PDPM Clinical Update JWB · 1 PDPM Clinical Update One Month In Nov 2019 Judy Wilhide Brandt, RN,...

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1 PDPM Clinical Update One Month In Nov 2019 Judy Wilhide Brandt, RN, BA, CPC, QCP, RAC‐MT, DNS‐CT 909‐800‐9124 [email protected] JudyWilhide.com 1 And you shall rise and show respect to the aged Facebook: /WilhideConsulting Objectives Review the clinical components of the PDPM rate to discussion lessons learned so far Discuss strategic ARD setting Examine the interrupted stay Factors to consider in IPA Discuss findings from review of initial IPA and 5 day submissions from around the country 2 1 2

Transcript of PDPM Clinical Update JWB · 1 PDPM Clinical Update One Month In Nov 2019 Judy Wilhide Brandt, RN,...

Page 1: PDPM Clinical Update JWB · 1 PDPM Clinical Update One Month In Nov 2019 Judy Wilhide Brandt, RN, BA, CPC, QCP, RAC‐MT, DNS‐CT 909‐800‐9124 judy@judywilhide.com

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PDPM Clinical UpdateOne Month InNov 2019

Judy Wilhide Brandt, RN, BA, CPC, QCP, RAC‐MT, DNS‐CT

909‐800‐9124

[email protected]

JudyWilhide.com

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And you shall rise and show respect to the aged

Facebook:  /WilhideConsulting

Objectives

• Review the clinical components of the PDPM rate to discussion lessons learned so far

• Discuss strategic ARD setting

• Examine the interrupted stay

• Factors to consider in IPA

• Discuss findings from review of initial IPA and 5 day submissions from around the country

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Primary Diagnosis Clinical Category Findings

• MD documentation of diagnosis is specific and supported, but ICD 10 code assigned is incorrect.

• Reasons:• Failure to follow ICD 10 coding guidelines

• Relying on software scrubbers to direct coding

• Primary Diagnosis documented in chart, but not selected as primary.

• Reasons:• Software scrubber directs to another code that is not the primary

• Misunderstanding of what can be used as primary

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Primary Diagnosis Clinical Category Findings

• Using MD documented diagnoses that are flat out wrong

• Reasons:• Believing the MD documentation, e.g “morbid obesity” pasted from a “past history” dx list when resident is 5’2” and 102 lbs.

• MD documentation is not supported by clinical record and MD is not queried.  E.g “viral pneumonia” with labs that clearly show S. pneumoniae bacteria

• Ineffectively dealing with return to provider primary diagnoses

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Incorrect use of the Z47.‐ series of ICD 10 codes

Z47 Orthopedic aftercare

• Excludes1: aftercare for healing fracture‐code to fracture with 7th character D

• Z47.1 Aftercare following joint replacement surgery• Use additional code to identify the joint (Z96.6‐)

• Z47.2 Encounter for removal of internal fixation device• Excludes1: 

• encounter for adjustment of internal fixation device for fracture treatment‐ code to fracture with appropriate 7th character; 

• encounter for removal of external fixation device‐ code to fracture with 7th character D

• infection or inflammatory reaction to internal fixation device (T84.6‐)

• mechanical complication of internal fixation device (T84.1‐)

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Z47‐ Continued

• Z47.3 Aftercare following explantation of joint prosthesis• Aftercare following explantation of joint prosthesis, staged procedure

• Encounter for joint prosthesis insertion following prior explantation of joint prosthesis

• Z47.31 Aftercare following explantation of shoulder joint prosthesis

• Excludes1:

• acquired absence of shoulder joint following prior explantationof shoulder joint prosthesis(Z89.23‐)

• shoulder joint prosthesis explantation status (Z89.23‐)

• Z47.32 Aftercare following explantation of hip joint prosthesis

• Excludes1: 

• acquired absence of hip joint following prior explantation of hip joint prosthesis (Z89.62‐)

• hip joint prosthesis explantation status (Z89.62‐)

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Z47.‐ Continued

• Z47.33 Aftercare following explantation of knee joint prosthesis

• Excludes1: 

• acquired absence of knee joint following prior explantationof knee prosthesis (Z89.52‐

• knee joint prosthesis explantation status (Z89.52‐)

• Z47.8 Encounter for other orthopedic aftercare• Z47.81 Encounter for orthopedic aftercare following surgical amputation

• Use additional code to identify the limb amputated (Z89.‐)

• Z47.82 Encounter for orthopedic aftercare following scoliosis surgery

• Z47.89 Encounter for other orthopedic aftercare

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Excludes1 NOT CODED HERE.  Excluded code(s) should never be used at the same time as the code above the “Excludes1” note.

Excludes2 Not included here.  Condition is not part of the condition represented by the code, but patient may have both at the same time.

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Example:

• Hip replacement due to DJD:  Z47.1

• Hip replacement due to fall and fracture:  S72.xxxD

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Incorrect ICD 10 code examples

• I0020B:  B00.1 Herpesviral vesicular dermatitis

• Code supported by MD documentation: B00.4 herpesviral encephalitis

• System failure:  Coder using dropdown box in MDS software to assign ICD 10 code without a coding book, saw herpesvir….. And clicked one.

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J2100: Recent Surgery

• Issues:

• Not checking the box when it applied

• Checking the wrong box

• Checking multiple boxes when there was only one surgery

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Coding Instructions

• Code 1, Yes: if the resident had major surgery during the inpatient hospital stay that immediately preceded the resident’s Part A admission.

Coding Tips

• Generally, major surgery for item J2100 refers to a procedure that meets the following criteria:

• 1. the resident was an inpatient in an acute care hospital for at least one day in the 30 days prior to admission to the skilled nursing facility (SNF), and

• 2. the surgery carried some degree of risk to the resident’s life or the potential for severe disability.

• The surgeries in this section must have been documented by a physician (nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 30 days and must have occurred during the inpatient stay that immediately preceded the resident’s Part A admission.

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ICD 10 coding, compliance and reimbursement:A case study

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Case data:86 year-old female with past medical history:

–Diabetes mellitus Type 2–Hypertension–COPD–Coronary artery disease

Clinical Data Documented in hospital record• Found down/unresponsive at home• Blood pressure 76/50• Respiratory rate 8• Heart rate 105• Temperature 104 degrees• Saturation on non-rebreather 87%• Chest x-ray negative• Complete blood cell count: white blood cell count 42,000• Basic metabolic profile: BUN 62, creatinine 3.4• Urinalysis: turbid urine, 4+ leuk esterase, > 50 WBCs, 4+ bacteria

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Clinical Treatment Documented• Treatment:

–Pt was given 3 liters fluid–Levophed drip (BP Support)–Vancomycin IV–Intubated & on ventilator

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What Was Documented in the hospital H&P and progress notes on day 2 of hospitalization

1.Urinary tract infection: vancomycin, cultures obtained.2.After ventilation, continue oxygen for COPD 2L NC3.Diabetes mellitus Type 2: monitor blood sugar, insulin started.4.Bacteremia: due to #1, continue to monitor CBC & continue antibiotic

therapy.5.Hypotension: probable due to urinary tract infection, give fluids and

levophed drip.6.Elevated BUN/creatinine: acute kidney injury vs. renal insufficiency.

Baseline creatinine from previous admission is 1.0.

SNF did not get any other hospital records.  No DC summary.

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Primary Diagnosis:  UTI N39.0Secondary:  Bacteremia R78.81Diabetes 2: E11.9Dependence on insulin: Z79.4Disorder of kidney and ureter: J28.9Essential hypertension: I10COPD: J44.1Dependence on oxygen:  Z99.81

SNF Diagnosis list upon admission from hospital:

MD, Nursing, PT, OT and ST evaluate and find:• Substantial Max assist with eating, oral hygiene, • Dependence (2 person assist)toileting hygiene, sit to stand, lying to sitting, sit 

to lying, toilet transfer, chair to bed• Did not attempt due to medical concern:  sit to stand, walking• PT/OT FS 2.  Nsg FS 1

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MD, Nursing, PT, OT and ST evaluate and find:• Substantial Max assist with eating, oral hygiene, • Dependence (2 person assist)toileting hygiene, sit to stand, lying to sitting, sit 

to lying, toilet transfer, chair to bed• Did not attempt due to medical concern:  sit to stand, walking• PT/OT FS 2.  Nsg FS 1• Resident has difficult swallowing regular consistency diet when tray presented 

upon admission, downgraded to mechanically altered by evening shift nursing. • SLP evaluation:  dysphagia begins treatment• BIMS on day 2:  10• BIMS on day 7: 13• PHQ9 day 2:  10• PHQ9 day 7:  2• IV medication for UTI continues in SNF• O2 2L NC

ARD Day 7: (Used interviews from day 7)

18Urban unadjusted rates

Compo

nentCMG CMI

Base 

Rate

Total day 

1 ‐3

Totally 

day 4‐20

PT TI 1.13 61.16 69.11 69.11

OT TI 1.17 56.93 66.61 66.61

SLP SC 2.66 22.83 60.73 60.73

Nsg CDE1 1.62 106.64 172.76 172.76

NTA NB 2.53 80.45 610.62 203.54

NCM 95.48 95.48 95.48

1075.30 668.22

Total: 1053.79 654.86(VBP -2%)

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Acute on chronic kidney failure Severe sepsis

What SNF Diagnosis list could have been:Primary Diagnosis:  UTI N39.0 Secondary:Severe Sepsis: R65.20*  Diabetes 2 with kidney disease: E11.22CKD: N18.9Dependence on insulin: Z79.4Disorder of kidney and ureter: J28.9HTN and CKD: I12.9COPD: J44.1Dependence on oxygen:  Z99.81

*RTP

What was on hospital DC summary after CDI

ARD on day 3, used earlier interviews, sepsis in I2100, Got PCP records and established diabetic retinopathy and risk of malnutrition

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Compo

nentCMG CMI

Base 

Rate

Total day 

1 ‐3

Totally 

day 4‐20

PT TI 1.13 61.16 69.11 69.11

OT TI 1.17 56.93 66.61 66.61

SLP SF 2.97 22.83 67.81 67.81

Nsg HDE2 2.39 106.64 254.87 254.87

NTA NA 3.25 80.45 784.39 261.46

NCM 95.48 95.48 95.48

1338.26 815.34

Total: 1311.50 799.03(VBP -2%)

+257.71 x 3 days+144.17 x 17 days= +3,224.00

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Discussion?

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Function Score:  For PT/OT and Nursing

• Issues:• Support not found

• Multiple GG assessments found in lookback, not identical, record does not indicate that one is more important than any other

• GG used for coding was not entered into medical record

• Using CNA ADL (from G) documentation to complete GG

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Free GG video CMS web based training

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SLP

• Tier One:• Acute Neuro• SLP Co‐morbidity• Cognitive Impairment

• Issues:• Using an acute neuro as primary specifically to get the SLP points when it’s not primary.

• Pulling Parkinson’s Disease up to primary when it was a hip fracture.  

• PT/OT/SLP Other Ortho, FS 10‐23, 0 SLP: $216.54• PT/OT/SLP Acute Neuro, FS 10‐23, 1 tier One, neither: $221.02• $4.50/day• With two tier one:  $17.71/day (Acute Neuro and BIMS)• With three tier one: $16.34 (Acute Neuro, BIMS and SLP Comorbidity

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SLP

• Comorbidity issues:• Dysphagia:  What counts, what doesn’t

• Putting any dysphagia that is not I69.‐, is not a comorbidity

• I4500:  CVA, TIA, Stroke:  Checking when it isn’t active in 7 day lookback.

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The resident had a stroke 4 months ago and continues to have left-sided weakness, visual problems, and inappropriate behavior. The resident is on aspirin and has physical therapy and occupational therapy three times a week. The physician’s note 25 days ago lists stroke.Coding: Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or Stroke item (I4500), would be checked.Rationale: The physician note within the last 30 days indicates stroke, and the resident is receiving medication and therapies to manage continued symptoms from stroke.

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SLP

• Cognitive Impairment Issues:• Not doing the BIMS very early in stay

• Inaccurate coding for C1000:  Cognitive skills for daily decision making when there is no interview

• Not doing the staff assessment for cognition with 5 day/Discharge/Unplanned if interviewable.  

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BIMS staff assessment

• Do not complete the Staff Assessment for Mental Status items (C0700‐C1000) if the resident interview should have been conducted, but was not done.

• ..only in the case of PPS assessments, staff may complete the Staff Assessment for Mental Status for an interviewable resident when the resident is unexpectedly discharged from a Part A stay prior to the completion of the BIMS. 

• In this case, the assessor should enter 0, No in C0100: Should Brief Interview for Mental Status Be Conducted? and proceed to the Staff Assessment for Mental Status.

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The intent of this item is to record what the resident is doing (performance). Focus on whether or not the resident is actively making these decisions and not whether staff believes the resident might be capable of doing so.Focus on the resident’s actual performance. Where a staff member takes decision-making responsibility away from the resident regarding tasks of everyday living, or the resident does not participate in decision making, whatever his or her level of capability may be, the resident should be coded as impaired performance in decision making.

• Code 1, modified independence: if the resident organized daily routine and made safe decisions in familiar situations, but experienced some difficulty in decision making when faced with new tasks or situations.

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Mild impairment is at least:

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SLP

• s/s swallowing disorder

• Issues:• Believing a diagnosis will apply here

• Inaccurate coding in K0100• Resident states he chokes when eating nuts or leafy vegetables

• Resident reports difficult swallowing

• Resident states he doesn’t eat barbeque because he chokes on it.

• Coding K0100 from a SLP evaluation when there was no actual food/liquid/medications consumed during that eval.

• Coding from a daily SLP note that is not in the medical record.

• The actual K0100 issues must occur during the lookback to check the box.

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Nursing CMG Issues

• Checking CMG boxes without support in the medical record

• SOB lying flat because there is an order for O2• No system to collect SOB lying flat• Surgical wound when there is not one• No evidence of diagnosis being active in lookback:  CVA, pneumonia

• Not getting a diagnosis of respiratory failure when oxygen being used

• Not setting ARD close to start of stay to capture sepsis, pneumonia, IV fluid for nutrition or hydration

• Not doing the PHQ9 as soon as possible when they are still sad

• Not setting ARD to capture high dollar items

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Financial Impact of Nursing CMG

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Using FY2020 Urban Unadjusted

Discussion

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NTA CMG Issues

• Being unfamiliar with the NTA list, not capturing diagnoses/services from the record onto the MDS

• Checking a diagnosis checkbox, and not adding the ICD 10 code when the code is what gives the NTA point

• E.g. ‘respiratory failure in I6300 and not coding J96.‐ in I8000.• Or, codingJ96.‐ in I8000 for the NTA point and failing to check I6300 (with O2 Special Care Low)

• Not understanding which ICD 10 codes in a category (e.g. opportunistic infections) actually give NTA points

• Not taking advantage of the “O2 package”

• Not considering Nsg/NTA as a package

• Not carefully reading and capturing complex medical situations from hospital records and other sources.

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Go to spreadsheet

Oxygen Package

• Oxygen is not for COPD or pneumonia.• Many people have those and do not need oxygen.

• Oxygen is for the respiratory failure (acute or chronic or both) that resulted from those conditions.

• If oxygen is ordered, we must query the provider for a respiratory failure diagnosis.  Then we have 1 NTA point and Special Care Low.  

• If COPD and SOB lying flat (Special Care High)

• If pneumonia and fever (Special Care High)

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CMI Rate 0 NTA points NTA/NSG

Oxygen and NFS 6‐

17, No depression 1.34 142.90 0.72 57.92 200.82

1‐2 NTA points (J96.‐ in I8000)

Respiratory Failure, 

O2, NFS 6‐14, No 

depression 1.43 152.50 0.96 77.23 229.73

28.91

COPD & SOB Lying 

flat, NFS 6‐14, No 

depression 1.85 197.28 0.96 77.23 274.52 73.69

COPD & SOB Lying 

flat, NFS 6‐14, 

Depression 1.99 212.21 0.96 77.23 289.45 88.62

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Check J1100C: if shortness of breath or trouble breathing is present when the resident attempts to lie flat. Also code this as present if the resident avoids lying flat because of shortness of breath.

1. Mrs. W. has diagnoses of chronic obstructive pulmonary disease (COPD) and heart failure. She is on 2 liters of oxygen and daily respiratory treatments. With oxygen she is able to ambulate and participate in most group activities. She reports feeling “winded” when going on outings that require walking one or more blocks and has been observed having to stop to rest several times under such circumstances. Recently, she describes feeling “out of breath” when she tries to lie down.Coding: J1100A and J1100C would be checked.Rationale: Mrs. W. reported being short of breath when lying down as well as during outings that required ambulating longer distances.

Get input from therapy

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Cardio Respiratory failure and shock:  1 NTA point

• Coding Tips

• Fever: Fever is defined as a temperature 2.4 degrees F higher than baseline. The resident’s baseline temperature should be established prior to the Assessment Reference Date.

• Fever assessment prior to establishing base line temperature: A temperature of 100.4 degrees F (38 degrees C) on admission (i.e., prior to the establishment of the baseline temperature) would be considered a fever.

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Fever and Special Care High

• Fever AND• Pneumonia OR

• weight loss OR

• Vomiting OR

• Qualifying feeding tube (51% calories OR 26% calories and 501 cc fluid) in the entire seven days, to include prior to admission.

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Weight Loss:  Either MD Dx or Not count with fever for Special Care High

• Steps for Assessment for K0200B, Weight

• 1. Base weight on the most recent measure in the last 30 days.

• 2. Measure weight consistently over time in accordance with facility policy and procedure, which should reflect current standards of practice (shoes off, etc.).

• 3. For subsequent assessments, check the medical record and enter the weight taken within 30 days of the ARD of this assessment.

• 4. If the last recorded weight was taken more than 30 days prior to the ARD of this assessment or previous weight is not available, weigh the resident again.

• 5. If the resident’s weight was taken more than once during the preceding month, record the most recent weight.

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Weight LossFor a New Admission

• 1. Ask the resident, family, or significant other about weight loss over the past 30 and 180 days.

• 2. Consult the resident’s physician, review transfer documentation, and compare with admission weight.

• 3. If the admission weight is less than the previous weight, calculate the percentage of weight loss.

• 4. Complete the same process to determine and calculate weight loss comparing the admission weight to the weight 30 and 180 days ago.

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Morbid Obesity:  1 NTA point

• Provider must document “Morbid obesity” for E66.‐

• Provider diagnosis alone is sufficient, even if BMI <40

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E6601 Morbid (severe) obesity due to excess calories E662 Morbid (severe) obesity with alveolar hypoventilation Z6841 Body mass index (BMI) 40.0-44.9, adult Z6842 Body mass index (BMI) 45.0-49.9, adult Z6843 Body mass index (BMI) 50-59.9 , adult Z6844 Body mass index (BMI) 60.0-69.9, adult Z6845 Body mass index (BMI) 70 or greater, adult

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Malnutrition or risk for malnutrition:  1 NTA

• I5600, malnutrition (protein or calorie) or at risk for malnutrition

• Required: Provider documentation: “Malnutrition” or “Risk for Malnutrition”

• There is no dx code for “Risk for Malnutrition” but there is a checkbox.  

• Failure to Thrive is RTP, malnutrition is Medical management.

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Position of the Academy of Nutrition and Dietetics: Individualized Nutrition Approaches for Older Adults: Long‐Term Care, Post‐Acute Care, and Other Settings 

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https://jandonline.org/article/S2212‐2672(18)30154‐0/pdf

JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS, April 2018 Volume 118 Number 4 

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45https://jandonline.org/article/S2212‐2672(18)30154‐0/pdf

47 – 62% at risk of malnutrition in LTC

Malnutrition/dehydration package

• IV fluid, while or while not a resident in K0510A1 or 2 = Special Care High

• Malnutrition 1 NTA Point

• If risk for dehydration, likely risk for malnutrition

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• Coding Tips for K0510A

• K0510A includes any and all nutrition and hydration received by the nursing home resident in the last 7 days either at the nursing home, at the hospital as an outpatient or an inpatient, provided they were administered for nutrition or hydration.

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• Parenteral/IV feeding—The following fluids may be included when there is supporting documentation that reflects the need for additional fluid intake specifically addressing a nutrition or hydration need. This supporting documentation should be noted in the resident’s medical record according to State and/or internal facility policy:

• — IV fluids or hyperalimentation, including total parenteral nutrition (TPN), administered continuously or intermittently

• — IV fluids running at KVO (Keep Vein Open)• — IV fluids contained in IV Piggybacks• — Hypodermoclysis and subcutaneous ports in hydration therapy• — IV fluids can be coded in K0510A if needed to prevent dehydration if the additional fluid intake is specifically needed for nutrition and hydration. Prevention of dehydration should be clinically indicated and supporting documentation should be provided in the medical record.

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• The following items are NOT to be coded in K0510A:

• — IV Medications—Code these when appropriate in O0100H, IV Medications.

• — IV fluids used to reconstitute and/or dilute medications for IV administration.

• — IV fluids administered as a routine part of an operative or diagnostic procedure or recovery room stay.

• — IV fluids administered solely as flushes.

• — Parenteral/IV fluids administered in conjunction with chemotherapy or dialysis.

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Examples

• 1. Mrs. H is receiving an antibiotic in 100 cc of NS via IV. She has UTI, fever, abnormal lab results (e.g., new pyuria, microscopic hematuria, urine culture with growth >100,000 colony forming units of a urinary pathogen), and documented inadequate fluid intake (i.e., output of fluids far exceeds fluid intake) with signs and symptoms of dehydration. She is placed on the nursing home’s hydration plan to ensure adequate hydration. Documentation shows IV fluids are being administered as part of the already identified need for additional hydration.

• Coding: K0510A would be checked. The IV medication would be coded at IV Medications item (O0100H).

• Rationale: The resident received 100 cc of IV fluid and there is supporting documentation that reflected an identified need for additional fluid intake for hydration.

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• 2. Mr. J is receiving an antibiotic in 100 cc of normal saline via IV. He has a UTI, no fever, and documented adequate fluid intake. He is placed on the nursing home’s hydration plan to ensure adequate hydration.

• Coding: K0510A would NOT be checked. The IV medication would be coded at IV Medications item (O0100H).

• Rationale: Although the resident received the additional fluid, there is no documentation to support a need for additional fluid intake.

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Infection Package:

• IV Medications:  5 NTA points• Opportunistic infections: (Specific list of codes) 2 NTA points

• Wound infection checkbox:  2 NTA points• MDRO infection checkbox: 1 NTA point• M86‐ Kinds of osteomyelitis: 2 NTA points

• Acute  or chronic Hematogenous• Other Acute or chronic• Subacute• Chronic Multifocal• Other Chronic• Chronic with draining sinus• “Other”. Not specified as acute or chronic• M86.9 Osteomyelitis unspecified

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Infection Package:

• Endocarditis:  Certain ICD 10 codes – 1 NTA point

• D70.3 Neutropenia due to infection ‐ 1 NTA point

• Nursing CMG: • Special Care High:  Septicemia, Fever and Pneumonia, Fever and vomiting, 

• Special Care Low:  Foot infection (Also NTA point)

• Clinically Complex:  IV medication while a resident, pneumonia (no fever)

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• IV med 5 + MDRO 1  + wound infection 2 + osteomyelitis 2 + risk of malnutrition 1 = 11 points

54Add COPD or Diabetes ‐ NA

NTA

NC 1.85 80.45 148.83

NB 2.53 80.45 203.54 54.71

NA 3.25 80.45 261.46 112.63

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NTA

NC 1.85 80.45 148.83

NB 2.53 80.45 203.54 54.71

NA 3.25 80.45 261.46 112.63

CMI Rate  5 NTA points NTA/NSG

Clinically Complex, 

6‐14  No depression 1.34 142.90 1.34 107.80 250.70

6‐8  NTA points 

Special Care Low, 

NFS 6‐14, No 

depression 1.43 152.50 1.85 148.83 301.33

9 ‐ 11 NTA Points 50.63

Special Care High, 

NFS 6‐14, No 

depression 1.85 197.28 2.53 203.54 400.82 150.12

Special Care High, 

NFS 6‐14, 

Depression 1.99 212.21 2.53 203.54 415.75 165.05

Cancer Package

• Clinically Complex minimum

• Opportunistic Infections:  2 NTA• E.g., Esophageal candidiasis 

• CML: 2 NTA (Can get this from prolonged chemo/radiation)

• Refractory anemia:  1 NTA

• Other myelodysplastic syndromes: 1 NTA

• Myelofibrosis: 1 NTA

• Antineoplastic chemotherapy induced pancytopenia: 1 NTA

• Agranulocytosis secondary to cancer chemotherapy: 1 NTA

• Acute pulmonary manifestations due to radiation: 1 NTA 

• Chronic and other pulmonary manifestations due to radiation: 1 NTA

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Complication Package

• M96.‐ Fracture of bone following insertion of orthopedic implant, joint prosthesis, or bone plate

• T84.‐• Implanted joint complications:

• Broken, loose, instability, dislocation, periprosthetic osteolysis (bone destruction), wear of bearing surface, other mechanical complication

• Internal fixation device• Breakdown, displacement, other mechanical complication

• Infection and inflammatory reaction to:• Implanted joints, fixation devices, other ortho implants• This one may have “A” 7th character if infection being treated in the SNF.

• Don’t forget to find out type of infection and whether it became hematogenous osteomyelitis, or wound infection, MRDO, etc. 

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IPA?

• Watch NTA and Nursing, if they both go up, worth it.

• If one goes up a lot, worth it.

• Consider IPA every time they go out if interrupted stay.

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PT/OT IPA considerationsDiscussion

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SLP IPA ConsiderationsDiscussion

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22.83

41.55

15.42

60.72

+26.23

+45.30

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Interrupted Stay:  Interruption window:  3 midnights after the last midnight you billed to Part A

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Note:  Starting Dec 3rd, you can say “yes” to A2400 on DC interrupted.Must dash Medicare End Date in this case.

Interrupted Stay

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Note:  Starting Dec 3rd, you can say “yes” to A2400 on DC interrupted.Must dash Medicare End Date in this case.

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Interrupted Stay

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Note:  Starting Dec 3rd, you can say “yes” to A2400 on DC interrupted.Must dash Medicare End Date in this case.

Interrupted Stay

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Questions/Discussion

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