Navigating Your Way Through PDPM: The Changing Face of Rehab

Making a difference in the lives of those we serve

Objectives

• Identify the components of PDPM

• Understand the implications for MDS accuracy

• Explain the role that Section GG will play

• Describe how the changes could impact provision of therapy services

• Describe the types of data that will be important to manage the new payment model successfully

• Identify what we need to be doing now to prepare

Embrace the Change Before you HAVE TO

PDPM Overview

• Current RUG IV System• RUG maximization results in the vast majority of payments

made under Rehab RUGs in the current system

• How does this change in PDPM?• Every patient gets a case mix score for all

5 case mix components of the daily rate

• These scores are based on resident characteristics taken from the MDS and not on the volume of services received.

• Volume of therapy minutes provided no longer matter in terms of determining revenue

Payment from 1 of

66 categorie

s

Nursing

Therapy

Non Case Mix

PDPM Classification

• Groups patients into one of 10 primary classifications that are used as a component in calculating five case-mix indexed components:1. PT

2. OT

3. SLP

4. NTA

5. Nursing

• The rates assigned to the five indexes are combined with a non-indexed component to derive the daily rate for patient.

PDPM Reimbursement

• Therapy minutes delivered has no impact on reimbursement.

• Section GG plays a major role in reimbursement

• PT/OT rates decline at day 21• 2% reduction every 7 days thereafter throughout the patient

stay

• Non Therapy Ancillary rates• 300% day 1-3

• 100% day 4-100

PDPM Modes of Treatment

• Group and concurrent therapy are financially beneficial

• Group and concurrent therapy combined is capped at 25% per patient, per discipline.

• Based on group and concurrent caps, at least 75% of therapy must be individualized.

Therapy Rate

Nursing Rate

Non Case Mix

PT OT ST

Nursing

Non-Therapy Ancillar

y

Non-Case Mix

PDPM Overview – Per Diem Rate

PT OT SLP Nursing NTA

PT and OT Components

Non-Case Mix

PDPM How the Therapy Case-Mix is Determined• All patients are assigned to three therapy groups (PT,OT,

SLP):

• PT and OT

• Clinical Category

• Major Joint Replacement or Spinal Surgery

• Non-Orthopedic Surgery and Acute Neurologic

• Other Orthopedic

• Medical Management

• Functional Score (0 – 24)

• Section GG

PDPM How the Therapy Case-Mix is Determined

• SLP

• Presence of…

• Acute Neurologic Classification

• Cognitive Impairment

• SLP Comorbidity

• Presence of…

• Mechanically Altered Diet or…

• Swallowing Disorder

PT and OT Components – Clinical Category

• Both PT and OT start with the diagnosis from the first line of I8000:

• Diagnoses are mapped to 4 Categories• Major Joint Replacement or Spinal Surgery

• Other Orthopedic

• Non-Orthopedic Surgery

• Medical Management

• CMS has provided the diagnostic mapping for ICD 10 codes to Clinical Categories

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

PT and OT Components – Section GG

Code Code Description Score

05, 06 Set up assistance, Independent 4

04 Supervision or touching 3

03 Partial/moderate assistance 2

02 Substantial/maximum assistance 1

01, 07, 09, 10, 88

Dependent, refused, not applicable, not attempted due to environmental

limitationsNot attempted due to medical condition

of safety concerns

0

PT and OT Components – Section GG

Section GG Function Score

Section GG Item Description Score

GG0130AI Self-care: Eating 0 – 4

GG0130B1 Self-care: Oral Hygiene 0 – 4

GG0130C1 Self-care: Toileting Hygiene 0 – 4

GG0170B1 Mobility: Sit to Lying 0 – 4 (average of 2 bed mobility items)GG0170C1 Mobility: Lying to Sitting on Side of the Bed

GG0170D1 Mobility: Sit to Stand

0 – 4 (average of 3 transfer items)GG0170E1 Mobility: Chair/Bed to Chair Transfers

GG0170F1 Mobility: Toilet Transfer

GG0170J1 Mobility: Walk 50 Feet with 2 Turns 0 – 4 (average of 2 walking items)GG0170K1 Mobility: Walk 150 Feet

PT and OT Case Mix Index

Clinical CategorySection GG

Function ScorePT/OT Case-

Mix GroupPT Case- Mix

IndexOT Case- Mix

IndexMajor Joint Replacement or Spinal Surgery 0-5 TA 1.53 1.49

Major Joint Replacement or Spinal Surgery 6-9 TB 1.69 1.63

Major Joint Replacement or Spinal Surgery 10-23 TC 1.88 1.68

Major Joint Replacement or Spinal Surgery 24 TD 1.92 1.53

Other Orthopedic 0-5 TE 1.42 1.41

Other Orthopedic 6-9 TF 1.61 1.59

Other Orthopedic 10-23 TG 1.67 1.64

Other Orthopedic 24 TH 1.16 1.15

Medical Management 0-5 TI 1.13 1.17

Medical Management 6-9 TJ 1.42 1.44

Medical Management 10-23 TK 1.52 1.54

Medical Management 24 TL 1.09 1.11

Non- Orthopedic Surgery and Acute Neurologic 0-5 TM 1.27 1.30

Non- Orthopedic Surgery and Acute Neurologic 6-9 TN 1.48 1.49

Non- Orthopedic Surgery and Acute Neurologic 10-23 TO 1.55 1.55

Non- Orthopedic Surgery and Acute Neurologic 24 TP 1.08 1.09

PT OT SLP Nursing NTA

SLP Component

Non-Case Mix

SLP Component

• Begins with a determination of the presence or absence of the following factors:• Acute Neurologic Condition - first line of I8000

• SLP-related Comorbidities - Section I, Section O

• Cognitive Impairment - PDPM Cognitive Level based on BIMS or CPS

• Then a determination of the presence of a swallowing problem and/or mechanically altered diet - Section K

SLP Component Comorbidities and Cognitive Impairment

SLP Related Comorbidities

Aphasia Laryngeal Cancer

CVA, TIA or Stroke Apraxia

Hemiplegia or Hemiparesis Dysphagia

Traumatic Brain Injury ALS

Tracheostomy Care (while a resident) Oral Cancers

Ventilator or Respirator (while a resident) Speech and Language Deficits

Cognitive Level BIMS Score CPS Score

Cognitively Intact 13 – 15 0

Mildly Impaired 8 – 12 1 – 2

Moderately Impaired 0 – 7 3 – 4

Severely Impaired 0 5 - 6

SLP Case Mix IndexPresence of Acute

Neurological 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 2.66

Any one Neither SD 1.46

Any one Either SE 2.33

Any one Both SF 2.97

Any two Neither SG 2.04

Any two Either SH 2.85

Any two Both SI 3.51

All three Neither SJ 2.98

All three Either SK 3.69

All three Both SL 4.19

PT OT SLP Nursing NTA

Nursing Component

Non-Case Mix

Nursing Component

• 25 Case mix groups

• Collapsed from the 43 RUG IV groups

• Same RUG criteria with the exception of ADL scoring

• Section G (ADLs) will be replaced with PDPM

• Now using Section GG

• Different scoring methodology from PT/OT

• Reduced number of PDPM case mix groups achieved by collapsing the ADL categories

Nursing Component – Section GG

Response Description ADL Score

05, 06 Set up assistance, Independent 4

04 Supervision or touching 3

03 Partial/moderate assistance 2

02 Substantial/maximum assistance 1

01, 07, 09, 88 Dependent, refused, N/A, not attempted 0

Nursing Components – Section GG

Section GG Function Score

Section GG Item Description ADL Score

GG0130A1 Self-care: Eating 0 – 4

GG0130C1 Self-care: Toileting Hygiene 0 – 4

GG0170B1 Mobility: Sit to Lying 0 – 4 (average of 2 bed mobility items)GG0170C1 Mobility: Lying to Sitting on Side of the Bed

GG0170D1 Mobility: Sit to Stand

0 – 4 (average of 3 transfer items)GG0170E1 Mobility: Chair/Bed to Chair Transfers

GG0170F1 Mobility: Toilet Transfer

Nursing Case Mix Index

RUG-IV Nursing

RUG

ExtensiveServices

Clinical Conditions

DepressionGG-Based Function

Score

PDPM Nursing

Case-Mix Group

Nursing Case-Mix

Index

ES3 Tracheostomy& Ventilator - - 0 – 14 ES3 4.04

ES2 Tracheostomy& Ventilator - - 0 – 14 ES2 3.06

ES1 Infection - - 0 – 14 ES1 2.91

HE2/HD2 - Serious Medical Conditions Yes 0 – 5 HDE2 2.39

HE1/HD1 - Serious Medical Conditions No 0 – 5 HDE1 1.99

HC2/HB2 - Serious Medical Conditions Yes 6 – 14 HBC2 2.23

HC1/HB1 - Serious Medical Conditions No 6 – 14 HBC1 1.85

LE2/LD2 - Serious Medical Conditions Yes 0 – 5 LDE2 2.07

PT OT SLP Nursing NTA

Non-Therapy Ancillary Component

Non-Case Mix

Non-Therapy Ancillary Component

NTA Score Range NTA Case-Mix Group NTA Case-Mix Index

12+ NA 3.25

9 – 11 NB 2.53

6 – 8 NC 1.85

3 – 5 ND 1.34

1 – 2 NE 0.96

0 NF 0.72

• Condition or extensive services from MDS (Sections H, I, K, M and O) and SNF Claims data

• Condition or service correlated to point scale

PT OT SLP Nursing NTA

Non-Case Mix Component

Non-Case Mix

PDPM Payment Categories

• 28,800 unique combinations based on:• PT/OT: 16 classifications

• SLP: 12 classifications

• Nursing: 25 classifications

• NTA: 6 classifications

• Note: While PT and OT have unique index values assigned to them, the actual classification is always the same for PT and OT under PDPM.

Variable Rate Adjustment

PPS Assessments

Interrupted Stay Policy

Additional Changes

Variable Rate Adjustments

NTA

Medicare Payment Days

Adjustment Factor

1 – 3 3.0

4 – 100 1.0

PT and OT

Medicare Payment Days

Adjustment Factor

1 – 20 1.00

21 – 27 0.98

28 – 34 0.96

35 – 41 0.94

42 – 48 0.82

49 – 55 0.9

56 – 62 0.88

63 – 69 0.86

70 – 76 0.84

77 – 83 0.82

84 – 90 0.8

91 – 97 0.78

98 – 100 0.76

Variable Rate Adjustment

PPS Assessments

Interrupted Stay Policy

Additional Changes

PDPM Assessments

• 1 scheduled assessment:

• 5 day

• 2 unscheduled assessments:

• PPS Discharge

• New Interim Payment Assessment (IPA)

PPS Assessment Schedule

Medicare MDS Assessment Schedule

Type

Assessment ReferenceDate

Applicable Standard Medicare Payment

Days

5-day Scheduled PPS Assessment Days 1 – 8

All covered Part A days until Part A discharge (unless an

IPA is completed)

PPS Discharge Assessment

PPS Discharge: Equal to the end Date of the most recent Medicare Stay (A2400C) or

End Date

N/A

NOTE: IPA will be an optional assessmentEffective payment date – IPA ARDWill not reset the variable payment schedule

PDPM Reporting Therapy Minutes

• Discharge assessments to include a modified “Section O” with greater detail, including the following for each discipline:• Start Date

• Stop Date

• Individual Minutes

• Concurrent Minutes

• Group Minutes

• Treatment Days

• This will likely be compiled by CMS along with the Section GG outcomes data and serve as a basis for rate adjustments for patient classifications in the future.

Variable Rate Adjustment

PPS Assessments

Interrupted Stay Policy

Additional Changes

Interrupted Stay Policy

• Final Rule – IPA will be an optional assessment

• Effective on October 1, 2019 in conjunction with PDPM

• CMS has not finalized the proposed criteria for triggering an IPA

• The facility will choose the ARD relative to the date that triggered the event

• The IPA ARD will not reset variable payment schedule

• Not susceptible to assessment penalties

Not susceptible to assessment penal

Interrupted Stay Policy

• Interruption Window – 3 day period

• Readmits to same SNF by 12:00am at the end of the third day• Continuation of the previous stay

• No change in the variable per diem adjustment

• Source of readmission is not relevant

• Readmits to same SNF after 3-day interruption window• Considered a new stay

• New 5-day assessment is required upon admission

• Variable per diem adjustment schedule resets to Day 1

Implications for Rehab

Implications for Data Collection• Evidence based clinical data

• Need for more accurate and timely diagnosis information• Timeliness will impact overall care planning especially for rehab

• Increase in importance of MDS accuracy to overall revenue equation

• Section GG - major increase in importance• Will need to address process issues

• GG rules remain the same as far as lookback periods but timeliness becomes more of an issue

• Who will own the process? MDS or rehab?

• Expansion of GG item set - need to ensure consistency with therapy documentation

Section GG - What is Changing?

• Becomes mandated by CMS on all new admissions on or after Oct 1, 2018

• Wording Clarifications

• Added Section- Prior Function- with different scoring scale

• New scoring choice added – 10 not attempted due to environmental limitations

• Deleted “Does resident walk?” gateway question

• Multiple new functional assessment questions

Section GG – What is Changing?

• GG0100 Prior Function: Everyday Activities. Indicate the resident’s usual ability with everyday activities prior to the current illness, exacerbation or injury.

A. Self-Care: Code the resident’s need for assistance with bathing, dressing, using the toilet, or eating prior to the current illness, exacerbation, or injury (OT)

B. Indoor Mobility (Ambulation): Code the resident’s need for assistance with walking from room to room (with or without a device such as cane, crutch or walker) (PT)

C. Stairs: Code the resident’s need for assistance with internal or external stairs (with or without a device such as cane, crutch or walker) (PT)

D. Functional Cognition: Code the resident’s need for assistance with planning regular tasks, such as shopping, or remembering to take medication (ST)

Section GG – What is Changing?

• GG0110 Prior Device Use: Indicate devices and aids used by the resident prior to the current illness, exacerbation, or injury. Check all that apply (PT)

A.Manual wheelchair

B. Motorized wheelchair and/or scooter

C.Mechanical lift

D.Walker

E. Orthotics/Prosthectics

Z. None of the above

Section GG – What is Changing?

• Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to amount of assistance provided. Use of codes 07,09,10, or 88 is permissible to code discharge goal(s). Activities may be completed with or without assistive devices.

Section GG – What is Changing?06. Independent - Resident completes the activity by him/herself with no assistance from a helper.05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.If activity was not attempted, code reason:07. Resident refused09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)88. Not attempted due to medical condition or safety concerns

Section GG – What is Changing?

• GG0130 – Self Care (Assessment period is days 1-3 of SNF PPS stay)• Questions added

• E. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower- OT

• F. Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable- OT

• G. Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear- OT

• H. Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable- OT

Section GG – What is Changing?

• GG0170 – MobilityA. Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed-PT

G. Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt-PT

I. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space- PT- (new gateway question)- If admission performance is coded 07, 09, 10, or 88 Skip to GG0170M, 1 step (curb)

L. Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel- PT

M. 1 step (curb): The ability to go up and down a curb and/or up and down one step-PT

N. 4 steps: The ability to go up and down four steps with or without a rail- PT

O. 12 steps: The ability to go up and down 12 steps with or without a rail- PT

P. Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor- PT

Implications for Rehab

• Changes to how therapists approach treatment:

• Currently often operates from a perspective of -“what is the maximum amount of treatment that a resident can tolerate to achieve the outcomes necessary”

• Will need to shift to more of a focused intervention strategy - “what is the most cost effective way to deliver the care necessary to achieve the outcome?”

• Implement evidence based clinical programs that impact quality measures

A Different Approach to Delivery of Care

John Smith, a patient with a recent CVA, is admitted to your SNF.

• Previously lived at home

• Swallowing deficits

• Severe effect to his left side

• He has good home support and wants to return home. Despite this, you feel he has no better than a 50% chance of discharging to home.

• How should we plan his care in order to provide the best care cost efficiently?

A Patient-Centered Approach to Delivery of Care

Primary DX: unspecified left femur fracture due to fall- 4 day hospital stay

Secondary DX: acute pulmonary edema, history of falls, muscle weakness, reduced mobility, lack of coordination, COPD

• Some communication difficulties• BIMS score of 8- mild cognitive impairment• No symptoms of depression• No behavioral symptoms• PLOF: Supervision with functional transfers and ambulation without

AD, Supervision for ADLs• Current functional level:

o Mod assist eating, supervision oral hygiene, max assist toileting.o Max assist for bed mobility and transfers, dependent toilet

transfers. Unable to functionally ambulate.• Healing surgical wound present • Anticipated DC to home with assistance of spouse

Implications for Rehab

• How does this shift the staffing equation?

• Group and Concurrent

• Prioritizing treatment

• Necessary disciplines

• Timing of disciplines

• Treatment Intensity

• Volume of minutes provided

• By who and when?

• Who will own the overall care plan?

Implications for Rehab

• Length of Stay

• Possible downward pressure but unlikely due to modest rates of decline in the variable adjustment

• Historical trending

• How much variation in overall care volume will occur?

• What risk does this create?

• Patient population (targeted diagnoses)

• Will play more of a role in the structure and function of the department

If Minutes Don’t Matter…

• Then what do we track?

• Section GG (other functional scale)

• Length of Stay relative to functional improvement

• Care provision volume based on diagnostic and functional factors

• Rehospitalization rates

• Successful discharge to home

• Specific therapy interventions and associated outcomes

• Episodic cost vs revenue

Nursing Preparation

• Review the Medicare Benefit Policy Manual – Chapter 8• Accurate ICD 10 coding is KEY

• CMS will not provide any training

• It is your responsibility to ensure accurate coding

• Diagnosis coding certification

• Improved documentation• Documenting the resident’s need for skilled care

• Staffing• Evaluate your current clinical competencies

• Clinical pathways

• Is additional clinical training needed in order to be able to serve more clinically complex residents

Key Takeaways

• RUGs to be replaced by PDPM – October 1, 2019• Diagnostic and patient characteristic driven vs minute driven

• Divorces reimbursement from volume of service provision

• Nursing categories to carry heavier impact on reimbursement

• Diagnosis becomes a key payment driver

• PT, OT, and ST separated into different structure for payment classification

• MDS schedule will change. COTs not required

Key Takeaways

• Front loaded payment - after day 20, PT and OT decreases in payment 2% every 7 days

• Payment levels potential combinations increase –28,800

• Nursing documentation will have to get better

• Accurate completion of the MDS is ESSENTIAL especially ICD 10 coding

• Section GG• Plays a major role in therapy reimbursement components

• Significant expansion of Section GG reporting criteria effective October 1, 2018, will put further focus on functional outcomes.

The Transition to PDPM

“With regard to the comment about a patient that begins a stay under RUG-IV but ends under PDPM, given that there will be no transition period between RUG-IV and PDPM, providers would bill under RUG-IV for all days up to and including September 30, 2019 and then bill under PDPM for all days beginning October 1, 2019. Further, RUG-IV assessment scheduling and other RUG-IV payment-related policies would be in effect until September 30, 2019.

Beginning on October 1, 2019, all PDPM related assessment scheduling and other PDPM payment-related policies would take effect.”

• Quality Measures Respond to the Intervention

• Section GG Improves

• Rehospitalizations Decrease

• Return to Home Increases

• CMS is Tracking Outcomes!

??Questions

Navigating Your Way Through PDPM

Making a difference in the lives of those we serve

Chance Victoriano, PT, RAC-CT

Senior Director of Data and Clinical Advancement cvictoriano@therapymgmt.com

225-229-0299