wounds to Special Care Low


• “Low Need” Days Medicaid residents only “New” admission to any Medicaid-certified after

January 1, 2010 Cognitive status indicated by a BIMS score greater

than or equal to 10 or cognitive performance score (CPS) of 0-2 Not experiencing occasional, frequent or

complete bowel incontinence

50


• “Low Need” Days CMI Values:

• PA1 = 0.19• PA2 = 0.21• PB1 = 0.28• PB2 = 0.29

51

18


• BC2 or Delinquent Days For Medicaid purposes only assessments are good for 113

days after which BC2 days will be assigned With the 48 Grouper this new value will be reduced from

0.50 to 0.45

• Residents discharging prior to completion of Admission Assessment LC2 – Discharge d/t death or transfer to hospital RAB – Discharge other than to death or hospital transfer

52

Strategies for Indiana RUGS IV

• Start learning differences between RUGS III and RUGS IV 48 groupers CMI point differences

• Know current RUG category before scheduling new assessment End of year conversion Therapy – remember distinct day requirement

53


• Activities of Daily Living Train, Train and Train again Limited vs. Extensive assist Monitor during assessment periods Observe care being given on the nursing units

• ADL Minimum Required Quadriplegia, Cerebral Palsy, Multiple Sclerosis,

Parkinson’s Disease and Hemiplegia Extensive Services and Special Care High and Low54

19


• Physician order logs Insulin dependent diabetics Insulin order changes

• Skin Conditions Stage 1 ulcers will not enter in RUG score 2 or more Stage II ulcers Stage 3, 4 or unstageable due to slough or eschar 2 or more venous/arterial ulcers Stage II plus one venous/arterial ulcer55


• Assess COPD residents for ability to breathe while lying flat during assessment periods

• Diagnosis of Parkinson’s Disease with medication

• Capture isolation as appropriate

• Documentation of respiratory therapy services and maintenance of staff training records

56


• Review hospital records In-house services IV/Parenteral fluids or feedings in 7-day look back

• Require services to be rendered in-house Respiratory failure with oxygen Radiation therapy, Dialysis, Transfusions Chemotherapy Oxygen IV medications Tracheostomy care, ventilator/respirator Isolation

57

20


• Ensure baseline temperatures are obtained and maintained Pneumonia, vomiting, weight loss, feeding tube

• Monitor physician orders and 24-hour reports for changes in condition or clinical services

• Review RUGS IV 48 Grouper reports on Myers and Stauffer portal

58


• RUGS III

• RUGS IV 48 Grouper

59


• RUGS III • RUGS IV – 48 Grouper

60

21

Myers and Stauffer Training

61

Special Care Unit Add-on

• MDS Items Medicaid payer (A0700) Room number (A1300B) Diagnosis of Alzheimer’s Disease (I4200) or Non-

Alzheimer’s Dementia (I4800)

• Special Considerations Medicare Transfer on to unit Modifications

62

Indiana Case-Mix Level of Care Audits

• Responsibility for audits was assumed by Myers and Stauffer (M&S) effective July 1, 2015

• New policies listed on M&S site Health Record Policy Excessive Wait Time for Medical Records Facility Request for Review Cancellation Medical Record Correction Policy

• Only original medical records will be accepted for supporting documentation

63

22


64


65

Item Set Changes for October 1, 2015

• MDS 3.0 Item Set Change Version 1.13.0 with a 10-1-15 effective date C1300 – Revised footnote

• “Adapted from Confusion Assessment Method. 1988, 2003, Hospital Elder Life Program, LLC. Not to be reproduced without permission. All rights reserved.”

66

23

THANK YOU!!!

[email protected]@bkd.com

Indiana Medicaid Reimbursement Update - cmcglobalfiles.cmcglobal.com/AdamsLake.pdf · Indiana...

Documents

Transcript of Indiana Medicaid Reimbursement Update - cmcglobalfiles.cmcglobal.com/AdamsLake.pdf · Indiana...