PPS Swing Bed Patient Driven Payment System (PDPM) Are …MDS Overview Under RUG IV, PPS SB/SNFs are...

PPS Swing Bed Patient Driven Payment System (PDPM)

Are You Ready For October 1, 2019?

June 27, 2019Updated on 07.08.2019

Mary Guyot Consulting 207-650-5830 (cell/text)

[email protected]

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The Participants should be able to:

• Define what PDPM is and why it was created• Discuss how the PDPM classification methodology differs from RUG IV• Explain the required tracking, MDS assessments and correction or inactivation of completed MDSs • Enumerate the 5 case-mix and the 1 non-case mix adjusted components of the PDPM• Describe key reinforced sections of the MDS (such as section C, GG, I, J etc.) including the new assessment schedule and how the payment will be impacted• Identify patient characteristics used to assign patients into CMGs to derive payment • Verbalize the ARD, completion and transmission requirements for the assessments• Comment on how ICD-10 codes will be used under PDPM• Break down the HIPPS Code under PDPM • Calculate rural per diem rates based on non-wage index • Explain what an Interim Payment Assessment (IPA) is • Calculate how the per diem payment is adjusted to reflect varying costs throughout the stay• Explain the process for billing for the patients in bed at 11:59 PM on September 30, 2019 and remaining in the program after Oct 1, 2019 under PDPM• Develop an action plan with SB team upon return to their respective hospitals

Program Objectives

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This information was prepared with the best of intention using CMS websites regarding PDPM information, FQA, webinars and tools, the updated MDS Manual and other resources regarding PDPM. This training is not intended to grant rights or impose obligations. This training may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage participants to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.

Disclaimer

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9:00 PDPM Overview

9:15 MDS Overview

9:30 MDS Changes or Item Reinforcement

10:30 BREAK

10:45 PDPM HIPPS Codes – How is the HIPPS code Developed?

11:45 LUMCH

12:45 ICD-10 Coding

1:30 Billing: PDPM Overview, HIPPS Code Overview, Variable Per Diem, Interim Payment Assessment (IPA), Transition process on Oct 1, 2019, Default Rate

2:45 BREAK

3:00 Case Study to Determine HIPPS Code and Per Diem

4:00 Action Planning

4:45 Q&A & Discussion

5:00 Adjourn

Agenda

PDPM Overview (9:00 – 9:15)

What is PDMP

Why is Medicare Implementing PDPM

How will it differ from RUG IV

>>>>>>>>>>>>>>>>>>

Applies to generic / traditional Medicare beneficiaries.

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PDPM Overview Definition: PDPM (Patient Driven Payment Model) is:

• A new case mix classification system for PPS SB/SNF patients in a Medicare Part A covered stay

• Effective beginning October 1, 2019, PDPM will replace the current case-mix classification system, the Resource Utilization Group, Version IV (RUG-IV).

Issues with the current case-mix model (RUG-IV) have been identified by CMS, the Office of Inspector General (OIG), the Medicare Payment Advisory Commission (MedPAC), the media, and others:• Therapy payments under the PPS SB/SNF are based primarily on the amount of

therapy provided to a patient, regardless of the patient’s unique characteristics, needs, or goals• Creates provider advantage• Payment inequities for different patient types• Patient selection being driven by payment due to disincentives to admit patient with low

therapy needs• Concerns about overutilization of therapy

It is anticipated that PDPM, effective October 1, 2019, will improve payments made under the PPS SB/SNF in the following ways:• Improves payment accuracy and appropriateness by focusing on the patient, rather than the

volume of services provided• Significantly reduces administrative burden on providers (much less MDSs to complete)• Improves PPS SB/SNF payments to currently underserved beneficiaries without increasing total

Medicare payments

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PDPM Overview Presently, to classify patients under the PPS SB/SNF, providers complete the MDS 3.0 to

classify a patient under the RUG-IV payment system

MDS assessments will also be used to classify patients into payment categories under PDPM but it includes a number of different changes to the MDS assessment and processes.

The RUG-IV payment methodology assigns patients to payment classification groups, called RUGs, within the payment components, based on • various patient characteristics and • the type and intensity of therapy services provided to the patient

Under the PDPM, six payment components are utilized to derive payment

The PDPM uses clinically relevant factors, rather than volume-based service for determining Medicare payment

Under the PDPM, patient characteristics are used to assign patients into CMGs across the payment components to derive payment

The Patient-Driven Payment Model (PDPM) is designed to “shift care from therapy to other forms of care as other categories are underutilized”

Additionally, the PDPM adjusts per diem payments to reflect varying costs throughout the stay

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The PDPM classification methodology:

• Utilizes a combination of six payment components to derive payment. • Five of the components are case-mix adjusted to cover utilization of PPS

SB/SNF resources that vary according to patient characteristics. • An additional non-case-mix adjusted component to address utilization of

PPS SB/SNF resources that do not vary by patient.

• Different patient characteristics are used to determine a patient’s classification into a case-mix group (CMG) within each of the case-mix adjusted payment components

• The payment for each component is calculated by:• First determine the CMGs then multiplying the case-mix index (CMI) that

corresponds to the patient’s CMG by the wage adjusted component base payment rate, then by

• The specific day in the variable per diem adjustment schedule when applicable

• The payments for each component are then added together along with the non-case-mix component payment rate to create a patient's total PPS SB/SNF per diem rate under the PDPM

PDPM Overview

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PDPM vs RUG IV Classification Methodology Under RUG-IV, payment is derived from:

• a combination of two case-mix adjusted payment components and • two non-case mix adjusted components

The RUG-IV payment methodology assigns patients to payment classification groups, called RUGs, within the payment components, based on• various patient characteristics and • the type and intensity of therapy services provided to the patient

Under RUG-IV, multiple MDS assessments are completed to determine if the per diem is to change or not going forward

Under the PDPM, six payment components are utilized to derive payment

The PDPM uses clinically relevant factors, rather than volume-based service for determining Medicare payment

Under the PDPM, patient characteristics are used to assign patients into CMGs across the payment components to derive payment

Additionally, the PDPM adjusts per diem payments to reflect varying costs throughout the stay

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PDPM vs RUG IV Classification Methodology

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(Non-Therapy Ancillary)

All patients will be classified into PT, OT, and SLP classification regardless of whether they are on therapy case load

Therefor no need for multiple MDS assessment to determine per diem rate change


Likewise, even if only 1 therapy treating, there will still be all 3 case-mix adjusted components (PT – OT – SLP)

Also includes a non-case-mix that remains the same for all patients.Not based on patient data

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PT, OT and SLP components are calculated regardless of whether the patient is receiving therapy or not.

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This info will be covered in more details later in the training

(room and board, admin cost, capital-related costs) + wage adjustment)

VPD = Variable Per Diem


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MDS Overview (9:15 – 9:30)

Goals of the new MDS

MDS Scheduled Assessments

• Now for RUG IV vs October for PDPM

CMS Resources for the Updated MDS Manual and MDS Forms

Which MDS Sections will impact the per diem rate

MDS Overview

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MDS Overview

The goals of the MDS 3.0 revisions are to:• Introduce advances in assessment measures, • Increase the clinical relevance of items, • Improve the accuracy and validity of the tool, • Increase user satisfaction, and • Increase the patient’s voice by introducing more patient interview items

Providers, consumers, and other technical experts in nursing home care requested that MDS 3.0 revisions focus on improving the tool’s clinical utility, clarity, and accuracy

CMS also wanted to increase the usability of the instrument while maintaining the ability to use MDS data for quality measure reporting and Medicare SNF PPS reimbursement

In addition to improving the content and structure of the MDS, the RAND/Harvard team also aimed to improve user satisfaction. User attitudes are key determinants of quality improvement implementation

Negative user attitudes toward the MDS are often cited as a reason that nursing homes have not fully implemented the information from the MDS into targeted care planning

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MDS Overview

Under RUG IV, PPS SB/SNFs are required to complete scheduled assessments on or around Days 5, 14, 30, 60, and 90 of a patient’s Part A PPS SB/SNF stay and unscheduled assessments that may be triggered by different events during a patient’s stay, such as when a PPS SB/SNF patient starts therapy, ends therapy, or when there is a change in the volume of therapy received by the patient or changes in the patient’s status

Also had to know about Start & End of Therapy and Short Stay MDSs

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MDS Overview

Under PDPM (effective October 1, 2019), there are 3 SNF PPS assessments: the 5-day Assessment, the Interim Payment Assessment (IPA) which is optional and the PPS Discharge Assessment• The 5day assessment and the PPS Discharge Assessment are required. • The IPA is optional and will be completed when providers determine that the patient has

undergone a clinical change that would require a new PPS assessment.

All OMRAs assessment (SOT, EOT, COT, Start & End of Therapy, Significant Clinical Change) including Short Stays no longer apply under PDPM!

(Optional)

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MDS Overview

Item Sets which applies to Non-Critical Access Swing Bed (PPS SB) – MDS continues to not apply to CAH SB

PPS (SP) Item Set (some changes)• This is the set of items active on a 5-Day PPS assessment

Discharge (SD) Item Set• This is the set of items active on a standalone Swing Bed Discharge assessment

(either return anticipated or not anticipated).

Interim Payment Assessment (IPA) Item Set (new)• This is the set of items active on an Interim Payment Assessment and used for

PPS payment purposes. This is a standalone assessment.

Tracking (ST) Item Set• This is the set of items active on an Entry Tracking Record or a Death in Facility

Tracking Record.

Inactivation (XX) Item Set• This is the set of items active on a request to inactivate a record in the QIES

ASAP system.

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MDS Overview

The MDS Manual layout remains the same• Chapter 1: Patient Assessment Instrument (RAI)• Chapter 2: Assessments for the patient Assessment Instrument (RAI) – (mostly

applies to Nursing Homes)• Chapter 3: Overview to the Item-by-Item Guide to the MDS 3.0 • Chapter 4: Care Area Assessment (CAA) Process and Care Planning (Applies to NH)• Chapter 5: Submission and Correction of the MDS Assessments (Refer to this PRN)• Chapter 6: Medicare Skilled Nursing Facility Prospective Payment System (SNF

PPS)

Appendices • Appendix A: Glossary and Common Acronyms • Appendix B: State Agency and CMS Regional Office RAI/MDS Contacts• Appendix C: Care Area Assessment (CAA) Resources (For NHs)• Appendix D: Interviewing to Increase patient Voice in MDS Assessments• Appendix E: PHQ-9 Scoring Rules and Instruction for BIMS (When Administered In

Writing)• Appendix F: MDS Item Matrix • Appendix G: References • Appendix H: MDS 3.0 Item Sets

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Section of the MDS

Red lined items do not apply to SB (F, L, V and probably G)

Circles items are areas where the Grouper gathersinformation from todetermine the PDPMpayment

The privacy act still remainswhere the patients has to benotified that the MDS will besent to Medicare (see the formin Chapter 1 page 15-17 forthe document)

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Many sections of the MDS more crucial than ever with PDPM

PDPM Payments based upon nursing, PT, OT, SLP, non-therapy ancillary, and non-case mix index

• 161 MDS item fields • PT-14 MDS items • OT-14 MDS items • SLP-33 MDS items • Nursing: 129 MDS items • Non-therapy Ancillary: 33 MDS items

Does require someone “minding the store” - this must be well managed to optimize the PDPM payment (to be discussed more later in the Action Plan section)

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MDS Overview New MDS schedule Effective Oct. 1, 2019

More discussion on these later

Does not apply to SB

Red lines does not apply to SB

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MDS Overview Note: The Entry tracking record for all patients and Death in Facility Tracking Record

(when applicable) both remain.

OBRA, CAA, SCSA, & SCPA still do not apply to SB.

There is now something called an “Interrupted Stay” in A0310• The interrupted stay policy applies to patients who either leave the SNF, then return

to the same SNF within the interruption window

• The interrupted stay policy does not apply to Swing Bed providers.

Because a PDPM cognitive level is utilized in the speech language pathology (SLP) payment component of PDPM, assessment of patient cognition with the BIMS or Staff Assessment for Mental Status is a requirement for all PPS assessments. (will be discussed further) (section C)

They appear to have kept section G even though section GG is completed and most affects the PDPM – not clear if that section will be on the computerized version since CMS states the section remains due to OBRA assessment which does not apply to SB

Section GG will be used to determine the PT, OT, and Nursing base rate therefore it will be crucial to know how to assess the patients’ functional & mobility levels along with documentation to support it

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MDS Overview New MDS Item: Section I: SNF Primary Diagnosis

To capture the patient’s primary diagnosis, which is used to classify the patient into a PDPM clinical category, CMS added Item I0020B, which allows providers to report, using an ICD-10 code, the patient’s primary SNF diagnosis.

The item asks “What is the main reason this person is being admitted to the SNF?”• Item I0020B will be coded when Item I0020 is coded as any response 1 – 13. • Item I0020A (Other Medical Issues) (under RUG IV) is being retired on the MDS

3.0. Only I0020 and I0020B will be used.

The above and Section I: Active Diagnosis/Comorbidities will greatly impact the PT, OT, SLP and Nursing scores • MDS Coordinators and Coders will be taking a bigger role in this section

New MDS Items: Section J: Patient Surgical History • In order to capture surgical information which may be relevant to classifying the

patient into a PDPM clinical category, CMS is adding new items in Section J of the MDS.

• These items are Items J2100 – J5000 used to capture any major surgical procedures that took place during the acute stay immediately preceding the SB/SNF stay

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MDS Overview

The calculation for the PT and OT scores will be based on The primary reason(s) for the skilled stay – divided in 4 categories

• Major Joint Replacement or Spinal Injury• Non-Orthopedic Surgery and Acute Neurologic• Other Orthopedic• Medical Management

As well as function score which includes 4 late loss ADLs and 2 early loss ADLs from 10 section GG items• Two bed mobility items• Three transfer items• One eating items• One toileting item• One oral hygiene item• Two walking items

PT and OT score will be calculated regardless of whether the patient is receiving PT and/or OT or not - though minutes of therapy will continue to be tracked and reported when receiving therapy

Daily skilled requirement remains – therefore, if the patient is in the program for daily therapy only, it will require at least 5 days of therapy per week and nursing will continue being 7 days/week

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MDS Overview

Therapy evaluation time

• Currently under RUGs, providers “bill for therapy evaluations” on the UB-04 • Therapy evaluation minutes are not counted on the MDS and only minutes

spent treating a patient is• The same policy will be in effect under PDPM. Therapy evaluation minutes

will not be counted on the MDS

Student time

• There is no change for how students’ time is “captured” in SNFs• For guidance on how a student’s time can be counted on the MDS, please refer

to the MDS RAI Manual, specifically in the section entitled “Modes of Therapy” in Chapter 3, Section O

Because therapy payment under PDPM is based on patient characteristics and not therapy minutes, it is possible that a patient will not have been seen by PT, OT, or SLP prior to the time the 5-day assessment is completed. However, SNF patients will still receive a classification for these therapy components and the associated payments for these components, based on the patient’s classification

Therapy minutes (what qualifies and not) will be calculated and documented in the same manner as under RUG system

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MDS Overview

SLP component will be impacted by 5 Characteristics• Acute Neurologic or Non-Neurologic active diagnosis noted in Section

I8000

• SLP-Related Comorbidity also from I8000

• Cognitive Impairment based on BIMS score in C0500

• Mechanically Altered Diet Determined by K0510C2

• Swallowing Disorder Determined by K0100Z

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MDS Overview Continue to be mindful of the use of dashes (-)

Almost all MDS 3.0 items allow a dash (-) value to be entered and submitted to the MDS QIES ASAP system

A dash value indicates that an item was not assessed. This most often occurs when a patient is discharged before the item could be assessed. (lacking assessment items may impact the payment if required to determine a score)

Dash values allow a partial assessment to be submitted when an assessment is required for payment purposes

There are four date items (A2400C, O0400A6, O0400B6, and O0400C6) that use a dash-filled value to indicate that the event has not yet occurred• For example, if there is an ongoing Medicare stay, then the end date for that Medicare stay

(A2400C) has not occurred, therefore, this item would be dash-filled

Dashes are acceptable when goal setting in Section GG – setting a goal may not be required or appropriate for every item

The few items that do not allow dash values include identification items in• Section A [e.g., Legal Name of patient (Item A0500), • Assessment Reference Date (Item A2300), • Type of Assessment (Item A0310), • Gender (Item A0800)] and • ICD diagnosis codes (Item I8000).

MDS Changes/Reinforced (9:30 – 10:30)

Review of Item Changes or Reinforced by CMS (as per MDS Manual Chapter 3)

Note: Take MDS form from the handout section to follow along

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MDS Sections & Items – v1.17.1 (10/1/2019)

ARD (item A2300) must be set for Days 1 through 8 of the Part A SNF covered stay MDS must be completed (item Z0500B) within 14 days after the ARD (ARD + 14 days) Authorizes payment for entire PPS stay (except in cases when an IPA is completed) Must be submitted electronically and accepted into the QIES ASAP system within 14 days after

completion (item Z0500B) (completion + 14 days) If a patient changes payers from Medicare Advantage to Medicare Part A, the SB/SNF must

complete a 5-Day assessment with the ARD set for one of days 1 through 8 of the Medicare Part A stay, with the patient’s first day covered by Medicare Part A serving as Day 1

This continues to be “99” for SB

Many items removed such as all the OMRAs

08 = IPA (new)

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MDS Sections & Items

Optional assessment (IPA) - (will cover in more details later in this training)

• ARD (item A2300) may be set for any day of the SNF PPS stay, beyond the ARD of the 5-Day assessment.

• Must be completed (item Z0500B) within 14 days after the ARD (ARD + 14 days).

• Authorizes payment for remainder of the PPS stay, beginning on the ARD

• Must be submitted electronically and accepted into the QIES ASAP system within 14 days after completion (item Z0500B) (completion + 14 days)

• The ARD for an IPA may not precede that of the 5-Day assessment

• May not be combined with any other assessments

• On the IPA, GG items will be derived from a new column “5”, which will capture the interim performance of the patient. The look-back for this new column will be a three-day window preceding and up to the ARD of the IPA

Note: PDPM is for regular/generic Medicare patients• Rules surrounding when to and when not to transmit for other payors such as

Medicare Advantage or commercial are not changing based on the Final Rule

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MDS Overview

Item A0310E

Coding Instructions for A0310E, Is This Assessment the First Assessment (OBRA, Scheduled PPS, or OBRA Discharge) since the Most Recent Admission/Entry or Reentry? • Code 0, no: if this assessment is not the first of these assessments since the most

recent admission/entry or reentry• Code 1, yes: if this assessment is the first of these assessments since the most

recent admission/entry or reentry.

Coding Tips and Special Populations • A0310E = 0

• Entry or Death in Facility tracking records (A0310F = 01 or 12); • A standalone Part A PPS Discharge assessment (A0310A = 99, A0310B = 99, A0310F

= 99, and A0310H = 1); or An Interim Payment Assessment (A0310A = 99, A0310B = 08, A0310F = 99, and A0310H=0).

• A0310E = 1 • on the first Scheduled PPS assessment that is completed and submitted

Not new but based on questions, it requires a review

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MDS Overview

Item A0310G

Item A2400 A-B-C

Not new but taking the opportunity to re-discuss since this is often confusing• See next slide for example that would apply to most of our SB stays

SB to respond 0 = No

The interrupted stay policy does not apply to Swing Bed providers.

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MDS Overview

Example 1 for A2400 (take MDS form out to follow along)

Mrs. G. began receiving services under Medicare Part A on October 14, 2018. Due to her stable condition and ability to manage her medications and dressing changes, the facility determined that she no longer qualified for Part A SB/SNF coverage and began planning her discharge. An Advanced Beneficiary Notice (ABN) and an NOMNC with the last day of coverage as November 23, 2018 were issued. Mrs. G. was discharged home from the facility on November 24, 2016.

Code the following on her combined OBRA and Part A PPS Discharge assessment: • A0310F = 10 (D/C Return not anticipated)• A0310G = 1 (Planned D/C)• A0310H = 1 (Part A D/C assessment)• A2000 = 11-24-2016 (D/C Date)• A2100 = 01 (D/C to Community)• A2300 = 11-24-2016 (ARD)• A2400A = 1 (Had Medicare Part A stay)• A2400B = 10-14-2018 (Start date of stay)• A2400C = 11-23-2018 (End covered date)

Rationale:Because Mrs. G’s last day covered under Medicare was one day before her physical discharge from the facility, a Part A PPS Discharge was completed.

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MDS Overview Example 2 for A2400

Mr. R. began receiving services under Medicare Part A on October 15, 2018. Due to complications from his recent surgery, he was unexpectedly discharged to the hospital for emergency surgery on October 20, 2018 but is expected to return within 30 days.

Code the following on his OBRA PPS Discharge assessment:• A0310F = 11 (D/C Return Anticipated)

(10 Return not anticipated would also workfor SB)

• A0310G = 2 (D/C Unplanned) • A0310H = 1 (Part A D/C Assessment)• A2000 = 10-20-2018 (ARD)• A2100 = 03 (D/C to Acute Care)• A2300 = 10-20-2018 (D/C Date)• A2400A = 1 (Had Medicare Part A stay)• A2400B = 10-15-2018 (Start date for above)• A2400C = 10-20-2018 (End date for above)

• Note: SB do not do OBRA Assessments so itwould be a PPS D/C assessment

Rational:Mr. R’s physical discharge to the hospital was unplanned, yet it is anticipated that he will return to the facility within 30 days. Therefore, only an OBRA Discharge was required. Even though only an OBRA Discharge was required, when the Date of the End of the Medicare Stay is on the day of or one day before the Date of Discharge, MDS specifications require that A0310H be coded as 1.

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Medicare Stay End Date

Algorithm (A2400C)

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No change BUT the importance of the interview has changed (see next slide)

Do ensure that the staff assigned to do interviews have been well trained and follow the instructions to the letter – review MDS form interview section and the MDS Manal Appendix D: Interviewing to Increase Resident Voice and Appendix E for scoring rules and Instruction for BIMS when administered in writing

Interview should not be conducted ONLY if the patient is rarely/never understood; cannot respond verbally, in writing, or using another method; or an interpreter is needed but not available. Skip to C0700, Staff Assessment of Mental Status.

If the patient interview was not conducted within the look-back period (preferably the day before or the day of) the ARD, item C0100 must be coded 1, Yes, and the standard “no information” code (a dash “-”) entered in the patient interview items.• Do not complete the Staff Assessment for Mental Status items (C0700-C1000) if

the patient interview should have been conducted, but was not done.


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A PDPM cognitive level is utilized in the SLP payment component of PDPM, assessment of patient cognition with the BIMS or Staff Assessment for Mental Status is a requirement for all PPS assessments.

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

• In the above 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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Coding Instructions for BIMS

• The total possible BIMS score ranges from 00 to 15

• If the patient chooses not to answer a specific question(s), that question is coded as incorrect and the item(s) counts in the total score

• If, however, the patient chooses not to answer four or more items, then the interview is coded as incomplete and a staff assessment is completed

• To be considered a completed interview, the patient had to attempt and provide relevant answers to at least four of the questions included in C0200-C0400

• To be relevant, a response only has to be related to the question (logical); it does not have to be correct


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See general coding tips below for patients who choose not to participate at all

Code 99, unable to complete interview: • if (a) the patient chooses not to participate in the BIMS• (b) if four or more items were coded 0 because the patient chose not to

answer or gave a nonsensical response, or • (c) if any of the BIMS items is coded with a dash.

Note: a zero score does not mean the BIMS was incomplete

To be incomplete, a patient had to choose not to answer or give completely unrelated, nonsensical responses to four or more items.

Occasionally, a patient can communicate but chooses not to participate in the BIMS and therefore does not attempt any of the items in the section. This would be considered an incomplete interview; • enter 99 for C0500, BIMS Summary Score, and • complete the staff assessment of mental status.


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Coding Instructions for Section G

Unclear if the section G will continue to be required though not part of what will determine the coding for PDPM (G0110: ADL Assistance, G0120: Bathing, G0300: Balance During Transitions and Walking, G0400: Functional Limitation in Range of Motion, G0600: Mobility Devices, and G0900: Functional Rehabilitation Potential • Will continue to be required for post Medicare Stay if remaining in the facility• Continue to complete as accurate as possible unless the MDS system no longer

brings up the Section G – still unclear at this point

Coding Instructions (if required for PPS SB/SNF stays)• Continue considering all episodes of the activity that occur over a 24-hour period

during each day of the 7-day look-back period, as a patient’s ADL self-performance and the support required may vary from day to day, shift to shift, or within shifts.

• If a patient uses special adaptive devices such as a walker, device to assist with donning socks, dressing stick, long-handled reacher, or adaptive eating utensils, code ADL Self Performance and ADL Support Provided based on the level of assistance the patent requires when using such items

The Rule of 3 still applies (see handout section for Algorithm chart))

MDS Sections & ItemsAppears that Section G will be deleted

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SECTION GG: FUNCTIONAL ABILITIES AND GOALS

Has 4 sections:• GG0100. Prior Functioning: Everyday Activities• GG0110. Prior Device Use• GG0130. Self-Care (Admission Assessment w/Goal setting) + (Discharge Assessment)• GG0170. Mobility (Admission Assessment w/Goal Setting) + (Discharge Assessment)


Note: Cane is not to be marked “D” Walker. If that is all they use, it would be marked “Z” None of the above

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Has 4 sections: (continued)• GG0100. Prior Functioning: Everyday Activities• GG0110. Prior Device Use• GG0130. Self-Care (Admission Assessment w/Goal setting) + (Discharge Assessment)• GG0170. Mobility (Admission Assessment w/Goal Setting) + (Discharge Assessment)

The last 2 sections are components to determine case mix groups (to be discussed later)

This requires a team approach

Must be completed within 3 days of admission (date of admission + 2 days)

Assess the patient’s self-care performance based on • direct observation, • incorporating patient self-reports and • reports from qualified clinicians, • care staff, or family

The admission functional assessment, when possible, should be conducted prior to the person benefitting from treatment interventions in order to determine a true baseline functional status on admission.

Treatment should not be withheld in order to conduct the functional assessment

Activities may be completed with (if they usually use a device or safer attempted with a device) or without assistive device(s). Coding is not based on devices.


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SECTION GG: FUNCTIONAL ABILITIES AND GOALS (cont’)

Patients with cognitive impairments/limitations may need physical and/or verbal assistance when completing an activity. Code based on the patient’s need for assistance to perform the activity safely (for example, choking risk due to rate of eating, amount of food placed into mouth, risk of falling). These are at the very lease not independent –will be coded a 5 (supervision/set up) or lower

If the patient performs the activity more than once during the assessment period and the patient’s performance varies, coding should be based on the patient’s “usual performance,” not the most independent or dependent performance over the assessment period.

Assess the patient’s self-care status based on:• direct observation, • the patient’s self-report, • family reports, and • direct care staff reports documented in the patient’s medical record during the assessment

period

Discussion at May 2019 Section GG Training in Kansas City – If facility does not have 12 steps, but have a 4-step training step device, could use it and have the patient climb the step unit three times –not in the early release of the manual


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CMS anticipates that an interdisciplinary team of qualified clinicians is involved in assessing the patient during the three-day assessment period

CMS defines “Qualified Clinician” as Healthcare professionals practicing within their scope of practice and consistent with Federal, State, local law and regulations”

This should not be a therapy only assessment – should be what patient’s usual performance is since admission – not just what they did with therapy

Read the description of the items to be coded very carefully – do not read into it more than its asking – Must be able to perform all aspects of the described items to be considered Independent.

Carefully read the coding key descriptions and choose what best fits the patient –always look at the descriptions before and after the one you think it is to make sure you have the correct one

All assessment items must be attempted to be coded – otherwise a reason for no attempt must be coded (see slides on “Exceptions”)

Do remember that unlike section G - “01 – Dependent” in section GG applies if the helper provides all the effort to complete an activity OR the assistance of 2 or more helpers is required


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Same items will be tested on discharge but naturally no goal setting at discharge

Must be completed within 3 calendar days of discharge including the day of discharge• For the Discharge assessment, code the patient’s discharge functional status, based

on a clinical assessment of the patient’s performance that occurs as close to the time of the patient’s discharge as possible to capture all areas of improvement possible

Same coding principles apply to discharge assessments as it did for the admission assessment and again, all assessment items must be attempted to be coded – otherwise a reason for no attempt must be coded

Patients should be allowed to perform activities as independently as possible for both admission and discharge, as long as they are safe for both admission & discharge assessments.

If helper assistance is required because the patient’s performance is unsafe or of poor quality, score according to the amount of assistance provided. Only use the “activity not attempted codes” if the activity did not occur; that is, the patient did not perform the activity and a helper did not perform that activity for the patient


49


GG0130 and GG0170 - Discharge Goals

• Use the 6 -point scale or “activity not attempted codes” to code the patient’s discharge goal(s);

• Use of codes 07, 09, 10, or 88 is permissible to code discharge goal(s)

• For the SNF (QRP), completion of at least one discharge goal is required for one of the self-care or mobility items for each patient (otherwise can have 2% reduction in Medicare payment)

• The use of a dash is permissible for any remaining self-care or mobility goals that were not coded; using the dash in this allowed instance does not affect Annual Payment Update (APU) determination

• Licensed, qualified clinicians can establish a patient’s discharge goal(s) at the time of admission

A new column, Column 5 will be added to Section GG to capture interim performance in the IPA but no new goals are documented on the MDS


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Admission Performance and Discharge Goal Setting

• Are coded on every 5-day PPS assessment (Start of Part A PPS Stay) regardless of length of stay and planned or unplanned discharge

If the patient has an incomplete stay:

• Complete admission performance and discharge goals

• Discharge self-care and mobility performance items are not required

Unplanned Discharges or Incomplete Stay

• Unplanned discharge (A0130G = 2) has a Discharge Date (A2000) that is on the same day or the day after the End Date of Most Recent Medicare Stay (A2400C) OR

• Discharge to an acute care, psychiatric, or long-term care hospital (A2100 = 03, 04, 09) on an MDS Discharge (A0310F = 10, 11) that the discharge date (A2000) is on the same day or the day after A2400C OR

• Patient’s death on Death in Facility tracker has a discharge date the same day or the day after A2400C OR

• Medicare Part A stay is less than 3 days as indicated by the End date A2400C minus the Start Date of the most Recent Medicare stay (A2400B) < 3 days


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Interim Payment Assessment (IPA) (Optional): NEW

The Interim Payment Assessment (IPA) is an optional assessment that may be completed by providers in order to report a change in the patient’s PDPM classification.

An example of when a program may want to complete an IPA is• If there is a large change when readmitted from hospital of less than a

3-midnight stay – though you may want to calculate what the new rate would be

For Section GG on the IPA, providers will use the same 6-point scale and activity not attempted codes to complete the column “Interim Performance,” which will capture the interim (new) functional performance of the patient.

On admission, the section GG items are completed only when A0310B = 01 (5-Day PPS assessment). For the Interim Payment Assessment (A0310B=08), the assessment period for Section GG is the last 3 days (i.e., the ARD and two days prior) - not last 7 days as it is for the 5-day admission assessment


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Interim Payment Assessment (IPA) (Optional): (continued)

In an IPA, goals are not reset – there are no column for such

The ARD for the IPA is determined by the provider, and the assessment period is the last 3 days (i.e., the ARD and the 2 calendar days prior). – (let’s discuss when you may want to complete an IPA)

It is important to note that the IPA changes payment beginning on the ARD and continues until the end of the Medicare Part A stay or until another IPA is completed.

The IPA does not affect the variable per diem schedule. VPR schedule still applies


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SECTION I: ACTIVE DIAGNOSES – Primary Reason for Admission

Indicate the patient’s primary medical condition category that best describes the primary reason for the Medicare Part A stay;

Then proceed to I0020B and enter the International Classification of Diseases (ICD) code for that condition, including the decimal – the code in Item I0020B is used for PDPM classification purposes.

Medical record sources for physician diagnoses include the most recent history and physical, transfer documents, discharge summaries, progress notes, and other resources as available.


See CMS definitions on slides 55-56-57

Definitions must be shared with providers and coders

Case Manager / MDS Coordinator should be discussing this with the provider on admission if not earlier.

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SECTION I: ACTIVE DIAGNOSES /COMORBIDITIES

Made up of a long lists of potential diagnosis + Additional Active Diagnosis

I4300 Active Diagnosis: Aphasia was added – would impact SLP component

Diagnosis and comorbidities will impact the PT, OT, SLP and Nursing score for PDPM (to be discussed further in this presentation)

There are two look-back periods for this section: • Diagnosis identification (Step 1) is a 60-day look-back period• Diagnosis status: Active or Inactive (Step 2) is a 7-day look-back period or up to the ARD

(except for Item I2300 UTI, which does not use the active 7-day look-back period – see the MDS Manual – Chapter 3 Page 1-8

• Check off each active disease. Check all that apply

Once a diagnosis is identified, it must be determined if the diagnosis is active

Active diagnoses are diagnoses that have a direct relationship to the patient’s current functional, cognitive, mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period

Do not include conditions that have been resolved, do not affect the patient’s current status, or do not drive the patient’s plan of care during the 7-day look-back period, as these would be considered inactive diagnoses


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Medical Condition/Reason – Definitions

• Code 01, Stroke = if the patient’s primary medical condition category is due to stroke. Examples include ischemic stroke, subarachnoid hemorrhage, cerebral vascular accident (CVA), and other cerebrovascular disease.

• Code 02, Non - Traumatic Brain Dysfunction = if the patient’s primary medical condition category is non-traumatic brain dysfunction. Examples include Alzheimer’s disease, dementia with or without behavioral disturbance, malignant neoplasm of brain, and anoxic brain damage.

• Code 03, Traumatic Brain Dysfunction = if the patient’s primary medical condition category is traumatic brain dysfunction. Examples include traumatic brain injury, severe concussion, and cerebral laceration and contusion.

• Code 04, Non - Traumatic Spinal Cord Dysfunction = if the patient’s primary medical condition category is non-traumatic spinal cord injury. Examples include spondylosis with myelopathy, transverse myelitis, spinal cord lesion due to spinal stenosis, and spinal cord lesion due to dissection of aorta.

Section I : Active Diagnosis

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• Medical Condition/Reason – Definitions (cont’)

• Code 05, Traumatic Spinal Cord Dysfunction = if the patient’s primary medical condition category is due to traumatic spinal cord dysfunction. Examples include paraplegia and quadriplegia following trauma.

• Code 06, Progressive Neurological Conditions = if the patient’s primary medical condition category is a progressive neurological condition. Examples include multiple sclerosis and Parkinson’s disease.

• Code 07, Other Neurological Conditions = if the patient’s primary medical condition category is other neurological condition. Examples include cerebral palsy, polyneuropathy, and myasthenia gravis.

• Code 08, Amputation = if the patient’s primary medical condition category is an amputation. An example is acquired absence of limb.

• Code 09, Hip and Knee Replacement = if the patient’s primary medical condition category is due to a hip or knee replacement. An example is total knee replacement. If hip replacement is secondary to hip fracture, code as fracture.


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• Medical Condition/Reason – Definitions (cont’)

• Code 10, Fractures and Other Multiple Trauma , if the patient’s primary medical condition category is fractures and other multiple trauma. Examples include hip fracture, pelvic fracture, and fracture of tibia and fibula.

• Code 11, Other Orthopedic Conditions = if the patient’s primary medical condition category is other orthopedic condition. An example is unspecified disorders of joint.

• Code 12, Debility, Cardiorespiratory Conditions = if the patient’s primary medical condition category is debility or a cardiorespiratory condition. Examples include chronic obstructive pulmonary disease (COPD), asthma, and other malaise and fatigue.

• Code 13, Medically Complex Conditions = if the patient’s primary medical condition category is a medically complex condition. Examples include diabetes, pneumonia, chronic kidney disease, open wounds, pressure ulcer/injury, infection, and disorders of fluid, electrolyte, and acid-base balance.


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SECTION J - HEALTH CONDITIONS• Pain Management• Pain Assessment Interview• Pain Intensity• Shortness of Breath• Prognosis• Problem Conditions• Falls• Surgery History

J2100: Recent Surgery Requiring Active SNF Care

A recent history of major surgery during the inpatient stay that preceded the patient’s Part A admission can affect a patient’s recovery

Type of surgery will impact the PT and OT score hence PDPM

Review the patient’s medical record (H&P, transfer document, surgical report, progress notes, D/C summary etc) to determine whether the patient had major surgery during the inpatient hospital stay that immediately preceded this SB stay

These impact Quality and/or PDPM

Generally, major surgery refers to a procedure that meets the following criteria:

1. the patient was an inpatient in an acute care hospital for at least one day in the 30 days prior to admission to SB/SNF, and

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


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Identify recent surgeries:

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 daysand must have

• occurred during the inpatient stay that immediately preceded the patient’s Part A admission.


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SECTION J: Recent Surgery (continued)

Determine whether the surgeries require active care during the SB/SNF stay

• Once a recent surgery is identified, it must be determined if the surgery requires active care during the SB/SNF stay

• Surgeries requiring active care during the SB/SNF stay are surgeries that have a direct relationship to the patient’s primary SB/SNF diagnosis, as coded in I0020B (ICD Code)

• Do not include conditions that have been resolved, do not affect the patient’s current status, or do not drive the patient’s plan of care during the 7-day look-back period, as these would be considered surgeries that do not require active care during the SB/SNF stay

Check all that apply

Examples of surgeries are included for each surgical category. For example, J2810, Genitourinary surgery - the kidneys, ureter, adrenals, and bladder—open, laparoscopic, includes open or laparoscopic surgeries on the kidneys, ureter, adrenals, and bladder, but not other components of the genitourinary system


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Coding Tips

There may be specific documentation in the medical record by a physician, nurse practitioner, physician assistant, or clinical nurse specialist

• They may specifically indicate that the SB/SNF stay is for treatment related to the surgical intervention. Specific documentation may be found in progress notes, most recent history and physical, transfer notes, hospital discharge summary, etc.

• In the rare circumstance of the absence of specific documentation that a surgery requires active SB/SNF care, the following indicators may be used to confirm that the surgery requires active SB/SNF care:

• The inherent complexity of the services prescribed for a patient is such that they can be performed safely and/or effectively only by or under the general supervision of skilled nursing.

• For example:• The management of a surgical wound that requires skilled care (e.g.,

managing potential infection or drainage).• Daily skilled therapy to restore functional loss after surgical procedures• Administration of medication and monitoring that requires skilled nursing


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Example # 1 of surgeries requiring active SNF care and related to the primary SNF diagnosis or not requiring such

Mrs. V was hospitalized for gram-negative pneumonia• Since this was her second episode of pneumonia in the past six months, a

diagnostic bronchoscopy was performed while in the hospital • She also has Parkinson’s disease and rheumatoid arthritis• She was discharged to a SB/SNF for continuing care

Coding: • I0020 is coded as 13, Medically Complex Conditions, and

• I0020B SNF ICD-10 code is J15.6, Pneumonia due to other aerobic Gram-negative bacteria.

• There is no documentation that the patient had major surgery; therefore, J2100 is coded 0 = No.

Rationale: Mrs. V did not receive any major surgery during the prior inpatient stay, and she was admitted to the SB/SNF for continued care due to pneumonia


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Example # 2 of surgeries requiring active SNF care and related to the primary SNF diagnosis or not requiring such

Mr. N was hospitalized for repair of a unilateral inguinal hernia with gangrene• He had surgery to repair the hernia, but • His post-operative course included management of his diabetes mellitus, cardiac

arrhythmias, and congestive heart failure• He was transferred to a SB/SNF for continuing care.

Coding: • I0020 is coded as 13, Medically Complex Conditions.

• I0020B SB/SNF ICD-10 code is K40.40 (Unilateral inguinal hernia, with gangrene, not specified as recurrent), and

• J2100 would be coded 1 = Yes

• J2910, Major surgery – the GI tract and abdominal contents from the esophagus to the anus, the biliary tree, gall bladder, liver, pancreas, spleen –open or laparoscopic, would be checked

Rationale: Surgery to repair an inguinal hernia with gangrene is a major surgery, and Mr. N was admitted to the SB/SNF for continuing care.


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SECTION K: Swallowing/Nutritional Status (K0100) – New

This may impact the SLP component if the patient has swallowing disorders as well as if the patient is on a mechanically altered diet in item K0510C

O0100D2 Special Treatments and Procedures: Suctioning: While a patient will be added to the Swing Bed PPS Assessment


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SECTION O: Therapy (some changes) and added: Complete only if A0310H = 1 (initial PPS Day 5 Assessment)

Added O04025AO0425BO04025C


66

SECTION O: (continued)

• Only 25% group and/or concurrent therapy can be provided to the patient

• Only 25% of total minutes can be provided in the group OR concurrent mode or a combination thereof

• In other words, at least 75% of the minutes provided to a patient will be provided in the individual mode

• Software companies continue to have this as a formula calculation? However, the new calculation is 25% for group and concurrent combined

• Presently 4 patient’s is considered a group – proposal to change to 2 to 6 patients

• Items O0425A1 – O0425C5 are added to Section O of the MDS to record the total amount of therapy a Part A patient receives during their entire SB/SNF Stay from what the 25% above can be calculated

O04020 was removed and changed to O04030 O0450A and O0450B (Resumption of Therapy) was deleted


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SECTION O: Therapy

There is no change in what constitutes skilled therapy and the calculation of minutes and days of therapy.

Under RUG-IV, minutes of therapy were crucial to obtain the best rates

Under PDPM, though minutes are still reported, what will impact the PDPM are based on diagnosis that require therapy and the self-care and mobility score. Others may equally improve with restorative nursing.

As it stands today, the RAI rules for tech/student usage are not changing. Techs/aides cannot be used. Students may be used but not treating at the same time as their supervisor is treating a patient.

SB programs may want to work on improving their rehab/restorative practice. What we call it is not important – what counts is rehab/restorative activities provided by nurses, nurses aids, rehab tech when skilled therapy is not required but important to improve the self-care and mobility outcome

Will the payment be impacted if one therapy discipline discharges the patient from their services prior to other disciplines?• PDPM is not based on utilization, the payment will not be impacted by adding or discharging

disciplines of therapy• For clinical reason, an IPA may be indicated if the clinical picture of the patient has changed

significantly. Significantly being the operative word.


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SECTION O0500. Restorative Nursing Programs

No different nursing rehab / restorative activities and for payment purpose applies to the low RUGs

• Should definitely improve self-care and mobility skills between admission & D/C = Quality


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SECTION O0500. Restorative Nursing Programs (continued)

Restorative nursing program refers to nursing interventions that promote the patient’s ability to adapt and adjust to living as independently and safely as possible

This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning

• A patient may be started on a restorative nursing program when he or she is admitted to the facility with restorative needs, but is not a candidate for formalized rehabilitation therapy, or

• When restorative needs arise during the course of a longer-term stay, or

• In conjunction with formalized rehabilitation therapy

Generally, restorative nursing programs are initiated when a patient is discharged from formalized physical, occupational, or speech rehabilitation therapy

The following criteria for restorative nursing programs must be met in order to code O0500: • A registered nurse or a licensed practical (vocational) nurse must supervise the activities in

a restorative nursing program• Restorative nursing does not require a physician’s order


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Criteria for restorative nursing programs (continued): • Measurable objective and interventions must be documented in the care plan and in the

medical record• If a restorative nursing program is in place when a care plan is being revised, it is appropriate

to reassess progress, goals, and duration/frequency as part of the care planning process • Good clinical practice would indicate that the results of this reassessment should be

documented in the patient’s medical record• Evidence of periodic evaluation by the licensed nurse must be present in the patient’s medical

record. When not contraindicated by state practice act provisions, a progress note written by the restorative aide and countersigned by a licensed nurse is sufficient to document the restorative nursing program once the purpose and objectives of treatment have been established

• Nursing assistants/aides must be trained in the techniques that promote patient involvement in the activity

• Programs may elect to have licensed rehabilitation professionals to supervise aides performing these maintenance services • In situations where such services do not actually require the involvement of a qualified therapist, the

services may not be coded as therapy in item O0400, Therapies or O0425, Part A Therapies, because the specific interventions are considered restorative nursing services (see item O0400, Therapies and O0425, Part A Therapies)

• The therapist’s time actually providing the maintenance service can be included when counting restorative nursing minutes

• Although therapists may participate, members of the nursing staff are still responsible for overall coordination and supervision of restorative nursing programs

• This category does not include groups with more than four patients per supervising helper or caregiver.


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Example of a restorative nursing activity:

Mrs. K. was admitted to the SB 7 days ago following repair to a fractured hip• Physical therapy was delayed due to complications and a weakened condition• Upon admission, she had difficulty moving herself in bed and required total assistance for

transfers• To prevent further deterioration and increase her independence, the nursing staff implemented

a plan on the second day following admission to teach her how to move herself in bed and transfer from bed to chair using a trapeze, the bed rails, and a transfer board

• The plan was documented in Mrs. K.’s medical record and communicated to all staff at the change of shift

• The charge nurse documented in the nurse’s notes that in the 5 days Mrs. K. has been receiving training and skill practice for bed mobility for 20 minutes a day and transferring for 25 minutes a day, her endurance and strength have improved, and she requires only extensive assistance for transferring

• Each day the amount of time to provide this nursing restorative intervention has been decreasing, so that for the past 5 days, the average time is 45 minutes.

Coding: Both Bed Mobility item (O0500D), Transfer item (O0500E), would be coded 5.

Rationale: Because this was the number of days that restorative nursing training and skill practice for bed mobility and transfer were provided

See handout section for Examples (Restorative Nursing Program)


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SECTION X

• X0600B – removed the options for Day 5-14-30-60-90 and OMRA Assessments (Now – now Day 5 and IPA)

• X0600C and X0600D were removed – X0600F and X0600H remain

• X0900 Reasons for Modification – X0900E. End of Therapy - Resumption (EOT-R) date was removed

• See MDS Manual – Chapter 5: Submission and Correction of the MDS Assessments for instructions


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SECTION Z:


74

SECTION Z: ASSESSMENT ADMINISTRATION SECTION

The HIPPS code is a Skilled Nursing Facility (SNF) Part A five-position billing code;• the first four positions represent the PDPM case mix version code and• the fifth is an assessment type indicator

Typically, the software data entry product will calculate this value

Coding Instructions for Z0100B, Version Code

• Typically, the software data entry product will calculate this value

• If the value for Z0100B is not automatically calculated by the software data entry product, enter the PDPM version code in the spaces provided.


75

Submission Time Frame for MDS Records

Further discussed under the billing section of this training.


76

PPS Eligibility Criteria Under SNF PPS

Has not changed

Beneficiaries must meet the established eligibility requirements for a Part A SNF-level stay. These requirements are summarized in this section. Refer to the Medicare General Information, Eligibility, and Entitlement Manual, Chapter 1 (Pub. 100-1), and the Medicare Benefit Policy Manual, Chapter 8

• Beneficiary is enrolled in Medicare Part A and has days available to use

• There has been a three-day prior qualifying hospital stay (i.e., three midnights)

• Admission for SB/SNF-level services is within 30 days of discharge from an acute care stay or within 30 days of discharge from a SB/SNF level of care.

• A beneficiary is eligible for SNF extended care if all of the following requirements are met:

• The beneficiary has a need for and receives medically necessary skilled care on a daily basis, which is provided by or under the direct supervision of skilled nursing or rehabilitation professionals.

• As a practical matter, these skilled services can only be provided in an IP SB/SNF

• The services provided must be for a condition: — for which the patient was treated during the qualifying hospital stay, or — that arose while the patient was in the SB/SNF for treatment of a condition for which he or she was previously treated in a hospital.


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Physician Certification

• Certifications continue to be required at the time of admission or as soon thereafter as is reasonable and practicable (42 CFR 424.20)

• The initial certification — affirms, per the required content found in 42 CFR 424.20, that the patient meets the existing SNF level of care definition, or —validates via written statement that the patient’s assignment to one of the upper PDPM groups (defined below) is correct• Those nursing groups encompassed by the Extensive Services, Special Care

High, Special Care Low, and Clinically Complex nursing categories; • PT and OT groups TA, TB, TC, TD, TE, TF, TG, TJ, TK, TN, and TO;• SLP groups SC, SE, SF, SH, SI, SJ, SK, and SL; and• The NTA component’s uppermost (12+) comorbidity group

Re-certifications

• Used to document the continued need for skilled extended care services

• At this time, based on the MDS Manual, the first re-certification is required no later than the 14th day of the SNF stay

• Subsequent re-certifications are required at no later than 30-day intervals after the date of the first re-certification

• New - The initial certification and first re-certification may be signed at the same time.


Break (10:30 – 10:45)

PDPM Calculation Detail (10:45 – 11:45)

HIPPS Determination

How are the 5 letters of the HIPPS determined

What is the AI code

Per Diem Rate Determination

80

When PDPM is implemented as the case-mix classification system for the PPS SB/SNF on Oct. 1, 2019, SB/SNFs will have to code a new set of health insurance prospective payment system (HIPPS) codes in MDS item Z0100A (Medicare Part A HIPPS code) and on the Part A claim to identify a SB/SNF patient’s payment classification.

CMS during the Dec. 11 SNF PPS: PDPM National Provider Call

PDPM also will use a five-character HIPPS code. However, instead of classifying into a single payment group like in RUG-IV, patients will classify into a payment group under each of the five PDPM case-mix-adjusted components: physical therapy (PT), occupational therapy (OT), speech-language pathology (SLP), nursing, and non-therapy ancillary (NTA), said officials

The first character represents the patient’s PT and OT payment group; the second, his or her SLP payment group; the third, his or her nursing payment group; the fourth, his or her NTA payment group; and finally, the fifth, identifies whether it’s a 5-day assessment or an IPA

PT and OT use the same classification criteria, so they end up having the same payment group, which is why they can share one character of the HIPPS code. • However, the PT and OT components use different base rates and case-mix indexes (CMIs),

and each case-mix-adjusted per-diem component rate is calculated independently• For example, a patient who classifies into the TC case-mix group for PT will also classify into

the TC case-mix group for OT. But the TC will pay differently in PT than it does in OT due to the different base rates and CMIs

PDPM Calculation Details

81


82


83

HIPPS Determination – How are the HIPPS Letters Determined..

1st letter of the HIPPS code = PT/OT Component


PT/OT Clinical Category is based on:

- Section I0020 = Active Diagnosis and

- Section J2300 to J5000 for Surgical Procedures

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HIPPS Determination – How are the HIPPS Letters Determined..(continued)

Section I – Active Diagnosis

• During the SNF ODF on 8/2/2018, John Kane made it clear that the hospital admitting diagnosis may or may not be the same as the SNF diagnosis

• In other words, the reason the patient was admitted to the hospital may be resolved, but the residual effects of that hospital stay may be why we are seeing them in the SNF

• It is our responsibility to code the admitting reason for the SB/SNF stay

Again, all patients will be classified into PT, OT, and SLP classification regardless of whether they are on therapy case load


85

HIPPS Determination – How are the HIPPS Letters Determined..

1st letter of the HIPPS code = PT/OT Component (continued)


Same Clinical Category chart is used for OT

PT and OT will have the same Case-Mix group, but the Case-Mix score will be different

For example, the PT and OT Case Mix Group of TI will have a PT Case Mix Index of 1.13 and an OT Case Mix Index of 1.17

Both the Case Mix Groups will be used – one for the PT portion of the per diem and the other for the OT portion of the per diem.

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HIPPS Determination

Patient’s function score calculation

The function score for patient classification under PDPM will be calculated using data from Section GG of the MDS 3.0 (Functional Abilities and Goals) rather than Section G items.

This advances CMS’s goal of using standardized assessment items across payment settings (IRF, LTAH, HH).

• PDPM makes no changes to how Section GG is coded.

• The functional score for the PT and OT components is calculated based on ten Section GG items that were all found to be highly predictive of PT and OT costs per day:

• Two bed mobility items • Three transfer items • One eating item • One toileting item • One oral hygiene item • Two walking items (50 ft w/2 turns & 150 ft)


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HIPPS Determination

Patient’s function score calculation (continued)

Similar to the RUG-IV ADL score, each of these ADL areas is assigned a score of up to 4 points

• Higher points are assigned to higher levels of independence

• CMS observed that patients who were unable to complete an activity had similar PT and OT costs as dependent patients, therefore, when the activity cannot be completed, the equivalent section GG responses (“patient refused,” “Not applicable,” “Not attempted due to medical condition or safety concerns”) are grouped with “dependent” for the purpose of point assignment

• For the two walking items, CMS uses an additional response level to reflect patients who skip the walking assessment due to their inability to walk. This allows them to assess the functional abilities of patients who cannot walk and assign them a function score

• Patients who are coded as unable to walk receive the same score as dependent patients to match with clinical expectations.


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HIPPS Determination (continued)

Scoring algorithm for items related to the PT and OT Functional Score

Note: Cognitive Measure is not a factor in classification for the PT/OT components under PDPM

But, the Walking Functional score is based on addition of score for 50 ft w/2 turns & 150 Ft –divided by 2


89

HIPPS Determination

Scoring algorithm for items related to the PT and OT Functional Score:(cont’)

Missing section GG responses will receive zero points for the function score calculation.

A dash or any other non-recognized character will be considered a missing value

Unlike section G, section GG measures functional areas with more than one item. This results in substantial overlap between the two bed mobility items, the three transfer items, and the two walking items• To adjust for this overlap, they calculate an average score for these related items. • That is, they average the scores for the two bed mobility items, the three transfer items, and

the two walking items.

The average bed mobility, transfer, and walking scores are then summed with the scores for eating, oral hygiene, and toileting hygiene, resulting in equal weighting of the six activities

This scoring algorithm produces a function score that ranges from 0 to 24


90

HIPPS Determination

Scoring algorithm for items related to the PT and OT Functional Score: (cont’)

The scores in Section GG are rounded only at the end of the calculation. • For example, if the transfer items have 1, 0, and 0 points, the unrounded

average is 0.33• This would be added to the other scores, unrounded, and then the total score

at the end of the sum calculation would be rounded to the nearest integer.


Oral Hygiene and the 2 Walking items are not used to calculate the Function Score for Nursing

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HIPPS Determination

Scoring algorithm for items related to the PT and OT Functional Score: (cont’)

Section GG Function score of 10: “Not attempted due to environmental limitations” shall receive zero points for function score assignment

Responses of 07 “patient refused,” 09 “not applicable,” and 88 “not attempted due to medical condition or safety concerns” shall all receive zero points for function score assignment

CMS also assign 0 points to “dependent” responses

PT and OT payment is higher for case-mix groups with higher functional independence in some cases (lets discuss – what can this mean)

• This reflects the finding that PT and OT utilization is highest for patients with moderate functional independence and lower for patients with both the highest levels of functional dependence and independence

• In the first case, this likely reflects patients whose functional abilities are too impaired to receive intensive therapy, while the second case likely corresponds to patients who require less therapy because they already have a high level of functional independence


92

HIPPS Determination

2nd letter of the HIPPS code = SLP Component


Same Diagnosis Clinical Category as PT & OT but SLP Clinical Categories are different

Presence of Comorbidity impacting the SLP Component

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HIPPS Determination

2nd letter of the HIPPS code = SLP Component (cont’)

Scoring algorithm for items related to SLP Cognitive Impairment

Patient’s cognitive status is assessed using either the BIMS (00-15) or, in cases where the BIMS is not or cannot be completed, a Staff Assessment for Mental Status is completed which translate to the Cognitive Performance Scale (CPS)

In order to receive a PDPM classification, all required items must be completed. • Either a BIMS score or CPS score is necessary to classify the patient under the SLP

component. • If neither the BIMS nor the staff assessment is completed, then the patient will not be

classified under PDPM and• a PDPM HIPPS code will not be produced for this assessment.


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HIPPS Determination

2nd letter of the HIPPS code = SLP Component (continued)

NOTE: The PDPM cognitive level is utilized in the SLP payment component of PDPM. One of four PDPM cognitive performance levels is assigned based on the BIMS or the Staff Assessment for Mental Status for the PDPM cognitive level. If neither the BIMS nor the staff assessment for the PDPM cognitive level is complete, then the PDPM cognitive level cannot be assigned and the PDPM case mix group cannot be determined.


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HIPPS Determination

3rd letter of the HIPPS code = Nursing Component

Nursing is based on:

• Functional Score (eating, toileting, bed mobility & transfer)

• Receiving services as it was calculated for the medical RUGs

• Whether the patient is receiving extensive services (trach, vent, isolation)

• Just as it is with RUGs, if the patient does not classify in the Extensive Services Category, proceed to the Special Care High Category


The RUG hierarchy still applies – it begins with groups with the highest resource use and descends to those groups with the lowest resource use. So, if the patient does not have an Extensive Service Condition, move down to Special Care High.

96

PDPM Calculation Details HIPPS Determination


Nursing is based on: RUG services (continued)

• Just as it was for RUG, if the patient does not have one of the conditions from the Extensive Services, skip to the Special Care High Category from this chart

• If at least one of the special care conditions on this chart is coded and the patient has a total PDPM Nursing Function Score of 14 or less, he or she classifies as Special Care High.

97

HIPPS Determination



• If the patient does not have one of the conditions from the Extensive Services nor Special Care High, skip to the Special Care Low Category from this chart

• If at least one of the special care conditions on this chart is coded and the patient has a total PDPM Nursing Function Score of 14 or less, he or she classifies as Special Care High.


98

HIPPS Determination



• If the patient does not have one of the conditions from the Extensive Services, nor Special Care Low, skip to the Clinically Complex Category from this chart regardless of their PDPM Nursing Function Score


99

HIPPS Determination



• Whether the patient has any of the following conditions (BA, BB 1 or 2)

• Whether the patient presents with one of the following behavioral symptoms:


If the patient did not meet any of the above service groups the system looks at Behavioral Symptoms and Cognitive Performance Problems

100

HIPPS Determination



• Determine Restorative Nursing Count (PA, PB, PC, PD, PE 1 or 2)


Just as it was for RUG, If the patient did not meet any of the above service groups the system looks at Reduced Physical Function

As it was under RUG IV, be aware if the patient only meets one of the lowest categories – do they have documented skilled needs or are they on a maintenance program. If skilled, what is the treatment plan and goal(s)

101

HIPPS Determination



• Whether the patient has S&S of depression or not

• Whether or not there are cognitive issues


102

HIPPS Determination

3rd letter of the HIPPS code = Nursing Component (continued)


103

HIPPS Determination



104

HIPPS Determination



105

HIPPS Determination



106

HIPPS Determination


4th letter of the HIPPS code = NTA Component


See next slides for NTA Score Range calculation

107

HIPPS Determination

4th letter of the HIPPS code = NTA (Non-Therapy Ancillary) Component

NTA comorbidity score

• The NTA comorbidity score is a weighted count of certain comorbidities that a SB/SNF patient has, which is then used to classify the patient into an NTA component payment group

• Comorbidities associated with higher increases in NTA costs are grouped into higher point tiers, while those that are associated with lower increases in NTA costs are grouped into lower point tiers

• One of the comorbidity is related to whether the patient received parenteral/IV feeding in the last 7 days while a SB/SF patient but must be determined if High or Low Intensity• High = proportion of total calories received thru parenteral or tube feeding was 51% or

more • Low = proportion of total calories received thru parenteral or tube feeding was 26 to 50%

and the average fluid intake per day by IV or tube feeding was 501 cc or more or more

• If the patient has HIV/AIDS there is an increase of 18% in payment


108

HIPPS Determination

4th letter of the HIPPS code = NTA (Non-Therapy Ancillary) Component

NTA comorbidity score (cont’)

• Patient’s comorbidity score calculation (see next slide for comorbidity list)

• The provider will report on the MDS each of the comorbidities that a person has

• The patient’s NTA comorbidity score (50 condition) is the sum of the points associated with each relevant comorbidity using the table below to determine CMG


From this chart we determine the CMG and hence the 4

thletter (A-

B-C-D-E or F) of the HIPPS code

109


50 conditions that impact the NTA score


110


In short


111

PT and OT CMGs & CMIs


112

SLP CMGs & CMIs


113

NTA CMGs & CMIs


114

Nursing CMGs & CMIs


115

Nursing CMGs & CMIs (cont’)


116

Nursing CMGs & CMIs (cont’)


117

Rural per diem base rates

Note: These are not wage index adjusted so, may be higher or lower based on where you are located

• Nursing $103.46 ($98.83 –rural)

• NTA $78.05 ($74.56 –rural)

• PT $59.33 ($67.63 –rural)

• OT $55.23 ($62.11 –rural)

• SLP $22.15 ($27.90 –rural)

• Non-case-mix $92.63 ($94.34 –rural)

Determine the case mix group which will provide you with CMI for each component x the per diem above = your per diem rate for each component – add all components per diem rate = total per diem

Note: multiply NTA rates by 3 for the first 3 days of stay


Per Diem reduction over time during the SB/SNF Stay

118

Example of a Rural Per Diem for a patient with Hip Replacement

Provided from Seagrove Rehab at an AANAC conference

Note


This and the next chart were provided by Seagrove Rehab at an AANAC conference

119

Example of an Urban Per Diem for a patient with Joint Replacement /Medically Complex

Provided from Seagrove Rehab at an AANAC conference

Note

See your CFO for info your wage adjusted index based on your county – May need to call your MAC.


120


121

Calculation Tips to Remember

PT & OT have the same clinical category and CMG but multiplied by different CMI to determine the per diem for each

SLP is not based on a Function score

Cognitive level (BIMS) only comes into play for SLP component calculation (not for PT/OT)• If the patient’s Summary Score is 99 or the Summary Score is blank or has a dash value, then

determine the patient’s cognitive status based on the Staff Assessment for Mental Status for the PDPM cognitive level

If the BIMS nor the Staff Assessment for Mental status was completed, the HIPPS code will not be able to be determined given that the Cognitive Level must be calculated for SLP – no HIPPS code can be determined with missing components

Cognitive Level is measured as follows:• The patient classifies as severely impaired if one of following conditions exist: a. Comatose

(B0100 = 1) and completely dependent or activity did not occur at admission (GG0130A1, GG0130C1, GG0170B1, GG0170C1, GG0170D1, GG0170E1, and GG0170F1, all equal 01, 09, or 88). b. Severely impaired cognitive skills for daily decision making (C1000 = 3)

• If not severely impaired, the system uses the following items to calculate whether the patient is moderately, mildly or cognitively intact• C1000 = for Cognitive Skills for Daily Decision Making• B0700 = for Makes Self Understood• C0700 = for patient has memory problems


122

Calculation Tips to Remember (continued)

PT/OT Function Score is calculated as follows:

• Note the admitting assessment Performance score for the following activities but changing what is on the MDS to the Function score using the chart below:

• Eating ___ Oral Hygiene ___ Toileting Hygiene____• Bed Mobility has 2 Function Score (Sit to Lying___ and Lying to Sitting on Side of Bed _)

– Add the 2 Bed Mobility Function scores and divide by 2 for Bed Mobility Function Score• Transfer has 3 Function score (Sit to Stand__ Chair/Bed-to-Chair___ Toilet Transfer__)

– Add the 3 Transfer Function scores and divide x 3• Walking has 2 Function scores (Walk 50 Feet with Two Turns__ Walk 150 Feet

- Add the 2 Walking Function scores and divide by 2• Finally, add the 6 Function Scores (from above) and round up or down for Final Function

Score – should be between 0 to 24 for both PT and OT


For instance, if Eating was scored a 5 on the MDS, you would use the Function Score “4” for the calculation

Transfer

Transfer

BedMobility

Walking

123


Nursing Function Score is calculated as follows:

• Note the admitting assessment Performance score for the following activities but changing what is on the MDS to the Function score using the chart below:

• Eating _____ Toileting Hygiene: ______• Bed Mobility has 2 Function Score (Sit to Lying___ and Lying to Sitting on Side of Bed __)

– Add the 2 Bed Mobility Function scores and divide by 2 for Bed Mobility Function Score• Transfer has 3 Function score (Sit to Stand___ Chair/Bed-to-Chair___ Toilet Transfer___)

– Add the 3 Transfer Function scores and divide x 3 for the Transfer Function Score• Walking scores do not apply to the nursing component• Finally, add the 4 Function Scores (Eating, Toileting Hygiene, Bed Mobility & Transfer

scores from above) and round up or down for Final Function Score – should be between 0 to 16 for Nursing


For instance, if Eating was scored a 5 on the MDS, you would use the Function Score “4” for the calculation

BedMobility

Transfer

124


Note how the Grouper calculates when the activity cannot be completed, the equivalent section GG responses (“patient refused,” “Not applicable,” “Not attempted due to environmental limitations,” “Not attempted due to medical condition or safety concerns”) are grouped with “dependent” for the purpose of point assignment.

• Patients who are coded as unable to walk the 10 Ft receive the same score as dependent patients for that and all other “walk” activities to match with clinical expectations

Missing section GG responses will receive zero points for the function score calculation. A dash or any other non-recognized character will be considered a missing value


LUNCH (11:45 – 12:45)

ICD-10 Coding Overview (12:45 – 1:30)

ICD-10 Codes under PDPM

Documentation of ICD-10 on the MDS

Required Documentation for Diagnosis/Comorbidity

IDT Members’ Role in Coding

High Level Overview of Dos & Don’t of Coding

Disclaimer – the presenter is not a coder nor has she had detailed training in coding – programs are responsible to not only train coders in PDPM but should ensure that they use knowledgeable coders and afford them the use of most recent annual coding manual

127

ICD-10 Coding OverviewICD-10 codes have a crucial role under PDPM – CODERS MUST BE INCLUDED

There are 3 ways in which ICD-10 codes will be used under PDPM1) Providers will be required to report on the MDS the patient’s primary diagnosis for the SB/SNF

stay• Each primary diagnosis is mapped to one of ten PDPM clinical categories, representing

groups of similar diagnosis codes, which is then used as part of the patient’s classification under the PT, OT, and SLP components

• Do stay away from “unspecified” codes as much as possible• Drill down as far as possible to be more specific

2) ICD-10 codes are used to capture additional diagnoses and comorbidities that the patient has, which can factor into the SLP comorbidities that are part of classifying patients under the SLP component

3) Diagnoses and comorbidities are also used to classify patients under the NTA component

Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established - Must be confirmed by the physician

A mapping between these ICD-10-CM codes and the Clinical Category, SLP and NTA comorbidities, used for patient classification is available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html - One comorbidity, HIV/AIDS, is reported on the SNF claim and not on the MDS in the same manner as under RUGIV

128

ICD-10 Coding Overview

SB Program is responsible to identify ICD-10 for sections that are not pre-ICD-10 in the system

Diagnosis and comorbidities must be reflected in the SB medical record.

Documentation on the MDS does not suffice

129

ICD-10 Coding Overview ICD-10 are based on diagnosis made by Physicians (Attending physician, covering

physicians, Radiologists, Specialists, etc.) • Nurse Practitioners • Clinical Nurse Specialists • Physician Assistants

Diagnosis may be found• History and Physicals (hospitals and SB)• ER records and other hospital records such as Observation prior to admission• Discharge summaries • X-ray and Lab reports• Surgical reports• Physician progress notes• Transfer records

Case Manager, MDS Coordinator, Staff Nurse, and Therapists may also have open communication regarding diagnostic information with the physician.• Diagnoses communicated verbally must be documented in the medical record by the physician • Diagnostic information, including past history obtained from family members and close

contacts, must also be documented in the medical record by the physician to ensure validity and follow-up

• A Rehab Diagnosis made by the therapists must also be in the physician’s documentation or therapy eval must be co-signed by the physician

Any active diagnosis checked off on the MDS must also be supported by the physician's documentation

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ICD-10 Coding Overview The diagnoses and ICD-10-CM codes are an important part of each patients’ medical

record

The new payment system (PDPM) effective 10/1/2019 focuses on patient characteristics and diagnoses to determine per diem rate (see below)

ICD-10-CM codes must be accurate, or billing issues can occur if the diagnosis codes on the UB-04 do not support the skilled services

CMS’s response to a FAQ for the following – “Is it required that the principal diagnosis on the SB/SNF claim match the primary diagnosis coded in item I0020B?” was that “while we expect that these diagnoses should match, there is no claims edit that will enforce such a requirement”• There is talk that future regulatory changes may be based on ICD-10CM codes submitted on

claims and MDS assessments – why not start now?

As coders are aware, ICD-10 codes are made up of 3-7 characters• 1st character is alpha (all letters are used except U) • 2nd character is numeric• Characters 3-7 are alpha or numeric• Decimal is used after the 3rd character • Alpha characters are not case sensitive• Fill out empty characters with an “x” when a code contains fewer than 6 characters and a 7th

character applies • When placeholder character applies, it must be used in order for the code to be valid

131

ICD-10 Coding Overview SB/SNFs typically use a code that is related to therapy delivery as the main

driver of payment under the existing RUG system as applicable. • A look at CMS’ clinical mapping tools shows that the codes that SB/SNFs

currently use don’t always match the ICD-10 figures that will be used under PDPM

Who can assign an ICD-10 code? – one would think its only coders, yet CMS knows that most Nursing Facilities do not have a coder and not even access to one

• SB programs are fortunate to have coders in the hospital or access to one

• But these coders will require education on how the ICD-10 codes chosen or not chosen may impact the payment and compliance

• Physicians will need to understand the specificity of their diagnosis

• Nursing and Therapy Directors will have to ensure comprehensive documentation - Coders cannot create ICD codes without supportive documentation

• MDS Coordinators need to be the liaison to ensure that the coders will have what they need to code appropriately

• Together, the team can identify or assist in identifying the primary reason for admission and other active diagnosis /comorbidities based on assessments and treatments

132

ICD-10 Coding Overview Regardless of who is responsible to code, the following is important

• Use an ICD-10 Coding Manual and not the ICD-10-PCS Manual – ensure that the coder understands the manual well and knows where to look for

• Coding Guidelines• Alphabetic Index (starting point for all diagnoses other than cancer)• Neoplasm Table (starting point for cancer coding) • Table of Drugs and Chemicals (use when a medication has been identified as a cause of

symptoms/problems • Tabular list (Must be used to determine the final code)

• Do NOT code from the internet, your phone, or code from a list

• Hospitals must purchase new coding manuals effective every October 1st

• Identify the main term of the diagnosis and do not hesitate to query the physicians if the diagnosis is unclear

• Do not use the ICD‐10‐CM codes from the hospital records unless you can verify that the codes are accurate and active for the SB stay for that patient

• Do NOT code symptoms you see in the licensed nursing notes, therapy documentation or in an IDT notes

• Do NOT code a diagnosis unless the physician has documented the diagnosis in the SB medical record

133

ICD-10 Coding Overview

The ICD-10 spreadsheet that CMS published shows which ICD-10 codes fall into which clinical category

• There will be times where one ICD-10 maps to two different clinical categories

• In those cases, the presence of a surgical procedure will be the determinant as to which category the patient will be classified into

• Section J2000 will be completed to fully classify the patient into one clinical category or another

Determining a process on how the MDS Coordinator will work with the Coder is crucial

PDPM Calculation Overview & Billing (1:30 – 2:30)

PDPM Overview

PDPM Calculation Overview

Relationship between the MDS Assessment & the Claim

Billing for patient in the SB/SNF program during the transition from RUG IV to PDPM

Variable Per Diem Calculation

Billing for Default

135

PDPM Calculation Overview & Billing Patient Driven Payment Model (PDPM) adjusts payment for each major element of a

patient’s PPS SB/SNF care, specifically for:• physical therapy (PT), • occupational therapy (OT), • speech-language pathology (SLP), • nursing, and • nontherapy ancillaries (NTA)

CMS provided a PDPM calculation worksheet. This calculation worksheet was developed in order to provide clinical staff with a better understanding of how PDPM works• See reference to website later in this presentation• The worksheet translates the standard software code into plain language to assist

staff in understanding the logic behind the classification system

The 5-Day assessment is the only required PPS assessment that is used to support PPS reimbursement – No more billing for a RUG code at day 5-14-30 etc

An optional assessment, the Interim Payment Assessment (IPA), may be used to reclassify the patient into a new PDPM classification, and would also affect the associated payment rates• Unless there is a IPA, there should only be 1 invoice for most SB short stays• The IDT (Interdisciplinary Team) leaders should be the ones to decide if an IPA

should be completed

136

Each patient is classified into a PT group, an OT group, a SLP group, a NTA group, and a nursing group

For each of the case-mix adjusted components, there are a number of groups to which a patient may be assigned, based on the relevant MDS 3.0 data for that component

PDPM classifies patients into a separate group for each of the case-mix adjusted components, each of which has its own associated case-mix indexes and base rates

• There are 16 PT groups, 16 OT groups, 12 SLP groups, 6 NTA groups, and 25 nursing groups

Additionally, PDPM applies variable per diem payment adjustments to three components, PT, OT, and NTA, to account for changes in resource use over a stay• The adjusted PT, OT, and NTA per diem rates are then added together with the

unadjusted SLP and nursing component rates and the non-case mix component to determine the full per diem rate for a given patient

• More info re: Variable Per Diem (VPD) payment adjustment later

PDPM Calculation & Billing

137

PDPM Calculation Overview & Billing

Transition from RUG IV to PDPM on October 2019

An IPA is also how the PDPM payment will be calculated for patients in the PPS SB/SNF on September 30th, 2019 and remaining in the program to complete their skilled stay from Oct. 1, 2019 or later

• Medicare will be invoiced under the RUG IV system for days since the day-1 of admission until Sept. 30 inclusive

• Oct. 1st will be treated as day-1 for the Day-1 to Day-5 IPA Assessment which will determine the new per diem from Day-1 until discharge

• But Medicare days will be counted from the admission date in September• Variable Per Diem days will also apply from the September admission date

• Any “transitional IPAs” with an ARD after October 7, 2019 will be considered late and the late assessment penalty would apply

Can providers complete a short-stay assessment for patients admitted in the last few days of September 2019? • No special rules apply in cases of patients admitted near the end of September 2019.

If the patient qualifies for a short-stay assessment (4 days or less), then a short-stay assessment may be completed. If the patient does not qualify for a short-stay assessment, then no short-stay assessment may be completed.

138

PDPM Classification

HIPPS codes are used to bill for the SNF Medicare stay• HIPPS Codes: Health Insurance Prospective Payment System (HIPPS) codes are billing

codes used when submitting Medicare Part A SNF payment claims to the Part A Medicare Administrative Contractor (MAC).

As in RUG billing, the MDS determines the HIPPS code which the MDS Coordinator reports to billing

The 1st character of the HIPPS code is based on the PT/OT component• PT/OT Component is based on Clinical Category (admitting diagnosis) + the

Section Function GG scores = PT/OT Case Mix Group (CMG) = a 1st letter for the HIPPS code

The 2nd character is based on the SLP Component • SLP Component is based on whether the patient has an Acute Neurologic

Condition, a SLP-Related Comorbidity, or Cognitive Impairment + whether the patient is on a Mechanically Altered Diet or Swallowing Disorder = SLP CMG = a 2nd letter for the HIPPS code


139

PDPM Classification (cont’)

The 3rd character is based on the Nursing Component

• The Nursing Component is based on the RUG IV clinical non-therapy RUGs

• ES3, ES3, ES1, HE2/HD2, HE1/HD1, HC2/HB2, HC1/HB1, LE2/LD2, LE1/LD1, or LC2/LB2 based on Clinical Conditions (Serious medical conditions e.g., comatose, septicemia, respiratory therapy, radiation therapy or dialysis) + whether they have S&S of depression or not + section GG based function scores = Nursing CMI = a 3rd letter for the HIPPS code

• Note: the # of Restorative Nursing Services only come into play for the Behavioral and Physical Assistant RUG groups as they were before (which is rarely the case in SB programs) – that does not mean that nursing rehab is meaningless – done to improve outcome

The 4th character is based on the Non-Therapy Ancillaries (NTA) Component or NTA Comorbidity Score - The NTA Component is based on the NTA Score Range which determines the NTA CMG = 4th letter of the HIPPS code

• NTA classification is determined by the presence of certain conditions or the use of certain extensive services that were found to be correlated with increases in NTA costs for SB/SNF patients.

• CMS identified a list of 50 conditions and extensive services that were associated with increases in NTA costs. The presence of these conditions and extensive services is reported on the MDS 3.0, with some of these conditions being identified by ICD-10-CM codes that are coded in Item I8000 of the MDS.


140

PDPM Classification (continued)

• In order to determine the patient’s NTA comorbidity score, a provider would identify all comorbidities for which a patient would qualify and then add the points for each comorbidity together. The resulting sum represents the patient’s NTA comorbidity

• The MDS systems makes the calculation automatically based on the MDS documentation hence important to capture the correct ICD-10 diagnosis and all active comorbidities

• A mapping between these ICD-10-CM codes and the Clinical Category, SLP and NTA comorbidities, used for patient classification is available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html

• One comorbidity, HIV/AIDS, is reported on the SNF claim in the same manner as under RUGIV

• The involvement of the hospital’s coder can probably be most helpful to ensure that the admitting ICD-10 and all active comorbidities are captured while remaining in compliance


141


The last position of the HIPPS code represents the AI code, identifying the assessment type.

The AI coding system indicates the different types of assessments that define different PPS payment periods and is based on the coding of item A0310B.

If the submitted AI code is incorrect on the assessment, the validation report will include a warning and provide the correct code. The facility must enter this correct AI code in the HIPPS code item on the bill.

The A1 code consists of one digit

The AI code identifies the assessment used to establish the per diem payment rate for the standard PPS payment periods. These assessments are:• the 5-Day assessment – A1 = 1 and • Interim Payment Assessment – A1 = 0

Except, in situations when the provider is to bill the default code, the AI provided on the validation report is to be used along with the default code, ZZZZZ, on the SB/SNF claim (more info later)


142


The PPS-required standard assessment is the 5-Day assessment, which has a predetermined time period for setting the ARD

• The SB/SNF provider must set the ARD on days 1–8 to assure compliance with the PPS SB/SNF PDPM requirements

• The 5-Day PPS Assessment sets payment rate for the entire stay (unless an IPA is completed

It is important to note that the IPA changes payment beginning on the ARD (based on 3 days) and continues until the end of the Medicare Part A stay or until another IPA is completed

When a patient on Medicare Part A returns following a therapeutic leave of absence or a hospital observation stay of less than 24 hours (without hospital admission), this is a continuation of the Medicare Part A stay, not a new Medicare Part A stay.

No change in the revenue code “0022” for each MDS assessment (most likely only one unless there was an IPA completed


143

Variable Per Diem (VPD)

As stated earlier, research found that certain costs and services do not remain constant throughout the Medicare stay

• Using a constant per diem rate allocates too few resources at beginning of stay when costs higher (e.g., therapy and drugs) and too many resources at end of stay when costs tend to be lower

• Impacts three of the six PDPM components:

• physical therapy (PT), • occupational therapy (OT), and • non-therapy ancillary (NTA)

• Default days are not skipped whencounting Medicare Days


144

Variable Per Diem (continued)

• If a patient goes to the hospital and does not have the 3 midnights but stayed for 2 days, the payment is adjusted

• When the patient returns to the same program after only two midnights, then the per diem will be based on the next PPS day

• Example 1 - if the patient left the program on the afternoon of day 18 for 2 midnights, the payment would be picked back up on day 17 (last covered day) • PT/OT components would be multiplied x 1.00 (since he/she did not have 20 covered

days yet• NTA would continue being multiplied by 1.00 (day 4-20)

• Example 2 – if the patient is transferred to acute care but not admitted on day 21 and returned two days later, the payment would pick back up on day 21 (day 20 was the last covered day)• PT and OT components would be multiplied by .98 based on the Variable Adjustment

Factors (over 20 covered days at 1.00)

• NTA component would be multiplied by 1.00 (day 4-20)

• Example 3 - If the patient had stayed that third midnight at the hospital they would return to the facility on day 1 of a new 5-day PPS assessment• PT and OT components would be multiplied by 1.00 based on day 1-20 • NTA multiplier of 3 for 1st 3 days then on to a multiplier of 1.00• Keep in mind that the patient would not have a new benefit period and would therefore

not have 100 days to use.


145

Relationship between the Assessment and the Claim

• The standard grouper uses MDS 3.0 items to determine both the PDPM group and the AI code

• It is anticipated that MDS 3.0 software used by the provider will incorporate the standard grouper to automatically calculate the PDPM group and AI code

• Detailed logic for determining the PDPM group and AI code is provided in Chapter 6 of the MDS Manual

• The Medicare Part A HIPPS code (Item Z0100A) is most often used on the claim.

• The PDPM version code in Item Z0100B documents which version of PDPM was used to determine the PDPM payment groups represented in the Medicare Part A HIPPS code.

• The HIPPS code (Z0100A) and PDPM version code (Z0100B) must be submitted to the QIES ASAP system on all Medicare PPS assessment records (indicated by A0310B = 01 or 08).

• Both of these values are validated by the QIES ASAP system.

• The final validation report will indicate if any of these items is in error and the correct value for an incorrect item.


146

Relationship between the Assessment and the Claim (continued)

• It is the responsibility of the provider (hospital program) to ensure that claims submitted to Medicare are accurate and meet all Medicare requirements• For example, if a patient’s status does not meet the criteria for Medicare Part A

SNF coverage, the provider is not to bill Medicare for any non-covered days.

• In these situations, the provider is responsible to ensure that the default code and not the PDPM classification-based HIPPS code validated by CMS in item Z0100A is billed for the applicable number of days.

• For services furnished on or after October 1, 2019, the following classifiers under the Patient Driven Payment Model (PDPM) and qualifies for the presumption• Those nursing groups encompassed by the Extensive Services, Special Care High, Special

Care Low, and Clinically Complex nursing categories;• PT and OT groups TA, TB, TC, TD, TE, TF, TG, TJ, TK, TN, and TO;• SLP groups SC, SE, SF, SH, SI, SJ, SK, and SL; and• The NTA component’s uppermost (12+) comorbidity group

• The IPA that will be completed after Oct. 1 will not qualify for a presumption – only keep patient after Sept 30th is clearly meeting skilled needs

• Once the patient no longer requires skilled services, the provider must not bill Medicare for days that are not covered. Therefore, this information is not to be considered all-inclusive and definitive. Refer to the Medicare Claims Processing Manual, Chapter 6 (no change from RUG IV requirements)


147

Patients with HIV/AIDS

• Patients with AIDS receive a special 18% add-on to the nursing component of the payment, and

• They are also assigned the highest point value (8 points) of any condition or service for purposes of classification under the PDPM’s NTA component.

• As under the previous RUG-IV model, the presence of an AIDS diagnosis continues to be identified through the SNF’s entry of ICD-10-CM code B20 on the claim.

• Further, the PDPM’s AIDS-related adjustments for both the nursing and NTA components will be handled through the Pricer tool rather than the Grouper tool

Rates for rural and urban providers under PDPM

• Similar to RUG-IV, PDPM has different base rates for urban and rural providers, which means that the case-mix adjusted rates for urban and rural providers will also be different

Wage Index

• The PDPM rates are still labor-adjusted in the same way as under RUGIV


148

Relationship between the Assessment and the Claim (continued)

• CMS provides standard software and logic for HIPPS code calculation

• CMS edits and validates the PDPM classification code of transmitted MDS assessments.

• Skilled nursing facilities are not permitted to submit Medicare Part A claims until the assessments have been accepted into the CMS database, and they must use the PDPM classification code as validated by CMS when bills are filed, except in cases in which the facility must bill the default code (ZZZZZ). details.

Billing for Late or Missed Assessments

• According to 42 CFR 413.343, an assessment that does not have an ARD within the prescribed ARD window will be paid at the default rate for the number of days the ARD is out of compliance

• Frequent late assessment scheduling practices or missing assessments may result in additional review.

• The default rate (ZZZZZ) takes the place of the otherwise applicable Federal rate. It is equal to the sum of the rate paid for the case-mix group reflecting the lowest acuity level under each PDPM component


149

Billing for Late or Missed Assessments (continued)

• Late Assessment

• If the SB/SNF fails to set the ARD within the defined ARD window for a PPS assessment, and the patient is still on Part A, the SNF must complete a late assessment

• The ARD can be no earlier than the day the error was identified

• The SB/SNF will bill the default rate for the number of days that the assessment is out of compliance.

• This is equal to the number of days between the day following the last day of the available ARD window and the late ARD (including the late ARD).

• The SNF would then bill the HIPPS code established by the late assessment for the remaining period of time that the assessment would have controlled payment.

• For example, a 5-Day assessment with an ARD of Day 11 is out of compliance for 3 days and therefore would be paid at the default rate for Days 1 through 3 and the HIPPS code from the late 5-Day assessment for the remainder of the Part A stay, unless an IPA is completed.

• In the case of a late assessment, the variable per diem schedule still begins on Day 1 of the stay and not with the late assessment ARD and default billing will be assessed prior to billing based on the late 5-Day assessment.


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Billing for Late or Missed Assessments (continued)

• Missed Assessment

• The provider may not bill for a SB/SNF stay if the SB/SNF fails to set the ARD of a PPS assessment prior to the end of the last day of the ARD window, and the patient is no longer a SNF Part A patient hence no MDS and no HIPPS code for billing purpose

• If the patient was already discharged from Medicare Part A when this is discovered, a PPS assessment may not be performed.

• However, there are instances when the SB/SNF may bill the default code when a PPS assessment does not exist in the QIES ASAP system.

• These exceptions are: 1) The stay is less than 8 days within a spell of illness, 2) The SB/SNF is notified on an untimely basis of or is unaware of a Medicare

Secondary Payer denial, 3) The SB/SNF is notified on an untimely basis of a beneficiary’s enrollment in

Medicare Part A,4) The SB/SNF is notified on an untimely basis of the revocation of a payment

ban, 5) The beneficiary requests a demand bill, or 6) The SB/SNF is notified on an untimely basis or is unaware of a beneficiary’s

disenrollment from a Medicare Advantage plan.


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Billing Department is responsible to monitor updates re: billing for SNF/SB detailed claims processing requirements and policies

Medicare Claims Processing Manual Chapter 6 - SNF Inpatient Part A Billing and SNF Consolidated Billing Table of Contents (Rev. 4157, 11-02-18) (Rev. 4247, 03-01-19)

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c06.pdf

No change in the above site – same rules apply re: consolidated billing, LOA, Occurrence Span and Condition codes, Midnight Rule, Denials, Demand Bills etc….

Billing Director would benefit from reviewing Chapter 6 of the MDS Manual

The PPS SB/SNF claim must include two data items derived from the MDS assessment: • Assessment Reference Date (ARD) - The ARD must be reported on the SNF claim.

CMS has developed internal mechanisms to link the MDS assessment and the claims processing system and

• HIPPS Code

Medicare Advantage Plans • For patients utilizing Medicare Advantage plans, the MA plans themselves will

decide whether they will incorporate any aspects of PDPM into their payment system.

Manual has not been updated with PDPM info – as of yet


BREAK (2:30 – 2:45)

Case Study to Determine Per Diem(2:45 – 4:00)

Divide into groups of 2-3 and calculate the HIPPS to determine the per diem for Mrs. Rodrigues (next slide)

Review as a whole and discuss to agree on a final HIPPS code

Team up to calculate the non-wage index rural per diem rate and total revenue for that patient

154

Mrs. Rodrigues was hospitalized for gram-negative pneumonia. Since this was her second episode of pneumonia in the past six months, a diagnostic bronchoscopy was performed while in the hospital. • The MDS identified the following:

• Item I0020 = 13 for Medical Management• Item I0020B = ICD-10 – J15.6 Pneumonia due to other Gram-Negative bacteria

for which she is receiving IV medication• She is being treated for her COPD with difficulty breathing when lying flat and

is receiving Respiratory Therapy• Has Hypertension the staff is monitoring her for• Other items reveal that the Mrs R is morbidly obese and considered

malnourished due to calorie intake• She admits to having little interest in doing things – feel tired with little energy• Her BIMS score was reported as 11• She does have some Short-term memory problems• Her admitting Self-Care & Mobility scores from Section GG are as follows:

• Eating = 6• Oral Hygiene = 5• Toileting Hygiene = 4• Bed Mobility: Sit to Lying = 5 & Lying to Sitting on Side of Bed = 4• Transfer: Sit to Stand = 4 & Chair/Bed-to-Chair = 4 & Toilet Transfer = 4• Walking 10 Ft = 4• Walking: Walk 50 Feet w/2 turns & Walk 150 Feet = 88

• Nursing Rehab/Restorative care plan includes 15 to 20 minutes/day x 7 days/wk for the following training services:• Bed Mobility, Transfer, Walking, Dressing & Grooming, and Swallowing Training

• Mrs. Rodrigues was admitted on Oct 10 and discharged on Oct 21

Case Scenario to Calculate the HIPPS Code

155

Determine the following: • PDPM cognitive level: ____________________• I0020B diagnosis: _____________________• Is the patient eligible for surgical clinical category & received significant major

joint replacement or spinal surgery: ____ Yes or ____ No?• Is the patient eligible for surgical clinical category & received significant non-ortho

surgical procedure: ____ Yes or ____ No• Primary diagnosis clinical category: ______________

• PT clinical category: ___________________• PT function code for Eating: ____ Oral Hygiene: ___ Toileting Hygiene____

• Bed Mobility: ____ Transfer: _____ Walking: ____• PT CMG based on Clinical Category & Function Score: ___________

• OT clinical category: ___________________• OT function code for Eating: ____ Oral Hygiene: ____ Toileting Hygiene ____

• Bed Mobility: ____ Transfer: _____ Walking: ____• OT CMG based on Clinical Category & Function Score: ___________

• SLP clinical category: __________________• SLP related comorbidities: ____ Yes or ____ No?• Presence of cognitive impairment:____ Yes or ____ No?• Presence of swallowing disorder: ____ Yes or ____ No?• Presence of mechanically altered diet: ____ Yes or ____ No?• SLP Case Mix Group: ________________


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• Nursing function code for Eating: _____ Toileting Hygiene: ____Bed Mobility: ____ Transfer: _____

• Determine the Nursing component Function Score: ________

• Determine which RUG level the patient falls into: ________________________

• Does patient have signs of depression: ___ Yes ___ No?

• Determine the PDPM Nursing CMG: _____________

• What is the NTA Comorbidity Score Calculation: __________ • What is the NTA CMG: ___________________

• What is the HIPPS Code: _________________

• What are the CMIs for: PT: _____ OT: _____ SLP: _____

Nursing: _____ NTA: _____

• What are the per diems for: PT: _____ OT: _____ SLP: ______

Nursing: _____ NTA: _____ Non-Case Mix: ______

• What will be the per diem rate for Mrs. Rodrigues? _____________• What will be the total revenue (gross) for this patient? ______________


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Discussion

Consider calculating what your per diem rate would be by doing this excurse using a present patient day-5 MDS to identify opportunities for improvement. Many programs start with this exercise before initiating the facility training and develop action plan partly based on findings.

Action Planning (4:00 – 4:45)

“Knowledge is Power” – Francis Bacon

Processes for Consideration

MDS Coordinator / Nurse Assessor Role

What Next? Action Planning

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Knowledge

Knowledge in Power - Francis Bacon

The famous proverb “ipsa scientiapotestas est” meaning “knowledge itself is power” was first quoted by Sir Francis Bacon. Meaning: The phrase “knowledge itself is power” means that knowledge is the most powerful tool to achieve or do anything. ... Knowledge empowers us to face the challenges of life.

To be successful in PDPM, the following people must receive training (at different levels)

• Executive administration team (CEO, CNO, CFO)• SB Coordinator / MDS Coordinator• Therapy Director and staff• Nursing Director and Staff• Providers• Coders• Revenue Cycle Director and Medicare billers

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Action Plan

First – digest all of this information – a lot to take in since you will be the key person to educate others

Create a team to do a SWOT Analysis: Strengths, Weaknesses, Opportunities & Threats

• PDPM can be a game changer in that the rules that have shaped reimbursement for skilled nursing care are completely morphed

• This is an opportunity to examine organization strengths, weaknesses, opportunities and threats and determine future directions

Fill your beds with patients who can benefit from skilled care

Give great care and strive for best outcomes possible

Be compliant

Support invoices with documentation that demonstrate your MDS assessments and services you provided

Collect your money

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Action Plan

Executive administration team (CEO, CNO, CFO)

• What is PDPM

• Why the change from RUG IV

• Overview of how the revenue is calculated

• Therapy role and contracting (if applicable)

• SB/MDS Coordinator role

• Coder role

• The need for continued ITP members not only to manage compliance but most importantly, QUALITY

• Involve management in the SWOT Analysis

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Action Plan

Staff Training

It is important for the clinical staff to understand how the PDPM is calculated in order to understand the need for thorough assessments ensuring no under or over coding and documentation to support the MDSs

Topics to share

• PDPM Overview

• ICD-10 and related coding is the principle basis for payment

• Overview of how the per diem is determined (what items of the MDS impacts the per diem

• Change in PT, OT and SLP role in determining the per diem

• Care Planning – must include all patient needs and interventions

• Documentation requirements, forms, system…

• Team approach to coding section GG and setting goals including for patients who do not need therapy rehab but rather nursing rehab

• Process for IDT (1st 3 days, weekly, PRN and discharge)

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Action Plan SB / MDS Coordinator

• Streamlining MDSs• System to document Entry Info, calculate the ARDs and MDS Completion, electronic

submission, verified and accepted

• Ensure that staff is well versed in how to code section GG

• Manage daily stand-up meetings until the section GG assessments are completed

• Work with the provider to determine admitting diagnosis, comorbidities…

• Work with coder for ICD-10 code

• Determine specialized surgery during IP acute stay

• Who will be interviewing the patient as expected for the MDS – provide training to ensure it is completed as intended

• Team approach to identifying all diagnosis and comorbidities

• Goal setting therapy (when involved) and nursing meeting by day 3 to determine discharge goals for section GG

• Manage the need for an IPA if appropriate and discuss with the team

• Schedule Discharge Assessment for section GG on day prior or day of discharge

• Participation in QRP (Quality Reporting Program)

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Action Plan

Pre-Admission Screening

• Who will we accept/deny based on PDPM (let’s discuss)

• Do we need to change the process

Coding

• What will our process look like?

• How will the MDS Coordinator work with the provider and the coders

• Active diagnosis

• Clinical Mapping Categories

• Use of CMS Tools/Mapping -Return to Provider

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Action Plan Providers

• Share overview of PDPM

• The impact of diagnosis coding for admission and comorbidities

• Documentation to support admitting diagnosis and what makes all diagnosis active

• Therapy utilization

• Cert/Recert

Nursing (licensed and non-licensed)

• PDPM overview

• Relationship of MDS and payment

• Section GG coding (Chapter 3 – Section O of the MDS Manual)

• Nursing Rehab & Competencies

• Care Planning

• Documentation

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Action Plan

Documentation

• This is another opportunity to evaluate our daily and weekly documentation to ensure that all issues to be identified on the MDS are documented

• What is needed to support diagnosis, S&Ss and comorbidities

• How do we demonstrate active diagnosis?

• Information to support when the staff has to complete sections for patients who cannot be interviewed

• Comments to support the section GG coding

• System to track therapy minutes and documentation in the chart

PDPM incentivizes shorter lengths of stay• Shorter LOS may negatively impact:

• Patient Satisfaction• Census• Claims-Based QMs• Value Based Purchasing

Usually not an issue with SB since our ALOS is already about 12 days.

As always – be leery of most all discharges scheduled for day 20

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Action Plan Therapy

• Do you employ therapists or are they contracted?

• Employ• This is an opportunity to re-evaluate how they are used. Let’s make sure they are

used for the patients who have rehab skilled therapy needs and potential for improvement in patient’s functional goals and the program’s quality outcome

• Contracted• Most therapy contracts are currently written to pay the contractor based

on a RUG IV rehab RUG. This RUG is based on a volume of therapy being provided. The more therapy that is provided the higher the RUG and the more the contractor gets paid.

• Under PDPM, the volume of therapy does not determine payment. There will be no RUG scores and a volume of therapy will not be linked to the various clinical categories. Therefore, the contract providers will have to come up with a new way to get paid for Part A service effective Oct.1, 2019.

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Action Plan

Therapy (cont’)

• PDPM Overview

• Explain PT, OT and SLP components (regardless of providing therapy or not)

• Section GG coding (Chapter 3 – Section O of the MDS Manual)

• How can we obtain great outcome and manage cost

• Role is completion of the section GG and setting goals

• Ortho and Neuro is a no-brainer as for the need of shilled therapy but could we use nursing rehab for many/most medical cases?

• Should we consider group therapy at times

• How is our documentation

Do not make radical changes in the way in which therapy and care have been provided

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Action Plan

MDS Completion and Discharge Goal Setting

TEAM = Together Everyone Achieves More

Who will: 1) Monitor the CMS PDPM website

for final changes,

2) Monitor MDS Manual updates and

3) Ensure that your MDS System has been updated (jRAVEN or other system) by Oct 1

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

Resources

Great CMS resource!

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Resources

CMS’s most recent MDS 3.0 in Version 1.17 and was released on May 20th, 2019 as well as the MDS forms

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html

https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/nursinghomequalityinits/nhqimds30technicalinformation.html

CMS indicated that what was posted is an “early release” and that we must “check back prior to October 1, 2019 for a final posting which may contain additional updates.”

MDS Manual

MDS Forms

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On a 1 to 10 – how much readier do you feel in setting a “getting ready plan” for Oct 1, 2019?

What worries you the most?

Let’s review the Program Objectives

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Any Remaining Questions??

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Adjourn

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