Is Your Triple Check PDPM Ready? Risks Claims Stacy Baker ... files/AM...Final Rule / Federal...

#1‐Is Your Triple Check PDPM Ready? Examining the Financial Risks of Aberrant

Claims

Stacy Baker & Shelly Maffia

Tuesday 11/19/2019

1 PM ‐ 2:30 PM

KBN # 5‐0002‐12‐19‐559

KAHCF – 2019 Fall Conference

www.proactivemedicalreview.com 2019

Is Your Triple Check PDPM Ready?

Examining Financial Risks of Aberrant Claims

Presented by:

Shelly Maffia, Director of Regulatory Services

Stacy Baker, Director of Audit Services

Objectives

1. Review best practices for internal audit of PDPM claims prior to

submission to decrease potential billing errors and promote accurate

reimbursement

2. Identify key roles of the interdisciplinary team in completion of a

collaborative triple check process of items/data elements impacting

PDPM reimbursement

3. Review key data collection, billing and monitoring processes important to

PDPM reimbursement accuracy including but not limited to

understanding the updated HIPPS codes and validating UB-04 accuracy

prior to submission.

2

PDPM COMPLIANCE

3



Medical Review & Data Monitoring

“Given the more holistic style of care emphasized under

PDPM, program integrity and data monitoring efforts will

also be more comprehensive and broad. For program

integrity, we expect provider risk will be more easily

mitigated to the extent that reviews focus on more clearly

defined aspects of payment, such as documentation

supporting patient diagnoses and assessment

coding.”

Source: CMS Quality Reporting Program Provider Training August 14, 2019, Slide 66 4

Medical Review & Data Monitoring

• CMS will be monitoring therapy

provision under PDPM, as compared

to RUG - IV, at the national, regional,

state, and facility level.

• Significant changes under PDPM, as

compared to RUG - IV, in volume or

treatment delivery may trigger

program reviews and potential policy

changes.

5

Documentation Compliance Risks

• PDPM does not change documentation requirements, but strengthens the importance of documenting all aspects of a patient’s/resident's care, consistent with PDPM’s focus on a more holistic care model.

• Given the increased relevance of a greater set of data elements supporting payment under PDPM, providers should ensure that there is strong documentation and support for the care associated with each PDPM component.

Source: CMS Quality Reporting Program Provider Training August 14, 2019 (slide

77)

6



PDPM Risk Areas

Active Dx / Section I Clinical

Conditions

HIV/AIDS Diagnosis

Surgery in Hospital

Comprehensive Resident Care

Plans

Accurate Functional Measures

MDS Interview Process

(BIMS/PHQ9)

Mechanically Altered Diet

Swallow Disorder

Therapy Intensity

Group / Concurrent

Therapy

IPA Determination

Interrupted Stay

7

Medicare Benefit Policy Manual

Chapter 8

Medicare Claims Processing Manual

Chapter 6

Resident Assessment Instrument 3.0 User’s

Manual

Final Rule /

Federal Register

Billing Compliance

8

PDPM BILLING

9

RUG-IV & PDPM: SNF services must be skilled service, required on a daily

basis, and be reasonable and necessary for the treatment of a

patient’s/resident's particular illness or injury, based on the individual’s

particular medical needs, and accepted standards of medical practice. Source: CMS Quality Reporting Program Provider Training August 14, 2019



Skilled Level of Care Criteria

All Existing Criteria for Eligibility and Access Remain

• Must require daily skilled service

• Qualifying hospital stay requirement

• Supportive Documentation

Skilled Nursing Services

• Observation & Assessment

• Management & Evaluation

of a Care Plan

• Teaching & Training

• Direct Skilled Nursing Care

10

Certification Timeframes

Certification • Admission

Initial Recertification

• No later than day 14 (May be combined with admission cert)

Subsequent Recertifications

• Every 30 days

11

Certifications & Interrupted Stay Policy

12

• Tied to SNF

Admission

• Cert schedule

does not change



Administrative Level of Care Presumption

Nursing Groups

Extensive Services Special Care High Special Care Low Clinically Complex

PT and OT Groups

TA TB TC TD TE TF TG TJ TK TN TO

SLP Groups

SC SE SF SH SI SJ SK SL

NTA Group

Uppermost 12+ Comorbidity Group

13

PDPM Payment for Patients with AIDS

• PDPM rate components were specifically designed to account

accurately and appropriately for the increased cost of AIDS-related

care

• PDPM addresses costs for this subpopulation in two ways:

• Highest point value (8 points) of any condition or service for under NTA

component

• 18% add-on to the PDPM Nursing component

• AIDS diagnosis continues to be identified through the SNF’s

entry of ICD-10-CM Code B20 on the SNF claim

14

5-character HIPPS code

• Character 1: PT/OT Payment Group

• Character 2: SLP Payment Group

• Character 3: Nursing Payment Group

• Character 4: NTA Payment Group

• Character 5: Assessment Indicator

15

Health Insurance Prospective Payment System (HIPPS) Rate Codes



UB04 Claim Example

16

HIPPS Code – Character 1

17


18



HIPPS Code –

Character 3

19

HIPPS Code- Character 4

20


21



22

5 Character HIPPS Code Example (NHNC1)

Character Component HIPPS Code Explanation

1 PT/OT

Payment

N – (TN) Non-Orthopedic Surgery & Acute Neurologic. Function Score 6-9. Documentation must

validate primary reason for SNF stay ICD-10 code appropriate and was a condition treated during

the hospital stay. Function score must be supported within the documentation as usual

performance during first 3 days of admission.

2 SLP Payment H – (SH) Documentation must support two of the following: Acute Neurologic Condition, SLP-

related Comorbidity, or Cognitive Impairment. Must also validate supporting documentation for

either swallow impairment or a mechanically altered diet.

3 Nursing

Payment

N – (CBC2) Documentation must support nursing category Clinically Complex which might include

Pneumonia, hemiplegia/hemiparesis with NFS <=11, open lesions with treatment or surgical

wounds, burns, receiving chemotherapy or oxygen therapy while a resident, or IV medications or

transfusions. PHQ9 score of >10 and the nursing function score for 6-14 must also be validated as

usual performance.

4 NTA Payment C – (NC) Documentation must support presence of certain comorbidities or use of certain

extensive services which total NTA score range 6-8.

5 AI 1 – (5 day) Documentation must support appropriate setting of ARD and documentation to support

coding items on the 5 day assessment.

PDPM Default Billing

• Default HIPPS Code: ZZZZZ

• Default rate refers to lowest possible per diem rate

• Equivalent to billing:

• PT – TP (1.08)

• OT – TP (1.09)

• SLP – SA (0.68)

• Nursing – PA1 (0.66)

• NTA - NF (0.72)

23

TRIPLE CHECK PROCESS

24



Ensuring Claim Accuracy: Triple Check

• Internal Claims Audit

• Pre-bill claims

• Medicare Part A Claims and other

payers designated by the facility

• IDT representatives

• Routine review

25

Why is Triple Check Important?

• Promotes Compliance

• CMS guidance and regulations

• Payment Accuracy Initiatives

• Reduce denied, rejected, adjusted claims

• Reduce potential for medical review

• Prevent submission of false claims

• Appropriate report of facility data

• Accurate billing for services provided

26

Triple Check Team

27

Business Office

MDS Department

Rehab Department

Clinical

DNS/ADNS

Administrator

/ Executive Director



Triple Check Process

Routine Meeting Time

Come Prepared

Efficiency

Checklist / Audit Form

Validate Accuracy

Identify Errors & Need for Follow-up

Ongoing Communication

28

Medical Record Review

1. UB-04 (draft claims)

2. ICD-10 Diagnosis List

3. MDS Assessment(s)

4. Medical Record

• Hospital documentation

• SNF Certification / Recertification

• Physician Documentation

• Nursing Documentation

• Therapy Documentation

29

Sample Triple Check Form

© Proactive 2019

30



EXAMINING THE FINANCIAL RISKS OF

ABERRANT CLAIMS

31

Common Claims Errors • Billing for service prior to verifying HIPPS code

• Inaccurate primary SNF condition identified as

extension of acute stay

• Proof of Active Condition(s)

• ICD10 codes not included in MDS Section I as

secondary conditions

• Conditions coded without active treatment supported (ie.

SLP comorbidity)

• Documentation to support swallow impairment, modified

diet

• Documentation to effective support function score

• Proof of sufficient of physician oversight

32

Section GG Function Score:

RAI Documentation Guidance

• CMS anticipates that an interdisciplinary team of

qualified clinicians is involved in assessing the

resident during the three-day assessment period

(GG-10)

• Documentation in the medical record is used to support

assessment coding of Section GG. Data entered should be

consistent with the clinical assessment documentation in the

resident’s medical record (GG-14)

LTC RAI MDS 3.0 User’s Manual V1.17 October 2019 Retrieved from: https://www.cms.gov/Medicare/Quality-Initiatives-

Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html

33

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html











34

Supporting Documentation Impact: OT/PT Function Score

Clinical

Category

Function

Score

PT-OT

CMG

PT

CMI PT Rate

OT

CMI OT Rate

Daily

Rate

Impact

LOS 20

Day

Impact

Major Joint

Replacement or

Spinal Surgery

0-5 TA 1.53 $92.95 1.49 $84.26

-$32.57 -$711.40

10-23 TC 1.88 $114.21 1.69 $95.57

Other

Orthopedic

0-5 TE 1.42 $86.27 1.41 $79.74 -$28.18 -$563.60

10-23 TG 1.67 $101.45 1.64 $92.74

Medical

Management

0-5 TI 1.13 $68.65 1.18 $66.73 -$44.05 -$881.00

10-23 TK 1.52 $92.34 1.54 $87.09

Non-Orthopedic

Surgery and

Acute

Neurologic

0-5 TM 1.27 $77.15 1.30 $73.52

-$31.14 -$622.80

10-23 TO 1.55 $94.16 1.55 $87.65

Supporting Documentation Impact: Nursing Function Score

Nursing Classification Function

Score

Nursing

CMG

Nursing

CMI

Nursing

Rate

Daily Rate

Impact

LOS 20 Day

Impact

Special Care High

0-5 HDE1 1.99 $210.78

-$13.77 -$275.40

6-14 HBC1 1.86 $197.01

Special Care Low

0-5 LDE1 1.73 $183.24

-$31.77 -$635.40

6-14 LBC1 1.43 $151.47

Clinically Complex

0-5 CDE1 1.62 $171.59

-$72.03 -$1,440.60

15-16 CA1 0.94 $99.56

Reduced Physical

Function

0-5 PDE1 1.47 $155.70 -$85.79 -$1,715.80

15-16 PA1 0.66 $69.91 35

Supporting Active Conditions

Therapy plans, MDS assessments and the UB-04 must include

relevant diagnosis codes to describe the medical condition(s) and

symptoms that have prompted SNF services.

• SNF stay = extension of hospitalization

• Physician approved active conditions

• Consider systems for maintaining

active diagnosis list

• Rehab diagnosis codes included

• Sec I of MDS: active conditions

• Under PDPM, dx codes & supporting

documentation directly Impact payment

36



SNF Primary

Diagnosis

Clinical

Category PT Rate OT Rate SLP Rate NTA Rate Nursing Rate

Total

Unadjusted Rate

Spinal stenosis,

lumbar region (M48.062)

Non-Surgical

Orthopedic $102.14 $93.37 $15.52 $107.00 $120.50 $534.01

Spinal stenosis,

lumbar region

(M48.062)

Non-Surgical

Orthopedic $102.14 $93.37 $15.52 $57.92 $120.50 $484.93

• BIMS Score = 14; Regular diet; No SLP

related comorbidities

• GG Function Score –PT/OT=16;

Nursing=9

• NTA Score = 3

NTA

points

Supporting Documentation NTA: Active Diagnosis

37

© Proactive 2019

Claim review:

NTA points

reduced to 0

SNF Primary

Diagnosis

Clinical

Category PT Rate OT Rate SLP Rate NTA Rate

Nursing

Rate

Total

Unadjusted

Rate

Sepsis, unspecified

organism (A41.9)

Acute Infections $92.96 $87.67 $65.29 $107.00 $120.50 $480.88

Sepsis, unspecified

organism (A41.9) Acute Infections $92.96 $87.67 $53.42 $107.00 $70.38 $469.01

• BIMS Score = 10, Mech Soft diet, SLP

related comorbidity CVA

• GG Function Score: OT/PT=20;

Nursing=16

• NTA Score = 5

CVA

38

© Proactive 2019

Supporting Documentation SLP Comorbidity:

Active Diagnosis

Claim review:

unable to

validate active

CVA condition

SNF Primary

Diagnosis Clinical

Category PT Rate OT Rate SLP Rate NTA Rate

Nursing

Rate

Total

Unadjusted

Rate

OA of Rt hip

(M16.11) Non-

surgical

ortho

$94.79 $95.64 $33.33 $107.80 $164.22 $495.78

Aftercare

following joint

replacement

surgery (Z47.1)

Major Joint

replace-

ment

$114.98 $88.24 $33.33 $107.80 $164.22 $508.57

• Diagnosis: Osteoarthritis of right hip. In

hospital underwent Right hip replacement

and is coming to SNF for skilled PT/OT.

• BIMS Score = 12; Regular diet; No SLP

related comorbidities

• PT/OT GG Function Score -12

• NTA Score = 4

+ Dx

39

© Proactive 2019

Triple Check review:

team identifies

inappropriate SNF Dx



SNF Primary

Diagnosis

Clinical

Category PT Rate OT Rate SLP Rate NTA Rate Nursing Rate

Total

Unadjusted Rate

Parkinson’s

Disease (G20)

Acute

Neurologic

$90.51 $85.40 $53.42 $103.49 $184.49 $517.31

Parkinson’s

Disease (G20)

Acute

Neurologic

$90.51 $85.40 $68.03 $103.49 $184.49 $531.92

• BIMS Score = 13; Mech Diet; No

Swallow Impairment, No SLP

comorbidities

• GG Function Score: OT/PT=7;

Nursing=3

• NTA Score = 4

+

Swallow

Disorder

40

© Proactive 2019

Triple Check review:

team identifies

documentation to support

swallow impairment

4

1

MITIGATE Compliance Risks

41

• Provider Behavior Changes

– Pathways/Protocols & trending of therapy intensity & mode

– MDS coding & supportive documentation audits

– Outcomes monitoring

• Negligence/Professional Liability

– Competencies established NTAs & higher acuity care

– Compliance work plan updates

• Targeted Medical Reviews

– Coding and Documentation Training

– Triple Check processes

– Formal auditing and monitoring

– Coaching and system updates in response to audit findings

Auditing & Monitoring

• ICD-10 Coding

• MDS accuracy

• Interview processes

• New reimbursement items

• PDPM relevant coding &

supportive documentation

• Care plans

• Overuse IPA / Interrupted Stay

• Clinical meeting processes

• Standards of care/Clinical

competency

• Therapy (modes and intensity)

• Skilled documentation

42

FY 2019 Final Rule (pg.

39198)

“the information reported to CMS

must be accurate. Inaccuracies

in the data reported to CMS, or a

failure to document the basis for

such data, will necessitate (the

same types of) administrative

actions”



4

3

Risk Mitigation

Triple

Check

QA Audits

Documentation Clinical Need Drives Care

Contact Information: [email protected]

[email protected]

Questions

PDPM

Billing

Accuracy

Proactive partners with providers for

regulatory compliance, training, and medical review solutions.

©2019 Proactive Medical Review & Consultants, LLC, may be used with permission by current affiliates.

4

5

1. Proactive Medical Review Triple Check Toolkit https://www.proactivemedicalreview.com/shop

2. Medicare Benefit Policy Manual Ch. 8 https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c08.pdf

3. Medicare Claims Processing Manual Ch. 6 https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c06.pdf

4. Medicare Claims Processing Manual Ch. 6 (Transmittal PDPM Update 10/8/19): https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4409CP.pdf

5. Center for Medicare and Medicaid Services. (2019). MDS 3.0 RAI Manual. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html

6. SNF PPS FY2019 Final Rule https://www.govinfo.gov/content/pkg/FR-2018-08-08/pdf/2018-16570.pdf

7. SNF PPS FY2020 Final Rule: https://www.federalregister.gov/documents/2019/08/07/2019-16485/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities

8. Centers for Medicare and Medicaid Services. (2019). Patient Driven Payment Model. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html

9. SNF QRP Provider Training Day 2, part 2 (August 14, 2019). Retrieved from: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Training.html

45

References and Resources

mailto:[email protected]

mailto:[email protected]

https://www.proactivemedicalreview.com/shop

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c08.pdf





https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c06.pdf






https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4409CP.pdf















https://www.govinfo.gov/content/pkg/FR-2018-08-08/pdf/2018-16570.pdf









https://www.federalregister.gov/documents/2019/08/07/2019-16485/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities

























https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html









https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Training.html



























Patient Driven Payment Model (PDPM) HIPPS Coding Crosswalk

May be used by permission only. Proactive Medical Review, LLC www.proactivemedicalreview.com

PT/OT Component HIPPS Guide (1st Character) Clinical Category Function Score PT-OT Case-mix Group HIPPS Character

Major Joint Replacement or Spinal Surgery

0-5 TA A 6-9 TB B

10-23 TC C 24 TD D

Other Orthopedic

0-5 TE E

6-9 TF F

10-23 TG G

24 TH H

Medical Management

0-5 TI I

6-9 TJ J

10-23 TK K

24 TL L

Non-Orthopedic Surgery and Acute Neurologic

0-5 TM M 6-9 TN N

10-23 TO O 24 TP P

SLP Component HIPPS Guide (2nd Character) Acute Neurologic Condition, SLP-related Comorbidity, or

Cognitive Impairment

Mechanically Altered Diet or Swallowing Disorder SLP Case-mix Group HIPPS Character

None Neither SA A None Either SB B None Both SC C

Any one Neither SD D Any one Either SE E Any one Both SF F Any two Neither SG G Any two Either SH H Any two Both SI I All three Neither SJ J All three Either SK K All three Both SL L

NTA Component HIPPS Guide (4th Character) Comorbidities / Conditions NTA Score Range NTA Case Mix Group HIPPS Character

See additional reference for Comorbidities Included in

NTA Comorbidity Score and Assigned Points

12+ NA A 9-11 NB B 6-8 NC C 3-5 ND D 1-2 NE E 0 NF F

Assessment Indicator Guide (5th Character) Assessment Type HIPPS Character

IPA 0 PPS – 5 Day 1

OBRA Assessment (not coded as a PPS Assessment) 6

http://www.proactivemedicalreview.com/



Nursing Component HIPPS Guide (3rd Character) Extensive Services Conditions /

Services Function

Score Nursing

Classification HIPPS

Character • Tracheostomy care• Ventilator / Respirator• Isolation or quarantine

0-14 ES3 A

0-14 ES2 B

0-14 ES1 C

Special Care High PHQ-9 Score Function Score

Nursing Classification

HIPPS Character

• Comatose and completelydependent or activity did notoccur

• Septicemia• Diabetes with both of the

following: 1) Insulin injectionsfor all 7 days; 2) Insulin order changes on 2 or more days

• Quadriplegia with NFS Score<=11

• COPD and SOB when lying flat • Fever with one of the following:

Pneumonia; Vomiting; Weight loss; Feeding tube withrequirements¹

• Parenteral/IV feedings• Respiratory Therapy for all 7 days

10 or greater 0-5 HDE2 D

Less than 10 0-5 HDE1 E

10 or greater 6-14 HBC2 F

Less than 10 6-14 HBC1 G

Special Care Low PHQ-9 Score Function Score


HIPPS Character

• Cerebral palsy with NFS <=11• Multiple sclerosis with NFS

<=11 • Parkinson’s disease with NFS

<=11 • Respiratory failure and oxygen

therapy (while a resident)• Feeding tube with

requirements¹• Two or more stage 2 pressure

ulcers with two or moreselected skin treatments²

• Any stage 3 or 4 pressure ulcer with two or more selected skintreatments²

• One stage 2 pressure ulcer and one venous/arterial ulcer withtwo or more selected skin treatments²

• Foot infection or diabetic footulcer or other open lesion of footwith application of dressings tothe feet

• Radiation treatment (while a resident)

• Dialysis treatment (while a resident)

10 or greater 0-5 LDE2 H

Less than 10 0-5 LDE1 I

10 or greater 6-14 LBC2 J

Less than 10 6-14 LBC1 K

Clinically Complex PHQ-9 Score Function Score


HIPPS Character

• Pneumonia• Hemiplegia/hemiparesis with NFS <=11• Open lesions (other than ulcers, rashes, and cuts) with any selected skin

treatment³ or surgical wounds• Burns• Any of the following while a resident: Chemotherapy; Oxygen therapy;• IV medications; Transfusions

10 or greater 0-5 CDE2 L Less than 10 0-5 CDE1 M 10 or greater 6-14 CBC2 N 10 or greater 15-16 CA2 O Less than 10 6-14 CBC1 P Less than 10 15-16 CA1 Q

Behavioral Cognitive Symptoms Restorative Programs

Function Score


HIPPS Character

• BIMS Summary Score <=9 OR CPS >=3• Hallucinations• Delusions• Any of the following 4 or more days: Physical behavioral symptoms

directed toward others; Verbal behavioral symptoms directed toward others; Other behavioral symptoms not directed toward others; Rejectionof care; Wandering

2 or more 11-16 BAB2 R

0 or 1 11-16 BAB1 S

Reduced Physical Function Restorative Programs

Function Score


HIPPS Character

• Behavioral Symptoms and Cognitive Performance with NFS <11• Residents who do not meet the conditions in any of the previous

categories • Restorative Nursing Services administered for 6 or more days

2 or more 0-5 PDE2 T 0 or 1 0-5 PDE1 U

2 or more 6-14 PBC2 V 2 or more 15-16 PA2 W

0 or 1 6-14 PBC1 X 0 or 1 15-16 PA1 Y




HIPPS Code Worksheet

Resident: HICN: Admit Date: Last Covered Day: Primary Payor: Secondary Payor: 5 Character HIPPS Code:

Interdisciplinary Team Members:

Character Place

PDPM Component

HIPPS Character

Case Mix Group Reason(s) for Case Mix Group Qualification

Example: Character 1 PT/OT Payment N TN Non-ortho surgery; GG score = 7

Character 1 PT/OT

Payment

Character 2 SLP

Payment

Character 3 Nursing

Payment

Character 4 NTA

Payment

Character 5 Assessment

Indicator � 5-day � IPA

Comments:


Is Your Triple Check PDPM Ready? Risks Claims Stacy Baker ... files/AM...Final Rule / Federal...

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Transcript of Is Your Triple Check PDPM Ready? Risks Claims Stacy Baker ... files/AM...Final Rule / Federal...