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PDPM WORKSHOP

PDPM – Road Map for Success

PDPM WORKSHOP

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1 PDPM Overview

2 Components/Characteristics & Functional/Cognitive Scoring

3 MDS & Billing Changes

4 Strategies for Success

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PDPM WORKSHOP

PDPMOverviewBrian Hickman, CPA, Partner – BKD,

LLP

PDPM WORKSHOP

Fun Facts

The Patient-Driven Payment Model (PDPM) is effective October 1, 2019

Specifications included in the SNF PPS Final Rule, published July 31, 2018

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PDPM WORKSHOP

From RUG-IV to PDPM

Payment Drives Culture

Brian Hickman, CPA

PDPM WORKSHOP

*Spoiler Alert*

ICD-10 coding: from compliance issue to payment driver

Rehab minutes: from payment driver (minutes) to outcomes focus

ADL to functional scoring, capturing patient conditions – The song remains the same

The rise of patient-centered care

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PDPM WORKSHOP

PT PT Base Rate PT CMI PT Adjustment Factor

OT OT Base Rate OT CMI OT Adjustment Factor

SLP SLP Base Rate SLP  CMI

Nursing Nursing Base Rate Nursing CMI

NTA NTA Base Rate NTA CMI NTA Adjustment Factor

Noncase Mix Noncase Mix Base Rate

PDPM Case Mix Adjusted Payment

PDPM WORKSHOP

Patient-Driven Payment Model Rate Components

Urban Rural Low High Low High

Nursing 103.46$   98.83$     0.66 4.04 68.28$         417.98$      

NTA 78.05$     74.56$     0.72 3.25 56.20$         253.66$      

PT 59.33$     67.63$     1.08 1.92 64.08$         113.91$      

OT 55.23$     62.11$     1.09 1.68 60.20$         92.79$        

SLP 22.15$     27.90$     0.68 4.19 15.06$         92.81$        

Non‐Case Mix 92.63$     94.34$     n/a n/a 92.63$         92.63$        

* Urban rates

Per‐Diem Base Rates Case‐Mix Index Base Rate Range*

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PDPM WORKSHOP

PDPM vs. RUG-IV Components

PDPM RUG‐IV Low High Low High

Nursing 103.46$   0.66 4.04

NTA 78.05       0.72 3.25

Routine component 181.51     181.44     0.54 3.58

PT 59.33       1.08 1.92

OT 55.23       1.09 1.68

SLP 22.15       0.68 4.19

Rehab component 136.71    176.83    0.28 1.87

Non‐Case Mix 92.63       92.60       * Urban rates

Case‐Mix Index‐PDPM Case‐Mix Index‐RUG‐IV

PDPM WORKSHOP

PDPM PT/OT Case Mix Classification Groups

Urban

Functional 

Score PT CMI OT CMI Total CMI

CMI 

Impact

Rate 

Impact

0‐5 1.53 1.49 3.02

6‐9 1.69 1.63 3.32 0.30 17.23

10‐23 1.88 1.68 3.56 0.24 14.03

24 1.92 1.53 3.45 (0.11) (5.91)

0‐5 1.42 1.41 2.83

6‐9 1.61 1.59 3.20 0.37 21.21

10‐23 1.67 1.64 3.31 0.11 6.32

24 1.16 1.15 2.31 (1.00) (57.32)

Major Joint 

Replacement or 

Spinal Surgery

Other 

Orthopedic

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PDPM WORKSHOP

PDPM PT/OT Case Mix Classification Groups

Urban

Functional 

Score PT CMI OT CMI Total CMI

CMI 

Impact

Rate 

Impact

0‐5 1.13 1.17 2.30

6‐9 1.42 1.44 2.86 0.56 32.12

10‐23 1.52 1.54 3.06 0.20 11.46

24 1.09 1.11 2.20 (0.86) (49.26)

0‐5 1.27 1.30 2.57

6‐9 1.48 1.49 2.97 0.40 22.95

10‐23 1.55 1.55 3.10 0.13 7.47

24 1.08 1.09 2.17 (0.93) (53.29)

Medical 

Man

agement

Non‐O

rtho 

Surgery & 

Acute 

Neurologic

PDPM WORKSHOP

PDPM SLP Case Mix Classification Groups

SLP Case Mix Index

Acute Neurologic 

Condition, SLP‐Related 

Comorbidity, or Cognitive 

Impairment Neither Either Both Neither Either Both

None 0.68 1.82 2.66 15.06$         40.31$         58.92$        

One 1.46 2.33 2.97 32.34$         51.61$         65.79$        

Two 2.04 2.85 3.51 45.19$         63.13$         77.75$        

Three 2.98 3.69 4.19 66.01$         81.73$         92.81$        

Mechanically Altered 

Diet/Swallowing Disorder

Mechanically Altered 

Diet/Swallowing Disorder

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PDPM WORKSHOP

PDPMComponents & CharacteristicsSherri Robbins, Senior Managing

Consultant, RN, BSN, LNHA, RAC-CT, CLNC – BKD, LLP

PDPM WORKSHOP

Clinical Categories Collapsed to 4 for PT & OT

PDPM Clinical Category Collapsed PT & OT Clinical Category

Major Joint Replacement or Spinal Surgery Major Joint Replacement or Spinal Surgery

Non‐Orthopedic SurgeryAcute Neurologic

Non‐Orthopedic Surgery & Acute Neurologic

Non‐Surgical Orthopedic/MusculoskeletalOrthopedic Surgery (Except Major Joint Replacement or Spinal Surgery)

Other Orthopedic

Medical ManagementAcute InfectionsCancerPulmonaryCardiovascular & Coagulations

Medical Management

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PDPM WORKSHOP

Section GG PT & OT Functional Score

Item Description Score Range

GG0130A1 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 items)

GG0170C1 Mobility: Lying to sitting on side of bed 0‐4 (average of 2 items

GG0170D1 Mobility: Sit to stand 0‐4 (average of 3 items)

GG0170E1 Mobility: Chair/bed‐to‐chair transfer 0‐4 (average of 3 items)

GG0170F1 Mobility: Toilet transfer 0‐4 (average of 3 items)

GG0170J1 Mobility: Walk 50 feet with 2 turns 0‐4 (average of 2 items)

GG0170K1 Mobility: Walk 150 Feet  0‐4 (average of 2 items)

PDPM WORKSHOP

PT & OT Case Mix Groups

Clinical CategorySection of GG

Function ScorePT OT Case Mix Group

PT Case - Mix Index

OT Case - Mix Index

Major 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 1.3

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

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PDPM WORKSHOP

SLP Comorbidities

Section I   Section I ICD‐10 Codes Section O

Aphasia Laryngeal Cancer Tracheostomy Care While a Resident

CVA, TIA or Stroke Apraxia Ventilator or Respirator While a Resident

Hemiplegia or Hemiparesis Dysphagia

Traumatic Brain Syndrome ALS

Oral Cancers

Speech & Language Deficits

PDPM WORKSHOP

SLP Component

Presence of oMechanically Altered Diet (Section K)

oSwallowing Disorder (Section K)

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PDPM WORKSHOP

SLP Case-Mix Classification Groups

Presence of Acute Neurologic Condition, SLP-Related Comorbidity or Cognitive Impairment

Mechanically Altered Diet or Swallowing Disorder

SLP Case - Mix Group

SLP Case - Mix Index

None Neither SA 0.68None Either SB 1.82None Both SC 2.66

Any One Neither SD 1.46Any One Either SE 2.33Any One Both SF 2.97Any Two Neither SG 2.04Any Two Either SH 2.85Any Two Both SI 3.51All Three Neither SJ 2.98All Three Either SK 3.69All Three Both SL 4.19

PDPM WORKSHOP

Nursing Component

Same RUG IV Major CategoriesoExtensive Services

oSpecial Care High

oSpecial Care Low

oClinically Complex

oBehavior Symptoms & Cognitive Impairment

oReduced Physical Function

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PDPM WORKSHOP

Nursing Functional Score

MDS Section GG – Functional Abilities & GoalsoAssessed during first three days of admission

oDocuments “usual performance”

oFunctional score ranges from zero to 16

Eating Average Bed Mobility

Toilet Hygiene Average Transfer

PDPM WORKSHOP

NURSING CMINursing RUG Function Score CMI

ES3 0‐14 4.04

ES2 0‐14 3.06

ES1 0‐14 2.91

HDE2 0‐5 2.39

HDE1 0‐5 1.99

HBC2 6‐14 2.23

NBC1 6‐14 1.85

LDE2 0‐5 2.07

LDE1 0‐5 1.72

LBC2 6‐14 1.71

LBC1 6‐14 1.43

CDE2 0‐5 1.86

CDE1 0‐5 1.62

Nursing RUG Function Score CMI

CBC2 6‐14 1.54

CA2 15‐16 1.08

CBC1 6‐14 1.34

CA1 15‐16 0.94

BAB2 11‐16 1.04

BAB1 11‐16 0.99

PDE2 0‐5 1.57

PDE1 0‐5 1.47

PBC2 6‐14 1.21

PA2 15‐16 0.70

PBC1 6‐14 1.13

PA1 15‐16 0.66

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PDPM WORKSHOP

Nursing Component

Important to NoteoNursing component will be increased by 18% for residents with HIV/AIDS

o8 points into the NTA count

• B20 must be on SNF claim

PDPM WORKSHOP

NTA Component

Calculated based on points assigned for 50 MDS items including diagnosis or extensive servicesoMany of the diagnoses will be based on ICD-10 codes

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PDPM WORKSHOP

Condition/Extensive Service Source Points

HIV/AIDS SNF Claim 8

Parental IV Feeding: Level High MDS Item K0510A2, K0710A2 7

Special Treatment Programs: Intravenous Medication Post-Admit Code MDS Item O0100H2 5

Special Treatment Programs: Ventilator or Respirator Post-admit Code MDS Item O0100F2 4

Parental IV Feeding: Level LowMDS Item K0510A2, K0710A2, K0710B2 3

Lung Transplant Status MDS Item I8000 3

Special Treatments/Programs: Transfusion Post-admit Code MDS Item O0100I2 2

Major Organ Transplant Status, Except Lung MDS Item I8000 2

Active Diagnoses: Asthma COPD Chronic Lung Disease Code MDS Item I6200 2

Bone/Joint/Muscle Infections/Necrosis - Except Aseptic Necrosis of Bone MDS Item I8000 2

Chronic Myeloid Leukemia MDS Item I8000 2

Wound Infection Code MDS Item I2500 2

Active Diagnoses: Diabetes Mellitus (DM) Code MDS Item I2900 2

Endocarditis MDS I8000 1

Immune Disorders MDS I8000 1

End-Stage Liver Disease MDS I8000 1

Other Foot Skin Problems: Diabetic Foot Ulcer Code MDS Item M1040B 1

Narcolepsy and Cataplexy MDS Item I8000 1

Cystic Fibrosis MDS Item I8000 1

Special Treatments/Programs: Tracheostomy Care Post-admit Code MDS Item O00100E2 1

Active Diagnoses: Multi-Drug Resistant Organism (MDRO) Code MDS Item I1700 1

Special Treatments/Programs: Isolation Post-admit Code MDS Item O0100M2 1

PDPM WORKSHOP

Condition/Extensive Service Source Points

Chronic Pancreatitis MDS Item I8000 1

Proliferated Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1

Other Foot Skin Problems: Foot Infection Code, Other Open Lesion on Foot Code, Except Diabetic Foot Ulcer Code

MDS Item M1040A, M1040B, M1040C 1

Complications of Specified Implant Device or Graft MDS Item I8000 1

Bladder and Bowel Appliances: Intermittent Catheterization MDS Item H0100D 1

Inflammatory Bowel Disease MDS Item I1300 1

Aseptic Necrosis of Bone MDS Item I8000 1

Special Treatments/Programs: Suctioning Post-admit Code MDS Item O0100D2 1

Cardio-Respiratory Failure and Shock MDS Item I8000 1

Myelodysplastic Syndromes and Myelofibrosis MDS Item I8000 1

Systemic Lupus Erythematosus, Other Connective Tissue Disorders, and Inflammatory Hemorrhage MDS Item I8000 1

Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1

Nutritional Approaches While a Resident: Feeding Tube MDS Item K0510B2 1

Severe Skin Burn or Condition MDS Item I8000 1

Intractable Epilepsy MDS Item I8000 1

Active Diagnoses: Malnutrition code I560 1

Disorders of Immunity - Except : RxCC97: Immune Disorders MDS Item I8000 1

Cirrhosis of Liver MDS Item I8000 1

Bladder and Bowel Appliances: Ostomy MDS Item H0100C 1

Respiratory Arrest MDS Item I8000 1

Pulmonary Fibrosis and Other Chronic Lung Disorders MDS Item I8000 1

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PDPM WORKSHOP

Condition/Extensive Service Source Points

Specified Hereditary Metabolic/Immune Disorders MDS Item I8000 1

Morbid Obesity MDS Item I8000 1

Special Treatments/Programs: Radiation Post-admit Code MDS Item O0100B2 1

Highest Stage of Unhealed Pressure Ulcer - Stage 4 MDS Item M0300D1 1

Psoriatic Arthropathy and Systemic Sclerosis MDS Item I8000 1

PDPM WORKSHOP

NTA Case Mix Classification Groups

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

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PDPM WORKSHOP

• Case StudyCVA, PT/OT function score 7, hemiplegia dominant side, BIMS 10, mechanical soft diet, swallowing disorder, 2 stage III ulcers with daily treatment, PHQ-9 score of 10, Nursing Function score of 5, diabetic with daily insulin injections and retinopathy, 2 insulin change orders, IV meds days 1 and 2 after admission for UTI treated in the hospital and a diagnosis of malnutrition.

•Case Mix ClassificationsPT = TN CMI of 1.48OT = TN CMI of 1.49SLP = SL CMI of 4.19Nsg = HDE2 CMI of 2.39NTA = NC CMI of 1.85 Using the Urban base rates we will calculate the daily per diem for:Days 1-3Days 4-20Days 21-27

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PDPM WORKSHOP

Per Diem Days 1-3

PT- $59.33 x 1.48 = $87.81

OT- $55.23 x 1.49 = $82.29

SLP- $22.15 x 4.19 = $92.81

Nsg- $103.46 x 2.39 = $247.27

NTA- $78.05 x 1.85 x 3 = $433.18

Daily per diem for this patient for days 1-3 of the stay is $943.36

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PDPM WORKSHOP

Per Diem Days 4-20

PT- $87.81

OT- $82.29

SLP- $92.81

Nsg- $247.27

NTA- $144.39

Daily per diem for this patient for days 4-20 of the stay is $654.57

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PDPM WORKSHOP

Per Diem Days 21-27

PT- $87.81 less 2% = $86.05

OT- $82.29 less 2% = $80.65

SLP- $92.81 remains unchanged

Nsg- $247.27 remains unchanged

NTA- $144.39 remains unchanged

Daily per diem for this patient for days 21-27 of the stay is $651.17. This is $3.40 lower than days 4-20.

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PDPM WORKSHOP

Functional & Cognitive Scoring

PDPM WORKSHOP

Section GG PT & OT Functional Score

Item Description Score RangeGG0130A1 Self-care: Eating 0-4GG0130B1 Self-care: Hygiene 0-4GG0130C1 Self-care: Toileting Hygiene 0-4GG0170B1 Mobility: Sit to lyingGG0170C1 Mobility: Lying to sitting on side of bedGG0130D1 Mobility: Sit to standGG0170E1 Mobility: Chair/bed-to-chair transferGG0170F1 Mobility Toilet transferGG0170J1 Mobility: Walk 50 Feet with 2 turnsGG0170K1 Mobility: Walk 150 Feet

0-4 (average of 2 items)

0-4 (average of 2 items)

0-4 (average of 3 items)

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PDPM WORKSHOP

Nursing Function Score

Item Description Score RangeGG0130A1 Self-care: Eating 0-4GG0130C1 Self-care: Toileting Hygiene 0-4GG0170B1 Mobility: Sit to lyingGG0170C1 Mobility: Lying to sitting on side of bedGG0170D1 Mobility: Sit to standGG0130E1 Mobility: Chair/bed-to-chair transferGG0170F1 Mobility: Chair/bed-to-chair transfer

0-4 (average of 2 items)

0-4 (average of 3 items)

PDPM WORKSHOP

Cognitive Performance Scale

Cognitive Level BIMS Score CPS Score

Cognitivity Intact 13-15 0

Mildly Impaired 8-12 1-2

Moderately Impaired 0-7 3-4

Severely Impaired - 5-6

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PDPM WORKSHOP

PDPMMDS/Billing Changes

Julie Bilyeu, Managing Director – BKD, LLP

PDPM WORKSHOP

Assessment Changes

Admission (Five‐Day)

• ARD – Days 1–8

• Covers entire stay unless IPA completed

Interim Payment Assessment (IPA)

• ARD can be no later than 14 days after change in first tier classification

• Pays from ARD  until discharge except if another IPA is completed

• Does not change the variable payment schedule

PPS Discharge Assessment

• ARD equals end date of the most recent stay

• Not used for payment purposes

• Section O therapy days/minutes

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PDPM WORKSHOP

PDPM HIPPS CODING

1 •PT/OT PAYMENT GROUP

2 •SLP PAYMENT GROUP

3 •NURSING PAYMENT GROUP

4 •NTA PAYMENT GROUP

5  •ASSESSMENT INDICATOR

PDPM WORKSHOP

ASSESSMENT INDICATORS

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

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PDPM WORKSHOP

HIPPS CODE CROSSWALKNursing Group HIPPS Character Nursing Payment  HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALK

PT/OT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

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PDPM WORKSHOP

PDPM Impact on OBRA Assessments

No changes to OBRA requirementsoAdmission/quarterly/annual/significant change

Optional state assessment (don’t expect this to impact Mo.)oUse of Medicare PPS MDS for case mix determination

oOnly supported through 9/30/2020

PDPM WORKSHOP

Variable Per Diem Adjustment Factor – NTA

Medicare Payment Days Adjustment Factor

1‐3 3.0

4‐100 1.0

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PDPM WORKSHOP

Variable Per Diem Adjustment Factor – PT & OT

Medicare Payment Days Adjustment Factor

1‐20 1.00

21‐27 0.98

28‐34 0.96

35‐41 0.94

42‐48 0.92

49‐55 0.90

56‐62 0.88

63‐69 0.86

70‐76 0.84

77‐83 0.82

84‐90 0.80

91‐97 0.78

98‐100 0.76

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight 

of day 3) is considered a 

continuation versus a new stay.

Readmission after 3 days is considered a new stay.  New MDS & variable payment 

resets.

Admission from another SNF is 

considered a new stay regardless of the timeframe.

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PDPM WORKSHOP

RUG IV/PDPM TRANSITION

RUG IV billing ends 9/30/19oMust have RUG with an ARD prior to 10/1/19 to bill

PDPM begins 10/1/19oTo establish PDPM payment an IPA with an ARD no later than 10/7/19 needs

completed for the transition

o10/1/19 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is completed with an ARD after 10/7/19 it will be considered late and the default penalty for days out of compliance will apply

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PDPM WORKSHOP

Don’t Let This Be You!Strategies for Success

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PDPM WORKSHOP

Diagnosis Coding

Assess staff competencies & provide education as needed

Include ALL ICD-10 codes on each applicable MDS

Review claims to ensure codes are pulling in the correct sequential order

PDPM WORKSHOP

Minimum Data Set (MDS)

•Perform an MDS process assessment

• Provide education on section GG & start coding now as if payment depends on it

• Learn & implement strategies to improve ADL/functional scoring

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PDPM WORKSHOP

Therapy Service Model

•Assess data & identify best practices

•Develop “care paths” for specific patient conditions

•Discuss with contract therapy likely contract revisions

• Potential Pricing Options• Percent of PDPM

• Time Based

• Risk Based

• Hybrid

PDPM WORKSHOP

Therapy-Nursing Communication

•Assess current communication system between nursing & therapy

• Evaluate current nursing restorative program & identify education needs for nursing staff

• Develop process for tracking therapy days & minutes for discharge assessment coding

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PDPM WORKSHOP

Length of Stay Management

•Assess length of stay data on current population by diagnosis/clinical condition

• Evaluate impact on PDPM payment

• Establish goals for length of stay management

PDPM WORKSHOP

Financial

•Revise triple check to include PDPM elements

• Provide education to billing staff on changes under PDPM

•Perform PDPM financial analysis

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PDPM WORKSHOP

Tools to Help You Succeed

•Ask your BKD advisor for a complimentary PDPM impact analysis

• Subscribe to BKD Thoughtware

•Contact information• Brian Hickman bhickman@bkd.com

• Sherri Robbins slrobbins@bkd.com

• Julie Bilyeu jbilyeu@bkd.com

• 417.865.8701

PDPM WORKSHOP

Questions?

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PDPM WORKSHOP

Thank You!

PDPM WORKSHOP

The information contained in these slides is presented by professionals for your information only and is not to be considered as legal advice. Applying specific information to your situation requires careful consideration of facts & circumstances. Consult your BKD advisor or legal counsel before acting on any matters covered.