PDPM ACADEMY – Business Solutions for Better Patient Care… · 2019-08-21 · 3/26/2019...

3/26/2019

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PDPM ACADEMY –Business Solutions for Better Patient Care

3/26/2019 IMPROVING LIVES BY DELIVERING SOLUTIONS FOR QUALITY CARE 1

PDPM Compliance and Ethics Guide & Assessment Tool

Presenters: Bill Ulrich, Janine Valdez, Dan Ciolek, & Mike

Cheek

Agenda

CMS RoP Compliance and Ethics Provision Serve as the Framework

Integrate PDPM Risk Areas into Existing Compliance and Ethics Work

as Part of Core Competency #4

Four themes of Risk Upon Which to Focus & High Risk Areas

AHCA Tools

PDPM High Risk Area Assessment

AHCA Compliance and Ethics Guide


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Count Down to PDPM Implementation As of March 26


Integrate PDPM into Current RoP Phase 3 Compliance & Ethics Work as Part of Core Competency #4 Efforts

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With New Flexibility, Comes New Risk


Patients Over Paperwork – CMS Balance Framework

Element PDPM Impact

Flexibility

• PDPM eliminates the RUGs MDS OMRA schedules offers more operational flexibility by freeing up staff time for more direct care coordination or care

• PDPM components, while numerous, allow providers to tailor services and related payments to patient needs and care design in a more targeted manner than RUGs IV

Transparency

• CMS “expects primary diagnosis on the SNF claim match the primary diagnosis coded in item I0020B” … while no hard edits will be in place1

• MDS Section GG Functional Items for Physical and Occupational Therapy and Nursing classification overlap except for two items – Oral Hygiene and Walking

• In addition to the Section GG items, above, CMS will have more clinical data to assess the appropriateness of care based on clinical characteristics which must be supported by medical documentation

Accountability

• “The new assessment schedule reduces provider burden while still providing enough data to accurately monitor provider behavior, changes in patient condition, and outcomes [emphasis added] via the 5-day assessment, IPA assessments, and discharge assessments2”

• “[CMS] agrees with commenters that quality and outcomes measures (like those in the SNF Quality Reporting Program) would be a positive way to evaluate the efficacy of therapy provision, and we will take this into consideration for future policy development3”


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CMS Expectations Under PDPM Elevate Long-Standing Requirements

• Physician Certification

• Skilled Benefit Requirements

• Supporting Medical Documentation

• Patient Engagement


PDPM Compliance In Context with SNF Benefit – Skilled Nursing and Rehabilitation


Source: Final Rule, Vol. 83, No. 153, page 39184

“As discussed in Chapter 8, Section 30 of the Medicare Benefit Policy

Manual (Pub. 100–02), to be covered, the services provided to a SNF

resident must be ‘‘reasonable and necessary for the treatment of a patient’s

illness or injury, that is, are consistent with the nature and severity of the

individual’s illness or injury, the individual’s particular medical needs, and

accepted standards of medical practice.’’ Therefore, we stated that services

which are not specifically tailored to meet the individualized needs and

goals of the resident, based on the resident’s condition and the evaluation

and judgment of the resident’s clinicians, may not meet this aspect of the

definition for covered SNF care, and we stated we believe that internal

provider rules should not seek to circumvent the Medicare statute,

regulations and policies, or the professional judgment of clinicians. (79 FR

45651 through 45652).”

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Core Competency # 4: Optimizing Resources

Overview of ROP Compliance Requirements: 42 CFR Section 483.85

• Written compliance and quality of care policies and procedures

• High-level program oversight

• Sufficient resources and authority to ensure compliance

• A screening process for positions with discretionary authority

• Effective communication of compliance standards to staff, contractors, and volunteers

• Procedures to promote compliance, such as auditing, monitoring, and an

anonymous reporting system

• Consistently enforced disciplinary actions

• Appropriate response to violations, and prevention of similar future violations

• An annual review and update of the compliance and ethics program


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Four PDPM Compliance Themes


1

2

3

4

Patient First Care Design

Accurate Assessment and Collection of Clinical Information at Admission

Integrity in Reporting and Documentation

Effective Monitoring and Auditing to Ensure Care Delivered to the Patient is Appropriate and Well Documented

Ensure Success by Following the Four PDPM Compliance Principles

Patient First Care Design

Holistic care planning is at the core of service delivery

Patient Voice clearly is documented

Overlay with Requirements of Participation Comprehensive

Person-Centered Plan of Care

Accurate Assessment & Collection of

Clinical Information

Proficiency and accurate approach to determining ARD and

coding initial diagnoses, comorbidities, as well as nursing

and NTA services received throughout stay

Appropriate use of Interim Payment Assessments

Appropriate use of Interrupted Stays

Effective Monitoring and Auditing to

Ensure Care Delivered to the Patient is

Appropriate and Well Documented

System to ensure that information on admission MDS,

matches information on any IPA Changes

IMPACT Act QRPs Are Evidence of Quality Care

Interrupted Stay-Based Changes

Discharge ICD-10 coding and MDS Discharge Assessment


Accurate documentation in care planning reflects needs

Communication among staff to ensure consistency in

assessment and documentation

Appropriate billing only for the services that are indicated,

rendered and which are fully documented in the patient’s

medical record


1 2

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Patient-First Care is Key


Sources: CMS PDPM Webinar (12/11); Final Rule, Page 39189

To develop a baseline care plan

within 48 hours of admission to

direct the care team while a

comprehensive care plan is

developed that incorporates the

resident’s goals, preferences, and

services that are to be furnished to

attain or maintain the resident’s

highest practicable physical, mental,

and psychosocial well-being.

Sources: Section 483.21, Final Rule Page 652

PDPM Drives “Holistic” Patient Assessment

Comprehensive Person-

Centered Care Planning Baseline

Care Plan Audit Checklist

RoP-Required Comprehensive Person-Centered Care Planning

Available at ahcancalED

OIG Expectations on Patient-First Nursing facilities should ensure that care planning includes all disciplines involved in the resident’s care. Perfunctory meetings or plans developed without the full clinical team may create less than comprehensive resident-centered care plans.

Facilities should design measures to ensure an interdisciplinary and comprehensive approach to developing care plans. Basic steps, such as appropriately scheduling meetings to accommodate the full interdisciplinary team, completing all clinical assessments before the meeting is convened,41 opening lines of communication between direct care providers and interdisciplinary team members, involving the resident and the residents’ family members or legal guardian

Another risk area related to care plans includes the involvement of attending physicians in resident care. Although specific regulations govern the role and responsibilities of attending physicians, the nursing facility also has a critical role—ensuring that a physician supervises each resident’s care.


• 2008 Federal

Register,

Page 56837

• CFR 483.21

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“[W]e expect that these diagnoses should match ….”*


Alignment and/or Supporting Documentation for Changes

Alignment

Primary Diagnosis at Admission

UB-04 Primary Diagnosis

Physician Recertification

Primary Reason for SNF Care

Nurse Daily Documentation of Skilled Care

Needs

Diagnosis Alignment and Supporting Medical Documentation

*Source: PDPM FAQs, February 14, 2019 Update. FAQ #1.8 – No hard edits on October 1, 2019 but CMS will monitor



High Risk Behavior

Examples Motivation Implications

Upcoding Revenue

Maximization

CMS will have a direct line of sight via ICD-10 and other

MDS document

Downsizing TherapyOverhead

Reduction

CMS is clear the SNF benefit and cover requirements

remain the same and will be monitoring for outcomes (e.g.,

QRPs)

Over-Use of

Interrupted Stay

Restart Variable

Per Diem

Risk of being placed under “heighten scrutiny”

Vague IPA Trigger

Definition

Room to Argue +/-

in CMGs and Rates

Any changes in CMGs using and IPA should be supported

by ample clinical documentation

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High Risk Areas & Recommended Assessment Format


Model High Risk Compliance Area Assessment Format


Compliance Area: [INSERT COMPLIANCE AREA NAME]

CMS Citations and Language: • IDENTIFY AND INSERT CMS REGULATORY LANGUAGE USING AN INTERDISCPLINARY APPROACH (E.G.,

CLINCAL STAFF, THERAPY STAFFMDS EXPERTS, PAYMENT AND BILLING, COMPLIANCE, AND ADMINISTRATION)

• SEVERAL SOURCES SHOULD BE EXPLORED: FY19 FINAL RULE, RAI MANUAL UPDATE – MAY 2019 (TO BE RELEASED), INTERIM PAYMENT ASSESSMENT ITEMS FORM, 2019 MDS, RoPs

SNF Compliance Strategy (e.g., monitoring, auditing, testing):

Strategy SNF Lead Operations Statements on how a SNF will operationalize monitoring, auditing and testing Lead Staff or Bodies

Insert Additional Items Insert Insert Additional Items Insert Insert Additional Items Insert

Compliance Define specific compliance approach – data, monitoring schedule, correction planning Lead Staff Insert Additional Items as Needed Insert Additional Items

as needed

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ICD-10 Coding


Compliance Area: ICD-10 Coding

CMS Citations and Language:

Page 39198 of Federal Register “...ICD-10 provides the most accurate coding and diagnosis information on patients…”

Page 39189 of Federal Register: “With regard to the potential consequences of ICD-10 coding errors on RAC audits, as under the current payment system, 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 as occur today.”

Page 39199 of Federal Register “…we believe that one of these reasons prompted transfer to the SNF. This reason would function as the patient’s primary diagnosis, as it represents the primary reason for the patient being in the SNF.”

Page 39200 of Federal Register “However, CMS recognizes that in many cases, the primary reason for the SNF care may not be the primary reason for the prior inpatient hospital stay.” “PDPM requires facilities to code the diagnosis that corresponds most closely to the primary reason for the SNF care….”

ICD-10 Action Steps SNF Compliance Strategy (e.g., monitoring, auditing, testing):


Strategy SNF Lead

Operations

Provide ICD-10 coding training to designated staff. Determine frequency of ongoing ICD-

10 education and methods to train necessary new staff as they are on boarded.

TBD

Determine process to obtain source documentation necessary to assign appropriate ICD-

10 code related to the primary reason the patient is in the SNF for a Medicare stay.

Interdisciplinary

team

Identify person or person(s) who will be responsible for assigning ICD-10 codes TBD

Compliance

Review appropriateness and accuracy of ICD-10 codes as part of Triple Check Process Triple Check Team

Consider external audit of ICD-10 codes as part of compliance plan; appropriate code

used with supporting documentation maintained

Compliance team

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Resident Interviews


Compliance Area: Resident Interview(s)

CMS Objective: Care design should be driven by patient goals and needs as well as discussions with the patient and his or her family.

CMS Citations and Language: Final Rule FR Page 39189: “…PDPM provides a more holistic approach to payment classifications. More specifically, by separately adjusting for

the nursing component, which utilizes patient interviews as a major component of patient classification.”

RAI 3.0 User Manual (10/1/18 Version) Page 1-11: “The goals of the MDS 3.0 revision are to …increase the resident’s voice by introducing more

resident interview items.”

RAI 3.0 User Manual (10/1/18 Version) Appendix D: “All residents capable of any communication should be asked to provide information

regarding what they consider to be most important facets of their lives. There are several MDS 3.0 sections that require direct interview of the

resident as the primary source of information. Staff should actively seek information from the resident…”

42 CFR 483.21 (10/1/18 Edition) Comprehensive Person-Centered Care Planning

Resident Interviews SNF Compliance Strategy (e.g., monitoring, auditing, testing):

Strategy SNF Lead

Operations Train personnel responsible for conducting resident interviews for MDS purposes TBD

Develop policy and procedures to assure occurrence of and accountability for the resident interview process at

each assessment

TBD

Develop and implement monitoring strategy to assure adherence to policy TBD

Assure timely, complete and accurate documentation of resident interview data TBD

Compliance Develop and implement Audit Tool to consider both Output and Outcome Measures

1. Example Output Measure – Did personnel complete resident interview per policy?

2. Example Outcome Measure – Was effective Care Plan created based upon information obtained during the

resident interview(s)?

Compliance Dept.

Document and Report Audit findings to Operations Team and Senior Leadership Compliance Officer


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Other Key High Risk Areas

Diagnosis• CMS monitoring at Admission and

subsequent changes

• Expectation of Alignment

Daily Skilled Care

• Assure each Medicare Part A resident in the skilled nursing facility meets the SNF coverage criteria

• Daily need for “skilled” care after an medically appropriate qualifying hospital stay.


Other High Risk Areas


Resource Underutilization

• PDPM classifies patients for purposes of reimbursement based on the resource utilization associated with treating those patients.

• CMS expects the payment system to change, not the patients

• Will be monitoring for substantial services changes and will look for supporting medical documentation monitored.

Interrupted Stay

• CMS explained that application of the variable per diem adjustment is of particular concern

• Addition of the Interrupted Stay Policy is intended to mitigate inappropriate attempts to restart the variable per diems

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Interim Payment Assessment

• CMS assumes stable patient characteristics

• IPA is optional and will be completed when providers determine that the patient has undergone a significant clinical change

• Expected to be infrequent

Upcoding

• PDPM creates new flexibility to develop patient-centered plans

• New flexibility creates new risk via an array of coding options

• CMS will be monitoring certain key upcoding risk areas carefully – depression, mechanically altered diet and others



Functional Status – Section

GG

• Section GG drives payment in three of the five clinical components of PDPM

• Section GG item overlap can be easily monitored

• CMS is increasing focused on Section GG for quality reporting metrics

Therapy Modalities

• CMS’ goal is to ensure delivery the appropriate amount of therapy to each resident based on the clinical needs of the resident – stinting will be monitored and addressed

• And, to assure that no more than 25% of therapy minutes by discipline is delivered using group and concurrent therapy

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Inappropriately Short Lengths

of Stay

• PT, OT and NTAS variable per diems are intended to better tailor relative resource use of the course of a stay to patients’ individuals needs

• CMS’ does not intend the variable per diem to serve as an incentive to shorten lengths of stay to the degree that patient health, safety, welfare and quality outcomes negatively are impacted

Addressing Risk Through Monitoring and Auditing


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Monitoring and Auditing Framework

Key Risk Area Source Risk

Level

Training,

Policies

Procedures

Monitoring

Tool

Auditing Tool Comments

Quality of Care

Appropriate use of

Psychotropic Drugs

Fed Reg 2008

Page 56838

Policies and

procedures that

outline best

practice

Consultant

Pharmacist monthly

review for

inappropriate use

Pre-Survey Focus on staff

training

Medication Management Fed Reg 2008

Page 56837

Policy and

procedure

outline process

to accurately

acquire, receive,

dispense and

administer

Medications

Consultant

Pharmacist monthly

review for

medication errors

Pre-Survey Focus on staff

training.


Example from Tool in Compliance Guide

Work Planning Inclusively and With a Deliberate Sense of Urgency


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• Aligned With Other Related SNF Compliance Efforts

• Mapped Against Key Risk Areas

• Timed with Realistic Capacity Building through Education

• Inclusively to Ensure Buy-In at All Levels

• With a Progress Monitoring and Auditing Plan

• Expressed Commitment to Getting it Right!

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AHCA Compliance & Ethics Toolkit


1. Go to ahcancal.org

2. Login using ahcancal.org Username and Password

3. Scroll down to ahcancalED

4. Search for Toolkit and Download

• Measures to watch in LTC Trend Tracker:

• Discharge to Community (AHCA)

• Length of Stay (AHCA)

• SS Improvement in Function, Risk Adjusted (Five Star)

• LS ADL Decline (Five Star)

• LS Worsening Mobility (Five Star)

• Medicare Spending per Beneficiary (QRP)

• Discharge to Community (QRP)

• SS Improvement in Self-Care (AHCA – coming soon!)

• SS Improvement in Mobility (AHCA – coming soon!)

• SS Discharge to Community (Five Star)

• Change in self-care (QRP – coming next year)

• Change in mobility (QRP – coming next year)

• Discharge self-care score (QRP – coming next year)

• Discharge mobility score (QRP – coming next year)

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Count Down to PDPM Implementation As of March 26


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Have We Addressed Questions & Concerns?


PDPM ACADEMY –Business Solutions for

Better Patient Care


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PDPM ACADEMY – Business Solutions for Better Patient Care… · 2019-08-21 · 3/26/2019...

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Transcript of PDPM ACADEMY – Business Solutions for Better Patient Care… · 2019-08-21 · 3/26/2019...