THE PATIENT DRIVEN PAYMENT MODEL (PDPM) A REVISED … PDPM FINAL 0619.pdf · • Issues with the...

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THE PATIENT DRIVEN PAYMENT MODEL (PDPM)

A REVISED MEDICARE PAYMENT MODEL FOR

SKILLED NURSING FACILITIES

Presented by:RKL Senior Living Services Consulting

June13, 2019

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• The information contained herein is of a general nature and is not intended to address the circumstances of any particular individual or entity. Although we endeavor to provide accurate and timely information, there can be no guarantee that such information is accurate as of the date it is received or that it will continue to be accurate in the future. No one should act upon such information without appropriate professional advice after a thorough examination of the particular situation.

Disclaimer

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PDPM

GENERAL OVERVIEW

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• Issues with the current case-mix model, theResource Utilization Groups, Version IV (RUG-IV), have been identified by CMS, OIG, MedPAC, themedia, and others

• Therapy payments under the SNF PPS are based primarily on the amount of therapy provided to a patient, regardless of the patient’s unique characteristics, needs or goals

Project Overview

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• The Patient Driven Payment Model (PDPM)represents a marked improvement over the RUG-IVmodel for the following reasons:

– Improves payment accuracy and appropriateness by focusing on the patient, rather than the volume of services provided

– Significantly reduces administrative burden on providers

– Improves SNF payments to currently underserved beneficiaries without increasing total Medicarepayments

Project Overview (cont’d)

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• RUG-IV consists of two case-mix adjusted components:

– Therapy: Based on volume of services provided

– Nursing: The nursing case-mix index (CMI) does not currentlyreflect specific variations in non-therapy ancillary utilization

RUG-IV Components

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• PDPM consists of five case-mix adjusted components, all based on data- driven, stakeholder-vetted patientcharacteristics:

– Physical Therapy (PT)

– Occupational Therapy (OT)

– Speech Language Pathology (SLP)

– Non-Therapy Ancillary (NTA)

– Nursing Classification Groups

• PDPM also includes a “variable per diem (VPD) adjustment” that adjusts the per diem rate over the course of the stay

PDPM Components

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• Each resident will be classified into five components rather than one RUG or single payment for all services.

• A sixth component would be a non-case mix component that is fixed based on your specific facility.

• Payment is calculated by multiplying the CMI for the resident’s group, first by the federal base payment rate and then by the specific day in the variable per-diem adjustment schedule.

PDPM Components

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PDPM Snapshot

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RUG-IV vs. PDPM

• While RUG-IV (left) reduces everything about a patient to a single, typically volume-driven, case-mix group, PDPM (right) focuses on the unique, individualized needs, characteristics, and goals of each patient

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Effect of PDPM

• By addressing each individual patient’s unique needs independently, PDPM improves payment accuracy and encourages a more patient-driven care model

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• Each component utilizes different criteria as the basis for patient classification

PDPM Classification

Case Mix Components

Classifiers

PT • Clinical Category• Function Score

OT • Clinical Category• Function Score

SLP • Presence of Acute Neurologic Condition • SLP‐Related Comorbidity or Cognitive

Impairment• Mechanically‐altered Diet• Swallowing Disorder

Nursing • Same characteristics as under RUG‐IV• Function Score

NTA • NTA Comorbidity Score

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MEDICARE PART A

THE BASICS

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• Health Insurance for:

‒ Age 65 or older;

• If receiving Social Security or Railroad Retirement Board (RRB) benefits Part A is automatic the first day of the 65th

birth month.

‒ Under age 65 with certain disabilities; and

• Part A is automatic after receiving disability benefits for 24 months.

‒ Any age with ESRD or ALS (Lou Gehrig's Disease).

• Part A is automatic the month disability benefits begin.

Medicare Basics

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• Different Parts of Medicare:

A ‐ Hospital, SNF, home health care, hospice care.

B ‐ Doctor & other health care services, Outpatient care, DME, many preventative services.

C ‐ Medicare Advantage Plan; Covers Part A, Part B and medications.

D ‐ Prescription Drug Benefit.

Medicare Basics

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Medicare Basics – Part A

• Enrolled in Part A and has benefit days to use;

• Three‐day qualifying hospital stay;

• Occupy a Medicare‐certified bed;

• Condition being treated for skilled care was treated in the hospital or arose while receiving care for a condition treated in a hospital; and

• 30‐day transfer requirement

Technical Eligibility Medical Eligibility

• Medical professional certifies that skilled nursing care is necessary; and

• Patient must require daily services that can only be provided in a skilled nursing facility.

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• Technical Eligibility

‒ Enrolled in Part A and has benefit days to use

• Determine Medicare or Medicare Advantage Plan

• For each benefit period, payment may be made for up to100 days of post hospital extended care services.

‒ Benefit period begins with the first day on which apatient is furnished extended care services by aqualified provider; and

‒ Benefit period ends with a close of a period of 60consecutive days during which the patient wasneither an inpatient of a hospital or a skilled patientin a SNF.


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• Technical Eligibility (cont’d)

‒ Three‐day qualifying hospital stay

• Three consecutive midnights as in inpatient in amedically‐necessary stay.

‒ Time in emergency, observation bed, etc. does NOTcount.

• Hospitals and CAH must furnish a Medicare OutpatientObservation Notice (MOON) to a patient who receivesobservation services for more than 24 hours.


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‒ Three‐day qualifying hospital stay

• The three consecutive calendar stay requirement can bemet by stays totaling three consecutive days in one ormore hospitals.

‒ Day of admission is counted;

‒ Day of discharge is not counted; and

‒ Hospital must be a Medicare‐participating hospitalor an institution that meets, at least, the conditionsfor an emergency services hospital.


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‒ Condition being treated for skilled care was treated in thehospital or arose while receiving care for a condition treatedin a hospital.

• The applicable hospital condition need not havebeen the principal diagnosis that actuallyprecipitated the beneficiary's admission to thehospital, but could be any one of the conditionspresent during the qualifying hospital stay.


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‒ 30‐Day Transfer requirement

• Post‐hospital extended care services represent anextension of care for which the individual receivedinpatient hospital services;

• Must be initiated within 30 days after discharge from ahospital stay that included at least three consecutive daysof medically necessary inpatient hospital services; and

• The day of discharge from the hospital is not counted inthe 30 day transfer count.


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• Medical Eligibility

‒ Physician Certification

• Payment for SNF services can only be made if requiredcertifications/recertifications are obtained.

‒ Facility must affirm on billing form that certificationhas been obtained.

• No requirement that a certain form be used.

‒ Information can be in forms, notes, or other records.

• Faxed signatures are accepted;

• Stamped signatures are not.


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• Medical Eligibility (cont’d)

‒ Medical professional certifies that skilled nursing care isnecessary. (Physician Certification)

• A provider must sign and date the initial certification,which should be done as soon as possible after admission


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• Medical Eligibility

‒ Medical professional certifies that skilled nursing care isnecessary. (Physician Certification)

• Must certify that SNF services are required to be given on an inpatient basis because of the resident’s need for skilled nursing or rehabilitation care.

• Physician/Physician Extender certifies that care is needed on a continuing basis for the condition(s) for which he/she was receiving inpatient hospital services prior to his/her transfer to the SNF.


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‐ Medical professional certifies that SNF is necessary.

• The first recertification is required no later than the14th day of the post‐hospital SNF care.

• The recertification statement must contain:

‒ A written record of the reasons for the continuedneed for post hospital care in a SNF;

‒ The estimated period of time the resident is toremain in the SNF;

‒ Any plans for post acute care; and

‒ Need for SNF care is for a condition related tohospital stay or which arose during the SNF stay.


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‒ Subsequent recertifications are required at no later than 30day intervals after the date of the first re‐certification; and

‒ The recertification must be signed and dated.

• The subsequent recertification timing requirements arebased on the date of the physician signature on theprevious recertification.


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‒ Physician or Physician Extender may sign thecertifications/recertifications

• May be the attending physician or a physician on theSNF staff with knowledge of the care.

• The Physician Extender cannot have a direct orindirect employment relationship with the SNF.

• The routine admission order established by aphysician is not a certification of the necessity forpost‐hospital extended care services for purposes ofthe program. There must be a separate signedstatement indicating that the patient will require on adaily basis SNF covered care.


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• Medical Eligibility (cont’d)‒ Patient must require daily services that can only be

provided in a skilled nursing facility.• Skilled nursing services or skilled rehabilitation

services must be needed and provided on a dailybasis.

‒ The daily requirement for skilled services ismet for rehabilitation services when theresident needs and receives the services atleast 5 days a week.

‒ The daily basis requirement can be met byfurnishing a single type of skilled service everyday, or by furnishing various types of skilledservices on different days of the week thatcollectively add up to daily skilled services.


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• Medical Eligibility (cont’d)‒ Patient must require daily services that can only be provided

in a skilled nursing facility.• As a practical matter, daily services can only be in a SNF

if they are not available on an outpatient basis where theindividual resides, or transportation to the closest facilitywould be:

‒ Excessive physical hardship;‒ Less economical;‒ Less efficient or effective than an inpatient

institutional setting; OR‒ If home care would be ineffective because the

patient has insufficient assistance to reside at homesafely.


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• Physician Orders

‒ The skilled nursing services and/or rehabilitation servicesmust be ordered by a physician.

‒ (Medicare Benefit Policy Manual, Chapter 8, Section 30 and Section 30.2)


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• Therapy Plan of Care

‒ Rehabilitation Services (PT, OT, ST)

• Must be ordered by a physician based on a qualifiedtherapist’s assessment and treatment plan;

• Documented in the resident’s medical record; and

• Care planned and periodically evaluated to ensure thatthe resident receives needed therapies and that currenttreatment plans are effective.

(RAI Manual, Chapter 3, Section O, Page 19)


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• Administrative Level of Care Presumption

• Under SNF PPS, beneficiaries who are admitted (or readmitted) directly to a SNF after a qualifying hospital stay are considered to meet the skilled level of care requirements when their initial classification is in one of the upper 52 RUGs of the 66‐group RUG‐IV Classification system.

• Not automatically classified as meeting/not meeting the presumption if categorized in a lower RUG‐IV category.

• Automatically classified as meeting the SNF level of care up to and including the assessment reference date on the 5‐day Medicare required assessment

• No later than day eight of the SNF stay


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• Administrative Presumption

‒ Does not apply when:

• Admission to the SNF does not immediately follow discharge from a qualifying hospital stay

• Directly admitted from qualifying hospital stay but the initial portion of the stay is covered by another insurer (Medicare is secondary payer)

• Beneficiary is readmitted to the SNF within 30 days after discharge from the initial SNF stay – no intervening hospitalization

• Transfer from one SNF to another


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• Administrative Presumption (cont’d)

‒ Administrative presumption for PDPM will apply to those groups encompassed by the same nursing categories as have been designated for this purpose under the current RUG‐IV model:

• Extensive Services;

• Special Care High;

• Special Care Low; and

• Clinically Complex.

‒ Additional PT, OT and SLP classifiers were added in the final rule and will be discussed later in the PDPM session

• TA, TB, TC, TD, TE, TF, TG, TJ, TK, TN and TO

• SC, SE, SF, SH, SI, SJ, SK and SL


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• Additional requirements continue:

‒ Skilled documentation to support services billed

‒ Medicare Part A Day of Discharge

‒ Beneficiary Notices

• Notice of Medicare Non‐Coverage (NOMNC)

• Skilled Nursing Facility Advance Beneficiary Notice of Non‐coverage (SNFABN)

• Detailed Explanation of Non‐Coverage (DENC)


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Historical Overview of SNF PPS


1972 1998 2006 2010 2019

Extended Medicare coverage to certain persons with disabilities and end‐stage renal disease (ESRD)

Beginning of SNF PPS

RUG‐III 44 RUG groups

“upper nine”

RUG‐III53 RUG groups

MDS 3.0

RUG‐IV66 RUG groups

PDPM

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SNF PPS Final Rule

• The SNF PPS rate is subject to change yearly

• The updates are published yearly around the end of July in the Federal Register, otherwise known as the SNF PPS Final Rule

• The per diem rate is expected to cover all operating and capital costs that efficient facilities would be expected to incur while furnishing most SNF services

• Certain high‐cost, low‐probability services are paid separately


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SNF PPS Final Rule

• The daily rate includes:

• Routine costs: regular room, dietary services, nursing services, minor medical supplies, medical social services, psychiatric social services, and the use of certain facilities and equipment for which a separate charge is not made

• Ancillary costs: specialized services such as therapy, drugs and laboratory services, that are directly identifiable to individual residents

• Capital‐related costs: land, building, equipment, and the interest incurred in financing the acquisition of such items


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FUNCTION SCORE

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• Notable differences between G and GG scoringmethodologies:

– Reverse scoring methodology:

• Under Section G, increasing score means increasing dependence

• Under Section GG, increasing score means increasing independence

– Non-linear relationship to payment:

• Under RUG-IV, increasing dependence, within a given RUG category, translates to higher payment

RUG-IV & PDPM Function Score Differences

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• Under PDPM, there is not a direct relationship between increasing dependence and increasing payment

• – Example: For the PT & OT component, payment for three clinical categories is lower for the most and least dependent patients (who are less likely to require high therapy amounts of therapy), compared to those in between (who are more likely to require high amounts of therapy)

RUG-IV & PDPM Function Score Differences (cont’d)

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• PDPM advances CMS’ goal of using standardized assessment items across payment settings, by using items in Section GG of the MDS as the basis for patient functional assessments.

• The function score for the PT, OT and Nursing components is calculated as the sum of the scores on seven Section GG items:

• Two bed mobility items

• Three transfer items

• One eating item

• One toileting item

• In addition to the above seven items PT & OT function score also includes:

• Two walking items

• One oral hygiene item

Function Score

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• Section GG: Self‐Care/Mobility (3‐day assessment period) Admission/Interim/Discharge (Start/Interim/End of Medicare Part A Stay)

‒ Assessment Period

• Admission: (Start of PPS stay – first assessment)

‒ The admission function scores are to reflect the resident’s admission baseline status and are to be based on an assessment. The scores should reflect the resident’s status prior to any benefit from interventions.

• Interim:

‐ Optional assessment, captures interim functional performance during the last 3 days (ARD and 2 days prior)

• Discharge: (End of PPS Stay)

‐ Assessment period is the last 3 days of the SNF PPS Stay. Code the resident’s usual performance at the end of the SNF PPS stay.

MDS 3.0: Section GG

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• Section GG Self‐Care/Mobility (3‐day assessment period) Admission/Interim/Discharge (Start/Interim/End of Medicare Part A Stay)

‒ Assess the resident’s self‐care and mobility performance based on direct observation, incorporating resident self‐reports and reports from qualified clinicians, care staff, or family documented in the resident’s medical record during the three‐day assessment period.

‒ CMS anticipates that an multidisciplinary team of qualified clinicians is involved in assessing the resident during the three‐day assessment period.

MDS 3.0: Section GG

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• Section GG: Self‐Care/Mobility (3‐day assessment period) Admission/Interim/Discharge (Start/Interim/End of Medicare Part A Stay)

‒ Definition: QUALIFIED CLINICIAN

• Healthcare professionals practicing within their scope of practice and consistent with Federal, State, and local law and regulations.

‒ Coding Instructions

• When coding the resident’s usual performance and discharge goal(s), use the six‐point scale, or use one of the four “activity was not attempted” codes to specify the reason why an activity was not attempted.

MDS 3.0: Section GG

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• Section GG Self‐Care/Mobility (3‐day assessment period) Admission/Interim/Discharge (Start/Interim/End of Medicare Part A Stay)

• The admission functional assessment, when possible, should be conducted prior to the resident benefittingfrom treatment interventions in order to reflect the resident’s true admission baseline functional status.

MDS 3.0: Section GG

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• MDS Coding:

• Safety and Quality of Performance ‐ If helper assistance is required because resident's performance is unsafe or of poor quality, score according to amount of assistance provided.

• Activities may be completed with or without assistive devices.

• 06. Independent ‐ Resident completes the activity by him/herself with no assistance from a helper.

• 05. Setup or clean‐up assistance ‐ Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity but not during the activity.

• 04. Supervision or touching assistance ‐ Helper provides verbal cues and/or touching/steadying/contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.

MDS 3.0: Section GG

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• MDS Coding (cont’d)

• Safety and Quality of Performance ‐ If helper assistance is required because resident's performance is unsafe or of poor quality, score according to amount of assistance provided.

• Activities may be completed with or without assistive devices..

• 03. Partial/moderate assistance ‐ Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.

• 02. Substantial/maximal assistance ‐ Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.

• 01. Dependent ‐ Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.

MDS 3.0: Section GG

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• MDS Coding (cont’d)

• If activity was not attempted, code reason:

• 07. Resident refused

• 09. Not applicable ‐ Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.

• 10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)

• 88. Not attempted due to medical condition or safety concerns

MDS 3.0: Section GG

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MDS 3.0 – Section GG

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• Items included: PT, OT and Nursing Function Score• Self-care (oral hygiene not included in Nursing)

Function Score: Section GG

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• Items included: PT, OT and Nursing Function Score• Mobility:

Function Score: Section GG

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• PT & OT and Nursing Function Score Construction (Non-walking Items)

Function Score: Item Response Crosswalk

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• Items included: PT and OT Function Score • Walking:

Function Score

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• PT & OT Functional Score Construction (Walking Items)

Item Response Score

05, 06 – Set-up Assistance, Independent 4

04 – Supervision or touching assistance 3

03 – Partial/Moderate assistance 2

02 – Substantial/Maximal assistance 1

01, 07, 09, 10, 88 – Dependent, Refused, Not applicable, Not attempted due to environmental limitations, Not Attempted due to medical condition or safety concerns, Resident Cannot Walk (Coded based on response to GG0170I1)

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PT & OT Function Score: GG Items

• Section GG items included in the PT & OT function score

Section GG Item Functional Score Range

GG0130A1 – Self‐care: Eating 0 – 4

GG0130B1 – Self‐care: Oral Hygiene 0 – 4

GG0130C1 – Self‐care: Toileting Hygiene 0 – 4

GG0170B1 – Mobility: Sit to Lying 0 – 4(average of 2 items)GG0170C1 – Mobility: Lying to Sitting on

side of bed

GG0170D1 – Mobility: Sit to Stand0 – 4

(average of 3 items)GG0170E1 – Mobility: Chair/bed‐to‐chairtransfer

GG0170F1 – Mobility: Toilet Transfer

GG0170J1 – Mobility: Walk 50 feet with 2turns

0 – 4(average of 2 items)

GG0170K1 – Mobility: Walk 150 feet

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• Mrs. P is in the SNF for rehabilitation following a fractured hip. The IDT collected performance data over the first three days of the Medicare stay. The NAC assessed this data and determined that the usual function for eating and oral hygiene was independent with setup help only, while partial/moderate assist was required for sit to lying, lying to sitting, and toilet transfer. The NAC assessed Mrs. P to require substantial/maximal assist with toileting hygiene, sit to stand, and bed‐to‐chair transfers. While Mrs. P was able to ambulate 10 feet by day three of the stay, the team determined this progress was made only after therapeutic intervention. Mrs. P was not able to attempt walking greater than 10 feet due to medical condition, but has a goal of achieving this by discharge.

PT/OT Function Score Practice

Use next slide to record answers

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GG ItemGG Admission Performance

Score

PDPMFunction Score

TotalScore

Eating (GG0130A1)

Oral hygiene (GG0130B1)

Toileting hygiene (GG0130C1)

Sit to lying (GG0170B1)

Lying to sitting on side of bed (GG0170C1)

Sit to stand (GG0170D1)

Chair/bed‐to‐chair transfer (GG0170E1)

Toilet transfer (GG0170F1)

Walk 50 feet with two turns (GG0170J1)

Walk 150 feet (GG0170K1)

Total Function Score:


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Score

PDPMFunction Score

TotalScore

Eating (GG0130A1) 5 4 4

Oral hygiene (GG0130B1) 5 4 4

Toileting hygiene (GG0130C1) 2 1 1

Sit to lying (GG0170B1) 3 2 2


3 2

Sit to stand (GG0170D1) 2 1 1.3

Chair/bed‐to‐chair transfer (GG0170E1) 2 1

Toilet transfer (GG0170F1) 3 2

Walk 50 feet with two turns (GG0170J1) 88 0 0

Walk 150 feet (GG0170K1) 88 0

Total Function Score: 12.3


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• Mrs. P is in the SNF for rehabilitation following a fractured hip. The IDT collected performance data over the first three days of the Medicare stay. The NAC assessed this data and determined that the usual function for eating and oral hygiene was independent with setup help only, while partial/moderate assist was required for sit to lying, lying to sitting, and toilet transfer. The NAC assessed Mrs. P to require substantial/maximal assist with toileting hygiene, sit to stand, and bed‐to‐chair transfers. While Mrs. P was able to ambulate 10 feet by day three of the stay, the team determined this progress was made only after therapeutic intervention. Mrs. P was not able to attempt walking greater than 10 feet due to medical condition, but has a goal of achieving this by discharge.

Nursing Function Score Practice

Use next slide to record answers

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Score

PDPMFunction Score

TotalScore

Eating (GG0130A1)

Toileting hygiene (GG0130C1)

Sit to lying (GG0170B1)


Sit to stand (GG0170D1)

Chair/bed‐to‐chair transfer (GG0170E1)

Toilet transfer (GG0170F1)

Total Function Score:


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Score

PDPMFunction Score

TotalScore

Eating (GG0130A1) 5 4 4

Toileting hygiene (GG0130C1) 2 1 1

Sit to lying (GG0170B1) 3 2 2


3 2

Sit to stand (GG0170D1) 2 1 1.3

Chair/bed‐to‐chair transfer (GG0170E1) 2 1

Toilet transfer (GG0170F1) 3 2

Total Function Score: 8.3


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PT/OT COMPONENT

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PT & OT Components: RUG-IV & PDPM

• Under RUG-IV, the number of PT, OT, and SLP therapy treatment minutes are combined for a total number of treatment minutes that is used to classify a given patient into a given therapy RUG

• Under PDPM, patient characteristics will be used to predict the therapy costs associated with a given patient, rather than rely on service use

• For the PT & OT components, two classifications areused:

– Clinical Category

– Functional Status

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PDPM Clinical Categories• SNF patients are first classified into a clinical category based on the

primary diagnosis for the SNF stay

• ICD-10-CM codes, coded on the MDS in Item I0020B, are mapped toa PDPM clinical category

– Clinical classification may be adjusted by a surgical procedure that occurred during the prior inpatient stay, as coded in Section J

– ICD-10 mapping available at: https://www.cms.gov/Medicare/Medicare- Fee-for-Service-Payment/SNFPPS/PDPM.html

PDPM Clinical Categories

Major Joint Replacement or Spinal Surgery Cancer

Non-Surgical Orthopedic/Musculoskeletal Pulmonary

Orthopedic Surgery (Except Major Joint Replacement or Spinal Surgery)

Cardiovascular and Coagulations

Acute Infections Acute Neurologic

Medical Management Non-Orthopedic Surgery

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PT & OT Clinical Categories• Based on data showing similar costs among certain

clinical categories, the PT & OT components use four collapsed clinical categories for patient classification.

PDPM Clinical Categories PT & OT Clinical CategoriesMajor Joint Replacement or Spinal Surgery Major Joint Replacement or Spinal

SurgeryAcute Neurologic

Non-Orthopedic Surgery &Acute Neurologic

Non-Orthopedic Surgery

Non-Surgical Orthopedic/Musculoskeletal

Other OrthopedicOrthopedic Surgery (Except Major Joint Replacement or SpinalSurgery)

Medical Management

Medical ManagementCancer

PulmonaryCardiovascular & Coagulations

Acute Infections

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• Section I0020: Indicate the resident’s primary medical condition category

‒ Steps for Assessment

• Review the documentation in the medical record to identify the resident’s primary medical condition associated with admission to the facility. Medical record sources for physician diagnoses include the most recent history and physical, transfer documents, discharge summaries, progress notes, and other resources as available.

Clinical Category- MDS 3.0: Section I

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• Section I0020: Indicate the resident’s primary medical condition category (October 1, 2019)

‒ Include the primary medical condition coded in this item in Section I: Active Diagnoses in the last 7 days.

Clinical Category-MDS 3.0: Section I

I0020. Indicate the resident’s primary medical condition categoryComplete only if A0310B = 01 or 08

Enter Code

Indicate the resident's primary medical condition category that best describes the primary reason for admission1. Stroke2. Non‐Traumatic Brain Dysfunction3. Traumatic Brain Dysfunction4. Non‐TraumaticSpinal CordDysfunction5. Traumatic Spinal CordDysfunction6. ProgressiveNeurologicalConditions7. OtherNeurologicalConditions8. Amputation9. Hip and Knee Replacement10. Fractures and OtherMultiple Trauma11. OtherOrthopedicConditions12. Debility, CardiorespiratoryConditions13. Medically Complex ConditionsI0020B.ICDCode

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• Prior surgery

‒ “Did the resident have a major surgical procedure during the prior inpatient hospital stay that requires active care during the SNF stay?” (New 10/1/2019)

‒ In order to capture surgical information which may be relevant to classify the patient into a PDPM clinical category, CMS is adding new items in Section J of the MDS. (10/1/2019)

• J2300‐J5000

Clinical Category- MDS 3.0: Section J

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MDS Changes: Patient Surgical Categories

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Item Surgical Procedure Category Item Surgical Procedure CategoryJ2100 Recent Surgery Requiring Active SNF Care J2610 Neuro surgery - peripheral and autonomic nervous

system - open and percutaneousJ2300 Knee Replacement - partial or total J2620 Neuro surgery - insertion or removal of spinal and

brain neurostimulators, electrodes, catheters, andCSF drainage devices

J2310 Hip Replacement - partial or total J2699 Neuro surgery - otherJ2320 Ankle Replacement - partial or total J2700 Cardiopulmonary surgery - heart or major blood

vessels - open and percutaneous proceduresJ2330 Shoulder Replacement - partial or total J2710 Cardiopulmonary surgery - respiratory system,

including lungs, bronchi, trachea, larynx, or vocal cords - open and endoscopic

J2400 Spinal surgery - spinal cord or major spinal nerves J2799 Cardiopulmonary surgery - otherJ2410 Spinal surgery - fusion of spinal bones J2800 Genitourinary surgery - male or female organsJ2420 Spinal surgery - lamina, discs, or facets J2810 Genitourinary surgery - kidneys, ureter, adrenals,

and bladder - open, laparoscopicJ2499 Spinal surgery - other J2899 Genitourinary surgery - otherJ2500 Ortho surgery - repair fractures of shoulder or arm J2900 Major surgery - tendons, ligament, or musclesJ2510 Ortho surgery - repair fractures of pelvis, hip, leg,

knee, or ankleJ2910 Major surgery - GI tract and abdominal contents

from esophagus to anus, biliary tree, gall bladder, liver, pancreas, spleen - open, laparoscopic

J2520 Ortho surgery - repair but not replace joints J2920 Major surgery - endocrine organs (such as thyroid, parathyroid), neck, lymph nodes, and thymus - open

J2530 Ortho surgery - repair other bones J2930 Major surgery - breastJ2599 Ortho surgery - other J2940 Major surgery - deep ulcers, internal brachytherapy,

bone marrow, stem cell harvest/transplantJ2600 Neuro surgery - brain, surrounding tissue/blood

vesselsJ5000 Major surgery - other not listed above

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• Enter the residents primary medical condition category in I0020 and the primary diagnosis (ICD code) in I0020B‒ Some ICD-10-CM codes map to more than one

clinical category depending on inpatient procedure history.

• The function score for the PT & OT components is calculated as the sum of the scores on ten Section GGitems:

– Two bed mobility items

– Three transfer items

– One eating item

– One toileting item

– One oral hygiene item

– Two walking items

Clinical categories

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• PT & OT Function Score Construction (Non-walkingItems)

Item Response Score

05, 06 – Set‐up Assistance, Independent 4




01, 07, 09, 10, 88, missing – Dependent, Refused, Not applicable, Not attempted due to environmental limitations, Not Attempted due to medical condition or safety concerns

0

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• PT & OT Function Score Construction (Walking Items)

ItemResponse Score

05, 06 – Set‐up Assistance, Independent 4




01, 07, 09, 10, 88 – Dependent, Refused, Not applicable, Not attempted due to environmental limitations, Not Attempted due to medical condition or safety concerns, Resident Cannot Walk (Coded based on response toGG0170I1)

0

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PT & OT Function Score: GG Items

• Section GG items included in the PT & OT functional score



GG0130B1 – Self‐care: Oral Hygiene 0 – 4


GG0170B1 – Mobility: Sit to Lying 0 – 4(average of 2 items)GG0170C1 – Mobility: Lying to Sitting on side

of bed


(average of 3 items)GG0170E1 – Mobility: Chair/bed‐to‐chairtransfer


GG0170J1 – Mobility: Walk 50 feet with 2turns

0 – 4(average of 2 items)

GG0170K1 – Mobility: Walk 150 feet

75

PT & OT Components: Payment Groups

Clinical CategoryPT &OT

Function ScorePT &OT

Case Mix GroupPTCMI OTCMI

Major Joint Replacement or Spinal Surgery 0‐5 TA 1.53 1.49

Major Joint Replacement or Spinal Surgery 6‐9 TB 1.69 1.63

Major Joint Replacement or Spinal Surgery 10‐23 TC 1.88 1.68

Major Joint Replacement or Spinal Surgery 24 TD 1.92 1.53

Other Orthopedic 0‐5 TE 1.42 1.41

Other Orthopedic 6‐9 TF 1.61 1.59

Other Orthopedic 10‐23 TG 1.67 1.64

Other Orthopedic 24 TH 1.16 1.15

MedicalManagement 0‐5 TI 1.13 1.17

MedicalManagement 6‐9 TJ 1.42 1.44

MedicalManagement 10‐23 TK 1.52 1.54

MedicalManagement 24 TL 1.09 1.11

Non‐Orthopedic Surgery and Acute Neurologic 0‐5 TM 1.27 1.30

Non‐Orthopedic Surgery and Acute Neurologic 6‐9 TN 1.48 1.49

Non‐Orthopedic Surgery and Acute Neurologic 10‐23 TO 1.55 1.55

Non‐Orthopedic Surgery and Acute Neurologic 24 TP 1.08 1.09

39

76

• PT and OT components will ALWAYS result in the same case‐mix group; however, the PT and OT case‐mix indices/payment levels will differ

PT & OT Components

77

SPEECH LANGUAGE COMPONENT

40

78

• For the SLP component, PDPM uses a number of different patient characteristics that were predictive of increased SLP costs:

• Acute Neurologic clinical classification

• Certain SLP‐related comorbidities

• Presence of cognitive impairment

• Use of a mechanically‐altered diet

• Presence of swallowing disorder

SLP - Component

79

• There are three conditions used to classify residents.‒ Clinical reasons for the SNF stay (acute neurologic

versus non-neurologic);‒ SLP-related comorbidities; and ‒ Presence of cognitive impairments

• Determine what above conditions are present then determine if there is a swallowing disorder or mechanically altered diet

SLP - Component

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80

• There are only two clinical categories used for classification in the SLP component:• Acute Neurologic• Non-Neurologic

Step 1 - Clinical Categories

Primary Diagnosis Clinical Category SLP Clinical Category

Major Joint Replacement or Spinal Surgery Non‐Neurologic

Orthopedic Surgery (Except Major Joint Replacement or Spinal Surgery)

Non‐Neurologic

Non‐Orthopedic Surgery Non‐Neurologic

Acute Infections Non‐Neurologic

Cardiovascular and Coagulations Non‐Neurologic

Pulmonary Non‐Neurologic

Non‐Surgical Orthopedic/Musculoskeletal Non‐Neurologic

Acute Neurologic Acute Neurologic

Cancer Non‐Neurologic

Medical Management Non‐Neurologic

81

• Comorbidities are determined utilizing Section I and O

Step 2 – SLP Related Comorbidities

MDS Item Description

I4300 Aphasia

I4500 CVA, TIA, or Stroke

I4900 Hemiplegia or Hemiparesis

I5500 Traumatic Brain Injury

I8000 Laryngeal Cancer

I8000 Apraxia

I8000 Dysphagia

I8000 ALS

I8000 Oral Cancers

I8000 Speech and Language Deficits

O0100E2 Tracheostomy Care While a Resident

O0100F2 Ventilator or Respirator While a Resident

42

82

• Mrs. W was admitted to the hospital presenting with a TIA. During the hospitalization, the underlying cause of the TIA was determined to be from bilateral carotid stenosis. The SNF coder assigned the primary SNF diagnosis as I65.23 (Occlusion and stenosis of bilateral carotid artery). The coder also noted an Excludes1 note under I65 which prohibits assigning codes in category G45 (nonspecific precerebral artery insufficiency) since the insufficiency is clearly specified as carotid artery stenosis. The PDPM Clinical Category Mapping crosswalks this ICD‐10‐CM code to the default clinical category of Medical Management. This means that this resident’s primary clinical category for SLP is not Acute Neurologic.

SLP Example

83

SLP Component

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84

• Mr. V was diagnosed with a bleeding disorder several years ago, but was recently admitted to the acute hospital following a brain aneurysm, resulting in a subarachnoid hemorrhage. This resulted in hemiplegia of Mr. V’s right, dominant side. On admission to the SNF, the coder determined the primary reason for the SNF PPS stay is I69.051, Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right dominant side. Use the PDPM clinical mapping file snippet on the following slide to determine whether this results in a PDPM clinical category of Acute Neurologic.

SLP Example

85

44

86

• Under RUG‐IV, a patient’s cognitive status is assessed using the Brief Interview for Mental Status (BIMS):

• In cases where the BIMS cannot be completed, providers are required to perform a staff assessment for mental status

• The Cognitive Performance Scale (CPS) is then used to score the patient’s cognitive status based on the results of the staff assessment

• Under PDPM, a patient’s cognitive status is assessed in exactly the same way as under RUG‐IV (i.e., via the BIMS or staff assessment):

• Scoring the patient’s cognitive status, for purposes of classification, is based on the Cognitive Function Scale (CFS), which is able to provide consistent scoring across the BIMS and staff assessment

PDPM Cognitive Scoring

87

• BIMS

‒ Determine the resident’s BIMS Summary Score on the MDS 3.0 based on the resident interview. Instructions for completing the BIMS are in Chapter 3, Section C. The BIMS involves the following items:

• C0200 Repetition of three words

• C0300 Temporal orientation

• C0400 Recall

‒ Item C0500 provides a BIMS Summary Score that ranges from 00 to 15. If the resident interview is not successful, then the BIMS Summary Score will equal 99.

Step 3 - Cognitive Performance

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88

• Because a PDPM cognitive level is utilized in the speech language pathology (SLP) payment component of PDPM, assessment of resident cognition with the BIMS or Staff Assessment for Mental Status is a requirement for all PPS assessments. As such, only in the case of PPS assessments, staff may complete the Staff Assessment for Mental Status for an interviewable resident when the resident is unexpectedly discharged from a Part A stay prior to the completion of the BIMS. In this case, the assessor should enter 0, No in C0100: Should Brief Interview for Mental Status Be Conducted? and proceed to the Staff Assessment for Mental Status.

Cognitive Performance

89

• BIMS (cont’d)

‒ Calculate the resident’s PDPM cognitive level using the following mapping:


PDPM Cognitive Level BIMS Score

Cognitively Intact 13‐15

Mildly Impaired 8‐12

Moderately Impaired 0‐7

Severely Impaired ‐

46

90

If the resident’s Summary Score is 99 or the Summary Score is blank or has a dash value, then determine the resident’s cognitive status based on the staff assessment for PDPM cognitive level using the following steps:

• STEP A: The resident 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).


91

• STEP B: If the resident’s Summary Score is 99 or the Summary Score is blank If the resident is not severely impaired based on Step A, then determine the resident’s Basic Impairment Count and Severe Impairment Count. For each of the conditions below that applies, add one to the Basic Impairment Count. ‒ a. In Cognitive Skills for Daily Decision Making, the

resident has modified independence or is moderately impaired (C1000 = 1 or 2).

‒ b. In Makes Self Understood, the resident is usually understood, sometimes understood, or rarely/never understood (B0700 = 1, 2, or 3).

‒ c. Based on the Staff Assessment for Mental Status, resident has memory problem (C0700 = 1).

Sum a, b, and c to get the Basic Impairment Count


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92

• STEP B: (Cont’d)For each of the conditions below that applies, add one to the Severe Impairment Count. ‒ a. In Cognitive Skills for Daily Decision Making,

resident is moderately impaired (C1000 = 2). ‒ b. In Makes Self Understood, resident is sometimes

understood or rarely/never understood (B0700 = 2 or 3).

Sum a. and b. to get the Severe Impairment Count


93

• The resident classifies as moderately impaired if the Severe Impairment Count is 1 or 2 and the Basic Impairment Count is 2 or 3.

• The resident classifies as mildly impaired if the Severe Impairment Count is 0 and the Basic Impairment Count is 1, 2, or 3.

• The resident classifies as cognitively intact if both the Severe Impairment Count and Basic Impairment Count are 0.


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94

• Cognitive performance is utilized in the calculation of the SLP component.

• If the PDPM cognitive level is cognitively intact, then the resident does not have a cognitive impairment. Otherwise, if the resident is assessed as mildly, moderately, or severely impaired, then the resident classifies as cognitively impaired.

STEP 3 - Cognitive Performance

95

Step 3: Cognitive Performance

• PDPM Cognitive Measure Classification Methodology

Cognitive Level BIMS Score CPS Score

Cognitively Intact 13 – 15 0

Mildly Impaired 8 – 12 1 – 2

Moderately Impaired 0 – 7 3 – 4

Severely Impaired ‐ 5 – 6

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96

• Determine how many of the following conditions are present: ‒ a. Based on Step 1, Is the resident classified in the

Acute Neurologic clinical category?‒ b. Based on Step 2, Does the resident have one or more

SLP-related comorbidities? ‒ c. Based on Step 3, Does the resident have a cognitive

impairment?

Step 4 - Conditions

97

• Determine if there is a swallowing disorder present as coded on the MDS in section K0100A through K0100D (Swallowing Disorder)

• If any of the above items are present, then the resident has a swallowing disorder

Step 5 – Swallowing Disorder

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98

• Determine if the resident is receiving a mechanically altered diet as coded on the MDS in Section K0510C2 (Nutritional Approaches – while a resident)

Step 6 – Mechanically Altered Diet

99

• RAI User’s Manual definition of mechanically altered diet

A diet specifically prepared to alter the texture or consistency of food to facilitate oral intake. Examples include soft solids, puréed foods, ground meat, and thickened liquids. A mechanically altered diet should not automatically be considered a therapeutic diet

• Coding Tip

• Enteral feeding formulas should not be coded as a mechanically altered diet

SLP Component

51

100

• Determine how many of the following conditions are present based on Steps 5 and 6:

‒ a. The resident has neither a swallowing disorder nor a mechanically altered diet.

‒ b. The resident has either a swallowing disorder or a mechanically altered diet.

‒ c. The resident has both a swallowing disorder and a mechanically altered diet.

Presence of Mechanically Altered Diet or Swallowing Disorder? (Neither/Either/Both)

Step 7 – Conditions

101

Step 8 - Resident Groups

Presence of Acute Neurologic

Condition, SLP Related

Comorbidity, or Cognitive

Impairment

Mechanically

Altered Diet or

Swallowing

Disorder

SLP Case

Mix

Group

SLP Case

Mix

Index

None Neither SA 0.68None Either SB 1.82

None Both SC 2.66Any one Neither SD 1.46

Any one Either SE 2.33

Any one Both SF 2.97Any two Neither SG 2.04

Any two Either SH 2.85

Any two Both SI 3.51All three Neither SJ 2.98

All three Either SK 3.69

All three Both SL 4.19

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• Mrs. B admitted to the SNF following a traumatic hip fracture. She had no SLP‐related comorbidities and is receiving a low‐salt diet. She completed the BIMS interview on the eighth day of the Medicare stay and scored 15. On the fourth and sixth days of the stay she experienced coughing episodes when attempting to swallow her medication. The team requested an SLP evaluation on day six.

• What SLP case‐mix group would Mrs. B qualify for?

SLP – component – example

103

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104

NURSING COMPONENT

105

• PDPM utilizes the same basic nursing classification structure as RUG-IV, with certain modifications.

– Function score based on Section GG of the MDS 3.0

– Collapsed functional groups, reducing the number of nursing groups from 43 to 25 (as compared to RUG-IV)

Nursing Component

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106

• Case‐Mix Methodology

• GG function score

• Qualifying services, conditions, and resources

• Indicators of depression

• Restorative programs

Nursing Component

107

• Qualifying services, conditions, and resources• Start at top of hierarchical groups and work down

• First PDPM nursing group the resident qualifies for is assigned

Nursing Component

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108

• The Classification Groups in this category are based on various services provided to the patient. (Hierarchical)

• Extensive Services

• Special Care High

• Special Care Low

• Clinically Complex

• Behavioral Symptoms and Cognitive Performance

• Reduced Physical Functioning

Nursing Component

109

• Determine the resident’s Function Score utilizing Section GG ‐

‒ Eating Performance (GG0130A1);

‒ Toileting Hygiene Performance (GG0130C1);

‒ Sit to Lying Performance (GG0170B1);

‒ Lying to Sitting on Side of Bed Performance (GG0170C1);

‒ Sit to Stand Performance (GG0170D1);

‒ Chair/Bed‐to‐Chair Transfer Performance (GG0170E1); and

‒ Toilet Transfer Performance (GG0170F1)

Nursing Component

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110

Nursing Function Score: GG Items

• Section GG items included in the Nursing functional score




GG0170B1 – Mobility: Sit to Lying 0 – 4(average of 2 items)GG0170C1 – Mobility: Lying to Sitting on side of bed


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


111

Performance (Column 1) Function Score

05, 06 4

04 3

03 2

02 1

01, 07, 09, 88 0

Nursing Component

57

112

Nursing Component

• Enter the Function Score for each item:

• Eating

• Toileting

• Bed Mobility – 2 components

• Transfer – 3 components

• Determine the resident’s case‐mix group using the hierarchical classification system.

113

• Extensive Services:

*While as Resident

Nursing Component

Extensive Service Conditions

PDPM Nursing Classification

Nursing Case Mix

Tracheostomy care* andventilator/respirator*

ES3 4.04

Tracheostomy care* orventilator/respirator*

ES2 3.06

Isolation or quarantine for active infectious disease *without tracheostomy care*without ventilator/respirator*

ES1 2.91

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114

• Special Care High• Determine whether the resident is coded for one of the following conditions or

services: B0100, Section GG items Comatose and completely dependent or

activity did not occur at admission (GG0130A1, GG0130C1, GG0170B1, GG0170C1, GG0170D1, GG0170E1, and GG0170F1, all equal 01, 09, or 88)

I2100 Septicemia I2900, N0350A,B Diabetes with both of the following: Insulin

injections (N0350A) for all 7 days Insulin order changes on 2 or More days (N0350B)

I5100, Nursing Function Score Quadriplegia with Nursing Function Score <= 11

I6200, J1100C Chronic obstructive pulmonary disease and shortness of breath when lying flat

J1550A, others Fever and one of the following; I2000 Pneumonia J1550B Vomiting K0300 Weight loss (1 or 2) K0510B1 or K0510B2 Feeding tube*

K0510A1 or K0510A2 Parenteral/IV feedings O0400D2 Respiratory therapy for all 7 days

*Tube feeding classification requirements: (1) K0710A3 is 51% or more of total calories OR (2) K0710A3 is 26%

Nursing Component

115

• Special Care High - Function Score:‒ The total Nursing Function Score must be 14 or less to

classify into the Special Care category. ‒ If the score is 15 or 16, the resident would classify into

the Clinically Complex Group.

Nursing Component

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116

• Special Care High – Depression Split

• The resident qualifies for depression with a Total Severity Score of greater than or equal to 10, but not 99

Nursing Component

Resident Staff DescriptionD0200A D0500A Little interest or pleasure in doing thingsD0200B D0500B Feeling down, depressed, or hopelessD0200C D0500C Trouble falling or staying asleep, sleeping too muchD0200D D0500D Feeling tired or having little energyD0200E D0500E Poor appetite or overeatingD0200F D0500F Feeling bad about yourself- or that you are a failure or have let

yourself down or your family downD0200G D0500G Trouble concentrating on things, such as reading the

newspaper or watching televisionD0200H D0500H Moving or speaking so slowly that other people could have

noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual

D0200I D0500I Thoughts that you would be better off dead, or of hurting yourself in some way

- D0500J Being short-tempered, easily annoyed

117

• Special Care High-

Nursing Component

Nursing Function Score

Depressed?PDPM Nursing Classification

Nursing Case-Mix

0-5 Yes HDE2 2.39

0-5 No HDE1 1.99

6-14 Yes HBC2 2.23

6-14 No HBC1 1.85

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118

Special Care Low:

Determine whether the patient is coded for one of the following conditions or services:

I4400, Nursing Function Score Cerebral palsy, with Nursing Function Score <=11

I5200, Nursing Function Score Multiple sclerosis, with Nursing Function Score <=11

I5300, Nursing Function Score Parkinson’s disease, with Nursing Function Score <=11

I6300, O0100C2 Respiratory failure and oxygen therapy while a patient

K0510B1 or K0510B2 Feeding tube*

M0300B1 Two or more stage 2 pressure ulcers with two or more selected skin treatments**

M0300C1, D1, F1 Any stage 3 or 4 pressure ulcer with two or more selected skin treatments**

M1030 Two or more venous/arterial ulcers with two or more selected skin treatments**

M0300B1, M1030 1 stage 2 pressure ulcer and 1 venous/arterial ulcer with 2 or more selected skin treatments**

M1040A, B, C; M1200I Foot infection, diabetic foot ulcer or other open lesion of foot with application of dressings to the feet

O0100B2 Radiation treatment while a patient

O0100J2 Dialysis treatment while a patient

Nursing Component

119

Special Care Low – Reminders:

*Tube feeding classification requirements:

(1) K0710A3 is 51% or more of total calories OR

(2) K0710A3 is 26% to 50% of total calories and K0710B3 is 501 cc or more per day fluid enteral intake in the last 7 days.

**Selected skin treatments:

M1200A, B Pressure relieving chair and/or bed M1200CTurning/repositioning

M1200D Nutrition or hydration intervention

M1200E Pressure ulcer care

M1200G Application of dressings (not to feet)

M1200H Application of ointments (not to feet)

#Count as one treatment even if both provided

Nursing Component

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120

• Special Care Low – Depression Split


Nursing Component







121

• Special Care Low –

Nursing Component



Nursing Case Mix

0-5 Yes LDE2 2.07

0-5 No LDE1 1.72

6-14 Yes LBC2 1.71

6-14 No LBC1 1.43

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122

• Clinically Complex:

*Selected Skin Treatments: M1200F Surgical wound care, M1200G Application of nonsurgical dressing (other than to feet), M1200H Application of ointments/medications (other than to feet)

Nursing Component

MDS Item Condition or Service

I2000 Pneumonia

I4900, Nursing Function Score Hemiplegia/Hemiparesis with Nursing Function Score <=11

M1040D,E Open lesion (other than ulcers, rashes, and cuts) with any selected skin treatment* or surgical wound

M1040F Burns

O0100A2 Chemotherapy while a resident

O0100C2 Oxygen Therapy while a resident

O0100H2 IV Medications while a resident

O0100I2 Transfusions while a resident

123

• Clinically Complex – Depression Split


Nursing Component







63

124

• Clinically Complex –

Nursing Component



Nursing Case Mix

0-5 Yes CDE2 1.86

0-5 No CDE1 1.62

6-14 Yes CBC2 1.54

6-14 No CBC1 1.34

15-16 No CA2 1.08

15-16 No CA1 0.94

125

• Behavioral Symptoms and Cognitive Performance:

• Step #1 – Determine the Function Score

‒ The total Nursing Function Score must be 11 or greater to classify into the Behavioral Symptoms and Cognitive Performance.

‒ If the score is less than 11, the resident would classify into the Reduced Physical Function Category.

Nursing Component

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126

Behavioral Symptoms and Cognitive Performance

Step #2:

Determine the patient’s cognitive status based on patient interview using the BIMS. Instructions for completing the BIMS are in Chapter 3, Section C. The BIMS items involve the following:

C0200 Repetition of three words

C0300 Temporal orientation

C0400 Recall

If the patient’s Summary Score is less than or equal to 9, he or she classifies in the Behavioral Symptoms and Cognitive Performance category. Skip to Step #5.

If the patient’s Summary Score is greater than 9 but not 99, proceed to Step #4 to check behavioral symptoms.

If the patient’s Summary Score is 99 (patient interview not successful) or the Summary Score is blank (patient interview not attempted and skipped) or the Summary Score has a dash value (not assessed), proceed to Step #3 to check staff assessment for cognitive impairment.

Nursing Component

127


Step #3:

Determine the patient’s cognitive status based on the staff assessment rather than on patient interview.

Check if one of the three following conditions exists:

1. B0100 Coma (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)

2. C1000 Severely impaired cognitive skills for daily decision making (C1000 = 3)

3. B0700, C0700, C1000 Two or more of the following impairment indicators are present:

Nursing Component

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128


Step #3 (cont’d):

B0700 > 0 Usually, sometimes, or rarely/never understood

C0700 = 1 Short‐term memory problem

C1000 > 0 Impaired cognitive skills for daily decision making

and

One or more of the following severe impairment indicators are present:

B0700 >= 2 Sometimes or rarely/never makes self understood

C1000 >= 2 Moderately or severely impaired cognitive skills for daily decision making

If the patient meets one of the three above conditions, then he or she classifies in Behavioral Symptoms and Cognitive Performance. Skip to Step #5. If he or she does not meet any of the three conditions, proceed to Step #4.

Nursing Component

129


Step #4:

Determine whether the patient presents with one of the following behavioral symptoms: E0100A Hallucinations

E0100B Delusions

E0200A Physical behavioral symptoms directed toward others (2 or 3)

E0200B Verbal behavioral symptoms directed toward others (2 or 3)

E0200C Other behavioral symptoms not directed toward others (2 or 3)

E0800 Rejection of care (2 or 3)

E0900 Wandering (2 or 3)

If the patient presents with one of the symptoms above, then he or she classifies in Behavioral Symptoms and Cognitive Performance. Proceed to Step #5. If he or she does not present with behavioral symptoms, skip to the Reduced Physical Function Category.

Nursing Component

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130


Step #5:

Determine Restorative Nursing Count

Count the number of the following services provided for 15 or more minutes a day for 6 or more of the last 7 days:

H0200C, H0500** Urinary toileting program and/or bowel toileting program

O0500A, B** Passive and/or active range of motion

O0500C Splint or brace assistance

O0500D, F** Bed mobility and/or walking training

O0500E Transfer training

O0500G Dressing and/or grooming training

O0500H Eating and/or swallowing training

O0500I Amputation/prostheses care

O0500J Communication training

**Count as one service even if both provided

Nursing Component

131

• Behavioral Symptoms and Cognitive Performance

Nursing Component


Restorative Nursing


Nursing Case Mix

11-16 2 or more BAB2 1.04

11-16 0 or 1 BAB1 0.99

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132

Reduced Physical Function

Step #1 ‐Determine Function Score

Step #2 ‐ Determine Restorative Nursing Count

Count the number of the following services provided for 15 or more minutes a day for 6 or more of the last 7 days:

H0200C, H0500** Urinary toileting program and/or bowel toileting program

O0500A, B** Passive and/or active range of motion

O0500C Splint or brace assistance

O0500D, F** Bed mobility and/or walking training

O0500E Transfer training

O0500G Dressing and/or grooming training

O0500H Eating and/or swallowing training

O0500I Amputation/prostheses care

O0500J Communication training

**Count as one service even if both provided

Nursing Component

133

• Reduced Physical Function –

Nursing Component


Restorative Nursing


Nursing Case Mix

0-5 2 or more PDE2 1.57

0-5 0 or 1 PDE1 1.47

6-14 2 or more PBC2 1.21

6-14 0 or 1 PBC1 1.13

15-16 2 or more PA2 0.70

15-16 0 or 1 PA1 0.66

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134

NON‐THERAPY ANCILLARIES (NTA)

COMPONENT

135

• The purpose of the NTA scoring is to capture certain comorbidity conditions and extensive services that are associated with increased cost.

• A resident’s total comorbidity score is the sum of the points associated with the resident’s comorbidities and services.

• There are 6 NTA case mix groups.• Comorbidity score is a weighted count of comorbidities

– Comorbidities associated with high increases in NTA costs grouped into various point tiers

– Points assigned for each additional comorbidity present, with more points awarded for higher-costtiers

NTA Scoring

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136

NTA Component: Comorbidity Coding

• Comorbidities and extensive services for NTA classification are derived from a variety of MDS sources, with some comorbidities identified by ICD-10-CM codes reported in Item I8000

• A mapping between ICD-10-CM codes and NTA comorbidities usedfor NTA classification is available on the CMS website 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 RUG-IV

– The patient’s NTA classification will be adjusted bythe appropriate number of points for this condition by the CMS PRICER for patients with HIV/AIDS

137

NTA Conditions/Services and assigned points

Condition/Extensive Service MDS Item Points

HIV/AIDS SNF claim 8

Parenteral IV Feeding: Level HighK0510A2, K0710A2

7

Special Treatments/Programs: Intravenous Medication Post-admit Code+

O0100H2 5

Special Treatments/Programs: Ventilator or Respirator Post-admit Code+

O0100F2 4

Parenteral IV feeding: Level LowK0510A2, K0710A2, K0710B2

3

Lung Transplant Status I8000 3

Special Treatments/Programs: Transfusion Post-admit Code+

O0100I2 2

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138



Major Organ Transplant Status, Except Lung

I8000 2

Active Diagnoses: Multiple Sclerosis Code+

I5200 2

Opportunistic Infections I8000 2

Active Diagnoses: Asthma COPD Chronic Lung Disease Code+

I6200 2

Bone/Joint/Muscle Infections/Necrosis -Except: Aseptic Necrosis of Bone

I8000 2

Chronic Myeloid Leukemia I8000 2

Wound Infection Code I2500 2

Active Diagnoses: Diabetes Mellitus (DM) Code+

I2900 2

139



Endocarditis I8000 1

Immune Disorders I8000 1

End-Stage Liver Disease I8000 1

Other Foot Skin Problems: Diabetic Foot Ulcer Code+

M1040B 1

Narcolepsy and Cataplexy I8000 1

Cystic Fibrosis I8000 1

Special Treatments/Programs: Tracheostomy Care Post-admit Code+

O0100E2 1

Active Diagnoses: Multi-Drug Resistant Organism (MDRO) Code

I1700 1

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140



Special Treatments/Programs: Isolation Post-admit Code+

O0100M2 1

Specified Hereditary Metabolic/Immune Disorders

I8000 1

Morbid Obesity I8000 1

Special Treatments/Programs: Radiation Post-admit Code+

O0100B2 1

Stage 4 Unhealed Pressure Ulcer Currently Present *+

M0300D1 1

Psoriatic Arthropathy and Systemic Sclerosis

I8000 1

Chronic Pancreatitis I8000 1

Proliferative Diabetic Retinopathy and Vitreous Hemorrhage

I8000 1

* If the number of Stage 4 Unhealed Pressure Ulcers is recorded as greater than 0, it will add one point to the NTA comorbidity score calculation. Only the presence, not the count, of Stage 4 Unhealed pressure ulcers affects the PDPM NTA comorbidity score calculation.

141



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

M1040A, M1040C

1

Complications of Specified Implanted Device or Graft

I8000 1

Bladder and Bowel Appliances: Intermittent catheterization

H0100D 1

Inflammatory Bowel Disease I1300 1

Aseptic Necrosis of Bone I8000 1

Special Treatments/Programs: Suctioning Post-admit Code

O0100D2 1

Cardio-Respiratory Failure and Shock I8000 1

Myelodysplastic Syndromes and Myelofibrosis

I8000 1

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Systemic Lupus Erythematosus, Other Connective Tissue Disorders, and Inflammatory Spondylopathies

I8000 1

Diabetic Retinopathy - Except : Proliferative Diabetic Retinopathy and Vitreous Hemorrhage

I8000 1

Nutritional Approaches While a Resident: Feeding Tube+

K0510B2 1

Severe Skin Burn or Condition I8000 1

Intractable Epilepsy I8000 1

Active Diagnoses: Malnutrition Code I5600 1

Disorders of Immunity - Except : RxCC97: Immune Disorders

I8000 1

Cirrhosis of Liver I8000 1

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Bladder and Bowel Appliances: Ostomy H0100C 1

Respiratory Arrest I8000 1

Pulmonary Fibrosis and Other Chronic Lung Disorders

I8000 1

• Utilizing the table and points value, determine the residents total NTA score.

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NTA Case-Mix Group and Index

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 3.259‐11 NB 2.536‐8 NC 1.853‐5 ND 1.341‐2 NE 0.960 NF 0.72

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ADDITIONAL CHANGES

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146

• CMS will now require only two scheduled assessments for PPS payment:‒ No change in OBRA‒ 5-day PPS assessment‒ SNF Part A PPS Discharge assessment – for all Part A

residents: those that remain in the facility and those that discharge.

PPS Assessment Schedule

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PPS Assessment Schedule under PDPM

Medicare MDS assessment schedule type

Assessment Reference Date

Applicable standard Medicare payment days

5‐Day Scheduled PPS Assessment

Days 1‐8 All covered Part A days until Part A discharge (unless an IPA is completed)

Interim Payment Assessment (IPA)

Facility discretion ARD of the IPA through Part A discharge (unless another IPA is completed)

PPS Discharge Assessment

PPS Discharge: Equal to the End Date of the Most Recent Medicare Stay (A2400C) or End Date

N/A

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• A new assessment utilized to reclassify a resident.

• The final rule (FY2019) changed this assessment from mandatory to optional‒ Providers may determine whether and when an IPA is

completed

• The assessment reference date should be the date the facility choses to complete the IPA relative to the triggering event that causes the facility to choose to complete the IPA

• The payment changes on the ARD through the discharge, unless another IPA is completed

• The IPA does not re-set the variable per-diem adjustment schedule.

Interim Payment Assessment

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Concurrent & Group Therapy Limit• Under RUG-IV, no more than 25% of the therapy

services delivered to SNF patients, for eachdiscipline, may be provided in a group therapysetting, while there is no limit on concurrent therapy.

• Definitions:

– Concurrent Therapy: One therapist with two patients doing different activities

– Group Therapy: One therapist with four patients doing the sameor similar activities (Per Final Rule FY 2019)*

*CMS has included a change to the definition of group therapy in the Proposed Rule released on 4/19/19. “Group therapy consists of two to six patients doing the same or similar activities.” This is the current guideline for other PAC providers like IRFs. “This definition serves to improve the agency’s consistency in payment policies across PAC settings.”

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Concurrent & Group Therapy Limit (cont’d)• Under PDPM, a combined limit for both concurrent

and group therapy to be no more than 25% of thetherapy received by SNF patients, for each therapydiscipline will be used.

*CMS has included a change to the definition of group therapy in the Proposed Rule released on 4/19/19. “Group therapy consists of two to six patients doing the same or similar activities.” This is the current guideline for other PAC providers like IRFs. “This definition serves to improve the agency’s consistency in payment policies across PAC settings.”

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Concurrent & Group Limit: Compliance• Compliance with the concurrent/group therapy limit will

be monitored by new items on the PPS Discharge Assessment (O0425).– Providers will report the number of minutes,

per mode and per discipline, for the entirety of the PPS stay

– If the total number of concurrent and group minutes, combined, comprises more than 25% of the total therapy minutes provided to the patient, for any therapy discipline, then the provider will receive a warning message on their final validation report

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Concurrent & Group Limit: Compliance (cont’d)• How to calculate compliance with the concurrent/group

therapy limit.– Step 1: Total Therapy

Minutes, by discipline (O0425X1 + O0425X2 +O0425X3)

– Step 2: Total Concurrent and Group Therapy Minutes, bydiscipline (O0425X2 + O0425X3)

– Step 3: C/G Ratio (Step 2 Result / Step 1 Result)– Step 4: If Step 3 Result is greater than 0.25, then

non-compliant

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• Example 1:

• Total PT Individual Minutes (O0425C1): 2,000

• Total PT Concurrent Minutes (O0425C2): 600

• Total PT Group Minutes (O0425C3): 1,000

• Does this comply with the concurrent/group therapy limit?

• Step 1: Total PT Minutes (O0425C1 + O0425C2 + O0425C3): 3,600

• Step 2: Total PT Concurrent and Group Therapy Minutes (O0425C2 + O0425C3): 1,600

• Step 3: C/G Ratio (Step 2 Result / Step 1 Result): 0.44

• Step 4: 0.44 is greater than 0.25, therefore this is non‐compliant

Concurrent & Group Limit Compliance

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• Example 2:

• Total SLP Individual Minutes (O0425C1): 1,200

• Total SLP Concurrent Minutes (O0425C2): 100

• Total SLP Group Minutes (O0425C3): 200

• Does this comply with the concurrent/group therapy limit?

• Step 1: Total SLP Minutes (O0425C1 + O0425C2 + O0425C3): 1,500

• Step 2: Total PT Concurrent and Group Therapy Minutes (O0425C2 + O0425C3): 300

• Step 3: C/G Ratio (Step 2 Result / Step 1 Result): 0.20

• Step 4: 0.20 is not greater than 0.25, therefore this is compliant

Concurrent & Group Limit Compliance

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MDS CHANGES

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MDS Changes: New Item Sets

• Interim Payment Assessment (IPA)

– Optional Assessment: May be completed by providers in orderto report a change in the patient’s PDPMclassification

• Does not impact the variable per diemschedule

– ARD: Determined by the provider

– Payment Impact: Changes payment beginning on the ARDand continues until the end of the Part A stay or until another IPA is completed

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• IPA Key Facts:

• Optional, other than during the transition period

• Only used to change PDPM Medicare rate

• Cannot be combined with any other PPS or OBRA assessment

• Cannot be scheduled prior to the 5‐Day (Initial Patient Assessment) ARD

• SNF staff determine when and whether to complete, based on their facility policy on IPA completion


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• Optional State Assessment (OSA)‐ Solely to be used by providers to report on Medicaid‐covered stays, per requirements set forth by their state‐ For example, a state may require Medicaid providers to

complete an OSA in each instance when a PPS scheduled or unscheduled assessment (other than the 5‐day PPS assessment) would have been required under RUG‐III or RUG‐IV.

• CMS will continue to report the RUG‐III and RUG‐IV Health Insurance Prospective Payment System (HIPPS) codes, as requested by the state, until September 30, 2020 on the 5‐day PPS, OBRA comprehensive and OBRA quarterly assessment types.

• Beginning October 1, 2020, states must use the OSA as the basis for calculating RUG‐III and RUG‐IV HIPPS codes. ‐ There is currently no definitive timeline for retiring the

OSA. Once states are able to collect the data necessary to consider a transition to PDPM, CMS will evaluate the continued need for the OSA, in consultation with the states.


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• For late assessments under PDPM, similar to under RUG‐IV, the provider will bill the default HIPPS code for the number of days out of compliance and then the 5‐day assessment HIPPS code for the remainder of the stay, unless an IPA is completed.

• One caveat is that the default billing will be assessed prior to the 5‐day assessment (Initial Patient Assessment) HIPPS code, in terms of counting days for the variable per diem. For example, if a 5‐day assessment is two days late, then Days 1 and 2 of the stay, with regard to the variable per diem adjustment, will be calculated using the default HIPPS code and then the 5‐day assessment (Initial Patient Assessment) HIPPS code will control payment beginning on Day 3 of the variable per diem schedule.

• Because the IPA is completely optional, there will be no late assessment penalties for that assessment.

Streamlined Assessment Policy

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MDS Changes: New & Revised Items• SNF Primary Diagnosis

– Item I0020B (New Item)

– This item is for providers to report, using an ICD‐10‐CM code, the patient’s primary SNF diagnosis

– “What is the main reason this person is being admitted to the SNF?”

– Coded in addition to when I0020 is coded as any response 1 – 13

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MDS Changes: New & Revised Items (cont’d)• Patient Surgical History

– Items J2100 – J5000 (New Items)

– These items are used to capture any major surgical procedures that occurred during the inpatient hospital stay that immediately preceded the SNF admission (i.e., the qualifying hospital stay)

– Similar to the active diagnoses captured in Section I, these Section J items will be in the form of checkboxes

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MDS Changes: Patient Surgical Categories

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Item Surgical Procedure Category Item Surgical Procedure CategoryJ2100 Recent Surgery Requiring Active SNF Care J2610 Neuro surgery - peripheral and autonomic nervous

system - open and percutaneousJ2300 Knee Replacement - partial or total J2620 Neuro surgery - insertion or removal of spinal and

brain neurostimulators, electrodes, catheters, andCSF drainage devices

J2310 Hip Replacement - partial or total J2699 Neuro surgery - otherJ2320 Ankle Replacement - partial or total J2700 Cardiopulmonary surgery - heart or major blood

vessels - open and percutaneous proceduresJ2330 Shoulder Replacement - partial or total J2710 Cardiopulmonary surgery - respiratory system,

including lungs, bronchi, trachea, larynx, or vocal cords - open and endoscopic

J2400 Spinal surgery - spinal cord or major spinal nerves J2799 Cardiopulmonary surgery - otherJ2410 Spinal surgery - fusion of spinal bones J2800 Genitourinary surgery - male or female organsJ2420 Spinal surgery - lamina, discs, or facets J2810 Genitourinary surgery - kidneys, ureter, adrenals,

and bladder - open, laparoscopicJ2499 Spinal surgery - other J2899 Genitourinary surgery - otherJ2500 Ortho surgery - repair fractures of shoulder or arm J2900 Major surgery - tendons, ligament, or musclesJ2510 Ortho surgery - repair fractures of pelvis, hip, leg,

knee, or ankleJ2910 Major surgery - GI tract and abdominal contents

from esophagus to anus, biliary tree, gall bladder, liver, pancreas, spleen - open, laparoscopic

J2520 Ortho surgery - repair but not replace joints J2920 Major surgery - endocrine organs (such as thyroid, parathyroid), neck, lymph nodes, and thymus - open

J2530 Ortho surgery - repair other bones J2930 Major surgery - breastJ2599 Ortho surgery - other J2940 Major surgery - deep ulcers, internal brachytherapy,

bone marrow, stem cell harvest/transplantJ2600 Neuro surgery - brain, surrounding tissue/blood

vesselsJ5000 Major surgery - other not listed above

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MDS Changes: New & Revised Items

• Discharge Therapy Collection Items– Items 0425A1 – O0425C5 (New Items)– Using a look-back of the entire PPS stay, providers

report, by each discipline and mode of therapy, theamount of therapy (in minutes) received by thepatient

– If the total amount of group/concurrent minutes, combined, comprises more than 25% of the total amount of therapy for that discipline, a warning message is issued on the final validation report

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MDS Changes: New & Revised Items (cont’d)

• Section GG Functional Items – Interim Performance– On the IPA, Section 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 the three-day window leading up to and including the ARD of the IPA (ARD and the 2 calendar days prior to theARD)

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MDS Changes: New & Revised Items

• Existing MDS Items Being Added to Swing BedAssessment– K0100: Swallowing Disorder– I1300: Ulcerative Colitis or Crohn’s Disease or

Inflammatory Bowel Disease

– I4300: Active Diagnosis:Aphasia– O0100D2: Special Treatments, Procedures &

Programs:Suctioning, While a Resident• Existing Items Being Added to 5-day PPS (Initial Patient

Assessment) Assessment andIPA– I1300: Ulcerative Colitis or Crohn’s Disease or

Inflammatory Bowel Disease

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PDPM

BILLING

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PDPM HIPPS Coding

• Based on responses on the MDS, patients are classified into payment groups, which are billed using a 5-character Health InsuranceProspective Payment System (HIPPS) code.

• The current RUG-IV HIPPS code follows a prescribed algorithm.

– Character 1-3: RUG Code

– Character 4-5: AssessmentIndicator• In order to accommodate the new payment groups, the PDPM

HIPPS algorithm is revised as follows:

– Character 1: PT/OT Payment Group

– Character 2: SLP Payment Group

– Character 3: Nursing Payment Group

– Character 4: NTA Payment Group

– Character 5: Assessment Indicator

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PDPM HIPPS Coding Crosswalk: PT, OT, NTA• PT/OT, SLP, NTA Payment Groups to HIPPS Translation

PT/OTPayment Group

SLPPayment Group

NTAPayment Group

HIPPSCharacter

TA SA NA ATB SB NB BTC SC NC CTD SD ND DTE SE NE ETF SF NF FTG SG GTH SH HTI SI ITJ SJ JTK SK KTL SL LTM MTN NTO OTP P

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PDPM HIPPS Coding Crosswalk: Nursing• Nursing Payment Group to HIPPS Translation

NursingPayment Group

HIPPSCharacter

NursingPayment Group

HIPPSCharacter

ES3 A CBC2 NES2 B CA2 OES1 C CBC1 P

HDE2 D CA1 QHDE1 E BAB2 RHBC2 F BAB1 SHBC1 G PDE2 TLDE2 H PDE1 ULDE1 I PBC2 VLBC2 J PA2 WLBC1 K PBC1 XCDE2 L PA1 YCDE1 M

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PDPM HIPPS Coding Crosswalk:AI• Assessment Indicator (AI) Crosswalk

HIPPSCharacter

Assessment Type

0 IPA

1 PPS 5-day (Initial Patient Assessment)

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VARIABLE PER DIEM PAYMENT ADJUSTMENT

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• Constant per diem rates do not accurately track changes in resource utilization throughout the stay, and may allocate too few resources for providers at beginning of stay.

• To account more accurately for the variability in patient costs over the course of a stay, under PDPM, an adjustment factor is applied (for certain components) and changes the per diem rate over the course of the stay.

• For the PT, OT, and NTA components, the case-mix adjusted per diem rate is multiplied against the variable per diem adjustment factor, following a schedule of adjustments for each day of the patient’s stay.

Variable Per-Diem Payment Adjustment

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PT/OT Variable Per Diem Adjustment Factors

Day in StayPT and OT Adjustment

Factor

1-20 1.00

21-27 0.98

28-34 0.96

35-41 0.94

42-48 0.92

49-55 0.90

56-62 0.88

63-69 0.86

70-76 0.84

77-83 0.82

84-90 0.80

91-97 0.78

98-100 0.76

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NTA Variable Per Diem Adjustment Factors

Days in Stay NTA Adjustment Factor

1‐3 3.00

4‐100 1.00

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INTERRUPTED STAY POLICY

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• A interruption window is defined as the 3-day period starting with the calendar day of discharge and additionally including the two immediately following calendar days.

• The length of the interrupted stay will determine the impact on the resident classification and the variable per diem adjustment schedule.

Interrupted Stay Policy

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• CMS defines an “interrupted” SNF stay as one in which a patient is discharged from Part A covered SNF care and subsequently readmitted to Part A covered SNF care in the same SNF (not a different SNF) within 3 days or less after the discharge (the “interruption window”).

• Note that if a resident drops to a non-skilled level of care or otherwise leaves Part A SNF care, the patient is considered to have been discharged for the purposes of the interrupted stay policy, even if the patient remains in the facility.


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• Continuation of the prior stay:‒ When a resident is discharged from the SNF and returns

to the same SNF by 12:00 a.m. at the end of the third day of the interruption window, this is considered a continuation of the previous stay for purpose of the resident classification and variable per diem adjustment schedule.

‒ No new PPS MDS Assessment would be required.• All OBRA assessments must be completed, per

OBRA requirements.‒ There would be no change in the variable per diem

adjustment schedule.• For example – if a resident discharges to the

hospital on day 7 of the stay and is re-admitted to the same SNF within the 3-day interruption window, the resident would not require a new MDS assessment and the payment schedule would continue where it left off, in this case, on day 7.


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• Readmission as a new stay• In cases where the resident is discharged and does not

return within the 3-day interruption window, a new stay occurs which would require a new 5-day MDS Assessment and the variable per diem adjustment schedule would restart on day 1.• For example – a resident is discharged on day 7 of the

stay and is readmitted to the same SNF on day 11 of the stay. A new 5-day MDS assessment is required and the variable per diem adjustment schedule begins on day 1.

• The same applies if a resident is discharged from one SNF and admitted to another SNF.• Another example is if a resident is discharged from

ABC Nursing Home and admits to Happy Acres Nursing Home. A new 5-day MDS assessment is required and the variable per diem adjustment schedule begins on day 1.


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PUTTING IT TOGETHER

THE RATE

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Current Case-Mix Adjusted Payment

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• While RUG-IV (left) reduces everything about a patient to a single, typically volume-driven, case-mix group, PDPM (right) focuses on the unique, individualized needs, characteristics, and goals of each patient

RUG-IV vs. PDPM

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Patient-Driven Care Under PDPM

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Determinants of Payment in PDPM

PT OT SLP Nursing NTA

• Primary reason for SNF care

• Functional status


• Functional status


• Cognitive status• Presence of

swallowing disorder or mechanically altered diet

• Clinical information from SNF stay

• Functional status• Extensive services

received• Presence of

depression• Restorative

nursing services received

• Comorbidities present

• Extensive services received

• Point in the stay (variable per diem adjustment)



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• FY 2020 Proposed Unadjusted Federal Rate per Diem

Determining your Medicare rate

Rate Component Nursing NTA PT OT SLPNoncase‐mix

Urban $106.64 $80.45 $61.16 $56.93 $22.83 $95.48

Rural $101.88 $76.86 $69.72 $64.03 $28.76 $97.25

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PDPM Snapshot

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• Wage Index‒ CMS will continue to update the federal base

payment rates and adjust for geographic difference in wages using recent hospital wage index data• SNF market basket

‒ Per the final rule, there will not be specific wage index adjustments to each component under PDPM‒ The PDPM Case-Mix Adjusted Per Diem will

have the Wage Index Adjustment for your particular area of the country taken on the Labor Portion of the total per diem rate

‒ The proposed FY 2020 Labor Portion is 70.8%.

‒ The Non-Labor portion of the PDPM Case-Mix Adjusted Per Diem will be added back on to the Wage index adjusted rate for your Total Case Mix and Wage Index Adjusted Rate.


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Determining your Medicare Rate

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• Transition‒ RUG–IV assessment scheduling and other RUG–IV

payment-related policies would be in effect until September 30, 2019.

‒ Beginning on October 1, 2019, all PDPM related assessment scheduling and other PDPM payment-related policies would take effect.


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• Case Studies


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• Resident admitted to facility from the hospital after having COPD with respiratory failure. He is SOB while lying flat. The resident is receiving oxygen and has diabetes with daily insulin injections.

• The resident has a BIMS score of 11 indicating mildly impaired cognition.

• He requires extensive assistance with bed mobility and transfer with assistance of one person, extensive assistance of two persons for toilet use and is independent with eating. He does not walk.

• He received six days and 720 minutes of therapy (combined between PT and OT)

RUG to PDPM Example

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• RUG-IV Calculation:

‒ RUB rate = $642.12 x 14 days‒ RHB rate = $432.02 X 4 days‒ The residents length of stay was 18 days‒ Reimbursement: $10,717.76

RUG to PDPM Example

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• PDPM Calculation:‒ PT: TK = $90.30‒ OT: TK = $84.89‒ SLP : SD = $32.30 ‒ Nursing Classification: LBC1 = $147.55‒ Non‐therapy ancillary: ND = $104.54‒ Non Case‐Mix rate = $92.63

Rate on day 1‐ 3 = $761.29Rate after day 3 = $552.21Total for 18 days = $10,566.97Difference: ($150.79)

RUG to PDPM Example

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• Resident admitted to facility from the hospital after having a hip replacement secondary to a fracture. He has Parkinson’s disease; dysphagia with coughing and choking with meals and is on a mechanically altered diet. He also has a Stage 2 pressure injury with skin treatments and a surgical wound with wound care.

• The resident has a BIMS score of 4 indicating moderately impaired cognition.

• He requires extensive assistance with bed mobility, transfer and toileting with the assist of 2 people, extensive assist of one person for eating. He does not walk.

• He receives five days and 540 minutes of therapy (combined between OT, PT and ST)

RUG to PDPM Example

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• RUG‐IV Calculation:

‒ RVC rate = $550.86 x 14 days

‒ RHB rate = $432.02 X 16 days

‒ The residents length of stay was 30 days

‒ Reimbursement: $14,624.36

RUG to PDPM Example (cont’d)

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• PDPM Calculation‒ PT: TB = $114.29‒ OT: TB = $101.24‒ SLP: SI = $97.93 ‒ Nursing Classification: LBC1 = $141.33‒ Non‐therapy ancillary: NF = $53.68‒ Non Case‐Mix rate = $94.34

Rate on day 1‐ 3 = $615.83Rate on days 4‐20 = $508.47Rate on days 21‐27 = $504.16Rate on days 28‐30 = $499.85Total for 30 days = $15,520.15Difference: $895.79

RUG to PDPM Example (cont’d)

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• Additional Case Studies


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• Ms. Nelson is a 68 year old who was admitted to Happy Acres on November 10, 2019 after elective left knee replacement due to osteoarthritis and also has a diagnosis of unstable diabetes. She was admitted to receive therapy and monitor and stabilize her blood sugars. The plan is for her to discharge back to her independent living cottage. She received physical and occupational therapy during her stay as well as changes to her insulin. She was discharged back to her cottage on November 20, 2019.

• The MDS information is on the handout –use the information to determine the PDPM HIPPS code

Case Study #1

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• What is the PT Component Case Mix Group?

• TC

• What is the Case‐Mix Index?

• 1.88

• What is the OT Component Case Mix Group?

• TC


• 1.68

Reason: The diagnosis code Z47.1 falls into the major joint replacement or spinal surgery

Case Study #1

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• What is the SLP Component Case Mix Group?

• SA


• 0.68

Reason: Non‐neurologic, no comorbidities, no swallowing disorder and no mechanically altered diet.

• What is the Nursing Component Case Mix Group?

• HBC1


• 1.85

Reason: The diagnosis of diabetes (I2900) with 7 days of insulin injections (N0350A) and 4 insulin physician orders (N0350B).

Case Study #1

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• What is the NTA Component Case Mix Group?

• NE


• 0.96

Reason: The diagnosis of diabetes (I2900) is 2 points

HIPPS: CAGE1

Case Study #1

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Stephanie Kessler, RAC‐CT, CHP

Partner

[email protected]

717.885.5724

Questions?

Tracy Montag, BSN, RN, RAC‐MT

Manager

[email protected]

717.885.5727

THE PATIENT DRIVEN PAYMENT MODEL (PDPM) A REVISED … PDPM FINAL 0619.pdf · • Issues with the...

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