Webinar 3 Sections o, p, q, CAA’s, PDPM

12/2/2020

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WEBINAR 3SECTIONS O, P, Q, CAA’S, PDPM

Demi Haffenreffer, RN

Haffenreffer and Associates, Inc

www.consultdemi.net

[email protected]

Outline

■ Section O – Special treatments

■ Section P – Restraints / Alarms

■ Section Q – Discharge Planning and Assessment Participation

■ Care Area Assessments

■ PDPM

SECTION O

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Section O0100 – Special Treatments

■ Overall Intent of Section O

– To identify any special treatments, procedures, and programs that the resident received during the specified

periods

■ Quality of Life and Care Planning

– May have a profound effects on health status, self-image, dignity, and quality of life

– Care planning should address ongoing monitoring and

needs

■ Steps for Assessment

– Review medical record

Section O0100 – Special Treatments

■ Coding

– If resident was admitted or reentered more than 14-days

ago leave column 1 blank

– If no items apply check Z – none of the above

– There are special coding requirements for each item –see section O0100

Section O0100

■ Chemotherapy O0100A – Do not code Hormonal Agents

■ O0100F – Invasive Mechanical Ventilator – Updated definition

■ O0100G – Non-invasive Mechanical Ventilator – Updated definition

■ O0300 – Pneumococcal Vaccine – Updated instructions to include

current recommendations – see next slide

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Section O0250 - Influenza

Quality of Life and Care Planning

Severe mortality rates and affects a large population

Vaccines have been proven effective in preventing hospitalizations

Steps for Assessment

Review medical record

Interview resident / family

If vaccination cannot be determined, administer the vaccine with consent

Coding

A = yes / no

B = Date

C = Reason for not receiving

Section O0300 – Pneumococcal Vaccine

■ If resident has had severe allergic reaction do not administer

■ If moderate to severe illness – admin after illness

■ If minor illness – check with physician

■ If resident has received one or more pneumococcal vaccinations

& is indicated to get an additional vaccination but not yet eligible

for next because of recommended time interval – code Yes

indicated vaccination up to date.

Section O0300 – Pneumococcal

Quality of Care and Care Planning

High Mortality rates

Early detection essential

Many conditions increase risk

National goal of 90% immunization – www.healthypeople.gov


Determine whether vaccine should be given – use algorithm


Interview resident / family / physician

Administer according to standards

Coding

A = No / Yes

B = Reason for not receiving

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O0400 - Therapies


Functional independence important for quality of life

Must meet skilled criteria for therapies & others require orders / plan



Coding

7-day look back

Include services only provided while a resident

Start date is evaluation date

Do not count therapies by aides vs. assistants

Initial evals not counted as minutes – reevaluations counted

Record actual minutes – do not round up or down

O0400 - Therapies

■ Individual Therapy

■ Concurrent Therapy (Medicare part A)

– Two residents treated at the same time

– Each resident performing different activities

– Regardless of payer source – does not include Medicare B

■ Group Therapy

– Treatment of 2 or more residents at the same time is documented

as a group treatment

– Regardless of payer source – Medicare A or B

– Who are performing similar activities

– Supervised by therapist or assistant who are not supervising any

other residents

Section O0400 D - F

■ Respiratory – Services provided by qualified professional, includes coughing,

deep breathing, heated nebulizers, aerosol treatments, assessing breath

sounds & mechanical vents. DOES NOT include hand-held medication

dispensers

■ Psychological – Treatment of mental & emotional disorders

■ Recreational – Services provided by or supervised by a qualified certified

recreational therapist

■ Coding

– 7-day look back

– Total minutes

– Total days received 15 minutes (need not be consecutive)

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Section O0420

■ Recording the number of distinct calendar days the

resident received therapy for 15 minutes in the last

7 days.

Section O0425 & O0430

■ Only completed on PPS Discharge Assessments

Section O – 0500 Restorative

■ Overall Intent of O-0500

– To document services provided in the specified time frames in

accordance with the coding definitions

■ Quality of Life and Care Planning

– Maintaining independence and autonomy important for quality of

life

– Decrease functional status can lead to other declines

– Restorative is a nursing program

– Can be initiated at any time & does not require an order

■ Assessment steps

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Assessment steps

Review Medical record documentation for 7-day look back

Coding for the number of days restorative provided during the 7-day look

back

Activity performed for 15 minutes in a 24-hour period counts as a day for

coding purposes

Other criteria for coding:

Care plan with measurable goals and objectives

Evidence of periodic evaluation (Restorative aide can perform & LN co-

sign)

Nursing assistants providing activities are trained

It is a nursing program – therapy can supervise some

Does not include groups with more than four residents per caregiver

Each activity must be coded separately

Coding Definitions

ROM Passive

Can include CPM

ROM Active

Splint or Brace Application

Training and Skill Practice

Bed mobility

Transfer

Walking

Dressing and/or grooming

Eating and/or swallowing

Amputation / Prosthesis Care

Communication

Restorative Programming

Based on principles

Is a nursing program

Includes restoration as well as maintenance

Formal vs. Informal

Requires documentation

Assessment

Care Planning

Reevaluation at least quarterly

Is part of the quality of care rules for maintaining or restoring highest

practicable status – Section G & other sections

Maximum function often underestimated

Requires skill, time and patience

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Section O

■ 0600 – Physician Examination

■ 0700 – Physician Visit

Restraints & Alarms

SECTION P

Section P0100

Intent

To record the frequency over the 7-day look-back period that the resident

was restrained by any of the listed devices at time. Assessors evaluate

whether or not a device meets the definition of a physical restraint and

then codes only those devices that meet the definitions


Not Prohibited

Lead to declines

Risk of use is often greater than not using

Requires assessment, trying alternatives, an specific order for use, the

least restrictive device, & ongoing gradual reduction or elimination

Care planning should focus on preventing the adverse effects of use

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Assessment steps & Coding


Discuss with staff

Apply coding definition of “restraint”

Any manual method or physical or mechanical device, material or

equipment attached or adjacent to the resident’s body that the individual

cannot remove easily which restricts freedom of movement or normal

access to one’s body.

Evaluate if the resident can remove easily & if it restricts freedom of

movement

Remove easily means can be removed intentionally

Freedom of movement means any change in place or position for body or

any part of the body

Assessment steps & Coding

If meets criteria code for frequency of use

Code for effect it has on resident not for use

Need Medical Symptoms / Diagnosis

An indication or characteristic of a physical or psychological condition

Other Definitions to consider

Bedrails

Trunk restraints

Limb restraints

Chairs that prevent rising

Restraints in emergencies or when requested or for fall prevention

Restraint reduction / elimination

What to exclude

Alarms

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Instructions for Completion

■ Defined as any physical or electronic device that

monitors a resident’s movement and alerts the staff when movement is detected.

■ 7-day look back

■ Document the number of days utilizing the alarm

SECTION QAssessment Involvement and Discharge Plan

Care Area Assessments

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CAAs1. Delirium 11. Falls

2. Cognitive 12. Nutritional Status

3. Visual 13. Feeding Tubes

4. Communication 14. Dehydration

5. ADL 15. Dental Care

6. Urinary Incontinence 16. Pressure Ulcer

7. Psychosocial well-being 17. Psychotropic Drug Use

8. Mood State 18. Physical Restraints

9. Behavioral Symptoms 19. Pain

10. Activities 20. Return to Community

Care Area Assessments (CAA)

■ Comprehensive Assessments that collects subjective and objective

data

■ Use CAA resources (Appendix C) and/or current, evidence-based or

expert-endorsed resources

■ There is documentation criteria

■ The written assessment tells us the “so what” about the real or

potential CAA problem and our rationale for care planning

■ May occur anywhere in the record – but should be organized

■ Care Process steps remain the same

Care Process

MDS

CATS

CAA

Care Plan Decision

Care Plan

Evaluation

Or other

assessment

i.e. qtr.

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Documentation Criteria - General

■ The nature of the issue or condition – What is the problem?

■ Causes and contributing factors – What are the factors causing or

potentially causing this? What are the factors affecting (good and bad)?

■ Complications – Are there complications by the care area?

■ Factors affecting care plan development – Do you want to proceed to care

plan? Discussion with resident. Rationale for proceeding or not proceeding.

■ Need for referrals – Do you need to get expert advice?

■ Sources used for the assessment – if not already cited.

Steps■ Clinical Process and Tasks

■ Identify what has triggered and why

■ Analyze the triggered item based on the trigger, your assessment,

resident characteristics and preferences as well as other information

– The analysis is based on your assessment utilizing CAA resources

and/or other resources available as well as consults

– Use your own chosen protocol or policy for assessment

■ Determine if the triggered item requires care planning

■ Document – Using resources available on computer or other

■ Completion of section V

– Where can information be found

– Proceed vs. not proceed

CAA - Care Plans

■ Completion of the Care Plan

– Directed toward highest functional status – preventing declines as possible

– Addressing resident strengths, needs, preferences and

right to decline treatment

– Management of Risk Factors

– Professional standards of practice followed

– Contains resident voice – person-centered

– Includes family / significant others as appropriate

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CAA - Care Plans

■ Completion of the Care Plan

– Based on assessment information – is congruent with assessment

– Measurable goals and timetables

– Accessible to staff who require the information

– Is dated and updated

Care Area Assessments

■ Use as a guide for all assessments

■ Goals

■ Triggers

■ Who usually completes

■ Specifics that need to be addressed for

each assessment

– Disease / Conditions

– Risk factors

– Medications

– Other Contributing factors

– Labs done or needed

– Referrals

– Resident / family perspectives

– Care Planning rationale and high-

level topic

CAA 1 Delirium

■ Goal:

– Identify if this is or is not Delirium so appropriate & swift treatment can occur (if treatable) – This problem is considered curative

■ Triggers:

– Worsening mental status is indicated by BIMS score having a non-missing value of 00 to15 on both current non-admission comprehensive assessment (annual, scsa or scpa) & prior assessment, & the score on the current non-admission assessment is less than the prior assessment.

– C1600 – Acute mental status change

■ Who completes assessment & documents:

– Clinically oriented - Nursing

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Delirium Assessment Details

■ Vital signs compared to baseline

■ Abnormal labs

■ Pain

■ Diseases and conditions

■ Infections

■ Dehydration

■ Functional status changes

■ Medications

■ Associated or progressive signs and symptoms

■ Other considerations

■ Resident/family/representative perspective

■ Consider referrals needed

CAA 2 Cognition

■ Goal:

– Identify the cause(s) and make the environment meaningful and safe – This problem is not considered curative but palliative

■ Triggers:

– BIMS score is less than 13, or has a missing value & there is a problem with long/short-term memory or difficulty making decisions, or BIMS, staff assessment or clinical record suggests presence of inattention, disorganized thinking or psychomotor retardation, or presence of behaviors, or rejection of care, or wandering


– Nursing, Social Services, Activities

Cognition Assessment Details

■ Potential reversible cause = Delirium – see CAA 1

■ Neurological factors such as IDDD; Alzheimer’s; Parkinson’s; Brain Tumors or traumatic brain injury; NPH; or other factors

■ Characteristics of this residents cognition and cognitive loss

– Include functional status

■ Any mood or behavioral issues

■ Medical issues that may impact cognition (current or potential)

– Constipation, Diabetes, Thyroid, CHF, Respiratory problems, Cancer, Liver disease, Renal failure, Psychiatric or mood disorders, Lab (Electrolyte issues), poor nutrition or hydration, Alcoholism, Failure to thrive, End of Life

■ Medications

■ Pain

■ Associated or progressive signs and symptoms




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CAA 3 Vision

■ Goal:

– Identify the cause(s) and treatable conditions

■ Triggers:

– Diagnosis of glaucoma, cataracts, or macular degeneration in section I

– Vision B1000 has a code of >1 and < 4


– Nursing in collaboration with Activities

Vision Assessment Details

■ Diseases and conditions (either diagnosis or symptoms present)

■ Other diseases and conditions that can cause visual disturbances

■ Functional limitations related to visual problems

■ Environmental issues / needs

■ Medications that can impair – as well as meds the resident is currently

taking related to vision problems

■ Use of visual appliances



CAA 4Communication

■ Goal:

– Focuses on the interplay between a resident’s receptive

and expressive communication and cognitive skills for

decision making.

■ Triggers:

– Hearing issues – value of 1-3 at B0200

– Impaired ability to make self understood, B0700 is >1

and < 3

– Impaired ability to understand, B0800 is >1 and < 3


– Nursing, Social Services, Activities

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Communication Assessment Details

■ Diseases and conditions that may be related to communication

issues / problems

■ Medications that could be affecting communication abilities

■ Characteristics of expressive and receptive communication

■ Other confounding problems

■ Use of communication devices



CAA 5 ADL Functional / Rehabilitation Potential

■ Goal:

– Maintenance or improvement of ADL status including ROM

■ Triggers:

– Cognitive skills for decision making has value of 0 through 2 or BIMS summary score is > 5 or greater and resident requires assistance with ADL’s > 1 and < 4 OR

– Decision making and BIMS as above and balance for any item a value of 1 or 2 OR

– Decision making and BIMS as above and staff or resident believe is capable of increased independence


– Therapy, MDS nurse, restorative nurse, other

ADL Assessment Details

■ Possible underlying problems that may affect function both reversible and

not

■ Abnormal labs

■ Medications

■ Limiting factors resulting in need for assistance with any of ADL’s

■ Problems that resident may be at risk for related to functional declines



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CAA 6 Urinary Incontinence & Catheter Use

– Goals:

■ Improve the number of times the resident is wet

■ To identify treatable conditions

■ Triggers:

– Any of following: Toileting assist 2 to 4; Catheter (external, indwelling, or

intermittent); Urinary Incontinence 1 to 3; Associated Moisture Skin Damage

(section M)


– Clinically oriented – nursing, urology, other

Incontinence & CatheterAssessment Details

■ Modifiable factors that may contribute to transitory incontinence

■ Other factors (not quite so modifiable)

■ Lab tests to consider


■ Types of incontinence (purpose here is for you to name it)

■ Medications

■ If using a catheter – then why? – The 5 reasons it can be used



CAA 7Psychosocial Well-Being

■ Goal:

– Improved psychosocial status

– When triggers in combination with mood or behavior, then those issues should be dealt with first

■ Triggers:

– PHQ9 or PHQ9OV “Little interest or pleasure in doing things.”

– Activity preference either interview or staff interview – value of 3 or 4 or not checked – “How important is it to you to do your favorite activities.” OR any 6 items on activity preference interview a value of 4 (& resident is primary respondent)

– Behaviors (physical, verbal) & Alzheimer’s / Dementia not checked


– Social Services, Activities, Nursing

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Psychosocial Assessment Details

■ Customary Lifestyle

■ Possible modifiable factors for relationship problems


■ Current Health status factors

■ Environmental factors

■ Resident strengths



CAA 8 Mood State

– Goals:

■ Identify and treat depression

■ Triggers:

– PHQ9 or PHQ9OV – resident thoughts of harm

– PHQ9 or PHQ9OV – summary score greater than prior assessment

– PHQ9 – summary score 10 through 27

– PHQ9OV – summary score 10 through 30


– Nursing or Social Services

Mood StateAssessment Details

■ Recent Psychosocial Changes

■ Clinical issues that may contribute to mood issues (many)

■ Medications that may contribute (many)

– Could have pharmacy review

■ Lab tests



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CAA 9 Behavioral Symptoms

■ Goal:

– To identify trends, causes and possible interventions

■ Triggers:

– Rejection of care

– Wandering

– Change in behavior

– Presence of at least one behavioral symptom


– Nursing, Social Services

Behavior SymptomsAssessment Details

■ First assess if the resident is an immediate threat to self or to others

■ Place resident on behavior tracking for at least fourteen days

■ Trend and analyze behavioral tracking

– Nature of behavioral disturbance

■ Medications that can cause behaviors

– Enlist pharmacist help

■ Illnesses or conditions that can cause behaviors

■ Factors that can exacerbate behaviors

■ Cognitive status issues




CAA 10Activities

– Goals:

■ Identify strategies to help residents become more involved in relevant

activities – those that interested or stimulated them in the past or new ones

that are consistent with their cognitive and functional capabilities.

■ Triggers:

– Little interest or pleasure in doing things on interview or staff interview –

D0200A1=1 or D0500A1=1

– Any six items on interview for activity preferences with value of 4 or 5 (not

important at all or important but can’t do or no choice)


– Activities or Social Services

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Activities Assessment Details

■ History and trends

– Activity preferences prior to admission

– Current interests

■ Health issues that may interfere with past and current preferences

■ Environmental or staffing issues

■ Resident’s unique skills and knowledge

■ Issues (other than health issues) that may result in reduced activity

participation



CAA 11 Falls

■ Goal:

– To identify risks and prevent falls

■ Triggers:

– Any of the following: Wandering; Balance problems; For admission assessment if resident has history of falls; Fallen since admission; Anti-anxiety; Anti-depressant; or trunk restraint use in bed or in chair.


– Therapy; MDS; restorative nurse

Falls Assessment Details■ Falls trending and history

■ Physical performance limitations

■ Medications

■ Internal risk factors that exist

■ Lab tests to consider

■ Environmental



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CAA 12 Nutrition

■ Goal:

– Identify factors that are impeding a resident’s ability to maintain appropriate nutritional status – either actual or potential

■ Triggers:

– Triggers when a resident has or is at risk for a nutrition issue: Dehydration, BMI too low or high, Weight loss, Weight gain, IV, Mechanically altered diet, Therapeutic, Pressure Ulcers.


– Dietary in collaboration with nursing – and if related to mood or behavior in collaboration with Social Services

Nutrition Assessment Details

■ Current eating patterns

■ Functional issues affecting ability to eat

■ Cognitive issues – including mood or behaviors

■ Communication issues

■ Dental or oral problems


■ Abnormal Labs

■ Medications

■ Environmental factors



CAA 13Feeding Tubes

■ Goal:

– To identify and address the underlying issues the

required the use of the feeding tube

– Assuming it is needed, to address the potential

complications related to its use

■ Triggers:

– Use of a feeding tube


– Dietary in collaboration with Nursing and Social Service input

may be needed

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Feeding Tube Assessment Details

■ Historical need for the feeding tube

■ Factors that impede removal

■ Complications – potential and actual

■ Psychosocial issues

■ Periodic evaluations that may be required



CAA 14Dehydration / Fluid Maintenance

– Goals:

■ Identify factors that are impeding a resident’s ability to maintain

appropriate hydration – either actual or potential

■ Triggers:

– Triggers with conditions that could potentially cause dehydration or

point to an already existing hydration problem: Fever, Vomiting,

Dehydration, Bleeding, Infection, Constipation, IV and Feeding Tube.


– Dietary in collaboration with nursing

CAA 14 Assessment Details

■ Currently existing signs and symptoms

– Current oral intake

■ Labs

■ Cognitive issues, mental health issues, and/or communication issues that

interfere with fluid intake




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CAA 15 Dental Care

■ Goal:

– Identify oral/dental issues and/or conditions related to dental care

– Identify related possible causes and/or contributing risk factors

■ Triggers:

– Any dental problem identified in MDS section L


– Nursing in collaboration with Dietary and Social Services

Dental Assessment Details

■ Cognitive issues affecting dental care

■ Functional impairments

■ Items that may cause dry mouth – hydration, medications


– Oral Exam



CAA 16 Pressure Ulcers / Injuries

Goals:

– To identify characteristics of current wounds, possible causes, contributing factors, and risk factors related to

development of further pressure ulcers / Injuries.

Triggers:

– MANY triggers: ADLs, Incontinence, Weight loss, Risk,

Actual Pressure Ulcers / Injuries and Restraint use.

Who completes assessment & documents:

– Nursing

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Pressure Ulcer / Injuries CAA Assessment Details

■ Existing Pressure Ulcers / Injuries

■ Extrinsic factors

■ Intrinsic factors

■ Medications

■ Diagnoses and conditions

■ Current treatments that could contribute or lead to


■ Referrals

CAA 17 Psychotropic Medication Use

■ Goal:

– Assuming the medication is needed, this CAA focuses on identification of adverse consequences

■ Triggers:

– Antipsychotic, Antianxiety, Antidepressant, or Hypnotic administered in one or more of the 7 days during look back


– Nursing, Social Services

Psychotropic Medication UseAssessment Details

■ Complete review – is it or is it not unnecessary?

– Class of medication taking, in what dose, for how long, why & how

monitored

– Review of possible treatable reasons for drug use

■ Review of adverse consequences of class of drug

– Present or not? And how monitored

– Any declines?

– Any possible drug related discomfort?



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CAA 18 Physical Restraints

Goals:

– To determine & document restraint need & prevent complications

– To develop an elimination plan

Triggers:

– Restraint use


– Therapy, MDS, Restorative nurse

Restraint Assessment Details

■ Evaluation of current restraint use

■ Medical conditions that lead to restraint use

■ Cognitive issues that lead to restraint use

■ Risk for falls that lead to restraint use

■ Adverse reactions or complication risks related to restraint use



■ Elimination plan

CAA 19 Pain Goals:

– To identify characteristics, possible causes, contributing factors, and

risk factors related to pain.

Triggers:

– Pain Interview questions:

■ Resident is having difficulty sleeping – J0500A=1

■ Resident has limited activity – J0500B=1

■ Verbal descriptor or numeric intensity or frequency values

– Staff Interview indicates non-verbal indicators of pain


– Nursing in collaboration with PCP

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Pain Assessment Details■ Diseases or conditions that may cause or be causing

■ Characteristics

– Is this acute or chronic or both

■ Trending / frequency or pain monitors and/or prn use

■ Non-verbal indicators

■ Affect on function

■ Additional associated signs and symptoms

■ Other consideration

■ Resident/family/representative perspective & goals for pain management

■ Past and present treatments and their effectiveness – both pharmacological and

non-pharmacological

■ Referrals

CAA 20 Return to Community

Goals:

– To promote open discussion about the resident’s preferences

for settings to receive care and services

– To assess strengths and risk factors related to resident

preferences (discharge assessment) and to develop a

discharge plan

Triggers:

– Referral is or may be needed to local contact agency and

referral as not been made


– Social Services in collaboration with the entire team & local

contact agency (if needed)

Community Referral Assessment Details

■ Steps in the Process

– Document in the care plan

– Discuss barriers & develop a transition plan with resident and/or family

– Consider other factors (functional / cognitive status, as well as equipment and other

services, including training)

– Create & inform discharge team

– Review past care planning issues related to discharge

– Initiate contact with State agency – 10 day time frame

– Communicate and collaborate


■ Consider other referrals as needed (Home Health, Therapy, Hospice, etc.)

■ Formalize the discharge care plan

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Additional assessment areas

■ Skin risks

■ Bowel

■ Range of Motion

■ Insomnia

■ Discharge Planning

■ Any needs the resident has regardless of whether it triggers a CAA

PDPMPATIENT DRIVEN PAYMENT MODEL

What is PDPM

“A new case-mix classification system for classifying SNF residents in a

Medicare Part A covered stay into payment groups under the SNF

Prospective Payment System – Effective beginning October 1, 2019.”

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Important Features of PDPM

■ Per Diem Payment Variable

■ Therapy Minutes No longer Drive Payment

■ Admission Assessment

– Patient Characteristics Drive Payment

■ Total Therapy Capped at 25% for Group & Concurrent Combined

■ Admission / IPA / MDS Coding Timing & Accuracy are Critical

PT Base Rate X PT CMI X PT VPD Adjustment PT

• +

OT Base Rate X OT CMI X OT VPD AdjustmentOT

• +

SLP Base Rate X SLP CMISLP

Nursing

NTA

Non-Case-Mix

Nursing Base Rate X Nursing CMI X 18% Adjustment

+

NTA Base Rate X NTA CMI X NTA Adjustment Factor

+

Non-Case-Mix Base Rate

+

Service Patient

Characteristics

Per-Diem

Structure

# of CM

Groups

PT Primary Reason for SNF Stay

Functional Status – MDS GG & late

loss

Payment decreases >

day 20

16

OT Primary Reason for SNF Stay

Functional Status – MDS GG & late

loss

Payment decreases >

day 20

16

SLP Primary Reason for SNF Stay

Cognition, swallowing disorder Or

MSD, Other comorbidities

Average daily payment

No variable payment

12

Nursing Clinical info, Functional Status – MDS

GG & late loss, extensive services,

depression, restorative

Average daily payment

No variable payment

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NTAS Comorbidities

Extensive Services Used

Payment decrease >

day 3

6

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PDPM ASSESSMENT SCHEDULEMedicare MDS

Schedule Type

Assessment Reference

Date

Applicable Medicare

Payment Days

5-day PPS Assessment Days 1-8 All covered Part A days until Part

A Discharge (unless an IPA is

completed)

Interim Payment Assessment

(IPA)

The date the facility chooses ARD of the assessment through

Part A discharge (unless another

IPA completed)

PPS Discharge Assessment PPS Discharge: Equal to the end

Date of the Most Recent

Medicare Stay (A2400C) or End

Date

N/A

PDPM Clinical Categories■ SNF Patients first classified into a clinical category based on the primary diagnosis – 10

categories

■ ICD 10 codes on MDS section I0020B are mapped to a PDPM Category

■ Clinical classification may be adjusted by a surgical procedure that occurred during the

hospital stay captured in items J2100 through J5000

Major Joint Replacement or Spinal

Surgery

Cancer

Non-surgical Orthopedic /

Musculoskeletal

Pulmonary

Orthopedic Surgery (Except Major

Joint Replacement or Spinal Surg.

Cardiovascular and Coagulations

Acute Infections Acute Neurologic

Medical Management Non-Orthopedic Surgery

PT and OT Clinical Categories

PDPM Clinical Categories

Major Joint Replacement or

Spinal Surgery

Acute Neurologic

Non-Orthopedic Surgery

Non-Surgical Orthopedic /

Musculoskeletal

Orthopedic- Surgical Extremities

Not Major Joint

Medical Management

Cancer

Pulmonary

Cardiovascular & Coagulations

Acute Infections

PT & OT Clinical Categories

Major Joint Replacement or Spinal Surgery

Non-Orthopedic Surgery and Acute

Neurologic

Other Orthopedic

Medical Management

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PT and OT Payment Groups

SLP Classification

■ Acute Neurological clinical classification

■ SLP Comorbidities

■ Presence of cognitive impairment

■ Use of Mechanically altered diet

■ Presence of Swallowing disorder

SLP COMORBIDITIES

APHASIA LARYNGEAL CANCER

CVA, TIA, OR STROKE APRAXIA

HEMIPLEGIA OR HEMIPARESIS DYSPHAGIA

TRAUMATIC BRAIN INJURY ALS

TRACHEOSTOMY (WHILE RES.) ORAL CANCERS

VENTILATOR (WHILE RES.) SPEECH & LANGUAGE DISORDER

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COGNITIVE SCORING■ Assessed using either the BIMS or if BIMS not completed, a Staff

assessment for mental status is completed

■ The Cognitive Performance Scale is then used to score the

patient based on responses to the staff assessment.

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

SLP Payment Groups

Nursing Components

■ Same structure as utilized for RUG IV

– Extensive Services

– Clinical Conditions

– Depression

– Restorative services

– Functional score

■ Function score is based on section GG

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Nursing Component - Payment Groups 1

Nursing Component Payment Groups 2

Nursing Component Payment Groups 3

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Non-Therapy Ancillary (NTA)■ Previously addressed under the nursing component

■ Result of a weighted count of a patient’s co-morbidities and extensive

services – 50 conditions each with a certain number of points 1-8.

NTA Score Range NTA CM Group NTA CM Index

12+ NA 3.25

9-11 NB 2.53

6-8 NC 1.85

3-5 ND 1.34

1-2 NE 0.96

0 NF 0.72

NTA CONDITION LISTING 1


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FUNCTIONAL SCORES

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PT / OT Functional

Score?

Two bed mobility items

Three transfer items

One eating item

One toileting item

One oral hygiene item

Two walking items

Nursing Functional Score

Eating

Toileting Hygiene

Sit to lying

Lying to sitting on side of bed

Sit to stand

Chair/Bed-to-Chair Transfer

Toilet Transfer

RUGS-IV vs. PDPM Differences

■ Reverse scoring methodology

■ Under section GG, increasing score means increasing

independence

■ Non-linear relationship to payment

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Section GG Items in the PT & OT Functional Score

PT & OT Functional Score – Walking Items

PT & OT & Nursing Functional Score(non-walking items)

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Nursing Functional Score Items

ADDITIONAL INFORMATION

SECTION I & J

ACCURATE COMPLETION

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Accuracy Components

■ Assessor understands key diagnostic drivers of PDPM

■ Facility obtains what is needed from Hospital / transferring facility

■ Assessor understands where to find key diagnostic drivers in the clinical

record

■ Assessor understands coding definitions in section I & J

■ Assessor understands how to use CMS ICD-10 mapping

■ Assessor understands how to find the correct ICD-10 code utilizing CMS mapping and ICD-10 manual

■ There is a process for checking accuracy of codes

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Where to Find Diagnoses

■ H & P

■ ER records

■ Discharge Summaries

■ X-Ray reports

■ Surgical reports

■ Transfer records

■ Physician Progress Notes

Importance of Accurate ICD-10 Code

■ Billing issues can occur

■ PDPM focuses on resident characteristics and diagnosis

■ ICD 10 Code tells a story that must be at the highest level of

specificity

■ Over 40,000 ICD-10 Codes can be used for primary reason for

SNF stay

■ Over 1500 ICD-10 Codes can be used to report the presence

of medical conditions that typically require a higher-cost NTA

ICD-10 FORMAT

■ Codes are 3-7 characters

■ 1st character is alpha (all letters 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

■ See next slide

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ICD-10 FORMAT

What you need!

■ The CMS mapping

■ A ICD-10 manual

– Contains alphabetic index; tabular list; neoplasm table;

table of drugs and chemicals; external causes index

(not required in SNF setting)

■ Classes

■ Practice

FIVE STEPS TO ACCURATE ICD-

10 CODING

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STEP ONE

■ Search Alphabetical Index for a Diagnostic Term

■ Hint!

– Look for disease, sign, symptom

– Body site is a sub-term

– Examples: Congestive Heart Failure; Fracture left hip

(femur); Amputation of left lower leg

STEP TWO

■ DRILL DOWN! Take code from Alphabetical List and now

Check Tabular List

■ Always take the code from the Alphabetic Index and

follow through in the Tabular List

■ Begin by finding the first 3 characters of the identified

code in the Tabular list

■ There may be special instructions – see step 3

– Then proceed to finding the correct code from the

Tabular List

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STEP THREE

■ Read and follow the coding instructions is there are

instructions

– May send you elsewhere

– Punctuations, symbols and exclusions important here

– See also step 4

STEP FOUR

■ You may need to add a seventh character = A, D, or S

■ See step 5

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STEP FIVE

■ Always code to the highest degree of accuracy and

completeness

■ If there is a fourth, fifth, sixth or seventh digit available

you must use it.

■ Document the ICD-10 code on the MDS

■ Check accuracy prior to transmitting

Example – Left Hip Fracture

■ S72.0 Fracture of head and neck of Femur

– S72.00 Fracture of unspecified part of neck of femur

Fracture of hip NOS

Fracture of neck of femur NOS

S72.001 Fracture of unspecified part of neck of

right Femur


left Femur


unspecified Femur

FINAL CODE = S72.002D

SECTION J REVIEW

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SECTION J

REVIEW

INTERRUPTED STAY POLICIES

CMS is concerned there is an incentive to

discharge SNF patients and readmit them

due to the variable per diem adjustment –

therefore new interrupted stay policies are

being implemented.


■ If a patient is discharged from a SNF and readmitted to the same

SNF no more than 3 consecutive calendar days after discharge,

then the subsequent stay is considered a continuation stay:

– Assessment schedule continues from the point just prior to

discharge

– Variable per diem schedule continues from the point just prior to

discharge

■ If patient is discharged from SNF and readmitted more than 3

consecutive calendar days after discharge, or admitted to a

different SNF, then the subsequent stay is considered a new

stay:

– Assessment schedule and variable per diem schedule reset to day

1

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■ This policy applies not only in instances when a patient physically

leaves the facility, but in cases when the patient remains in the

facility but is discharged from Medicare Part A

– Example: If a patient in a SNF stay remains in the facility under a

Medicaid-covered stay and returns to skilled care within the

interruption window.

What could go wrong?

■ Care delivery not patient motivated or in accordance

with clinical needs

■ MDS inaccuracy will lead to incorrect payments

■ If you don’t staff for your case mix

■ Not optimizing resources effectively

■ Poor admission information from discharging hospital

■ Not understanding relevancy to the roles nursing,

therapy, social work, food / nutrition, activities, etc., play

■ Poor clinical documentation

Key Payment Implications

■ Patient characteristics, nursing and NTA services determine

payment

■ Therapy no longer drives payment

■ Only two assessments required

■ PT, OT and NTA payments taper throughout the stay

■ Payments can be adjusted using IPA but do not reset to day one for tapering purposes

■ Interrupted stays

■ Certain clinical conditions receive higher payment

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Resources

■ LeadingAge.org

■ OHCA.org

■ Joy Ramsby, M.Ed. 503-407-1488 - [email protected]

■ [email protected]

■ https://www.aanac.org/Information/Government-Source-Documents

■ https://www.cms.gov/medicare/medicare-fee-for-service-

payment/snfpps/pdpm.html

■ QRP Manual

– https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment

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mailto:[email protected]

mailto:[email protected]

https://www.aanac.org/Information/Government-Source-Documents

https://www.cms.gov/medicare/medicare-fee-for-service-payment/snfpps/pdpm.html

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment

Webinar 3 Sections o, p, q, CAA’s, PDPM

Documents

Transcript of Webinar 3 Sections o, p, q, CAA’s, PDPM