Post-Acute Care Network Symposium€¦ · Post-Acute Care Network Symposium Patient Driven Payment...
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Post-Acute Care Network Symposium Patient Driven Payment Model (PDPM) – What the C-suite needs to Know May 1, 2019
Transcript of Post-Acute Care Network Symposium€¦ · Post-Acute Care Network Symposium Patient Driven Payment...
Post-Acute Care Network SymposiumPatient Driven Payment Model (PDPM) – What the C-suite needs to Know
May 1, 2019
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Table of Contents
Early Results………….……………………........4-6
Introduction to PDPM………………………..7-10
How PDPM uses Clinical information…..11-18
How PDPM uses Therapy information….19-30
How PDPM pays for Non Therapy………..31-36
Therapy Contracting……………………………37-43
Live Example of Benchmarking
PDPM Data Summary – CMS data files
State % Winners %
Losers
# of
Facilities
Total Winners Total
Losers
Overall Impact
OH 59% 41% 910 534 376 $ 15,474,881
MI 73% 27% 411 300 111 $ 18,737,935
IL 53% 47% 672 356 316 $ (21,284,727)
IN 63% 37% 525 331 194 $ 2,444,378
CO 64% 36% 186 119 67 $ 507,890
PA 60% 40% 645 387 258
$ 13,412,238
National 59% 41% 13,769 8,101 5,668 $ (4,536,633)
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Per Diem Rate Impact – CMS data files
WINNERS
Average RUG
Rate
Average
PDPM Rate
$ 471.56 $ 505.16
$ 480.49 $ 511.42
$ 496.34 $ 496.34
$ 471.63 $ 504.61
$ 504.34 $ 539.76
$ 480.89 $ 514.47
$ 489.50 $ 524.46
LOSERS
Average RUG
Rate
Average
PDPM Rate
$ 510.34 $ 488.29
$ 525.48 $ 505.26
$ 559.32 $ 530.50
$ 523.72 $ 496.73
$ 554.55 $ 529.09
$ 525.70 $ 502.36
$ 558.38 $ 529.59
State
OH
MI
IL
IN
CO
PA
National
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Comparison of CMS Estimated Impact to Actual
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CMS 2017 PDPM Impact extrapolated using total 6/30/2018 Medicare days
Facility RUGs PPD PDPM PPD Difference
Sample
Dollar
Impact
Extrapolate
d
Dollar
Impact
Mission $484.90 $455.48 $(29.42) ($60,228) ($224,502)
Vista $485.09 $458.44 ($26.65) ($15,910) ($40,534)
Total Impact ($76,138) ($265,036)September to December 2018 – 5 day MDS assessments sample impact extrapolated using
same FY 2018 Medicare days
Name of SNF
No. of days
in FY 2018
Total Per
diem ($)
RUG-IV
Total
Payment ($)
RUG-IV
Total Per
diem ($)
PDPM
Total
Payment ($)
PDPM
Total Per
diem ($)
Diff
Total
Payment ($)
Difference
The Mission at BST East 7,631 460.51 3,514,158 462.57 3,529,852 2.06 15,694$
The Vista at BST West 1,521 430.01 654,043 461.10 701,328 31.09 47,285$
Total Impact per CMS using FY 2018 Medicare Days 62,979$
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FY18 Part A
MCR Rate
Sample Part A
MCR Rate
FY18 Part A
MCR Rate
Sample
Part A MCR
Rate
194.49$ 198.70$ 190.13$ 208.76$
188.75 197.93 175.73 180.35
85.29 88.27 90.27 95.98
Total Rate 468.53$ 484.90$ 456.13$ 485.09$
Part A MCR
Rate
Part A MCR
Costs (A)
200.84$ 208.37$
171.99 170.44
82.65 79.63
Total Rate 455.48$ 458.44$
2.14$ (0.39)$
(25.94) (9.91)
(5.62) (16.35)
Total Rate (29.42)$ (26.65)$
16,332$ (593)$
(197,946) (15,073)
(42,888) (24,868)
Total Rate (224,502)$ (40,534)$
Nursing Rate
Therapy Rate
NTA Rate
Therapy Rate
NTA Rate
Net Estimated Change from PPS to PDPM
Nursing Rate
Therapy Rate
NTA Rate
Under PPS
Nursing Rate
Therapy Rate
NTA Rate
Under PDPM
Nursing Rate
Blue Skies of Texas
Estimated breakdown by components for net impact
to convert to PDPM
Mission VistaFacility 1 Facility 2
Introduction PDPM
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Introduction to PDPM
The thought is PDPM will “better account for resident characteristics and care needs, thus better aligning SNF PPS payments with resource use, and eliminating therapy provision-related financial incentives inherent in the current payment model used in the SNF PPS.”
First major change to SNF Medicare reimbursement model in more than 20 years
Replaced proposed RCS-1 model but the two have similar characteristics
Payment is still in the form of a per-diem rate
Incentive for delivery of therapy no longer exists as therapy minutes removed from rate calculation
Increased number of rate components, each based on patient characteristics
Payment is tapered off as length of stay increases
PDPM Details included in Federal Register Final Rule published August 8, 2018
Effective date of October 1, 2019
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Patient Driven Payment Model
Currently 60% of PPS days are billed using one of the 3 Ultra High Rehab Categories
Funding will be budget neutral
Tapering (therapy portion) of the Medicare rate will change methodology to be more like episodic reimbursement vs. FFS
Rate tapering proposed to start day 21; reduces by 2% therapy component every 7 days for PT&OT; SLP no rate tapering
Nursing component – no tapering
Non-therapy ancillary reduced to 1.0 adjustment factor for days 4-100 (from 3.0 days 1-3)
Clinical
Administrative Form Completion
Deliver Therapy Minutes
Coordinate Patient Care
Diagnose Patients
RUG-
IV
PDPM
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Nursing Base Rate
Nursing CMI
SLP Base Rate
SLP CMI
NTA Base Rate
NTA CMI
NTA Adjustment Factor
Non Case-Mix Base Rate
OT Base Rate
OT CMIOT Adjustment Factor
Payment structure under PDPM
P
T
SLP
Nursing
NTA
Non Case-Mix
PT Base Rate
PT CMI PT Adjustment Factor
O
T
Per Diem Rate
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How PDPM Uses Clinical Information
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MDS Assessment Schedule under PDPM
Medicare MDS Assessment Schedule
Type
Assessment Reference Date 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)
Interim Payment Assessment (IPA) -
Optional
The date the facility chooses to complete
the IPA.
ARD of the assessment through Part A
discharge (unless another IPA
assessment is completed)
PPS Discharge Assessment PPS Discharge: Equal to the End Date of
the Most Recent Medicare Stay (A2400C)
or End Date
N/A
*Per CMS-1696-F
New 5-day assessments will be required for Medicare residents in-house as of the October 1, 2019 PDPM effective date, with an ARD no later than October 7, 2019. October 1, 2019 will be considered day 1 of the variable per diem schedule.
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MDS Changes: New & Revised Items
SNF Primary Diagnosis
Item I0020B (New Item)
This item is for providers to report, using an ICD-10-CM code, the patient’s primary SNF diagnosis
“What is the main reason this person is being admitted to the SNF?”
Coded when I0020 is coded as any response 1-13
Patient Surgical History
Items J2100-J5000 (New Items)
These items are used to capture any major surgical procedures that occurred during the inpatient hospital stay that immediately preceded the SNF admission (i.e., the qualifying hospital stay)
Similar to the active diagnosis captured in Section I, these Section J items will be in the form of checkboxes.
https://www.cms.gov/Medica
re
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Clinical Category
A resident is grouped into 1 of 10 PDPM Clinical Categories based on CMS mapping* criteria. The ICD-10 code in I0200B will be used to map PDPM.
PDPM CLINICAL CATEGORY PT & OT CLINICAL CATEGORY
Major Joint Replacement or Spinal Surgery Major Joint Replacement or Spinal Surgery
Non-Surgical Orthopedic/Musculoskeletal Non-Orthopedic Surgery and Acute Neurologic
Acute Neurologic Non-Orthopedic Surgery and Acute Neurologic
Non-Surgical Orthopedic/Muskoskeletal Other Orthopedic
Orthopedic Surgery (Except Major Joint Replacement of
Spinal Surgery)Other Orthopedic
Medical Management Medical Management
Acute Infections Medical Management
Cancer Medical Management
Pulmonary Medical Management
Cardiovascular and Coagulations Medical Management
The 10 PDPM Clinical Categories collapse into 4 categories for the PT & OT rates.
*Mapping criteria can be found at https://www.cms.gov/Medicare-Fee-for-Service-payment/SNFPPS/PDPM.html under *ICD-10 Clinical Category
Crosswalk.”
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Nursing Case-Mix Classification
• The Nursing Case-Mix classification under PDPM uses the RUG-IV nursing category.
• The RUG-IV category is converted to its PDPM combined counterpart.
• A function score is derived from Section GG of the MDS.
• The PDPM Nursing Case-Mix grouping is the result.
Section GG Item 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 items)
GG0170C1
Mobility: Lying to sitting on side of
bed
GG0170D1 Mobility: Sit to stand 0-4 (average of 3 items)
GG0170E1
Mobility: Chair/bed-to-chair
transfer
GG0170F1 Mobility: Toilet transfer
Current MDS
PDP
M
Response Score
05,06
Set-up assistance,
Independent 4
04
Supervision or touching
assistance 3
03 Partial/moderate assistance 2
02
Substantial/maximal
assistance 1
01, 07, 09,
10, 88
Dependent, Refused, N/A,
Not Attempted 0
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Nursing Component RUG-IV to PDPM Conversion Table
RUG-IV
Nursing
RUG
Extensive
Services Clinical Conditions Depression
# of Restorative
Nursing Services
GG-based
Function
Score
PDPM Nursing
Case-Mix
Group
Nursing
Case-Mix
Index Category
ES3
Tracheostomy&
Ventilator - - - 0-14 ES3 4.04 Extensive Services
ES2
Tracheostomy or
Ventilator - - - 0-14 ES2 3.06 Extensive Services
ES1 Infection - - - 0-14 ES1 2.91 Extensive Services
HE2/HD2 - Serious Medical Conditions e.g. comatose, septicemia, respiratory therapy Yes - 0-5 HDE2 2.39 Special Care High
HE1/HD1 - Serious Medical Conditions e.g. comatose, septicemia, respiratory therapy No - 0-5 HDE1 1.99 Special Care High
HC2/HB2 - Serious Medical Conditions e.g. comatose, septicemia, respiratory therapy Yes - 6-14 HBC2 2.23 Special Care High
HC1/HB1 - Serious Medical Conditions e.g. comatose, septicemia, respiratory therapy No - 6-14 HBC1 1.85 Special Care High
LE2/LD2 - Serious Medical Conditions e.g. radiation therapy or dialysis Yes - 0-5 LDE2 2.07 Special Care Low
LE1/LD1 - Serious Medical Conditions e.g. radiation therapy or dialysis No - 0-5 LDE1 1.72 Special Care Low
LC2/LB2 - Serious Medical Conditions e.g. radiation therapy or dialysis Yes - 6-14 LBC2 1.71 Special Care Low
LC1/LB1 - Serious Medical Conditions e.g. radiation therapy or dialysis No - 6-14 LBC1 1.43 Special Care Low
CE2/CD2 -
Conditions requiring complex medical care e.g. pneumonia, surgical wounds,
burns Yes - 0-5 CDE2 1.86 Clinically Complex
CE1/CD1 -
Conditions requiring complex medical care e.g. pneumonia, surgical wounds,
burns No - 0-5 CDE1 1.62 Clinically Complex
CC2/CB2 -
Conditions requiring complex medical care e.g. pneumonia, surgical wounds,
burns Yes - 6-14 CBC2 1.54 Clinically Complex
CA2 -
Conditions requiring complex medical care e.g. pneumonia, surgical wounds,
burns Yes - 15-16 CA2 1.08 Clinically Complex
CC1/CB1 -
Conditions requiring complex medical care e.g. pneumonia, surgical wounds,
burns No - 6-14 CBC1 1.34 Clinically Complex
CA1 -
Conditions requiring complex medical care e.g. pneumonia, surgical wounds,
burns No - 15-16 CA1 0.94 Clinically Complex
BB2/BA2 - Behavioral or Cognitive symptoms - 2 or more 11-16 BAB2 1.04 Behavior/Cognition
BB1/BA1 - Behavioral or Cognitive symptoms - 0-1 11-16 BAB1 0.99 Behavior/Cognition
PE2/PD2 - Assistance with daily living and general supervision - 2 or more 0-5 PDE2 1.57
Reduced Physical
Function
PE1/PD1 - Assistance with daily living and general supervision - 0-1 0-5 PDE1 1.47
Reduced Physical
Function
PC2/PB2 - Assistance with daily living and general supervision - 2 or more 6-14 PBC2 1.21
Reduced Physical
Function
PA2 - Assistance with daily living and general supervision - 2 or more 15-16 PA2 0.7
Reduced Physical
Function
PC1/PB1 - Assistance with daily living and general supervision - 0-1 6-14 PBC1 1.13
Reduced Physical
Function
PA1 - Assistance with daily living and general supervision - 0-1 15-16 PA1 0.66
Reduced Physical
Function
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Additional Nursing Component Information
High independence results in a higher functional status, and
indicates a lower need for nursing services. Therefore, a high
Section GG based function score has a lower case mix index.
Indication of depression within each case-mix group results in a
higher case mix index for that group.
There is an 18% payment add-on to this component for HIV/AIDS.
This additional payment is determined by the presence of ICD-
10-CM code B20 on the actual Medicare claim.
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PDPM
Nursing
Case-Mix
Group
Days Rates
Benchmark
(Acumen
Study(A)
)
1st Teir Category Depression
# of
Restorative
Nursing
Services
2nd Teir GG-
based
Function
Score
Nursing Case-
Mix Index
ES3 - 479.77 Extensive Services 0-14 4.04
ES2 - 384.50 2.0% Extensive Services 0-14 3.06
ES1 - 369.92 Extensive Services 0-14 2.91
HDE2 - 319.37 Special Care High Yes 0-5 2.39
HDE1 - 280.49 Special Care High No 0-5 1.99
HBC2 - 303.82 13.7% Special Care High Yes 6-14 2.23
HBC1 - 266.88 Special Care High No 6-14 1.85
LDE2 - 288.26 Special Care Low Yes 0-5 2.07
LDE1 - 254.24 Special Care Low No 0-5 1.72
LBC2 - 253.27 16.5% Special Care Low Yes 6-14 1.71
LBC1 - 226.05 Special Care Low No 6-14 1.43
CDE2 - 267.85 Clinically Complex Yes 0-5 1.86
CDE1 - 244.52 Clinically Complex No 0-5 1.62
CBC2 - 236.74 Clinically Complex Yes 6-14 1.54
CA2 - 192.02 35.5% Clinically Complex Yes 15-16 1.08
CBC1 - 217.30 Clinically Complex No 6-14 1.34
CA1 - 178.41 Clinically Complex No 15-16 0.94
BAB2 - 188.13 Behavior/Cognition 2 or more 11-16 1.04
BAB1 - 183.27 2.0% Behavior/Cognition 0-1 11-16 0.99
PDE2 - 239.66 Reduced Physical Function 2 or more 0-5 1.57
PDE1 - 229.94 Reduced Physical Function 0-1 0-5 1.47
PBC2 - 204.66 Reduced Physical Function 2 or more 6-14 1.21
PA2 - 155.08 30.3% Reduced Physical Function 2 or more 15-16 0.7
PBC1 - 196.88 Reduced Physical Function 0-1 6-14 1.13
PA1 - 151.19 Reduced Physical Function 0-1 15-16 0.66
PACN Place
Patient Nursing Profile Analysis
Cincinnati, OH-KY-IN
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How PDPM Uses Therapy Information
PT & OT Case-Mix Classification
The PT & OT Clinical Category is the main therapy cost predictor. The MDS Section GG function scores determine the PT/OT Case-Mix Index.
Section GG Item Score
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
GG0170D1 Mobility: Sit to stand 0-4 (average of 3 items)
GG0170E1 Mobility: Chair/bed-to-chair transfer
GG0170F1 Mobility: Toilet transfer
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)
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PT/OT Case Mix Groups
Clinical Category Function Score PT OT Case Mix Group PT CMI OT CMI
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 1.30
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
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MDS Section GG Response
Current MDS PDPM
Response Score
05,06 Set-up assistance, Independent 4
04 Supervision or touching assistance 3
03 Partial/moderate assistance 2
02 Substantial/maximal assistance 1
01, 07, 09, 10, 88 Dependent, Refused, N/A, Not Attempted 0
Under PDPM, higher function scores indicate greater Independence.
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PT and OT
Case-mix
Classification
Groups
Rates
(Days 1-20
Only)
Benchmark
(Acumen
Study(A))
1st Tier Clinical Category grouped from
Section I8000 A
2nd Tier
Section GG
Function
Score
Benchmark
(Acumen
Study(A)
PT Case-
Mix Index
OT Case-
Mix Index
TA 167.51 Major Joint Replacement or Spinal Surgery 0-5 5.3% 1.53 1.49
TB 184.18 Major Joint Replacement or Spinal Surgery 6-9 11.2% 1.69 1.63
TC 197.77 8.6% Major Joint Replacement or Spinal Surgery 10-23 82.5% 1.88 1.68
TD 192.05 Major Joint Replacement or Spinal Surgery 24 1.1% 1.92 1.53
TE 156.92 Other Orthopedic 0-5 10.0% 1.42 1.41
TF 177.45 Other Orthopedic 6-9 22.2% 1.61 1.59
TG 183.57 14.8% Other Orthopedic 10-23 67.3% 1.67 1.64
TH 128.09 Other Orthopedic 24 0.5% 1.16 1.15
TI 127.44 Medical Management 0-5 14.9% 1.13 1.17
TJ 158.52 Medical Management 6-9 17.1% 1.42 1.44
TK 169.61 59.5% Medical Management 10-23 66.6% 1.52 1.54
TL 121.93 Medical Management 24 1.4% 1.09 1.11
TM 142.42 Non-Orthopedic Surgery & Acute Neurologic 0-5 15.5% 1.27 1.30
TN 164.64 Non-Orthopedic Surgery & Acute Neurologic 6-9 16.3% 1.48 1.49
TO 171.87 17.2% Non-Orthopedic Surgery & Acute Neurologic 10-23 66.9% 1.55 1.55
TP 120.29 Non-Orthopedic Surgery & Acute Neurologic 24 1.4% 1.08 1.09
PACN PlacePatient PT OT Profile Analysis
Cincinnati, OH-KY-IN
PT and OT Length of Stay Adjustment
Variable Per-Diem Adjustment Factor and
Schedule
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
Incentivized to get resident home quicker
What is your average length of stay? Range in sample from 1 to 100 days.
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Rate tapering sample;
Days 21 to 27 is reduction of $3.16 per day
Day 84-90 is a $31.60 reduction from days 4-20
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RESIDENT #4 3.00 20.00 27.00 34.00 41.00 48.00 55.00 62.00 69.00 76.00 83.00 90.00
Total days in span Days 1-3 Days 4-20 Days 21-27 Days 28-34 Days 35-41 Days 42-48 Days 49-55 Days 56-62 Days 63-69 Days 70-76 Days 77-83 Days 84-90
PROJECTED length of stay 87.00
Daily payment rate 597.89 468.74 465.58 462.42 459.26 456.10 452.94 449.78 446.62 443.46 440.30 437.14
Payment for FULL variable payment span 1,793.66 7,968.58 3,259.06 3,236.94 3,214.82 3,192.70 3,170.58 3,148.46 3,126.34 3,104.22 3,082.10 3,059.98
Cumulative Payment for Length of Stay 1,793.66 9,762.24 13,021.30 16,258.24 19,473.06 22,665.76 25,836.34 28,984.80 32,111.14 35,215.37 38,297.47 40,046.03
Final actual payment for this Length of Stay 40,046.03
460.30
SLP Case-Mix Classification
There are 5 predictors that contribute to the SLP case-mix classification.
The more predictors present in the MDS, the higher the SLP case-mix score.
PDPM Clinical Category: The only Category that qualifies for credit in the SLP score is Acute Neurologic Condition.
Cognitive Impairment: Source: MDS C0500: BIMS score. Credit is given if the BIMS score is less than 13.
OR -
Source: MDS B0100, B0700, C0700, and C1000: CPS Score. Impaired if CPS Score is greater than zero.
SLP Comorbidities*: Source: MDS I4300, I4500, I5500, I8000, O0100E2, O0100F2.
Credit is given for the presence of any one comorbidity.
Swallowing disorder Source: MDS K0100A-D
Mechanically altered diet Source: MDS K0510C2
*A DRAFT mapping tool is available in draft form from CMS at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-payment/SNFPPS/PDPM.html ,
under PDPM Resources, “PDPM Classification Walkthrough”, starting on page 16 of the .pdf.
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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 0.68
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
SLP Case-Mix Classification Groups
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SLP Component Primary Tier
Three Criteria:
1. Acute Neurologic Condition
2. SLP-Related Comorbidity
• Aphasia• CVA, TIA, or Stroke• Hemiplegia or Hemiparesis• Traumatic Brain Injury• Tracheostomy Care (While a resident)• Ventilator or Respirator (While a resident)• Laryngeal Cancer• Apraxia• Dysphagia• ALS• Oral Cancers• Speech and Language Deficits
3. Cognitive Impairment
PDPM Cognitive Level BIMS Score Staff Assessment Score
1 – Cognitively Intact 13-15 0
2 – Mildly Impaired 8-12 1-2
3 – Moderately Impaired 0-7 3-4
4 – Severely Impaired - 5-6
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SLP Component Secondary Tier
Two Criteria
1. Swallowing Disorder
2. Mechanically Altered Diet
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SLP Case-Mix
Group
Rates
(No LOS
Adj)
Benchmark
(Acumen
Study(A))
1st Tier -Presence of
Acute Neurologic
Condition, SLP-Related
Comorbidity or
Cognitive Imp. Per
K0100
Benchmark
(Acumen
Study(A)
Mechanically
Altered Diet or
Swallowing
Disorder
SLP Case-
Mix Index
SA 14.58 None 86.4% Neither 0.68
SB 39.02 51.6% None 12.0% Either 1.82
SC 57.03 None 1.5% Both 2.66
SD 31.30 Any one 65.9% Neither 1.46
SE 49.95 37.7% Any one 29.5% Either 2.33
SF 63.67 Any one 4.6% Both 2.97
SG 43.74 Any two 58.1% Neither 2.04
SH 61.10 8.6% Any two 35.5% Either 2.85
SI 75.25 Any two 6.5% Both 3.51
SJ 63.89 All three 46.3% Neither 2.98
SK 79.11 2.2% All three 43.3% Either 3.69
SL 89.83 All three 10.4% Both 4.19
Patient SLP Profile Analysis
PACN Place
Cincinnati, OH-KY-IN
Non-Therapy Ancillary (NTA) Case-Mix Classification
The NTA score is based on the number of NTA comorbidities present on the MDS.
• Each comorbidity is assigned a point value.
• A maximum of 12 points can be assigned.
The more comorbidities, the greater the number of points, the higher the NTA case-mix.
CMS has provided an ICD-10 NTA Comorbidity Crosswalk at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-payment/SNFPPS/PDPM.html.
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NTA Component Case Mix
NTA Component Case Mix Group
NTA Comorbidity Score NTA Case Mix Group CMI
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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NTA Component: Length of Stay Adjustment
Variable Per-Diem Adjustment Factors and
Schedule
Medicare Payment
Days
Adjustment Factor
1-3 3.00
4-100 1.00
On day four adjustment factor is cut by 2/3
Incentive to ensure all diagnostics are done early in the stay
Example: NTA x CMI x Adjustment Factor
Days 1-3: $78.05 x 1.85 x 3.00 = $433.17
Days 4-100: $78.05 x 1.85 x 1.00 = $144.39
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NTA Comorbidities & Point Values
Condition/Extensive Service Source Points
HIV/AIDS SNF Claim (ICD-10-CM code B20) 8
Parenteral IV Feeding: Level High MDS Item K0510A2, K0710A2 (>50%) 7
Special Treatments/Programs: Intravenous Medication Post-admit Code MDS Item O0100H2 5
Special Treatments/Programs: Ventilator or Respirator Post-admit Code MDS Item O0100F2 4
Parenteral IV Feeding: Level Low MDS Item K0510A2, K0710A2, K0710B2 (>25% and <50%) 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: Multiple Sclerosis Code MDS Item I5200 2
Opportunistic Infections 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 Item I8000 1
Immune Disorders MDS Item I8000 1
End-Stage Liver Disease MDS Item 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 O0100E2 1
Active Diagnoses: Multi-Drug Resistant Organism (MDRO) Code MDS Item I1700 1
Special Treatments/Programs: Isolation Post-admit Code MDS Item O0100M2 1
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
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NTA Comorbidities & Point Values (cont’d.)
Condition/Extensive Service Source Points
Highest Stage of Unhealed Pressure Ulcer - Stage 4 MDS Item M0300D1 1
Psoriatic Arthropathy and Systemic Sclerosis MDS Item I8000 1
Chronic Pancreatitis MDS Item I8000 1
Proliferative 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 MDS Item M1040A, M1040B, M1040C 1
Complications of Specified Implanted Device or Graft MDS Item I8000 1
Bladder and Bowel Appliances: Intermittent Catheterization MDS Item H0100D 1
Inflammatory Bowel Disease MDS Item I8000 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 Spondylopathies 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 MDS Item I5600 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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36
NTA Case-Mix
Group
Rates
(Days 1 - 3)
Rates
(Days 4 - 100)
Benchmark
(Acumen
Study(A))
NTA Case-Mix
Index
Est. NTA
Average Score
Range
NA 736.56 245.52 1.3% 3.25 12
NB 573.38 203.87 3.5% 2.53 10
NC 419.27 149.07 16.7% 1.85 7
ND 303.69 107.98 23.8% 1.34 3
NE 217.57 77.36 18.7% 0.96 2
NF 163.18 58.02 36.1% 0.72 -
Acumen Study 1,592,759 100.0% 1.20 2.66
PACN Place
NTA Patient Profile
Cincinnati, OH-KY-IN
The PDPM Shift for Therapy
• Therapy no longer drives reimbursement
• Will be a decrease in therapist hours
• A need for creative approaches to efficiently achieve favorable therapy outcomes
• Productivity will now be measured by Outcomes Efficiency not basedupon old minute thresholds
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Factors to consider with Therapy Provider
• SNF Profitability Does the therapy provider guarantee the SNF a profit margin?
• Financial Risk Who will assume most of the financial risk?
• TechnologyDoes the therapy provider utilize the best software to manage PDPM?
• Clinical Pathways Does the therapy provider utilize evidence-based clinical pathways?
• Coding and Scoring Will the therapy provider be incentivized for improvement in coding and scoring?
• Length of Stay Rate Reductions Will the therapy provider be incentivized for LOS payment reductions?
• Ease of Implementation Can the therapy provider demonstrate easy of transition?
• Other PayorsHow will the therapy company manage and price Other payors?
38
Therapy Pricing Goals
1. Ensure all parties are aligned on clinical drivers to make certain appropriate reimbursement is achieved (Optimize Revenue first)
2. Achieve optimal levels of patient outcomes at the lowest costs utilizing new clinical pathways (Optimize efficiency)
3. Maintain compliance (Optimize reduced risk)
4. Optimize financial opportunities and for both the therapy provider and the skilled nursing facilities (Create Win partnership)
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Critical Pricing Considerations
• Focus on alignment of incentives (Win Win)
• Understand new contractual indemnifications
• Do you diligence with pricing options
• Be flexibility to change options after defined period (adjustments to capitated rate)
• Evaluate value add-ons ( Census building, Technology, Outcomes Management)
• We can’t forget about Managed Care / Part B pricing
40
PDPM Pricing Methods
• Time in Facility & Part A Cost Per Minute (least desirable)
• Flat capitated per diem rate (Better but depends on rate)
• Fixed Per Diem per PDPM Tier (better with aligned incentives)
• Risk Share Per Diem per PDPM group (Better but more complicated financially)
• Combination of above using your internal staff (PT assistant, restorative staff)
41
Understand your current therapy operations
42
PART A THERAPY EFFICIENCY
Total Hours Part A Part B Mng Care Medicaid Other
Contracted Therapy Hours -
In-House Therapy Hours 24,180
Total Hours Reported 24,180 13,275 2,845 6,638 - 1,422
Total Estimated Therapy FTEs: 11.6 6.4 1.4 3.2 - 0.7
Average Direct Hours
Productivity
Ratio
Billed
Contract Cost
Per Minute of
Estimated
Part A Cost
Therapy Group / Index Days Minutes at Threshold 90% 0.97 per min Per Day
Rehab Ultra High (2.25) 3,900 720/ 6 7,974 8,860 99.77 389,109$
Rehab Very High (1.41) 2,400 500/ 6 3,463 3,846 69.29 166,286
Rehab High (.94) 500 325/ 6 432 480 45.04 22,518
Rehab Medium (.77) 200 150/ 6 80 89 20.79 4,157
Rehab Low (.43) - 45/ 6 - - 6.24 -
Rehab Subtotal 7,000 11,949 13,275 582,070$
Non Rehab Days 600 0.73 Therapy's Est. Cost Per Minute
Total Part A Days 7,600 1.90 Total Hours per therapy day
683
PACN Place
Comparison of Part A Margin from MCR CR to Actual Part A Contract
minutes over 6 days
Understand your current therapy operations, Cont.
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THERAPY PROFIT (LOSS) ANALYSIS
Part A Profit Profit/ (Loss)
Direct Costs Overhead Total Costs Net Revenue (Loss) w/ o OVH
Part A Therapies Per CR $ 730,000 $ 146,000 $ 876,000 $ 1,300,000 $ 424,000 $ 570,000
Part A Therapies Per Rehab Day $ 104.29 $ 20.86 $ 125.14 $ 185.71 60.57$ 81.43$
Part A Margin 32.6% 43.8%
Part A Therapies Per Contract $ 582,070 $ 116,414 $ 698,484 $ 1,300,000 $ 601,516 $ 717,930
Part A Therapies Per Rehab Day $ 83.15 $ 16.63 $ 99.78 $ 185.71 85.93$ 102.56$
Part A Margin 46.3% 55.2%
Overhead %/Cost to Charge Ratio 20.0%
Let’s go Live
If all you heard this afternoon was…..
1) Don’t think your safe if CMS’s estimates show a positive. Training is imperative!
2) Continue to use a crosswalk tool until MatrixCare or PCC develops a MDS conversion
3) Train group on importance of ICD-10 coding and Section K and GG of MDS
4) Remember your therapy company is a key component for success, negotiations have to be a WIN WIN
45
Thank you for joining us this afternoon
Christopher S. Joos, CPAHealthcare Consulting PartnerPlante [email protected]
