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What Therapists Need to Know About PDPM

PDPM replaces the RUG-IV system beginning 10/1/19. The methodology for determining payment shifts from resource usage (or amount of services provided) to patient characteristics. Currently, under RUG-IV, there are 3 components: Nursing, Therapy, and Non-Case Mix. PDPM is meant to be “Budget-Neutral” and breaks the per diem payment into 6 components: Nursing, Non-Therapy Ancillary, PT, OT, SLP, and Non-Case Mix. Each of the 6 components creates a per diem amount. The sum of all 6 components establishes the total per diem rate of reimbursement.

Calculation of Per Diem Rate

PT and OT are calculated by first determining the clinical category (based on the primary ICD-10 code entered on the MDS). Next, the functional score is determined based on Section GG coding on the 5-day assessment (functional areas used for scoring include: eating, oral hygiene, toilet hygiene, bed mobility items, transfer items, and walking items). These criteria result in a PT and an OT case-mix group which then correlates to a PT and an OT case-mix index. The CMI is then multiplied by the urban or rural federal rate per diem to establish the reimbursement rate for PT and OT. Additionally, a variable per diem adjustment is applied to both PT and OT after day 20. Beginning with day 21, a 2% reduction is applied every 7 days. Up to 25% of the total therapy provided is permitted to be in group or concurrent (25% per discipline).

SLP is calculated by first determining if the clinical category is acute neurologic or non-neurologic based on the ICD-10 diagnoses coded on the MDS. Other factors include whether there is a presence of cognitive impairment, any SLP co-morbidities, swallowing disorder, or an altered diet. These criteria result in a SLP case-mix group which correlates with a SLP case-mix index. The CMI is then multiplied by the urban or rural federal rate per diem to establish the reimbursement rate for SLP. There is no variable per diem adjustment applied to SLP. Up to 25% of therapy is permitted to be group or concurrent.

Nursing is calculated very similarly as to how it is calculated now under RUG-IV. Under PDPM, the 43 Nursing RUGs are collapsed into 25 classifications. Several Nursing RUGs are combined into 1 PDPM Nursing case-mix group. Additionally, the function score for nursing will use Section GG (instead of Section G). In contrast to the RUG-IV ADL scoring, the PDPM function score assigns higher points to higher levels of Independence. Additionally, an 18% increase in the nursing per diem will be applied for patients with HIV/AIDS as coded on the SNF claim. No variable per diem adjustment is applied to Nursing.

Non-Therapy Ancillary (NTA) is calculated by assigning points to specific patient conditions and services based on MDS coding and from data on the claim. The total number of points obtained results in a NTA case-mix group which correlates to a NTA case-mix index. The CMI is then multiplied by the urban or rural federal per diem rate to establish the reimbursement for NTA. A variable per diem adjustment of X 3 is applied to days 1-3, and beginning on day 4, the rate returns to the base NTA CMI with no further adjustment.

Non-Case Mix remains as currently calculated under RUG-IV.
The per diem amount for each component is summed for the total per diem rate.

Additional Elements to PDPM

MDS Assessments: PDPM requires only 5-Day and Discharge Assessments. The 5-Day Assessment drives reimbursement for the duration of the stay. SOT’s, COTS, and EOTS are eliminated. The new Discharge Assessment adds multiple therapy details as a means for CMS to monitor provider behavior changes (specifically reduction of therapy services) and to oversee the amount of group and/or concurrent therapy provided. CMS indicates that provider behavior changes and exceeding the 25% limit for group/concurrent may result in reviews, denial of coverage, and/or policy changes. An Interim Payment Assessment (IPA) is added as an optional assessment that providers may elect to perform if a patient’s condition changes to the extent that reimbursement would be modified.

Interrupted Stay: The interrupted stay rule applies when a patient discharges from the SNF, but returns to the same SNF within 3 days. When this occurs, the stay resumes using the original 5-Day assessment results. No new MDS is completed. The variable per diem adjustments do NOT re-set. If a patient returns after 3 days, a new MDS is completed and a new stay is initiated. If a patient admits to a different SNF, a new MDS is completed and a new stay is initiated. The discharge destination is not a factor for applying the interrupted stay rule.

General Projections of Impact

While PDPM is intended to be budget-neutral, providers may experience varying levels of reimbursement impact. Based on CMS provided data using FY 2017 claims, broad generalization may be applied with the following characteristics most likely to generate increased reimbursement levels: shorter length of stays, smaller facilities, non-profit organizations, rural facilities, higher nursing needs (Extensive Services), prevalence of conditions requiring expensive medications, and moderate-to-lower levels of therapy intensity. Specifically, providers with a large volume of Ultra High level of therapy will likely see a decrease in reimbursement under PDPM. Providers who have historically provided moderate therapy intensity while achieving excellent outcomes will be the winners under PDPM.

Provider Impact and Operational Success

Timely and accurate processes are critical to successful operation under PDPM. The 5-Day assessment determines the case-mix classifications (or reimbursement) for the entire stay. Providers need to provide extensive training for accurate ICD-10 coding as the clinical category is a primary factor for CMI for Nursing, PT, OT, SLP, and NTA.

Additionally, Section GG coding directly impacts the functional score element for the PT, OT and Nursing Case-Mix Groups. Comprehensive training and auditing to ensure accurate coding for these items will aid in capturing the precise functional statuses for calculation of the CMIs. With this fundamental change in methodology, SNFs need to collaborate closely with their software provider to confirm functionality and utilize all available tools. Additionally, partnering with your therapy provider to implement processes and practices for best outcomes will secure your position in the market.

The SNF VBP and QRP mandates continue under PDPM. Clinical programs that cater to the needs of the residents you serve will result in reduced hospital re-admissions, improved quality measures, and higher star ratings. Through detailed analysis of the provider-specific impact files published by CMS using FY 2017 claims, SNFs can identify areas for improvement, implement enhanced programs and processes to promote success under PDPM.

 

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Live Pain Free in 2019!

More people in America suffer from pain than diabetes, cancer and heart disease combined. When pain lasts for a long time (3 to 6 months or more), it is called chronic pain. The CDC recently released a report estimating that 50 million Americans, more than 20 percent of the adult population, have chronic pain.

Managing & Treating Your Pain

Chronic pain can have real effects on your day-to-day life and your overall health. Treating chronic pain can be difficult because it varies from person to person as well as many different causes and possible treatments. Developing the right treatment plan for your diagnosis is often the work of a multidisciplinary team of medical professionals. When consulting with your doctor, he may refer you to visit a physical and occupational therapist.

Physical Therapy (PT)
Physical therapy practitioners can assess your chronic pain, and based on your goals, will establish a therapy treatment plan fit for you. Treatment may include both passive and active treatments. Passive treatments help you to relax, while active treatments are therapeutic exercises that strengthen your body and help you deal with your pain.

Occupational Therapy (OT)
Occupational therapy practitioners understand that pain it subjective and complex. OT’s work individually with you to evaluate the pain’s impact on your desired activities and quality of life. They teach you skills and strategies to manage and cope with your pain.

Pain Reducing Technology
Therapists may use non-invasive technology such as Electrical Stimulation (e-stim) which blocks the pain signal to the affected area while reducing inflammation. Also, Ultrasound and a combination of heat and cooling therapies may be used to reduce pain.

If you or a loved one suffer with chronic pain, it is important to pay attention to your body. Be proactive to keep your pain under control. Consult with your doctor and ask if physical and occupational therapy can help you!

References: American Occupational Therapy Association

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PTJ:  Physical Therapy Continuity of Care Linked to Lower Rate of Surgery, Lower Costs

Article By:  PT in Motion, www.apta.org

Patients with low back pain (LBP) who see a single physical therapist (PT) throughout their episode of care may be less likely to receive surgery and may have lower downstream health care costs, researchers suggest in a study published in the December issue of PTJ (Physical Therapy). “Limiting the number of physical therapy providers during an episode of care might permit cost savings,” authors write. “Health care systems could find this opportunity appealing, as physical therapy provider continuity is a modifiable clinical practice pattern.”

Authors examined data from nearly 2,000 patients in Utah’s statewide All Payer Claims Database (APCD) to look for associations between continuity of care for LBP patients and utilization of related services such as advanced imaging, emergency department visits, epidural steroid injections, and lumbar spine surgery in the year after the first primary care visit for LBP. APTA members John Magel, PT, PhD; Anne Thackeray, PT; and Julie Fritz, PT, PhD, FAPTA, were among the authors of the study.

Patients were between the ages of 18 to 64 who saw a PT within 30 days of a primary care visit for LBP. Researchers excluded patients with certain nonmusculoskeletal conditions; neurological conditions, such as spinal cord injury, that could affect patient management; and “red flag” conditions such as bone deficit or cauda equina syndrome.

Researchers found that greater provider continuity significantly decreased the likelihood of receiving subsequent lumbar spine surgery, noting that “disparate management strategies across a variety of providers might inhibit or prolong the recovery in a patient with a worsening condition and contribute to the patient eventually receiving lumbar surgical intervention.” They also note that a strong therapeutic alliance is associated with improved outcomes.

Contrary to authors’ expectations, high provider continuity was not associated with decreased use of advanced imaging, steroid injections, or emergency department visits. “The timing of physical therapy for LBP might have a greater impact on these outcomes than does provider continuity,” they suggest. Researchers did find a link between use of these services and the presence of comorbidities, previous lumbar surgery, and use of prescription opioids or oral steroids.

The average cost of care in the year following the initial primary care visit was $1,826 per patient. Costs were slightly less, at $1,737, for the 90% of patients with high provider continuity but rose to $2,577 for patients with a lower level of provider continuity.

While the study’s findings do not identify any cause-and-effect relationships, “it seems reasonable that physical therapists should consider approaches to managing patients with LBP that limit provider discontinuity,” authors write.

Click here to continue reading this article.

 

 

Speak with your doctor to find out how therapy could benefit you!

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Thrive Successful Care Transitions

Thrive Successful Care Transitions

We provide a step-by-step implementation guide for successful addition to your care transitions strategy.

HTS is excited to introduce Thrive, a successful care transitions program designed for skilled care providers. Thrive was developed by a collaboration of HTS therapists, partner communities, nurse practitioners and physicians to create a robust, turn-key system to implement successful transitions of care. This program is perfect for post-discharge from skilled nursing back into the community, or to an senior living campus.

Core Objectives:

  • Follow Patient For Up To 90 Days Post-discharge
  • Utilize a Turn-key System For All Members of the Care Team
  • Provide Risk Stratification for Potentially Preventable SNF 30-day Readmissions
  • Reduce Hospital Readmissions with a Collective & Thorough Approach

Thrive is evidence-based and focused on empowering and equipping each member of the care team with the necessary tools to promote the best outcomes for each patient.

Elements of the Thrive Program:

  • Pre-discharge Patient Consultation Tool
  • Rehabilitation Successful Care Transitions Planner
  • Community Resources & Support Guide
  • Discharge IDT Family/Stakeholder Meeting Guide
  • Post-Discharge Communication Guide
  • Quarterly Analysis
  • Thrive Patient Outcomes Tracker

HTS will be rolling out Thrive to all partnering communities. Our proprietary clinical programs are just another way that we move our clients forward as leaders of rehabilitation in the markets they serve.

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CY2019 Physician Fee Schedule Final Rule

By: Cassie Murray, Chief Operating Officer I Chief Clinical Officer

The CMS Fact Sheet for the CY2019 Physician Fee Schedule Final Rule was released Thursday, November 1, 2018.

Note that CMS finalized the discontinuation of the Functional Status Reporting (G-Codes) for outpatient therapy services effective January 1, 2019.

Additionally, the payment reduction to 85% for outpatient therapy provided by PTAs and OTAs will go into effect January 1, 2022. CMS clarifies that the new modifiers for therapy provided by PTAs (CQ) and OTAs (CO) will be used alongside the current PT and OT modifiers (GP, GO, and GN). CMS explained that the new modifiers (and payment reduction) will apply when more than 10 percent of the service is furnished by the PTA or OTA. These new modifiers will be required on claims beginning January 1, 2020. The payment reduction will begin January 1, 2022.

For calendar year 2019, the KX modifier must be applied when therapy services reach $2,040.

Click here to read the CMS Fact Sheet.

 

 

Speak with your doctor to find out how therapy could benefit you!

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Peripheral Neuropathy – Managing Your Pain

Did You Know?

An estimated 30 million people in the U.S. suffer from some form of peripheral neuropathy.
Peripheral neuropathy (PN) is not a single disease. It’s a general term for a series of disorders that result from damage to the body’s peripheral nervous system. PN occurs when nerves are damaged or destroyed and can’t send messages from the brain and spinal cord to the muscles, skin and other parts of the body. PN often causes weakness, numbness and pain, usually in your hands and feet.

Can have no symptoms, but people may experience…

  • Burning, tingling or sharp pain in the back, face, foot, hands, or thigh
  • Muscle weakness and cramping
  • Sensation of pins and needles
  • Poor balance, slow reflexes

 

Tips for Self-Managing Your Pain:

  • Maintain a well-balanced diet
  • Avoid exposure to toxins
  • Exercise and stretch often
  • Take vitamin supplements
  • Buy shoes with shock absorbers and cushioned socks
  • Limit or avoid alcohol
  • Drink lots of water to improve circulation
  • Talk with your doctor about prescription drug options

 

How Can Therapy Help?

There are many options available for treating peripheral neuropathy. The most effective ones address the underlying cause. Most often, the focus of treatment is on symptom control. Some people are helped by physical, occupational and speech therapy.

OCCUPATIONAL THERAPY
Improve Motor Skills  |  Regain Sense of Independence  |  Enhance Recovery & Outcome  |  Prevent Secondary  |  Complications  |  Restore Confidence & Happiness

PHYSICAL THERAPY
Prevent Long-term Pain  |  Improve & Gain  |  Full Range of Motion  |  Increase Ability to Move & Perform Activities  |  Relieve Muscle Tension  |  Electrical Stimulation for Pain Management

SPEECH THERAPY
Prevent Loss of Facial  Muscle Control  |  Improve Swallowing & Speech Capabilities  |  Enhance Ability to Express Thoughts & Feelings  |  Relieve Emotional Tension Caused by Physical Issues or Mental Stress

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Indiana Medicaid Releases Proposed Rule for Overhaul of Medicaid Integrity Requirements

By: Christa Roberts, PT, MPT, RAC-CT and Eleisha Wilkes RN, RAC-CT

The details of proposed rule LSA #18-251 were published on October 4, 2018 by the Indiana Family and Social Services Administration, and introduces plans to revamp the Medicaid program integrity requirements. LSA #18-251 is extensive and impacts the bulk of business facets for Indiana Medicaid providers, including claims filing time limits, medical record retention, provider enrollment, sanctions, audits, and provider appeals.

LSA #18-251 consolidates existing rules, clarifies requirements and adds new program integrity requirements affecting Medicaid providers. Some of the more significant changes are as follows:

  • Currently, providers have up to one year from the date of service to submit an original claim; however, under the proposed rule, providers would have to submit claims for payment within 180 days of the date of service or the claim would be denied (effective January 1, 2019).
  • Providers will be subject to a medical record retention for financial records period of 3 years following submission to Indiana Medicaid (there is currently no record retention policy).
  • The proposed rule consolidates and adds new provider enrollment requirements.
  • Medicaid payment suspension procedures authorized by Federal law are outlined.
  • A new section is added regarding provider exclusions and readmissions (specifically, the rule lists various offenses that could result in an exclusion and sets a duration of up to 3 years for such exclusion).
  • A new section describes prepayment review processes and procedures (previously only available in agency manuals).
  • The proposed rule revises existing Medicaid overpayment provisions to align with changes in Indiana law (adds a 3-year look back period for audits initiated after July 2, 2019, though may be extended to 7 years under certain circumstances).
  • Administrative appeals procedures are consolidated and changed to align with Indiana law.

LSA #18-251 is open for public comment until the public hearing, which is preliminarily scheduled for October 26, 2018. A copy of the proposed rule can be reviewed at: www.in.gov/legislative/iac/20181003-IR-405180251PRA.xml.pdf

 

 

Speak with your doctor to find out how therapy could benefit you!

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Hospitals hit with fines over patient readmissions

Indiana hospitals are racking up millions of dollars in penalties for having too many patients return for care within a month of discharge.

Sixty-six Hoosier hospitals—including 17 in central Indiana—will see their Medicare payments docked next year by a total of about $12 million as a result of having patients readmitted within 30 days. That’s up from $9 million in penalties three years ago.

The federal government says readmissions are often unnecessary and cost taxpayers tens of billions of dollars a year for treatments that should have been caught the first time around, or were not followed up adequately.

So for the seventh consecutive year, it is using the pressure of lower reimbursements to get hospitals to improve their numbers.

Hospitals, for their part, say they are working with patients every way they can think of to keep readmissions at a minimum.

Many are sending patients home with a thick, detailed packet of discharge instructions and a month’s worth of medications. Hospitals send nurses and aides to discharged patients’ homes to see how they are doing. In some cases, patients are given vouchers for cabs or van shuttles to get to their primary care physicians for follow-up visits.

Still, the penalties keep climbing.

“It’s getting more difficult,” said Brian Tabor, president of the Indiana Hospital Association. “Hospitals have picked a lot of the low-hanging fruit in terms of strategies. And so the work gets harder and harder.”

Click here to continue reading this article.

Hospitals are going to be looking to post-acute providers now more than ever to step-up their game. This spring, HTS launched THRIVE a turn-key system to promote successful care transitions following a post-acute stay. Our proprietary clinical programs are just another way that we move our clients forward as leaders of rehabilitation in the markets they serve. Contact us today to learn how partnering with HTS can help improve outcomes and reduce readmissions.

 

October is National Physical Therapy Month!
National Physical Therapy Month is designed to recognize the impact that physical therapists and physical therapist assistants make in restoring and improving motion in people’s lives. Physical therapy may be necessary for those recovering after an illness, a fall, injury, surgery or chronic condition. Physical therapists work hard to help patients retain and regain their quality of life.

 

Speak with your doctor to find out how therapy could benefit you!

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Getting Around Safely Using a Cane or Walker

The use of a cane or walker has become the norm for most seniors today to help prevent falls. Ironically, these tools can be just as dangerous as they are helpful if they are not used properly. The CDC estimates nearly 50,000 seniors end up in the emergency room each year after falling while using a cane or walker. Health professionals are urging adults who use canes and walkers as walking aids to be properly assessed and fitted by a therapist to avoid fall-related injuries. Physical Therapists are trained professionals that are able to assess your individual needs to ensure that you are using the proper walking aid as well as make sure it is in proper working condition.

Tips for Using Canes & Walkers

  1. The walker or cane should be about the height of your wrists when your arms are at your sides.
  2. In order to be properly supported by a cane, you should be using it on the side of your body opposite from your injury or weakness.
  3. When using a walker, your arms should be slightly bent when holding on, but you shouldn’t have to bend forward at the waist to reach it.
  4. Periodically check the rubber tips at the bottom of the cane or walker. Be sure to replace them if they are uneven or worn.
  5. Wear flat shoes to provide a good base of support.

 

Therapy Can Help Reduce Falls & Improve Balance

Maintaining proper balance and sense of body position is critical to preventing falls. A Physical Therapist works with individuals to identify risk factors and designs an individualized program of exercises and activities with an emphasis on strength, flexibility, and proper gait. Occupational Therapists work with you to discuss changes and modifications that can be made around your home to help prevent falls from occurring. If you have concerns about your balance, ask your doctor if you could benefit from therapy.

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Collaborating for a successful transition to the new Medicare payment model

HTS is excited to collaborate with our partners for a successful transition to the new Medicare payment model. Our ongoing focus on clinical quality, patient-centered programs, and functional outcomes has prepared our staff in advance to succeed under PDPM. In addition to implementing proprietary clinical program efficacy analysis, HTS has assessed the financial impact of PDPM and is committed to supporting our partners through the challenges of adapting to the new reimbursement model.

HTS will be providing PDPM solutions that include:

  • Staff Education and Training in Critical Areas such as Section GG and ICD.10 Coding
  • PDPM Live Trainings for Partners and Staff in Multiple Locations
  • Internal System Transitions
  • RUGs IV to PDPM Facility-specific Impact Analysis

Our alliance with Proactive Medical Review, the PDPM experts currently providing education on this topic to 25 states, allows us to uniquely provide our partners with additional support for strategic planning, MDS coding efficacy, and nursing best practices.

Patient-Driven Payment Model (PDPM) training dates:

  • Friday, September 21 – Evansville, IN
  • Thursday, October 4 – Fort Wayne, IN
  • Thursday, October 11 – Louisville, KY
  • Tuesday, October 16 – Greenwood, IN
  • Tuesday, October 23 – Kokomo, IN
  • Friday, November 9 – Edmonton, KY
  • Thursday November 15—Phelps, KY

We remain optimistic considering the enormous changes we are facing with this new payment model. As partners in therapy, you can be confident in our resources and unmatched expertise to navigate this change while working together toward a successful transition.

If you have any questions at all about this information, please contact us directly.

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