Blog by:  Shelly Maffia, MSN, MBA, RN, LNHA, QCP, CHC, CLNC, CPC-A, Director of Regulatory Services, Proactive Medical Review and Jessica Cairns, RN, RAC-CT, CMAC, Clinical Consultant, Proactive Medical Review

July 29th, 2021, the Skilled Nursing Facility (SNF) prospective payment system (PPS) final rule was released. The rule, which goes into effect October 1, 2021, contained several updates, including factors affecting the usual payment rates, changes to diagnosis code mapping under the Patient Driven Payment Model (PDPM), and updates to both the SNF Quality Reporting Program (QRP) and SNF Value-Based Purchasing (VBP) Program. In addition, there was discussion surrounding the much-debated future PDPM parity adjustment which considers how SNFs will pay back the estimated $1.7 Billion “overpayment” for the first year of PDPM. In this blog, we will take a look at some of the biggest takeaways affecting our business and how to prepare.

Medicare Part A Rates

The Federal Per Diem rates are updated annually and take effect every October 1st. The typical “raise” SNFs receive is over 2%. This October, CMS anticipates a 1.2% rate increase, which equates to approximately $411 million more in PPS reimbursement as compared to 2021. This is based on an unadjusted increase of 2.7% reduced by both a 0.08% forecast error and a 0.07% productivity adjustment. The unadjusted per diem components of the rates for FY 2022 are listed below for both urban and rural providers. Of these rates, 70.4% of each component is adjusted by the wage index, which varies for each core-based statistical area. Listed below are the unadjusted rates for October 1st, 2021.

Unadjusted Federal Rate Per Diem-Urban

Unadjusted Federal Rate Per Diem-Rural

To give you an idea of the daily rate changes [urban] from FY2021 to FY2022, the PT component will increase $0.78/day, OT component to $0.73/day, SLP to $0.29/day, Nursing to $1.35/day, NTA to $1.02/day and the Flat Rate $1.22/day.

Delayed PDPM Parity Adjustment

SNF’s can celebrate this small victory. The parity adjustment was the top concession that CMS made in response to feedback on the proposed rule. This proposed rule left us with the potential of $1.7 billion (5%) parity reduction as CMS data supported that PDPM was not budget neutral as it intended. Said differently, depending on the different component combinations, the rate could have been $10-48.00 per day lower. While we get a pass this year, the rate recalibration will be re-examined in the Proposed Rule for FY2023.

ICD-10-CM code mappings for PDPM classification

The final rule contained updates to the mapping of several diagnoses and where they are classified under the PDPM. Some of the conditions affected include the following:

The FY 2022 PDPM ICD-10 Mapping file is available at https://www.cms.gov/files/zip/fy-2022-pdpm-icd-10-mappings.zip

HIV Add-On

The add-on for HIV was renewed and remains unchanged from prior years, including a 12.8 percent increase to the nursing component and an additional add-on of 8 points to the non-therapy ancillary (NTA) component. This add-on is based on claims data containing a diagnosis code for HIV or AIDS (B20).

VBP Program

CMS is suppressing the use of SNF readmission measure data for purposes of scoring and payment adjustments in the FY 2022 SNF VBP Program Year as a result of the PHE. They will use the previously finalized performance period (4/1/2019-12/31/2019 and 7/01/2020-09/30/2020) and baseline period (FY 2019) to calculate each SNF’s RSRR for the SNFRM and assign all SNFs a performance score of zero in the FY 2022 SNF VBP Program Year, resulting in all SNFs receiving an identical performance score and incentive payment multiplier. SNFs will not be ranked for the FY 2022 SNF VBP program.

CMS will reduce each participating SNF’s adjusted Federal per diem rate for FY 2022 by 2 percentage points and award each participating SNF 60 percent of that 2 percent withholding, resulting in a 1.2 percent payback for the FY 2022 SNF VBP Program Year. Those SNFs subject to the Low-Volume Adjustment policy (fewer than 25 eligible stays during the performance period) would receive 100 percent of their 2 percent withhold.

For FY2024, the performance period will be FY 2022 and the baseline period will be FY2019.

Currently, the SNF VBP program only includes the readmission measure. CMS is considering adding additional measures in the future. The table below shows the additional measures under consideration, in addition to these measures, CMS is also considering adding a measure related to staff turnover.

(SOURCE: Federal Register)

Consolidated Billing

Effective with items and services furnished after 10/01/2021, CMS has established an additional category of excluded codes for certain blood clotting factors for the treatment of patients with hemophilia and other blood clotting disorders, which includes those identified by HCPCS codes J7170, J7175, J7177-J7183, J7185-J7190, J7192-J7195, J7198-J7203, J7205, and J7207-J7211. The latest list of excluded codes can be found on the SNF Consolidated Billing website at https://www.cms.gov/​Medicare/​Billing/​SNFConsolidatedBilling.

QRP

The SNF QRP currently has 13 measures for the FY 2022 SNF QRP:

  • MDS Assessment-Based
    • Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury
    • Application of Percent of Residents Experiencing One or More Fall with Major Injury (Long Stay) (NQF #0674)
    • Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631)
    • Application of IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients (NQF#2634)
    • Application of IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients (NQF#2636)
    • Application of IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients (NQF#2633)
    • Application of IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients (NQF#2635)
    • Drug Regimen Review Conducted with Follow-Up for Identified Issues- Post Acute Care (PAC) Skilled Nursing Facility (SNF) Quality Reporting Program (QRP)
    • Transfer of Health Information to the Provider Post-Acute Care
    • Transfer of Health Information to the Patient Post-Acute Care
  • Claims-Based
    • Medicare Spending Per Beneficiary (MSPB) – PAC SNF QRP
    • Discharge to Community – PAC SNF QRP (NQF #3481)
    • Potentially Preventable 30-day Post-Discharge Readmission Measure for SNF QRP

CMS will adopt two new SNF QRP measures beginning with the FY 2023 SNF QRP:

  • SNF Healthcare-Associated Infections Requiring Hospitalization measure –
    • Will use FY 2019 claims data to calculate this measure for the FY 2023 QRP.
    • This measure will be publicly reported beginning with the April 2022 Care Compare refresh.
  • COVID-19 Vaccination Coverage among Healthcare Personnel measure –
    • Will use data submitted to NHSN by SNFs to calculate this measure with an initial data submission period from 10/1/2021-12/31/2021.
    • Starting in CY 2022, SNFs will be required to submit data for the entire calendar year beginning with the FY2024 SNF QRP.
    • This measure will be publicly reported beginning with the October 2022 Care Compare refresh or as soon as technically feasible using data collected for Q4 2021 and the most recent quarter of data will be reported during each advancing Care Compare refresh.

In addition, CMS is also updating the denominator for the Transfer of Health Information to the Patient PAC measure to exclude residents discharged home under the care of home health or hospice service.

How to Prepare

Make plans to share this information and assess the impact on your facility over the next two months in preparation for the October 1 effective date.

Quick list of action items:

  • Review the rate changes including modifications to VBP adjustments, to determine the financial impact they will have on your organization
  • Incorporate updated rates into your budget and plan accordingly
  • Ensure the billing office is up to date on the current components that affect Medicare rates. This includes ensuring updates to billing software.
  • Discuss the changes in the ICD-10 mapping with the appropriate staff and include the new consolidated billing exclusions related to blood-clotting factors in that conversation.
  • Provide education to clinical staff on changes to VBP and QRP and verify you have processes in place to report all required information.
  • Ensure the infection control nurse has a process in place to report required vaccine information to the CDC.
  • Continue to monitor facility readmission rates and ensure a process is in place to mitigate unnecessary rehospitalizations.

References

 

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About Proactive Medical Review
HTS partners with Proactive Medical Review, a third party company who specializes in ensuring compliance with regulatory standards and promoting measurable care excellence. The team includes SNF experienced nurse, MDS, Health Facility Administrator, therapist and reimbursement specialists with experience serving in multi-site contract therapy operations, as corporate directors of quality, clinical program specialists, and Compliance Officers. Proactive is uniquely positioned to assist in managing the many changes and challenges facing providers partnered with HTS. Learn more about our commitment to compliance here.

Looking back from 2020, the start of this New Year has been more reflective than most. As an organization, fully “seeing 20/20” in 2021 has been made possible by the clarity gained through the experiences and challenges we all faced last year. In 2020, we relied more on our clinical knowledge than ever before to develop creative solutions for staffing, in-room treatments and utilizing tele technology–all while emphasizing the patient-centered delivery model. Although it is likely that 2021 will bring similar challenges as those from last year, as an industry we know what we are capable of accomplishing. We are also now better equipped to overcome COVID-19 related obstacles with the use of exponentially expanded partner and therapist toolkits, policies, and procedures.

We at HTS have identified the top 5 therapy clinical outcome focus areas for 2021 to improve processes and clinical delivery across the IDT.

 

This month’s clinical focus area is:

Workflow Process Improvement

Optimizing processes for workflow improvement allows organizations to work smarter and more efficiently. This can be as simple as reducing redundant information sharing to using static agendas and communication tools.

HTS supports our valued partners with a “best practice” workflow system analysis. Our HTS management team is uniquely positioned to facilitate workflow processes to allow more efficient identification for educational and training opportunities. These action items are then used to drive process improvement with the facility’s interdisciplinary team.

Check out the top 3 ways your building can enhance processes for maximum efficiency and coding accuracy. Use of these HTS tools and resources are available exclusively for HTS partners.

1.  Use of the HTS Preadmission Screening Tool

The HTS PDPM Pre-Admission Evaluation Tool is a 3-page screening document that assists care coordinators in capturing clinically indicated patient characteristics to attain a projected PDPM clinical category and per diem rate (available via a rate estimator). This is a great guiding tool for admissions and clinical liaisons to use while gathering information from the hospital record. This tool also assures accuracy with coding. Our interdisciplinary teams have found this tool to be especially useful when capturing NTA comorbidities and CMG classification.

2.  Formalized Meeting Guides

PDPM implementation required system adaptation and modification for success. The PDPM Initial Medicare Assessment Meeting Tool is highly recommended to bring the team together for a guided, patient-specific clinical discussion. Suggested medical record items for interdisciplinary meeting discussion are recommended and a template for documentation of communicated action items is also provided.

Buildings that have implemented use of this specific tool have observed a marked improvement in the quality of communication. Additionally, they specifically saw an increase in timeliness when querying the physician and an improved ability to capture NTA comorbidities. Providing a standardized and formalized platform to determine usual performance for Section GG has also streamlined consistency across the record. Our partners agree this is definitely a “must have” for PDPM meetings.

We also recommend use of a weekly Medicare Meeting Form to provide a more structured, formal discussion of patient specific clinical complexities. The HTS Medicare Meeting Form which was revised in 2020 paired with use of the Medicare Meeting Discussion Guide ensures all attendees are present, timely, and prepared to stimulate discussion with the team.

3.  Optimization of IDT Communication to Achieve Consistency Across the Medical Record

“Consistency across the record” is one big component all providers strive to achieve. This consistency is primarily accomplished by effective interdisciplinary communication. MDS coding lacking supportive documentation puts a claim at risk for medical review, which could negatively impact reimbursement.

Rate setting, captured by coding on the MDS, involves a team approach to integrate systems in order to achieve reimbursement appropriate for the patient’s clinical complexities. For example, Section GG requires multiple disciplines between days 1-3 to determine the usual functional performance. Simply attaining function scores from one discipline, such as only nursing or only therapy, puts the claim at risk for medical review. Furthermore, coding that is not supported by documentation within the chart is another risk factor for medical review.

Since Section GG contributes to 3 of the 5 components of the PDPM rate, effective GG function score procedures are imperative for success under PDPM. Some great solutions are available within the Section GG Workflow Resources section of our PartnerHQ portal. Tools such as the Function Score Quick Tips are also available to optimize processes in your building to minimize medical review risk and achieve consistency across the medical record.

Need a Powerful Therapy Partner? Contact Amanda Green, Executive Director of Strategic Development amanda@htstherapy.com for information about our contract therapy partnerships.

HTS has identified the top 5 therapy clinical outcome focus areas for 2021 based on our experiences from 2020 which makes us better equipped to overcome COVID-19 related obstacles. Furthermore, after attending a 15-hour training and certification process, HTS management staff have all become “PDPM Masters.” These additional “feathers in our cap” allow us to uniquely champion process improvement initiatives alongside your interdisciplinary team. As HTS continues to identify opportunities for clinical growth, a key process improvement area will be discussed each month.

 

This month’s clinical outcome focus area is:

Medicaid CMI

HTS has made it our goal to partner with our clients in every facet of the skilled nursing facility – not just within the walls of the therapy gym. Through business review meetings and discussions with HTS therapists and regional directors, we have become aware of the need for a more detailed look at Medicaid CMI. The HTS team immediately went to work to create a deep-dive analysis program. Now, HTS management is able to apply operational, clinical, and strategic insight to provide solutions to help our clients efficiently assign a dollar value to the treatment of Medicaid patients that is consistent with medical needs. HTS is here to serve you as a facilitator of opportunity and process improvement initiatives through a Medicaid CMI Deep-Dive. Medicaid CMI success is achieved through a three-pronged approach:

Medicaid CMI Deep-Dive Services currently available to HTS Clients

HTS management completes report interpretation at the site level by analyzing data provided within the Time-Weighted CMI Resident Roster Report. A summary of potential vulnerabilities and opportunity areas are identified and reported to the interdisciplinary team. Opportunities are then discussed and assigned to a process improvement champion. Timeframes are designated to keep the team on track with system development. CMI information is then tracked on a quarterly basis to show benchmarking and trends. This value-add service comes with a standard rate of $500. However, for HTS clients, this proprietary deep-dive is offered as a complimentary service.

See below for additional step-by-step details of the deep-dive process:

  1. The Time-Weighted CMI Resident Roster Report for the last 4 quarters are requested.
  2. Reports are interpreted and analyzed by the HTS Management Team
  3. A site-specific, customized presentation of Medicaid CMI data analysis is provided. Opportunities for Medicaid CMI improvement are identified and discussed.
  4. Medicaid CMI data tracking continues as reports are received.
  5. HTS Regional Directors are your “boots on the ground” to facilitate process improvement initiatives.

Need a Powerful Therapy Partner? Contact Amanda Green, Executive Director of Strategic Development amanda@htstherapy.com for information about our contract therapy partnerships.

HTS has identified the top 5 therapy clinical outcome focus areas for 2021 based on our experiences from 2020 which makes us better equipped to overcome COVID-19 related obstacles. Furthermore, after attending a 15-hour training and certification process, HTS management staff have all become “PDPM Masters.” These additional “feathers in our cap” allow us to uniquely champion process improvement initiatives alongside your interdisciplinary team. As HTS continues to identify opportunities for clinical growth, a key process improvement area will be discussed each month.

 

This month’s clinical outcome focus area is:

PDPM Case Mix

“It’s not enough to be providing excellent patient care anymore. Under PDPM, if you don’t code correctly on the MDS, you’re not going to get credit for it.” – Sheena Mattingly M.S., CCC-SLP, RAC-CT, HTS Director of Clinical Outcomes.

HTS has identified 5 areas of opportunity to improve PDPM Case Mix. Let’s take a deeper-dive by discussing the 5 areas of attack to optimize PDPM case mix classification coding.

1.  Assure good communication and collaboration of the function score (Section GG) which drives the nursing, and PT/OT CMG classification.

At this point we are all aware of Section GG’s impact on Medicare reimbursement under PDPM, but odds are we still need some fine tuning. Review current processes for attaining Section GG coding to assure IDT collaboration of usual performance is documented and available within the medical record. Section GG is of utmost importance not only for PDPM reimbursement but also for Quality Measures, SNF QRP, and 5-Star Rating.

2.  Review your facility’s process for querying the physician to capture any coding opportunities. HTS recommends use of our Initial Medicare Meeting Tool.

Imagine this all too familiar scenario, the speech-language pathologist (SLP) in your building identifies a newly admitted patient has aphasia. This SLP then brings this information to the Initial Medicare Meeting and presents her findings. The IDT agrees and proceeds to query the physician for a diagnosis so that the aphasia is considered active within the 7-day lookback period and can be coded in section I4300 of the MDS. This example of excellent communication results in a more accurately coded MDS that is reflective of the patient’s clinical needs. More specifically, the coding opportunity identified is counted as a SLP-Related Condition in the SLP PDPM “bucket” which is directly tied to PDPM reimbursement.

3.  Use the HTS IMA SLP Component Communication Tool.

This tool is to be assigned to be completed by a SLP or an OT. It is designed to be used to identify potential coding opportunities from the SLP’s or OT’s skilled perspective. The opportunity can then be presented to the IDT for discussion. Prior to PDPM, components such as Section K of the MDS or coding of a mechanically altered diet did not correlate to a rate setting. Now, we do get “credit” for these types of clinically indicated coding opportunities which means communication is key.

4.  Use the HTS Nursing Case-Mix Classification Quick Tip Handouts which is available to HTS Partners on the PartnerHQ Web Portal.

Each nursing component Quick Tip Handout is paired with a HTS High Impact Webinar available on demand on the PartnerHQ Web Portal. For example, when reviewing the Special Care High Quick Tip Handout, you will see that a commonly overlooked classification item may be a patient with COPD. If this patient has shortness of breath while lying flat and this is documented within the medical record, this patient would classify as Special Care High versus Physical Functioning. There are several Quick Tip Handouts. They are a one-page resource that aide in familiarizing yourself with the details of the components for each nursing classification.

5.  Rely on the HTS therapy department for key performance indicator data analysis.

HTS Therapy Rehab Managers use a PDPM Analytic Business Intelligence Dashboard which is powered through Net Health Therapy (formally known as Optima). This report is pulled on a weekly basis to identify areas of opportunity. An action plan is then discussed with the therapy team and the HTS Regional Director is also consulted to drive process improvement. Key performance indicators analyzed include but are not limited to:

  • PDPM Covered Day Count and Patient Count
  • Case Mix Group Distribution
  • Treatment Minutes per Visit
  • PT/OT/ST B Units per Visit
  • Section GG Outcome Data

Need a Powerful Therapy Partner? Contact Amanda Green, Executive Director of Strategic Development amanda@htstherapy.com for information about our contract therapy partnerships.

Blog by: Stacy Baker, OTR/L, RAC-CT, CHC, Proactive Medical Review

Following a year of little to no medical review and extensive government spending, most experts forecast reimbursement compliance audits ramping up in 2021. Multiple areas are ripe for potential scrutiny, including, but not limited to PDPM coding and supportive documentation, the proper use of SNF waivers, and appropriate access to and accounting for Provider Relief Funds. Get the facts and ensure readiness with these insights into the current audit environment and the medical review entities that may rain on providers in the months ahead. CMS suspended audits between March 30 and August 3 of 2020 in order to reduce provider strain during the COVID-19 pandemic. This year, however, audits are resuming in full swing.

  • Under the new Biden administration, many industry leaders and healthcare attorneys predict an uptick in audits and healthcare prosecutions with “both government initiated litigation and qui tam suits…set for continued growth in 2021” according to Georgia Ravitz et. al (i) With Xavier Becerra, a former prosecutor, appointed secretary of HHS, the government is poised to advance fraud prevention efforts.
  • False Claims Act (FCA) recoveries in FY2020 were $2.2 billion, down from $3.1 billion in 2019 and lower than any year since 2008 at a time when spending has escalated throughout the pandemic. Healthcare made up 85% of FCA recoveries in 2020 and that trend is likely to continue through both standard channels and a focus on new risk areas such as telehealth billing fraud. ii
  • Recovery Audit Contractors are now authorized to review for Medical Necessity and Documentation Requirements specific to the Patient Driven Payment Model (PDPM), and the OIG has added new focus to the Work Plan to identify program integrity risks associated with Medicare telehealth services during the pandemic.

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About Proactive Medical Review
HTS partners with Proactive Medical Review, a third party company who specializes in ensuring compliance with regulatory standards and promoting measurable care excellence. The team includes SNF experienced nurse, MDS, Health Facility Administrator, therapist and reimbursement specialists with experience serving in multi-site contract therapy operations, as corporate directors of quality, clinical program specialists, and Compliance Officers. Proactive is uniquely positioned to assist in managing the many changes and challenges facing providers partnered with HTS. Learn more about our commitment to compliance here.

On April 8, 2021, CMS released the new Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Proposed Rule which, once finalized, is effective October 1, 2021. This proposed rule updates Medicare payment policies for facilities under SNF PPS for fiscal year 2022. The proposed rule also includes information for the SNF Quality Reporting Program (QRP) and SNF Value-Based Program (VBP) for FY 2022.

See below for the most significant areas of updates:

  1. FY 2022 updates to the SNF payment rates
  2. Methodology for recalibrating the PDPM parity adjustment
  3. Rebase and revision of the SNF market basket to improve payment accuracy under the SNF PPS
  4. New Blood Clotting Factor Exclusion from SNF Consolidating Billing
  5. Changes in PDPM ICD-10 Code Mappings – The ICD-10 code mappings and lists used under PDPM are available on the PDPM Website at: https://www.cms.gov/Medicare/MedicareFee-for-Service-Payment/SNFPPS/PDPM
  6. SNF QRP update – modification to the public reporting SNF quality measures
  7. SNF VBP Program proposal to suppress the SNF readmission measure

For more information on this proposed rule, please visit the Federal Register’s Public Inspection Desk under “Special Filings,” at http://www.federalregister.gov/inspection.aspx.

 

By: Sheena Mattingly, Director of Clinical Outcomes

In case you are in need of a recap, let’s start from the beginning. PDPM came into our lives on October 1, 2019. IDT processes and collaborative effort toward patient-centered care became even more imperative. Therapy remained a necessity in the recovery process under the methodology. The Centers for Medicare & Medicaid Services made it clear as mud that they will be looking at provision of services and outcomes. Presumably, medical review will surround any substantial changes in these areas. Let us also not forget that outcomes are publicly reported and impact quality measures, QRP, VBP, five-star, and so much more. Now that you are all caught up, let’s get to the good stuff!

HTS has shown improved Section GG outcomes when FY2019 is compared to the first six months post PDPM implementation.

So, what does this mean? If outcomes are equal to or above historic values, there is less risk for medical review and it means patient care and delivery is not compromised under PDPM. Also, improved outcomes provide further evidence of the great care HTS therapists deliver…even during a Public Health Emergency!

The proof is in the GG but in case you want more, check out the list below to see just a few more accomplishments from the past couple months:

  • Outpatient clinics are back up and running at almost full capacity!
  • Therapists are now equipped to use two new delivery service modes: telecommunication technology and telehealth.
  • Procedures such as cleaning, disinfecting, and sanitizing have been successfully implemented company-wide in order to mitigate risk of exposure to COVID-19.
  • Therapists have utilized a new Treatment Hierarchy Guide provided by HTS to help prioritize the treatment visits and provide services in a sequential manner according to priority level to further mitigate risk of exposure.
  • The Breathe Program introduced in April has improved pulmonary intervention for patients.
  • Therapists have demonstrated commitment to best practice by accommodating new regulation and compliance standards due to the public health emergency with quick turnaround time! This has allowed HTS to continue to provide services to patients in need during uncertain times.

The Bottom Line… HTS therapists have been rocking it out even harder than ever before and for that we thank you!

SNF PEPPER summarizes data statistics which are obtained from paid SNF Medicare UB-04 Claims for SNF episodes of care that end in the most recent three federal fiscal years (the federal fiscal year spans October 1-September 30). The current version of PEPPER now available reviews episodes of care through quarter 4 of FY2019 including statistics for 2017, 2018, and 2019. SNFs are compared to other SNFS in three comparison groups: nation, MAC, and state. These comparisons enable a SNF to determine if their results differ from other SNFs and whether it is an outlier and/or at risk for improper payments.

Target Area Updates

The following RUGs focused target areas will be phased out for FY2020 as a result of PDPM: Therapy RUGS with High ADL, Nontherapy RUGs with High ADL, Change of Therapy Assessment, & Ultrahigh Therapy RUGS. These target areas are included in the current FY2019 report along with the target areas: 20-day episodes of care, 90+ day episodes of care, and a new target area: 3-5 day readmissions which reviews readmissions to the SNF following a 3-5 calendar day gap. Please note this target area will not reflect claims until FY2020 and is intended to give providers information on readmission practices before and after PDPM implementation in order to assess the level to which facilities “may attempt to circumvent interrupted stay rules.”

Please click here for a table of target area definitions and suggestions.

Accurate coding for the SLP Component under the PDPM reimbursement methodology has been an area of opportunity across the industry. HTS has uniquely positioned itself with a team of seasoned therapists and nurses to analyze data and trends to optimize systems and processes to assure a smooth transition into PDPM. Now that we have three months of PDPM under our belt, here is what we have learned:

  • A tool to communicate SLP evaluation findings to the IDT will streamline the process and optimize IDT collaboration. Our MDS coordinators have enough on their plates. Let’s make it as easy as possible to present them with information so they can make the best coding decisions. HTS has created a tool for this, “HTS IMA SLP Component Communication Tool.” This tool is completed by the SLP and/or OT to provide information regarding sections B, C, I, and K related to the SLP therapy PDPM component. The tool is also equipped with a coding reference to assure that therapists are familiar with the RAI language and coding instructions.
  • Best practices when administering the BIMS is an area of opportunity. HTS recommends reviewing interview guidelines from the RAI, coding tips, and BIMS basics. Use HTS’ “Cognitive Assessment Quick Reference” for a guide to optimize practices in these areas. Also, remember the BIMS is a brief test and is not sensitive enough to capture some cognitive deficits such as executive functioning impairments. Even if a patient is “cognitively intact” (BIMS score of 13, 14, or 15), they still may benefit for cognitive-communicative therapy. The SLP will have formal testing to identify these areas of deficit and create short term goals associated with these areas.
  • If a patient scores in the SA case mix group indicating there are no items coded for the SLP component, the patient can still qualify and benefit from therapy. As mentioned in #2, the formal testing selections by a SLP will be more sensitive to cognitive impairment and therefore capture deficits more brief tests will not. However, if a patient is coded as “SA” and would benefit from speech-language therapy, HTS recommends going over the patient record to assure coding accurately reflects the patient’s medical complexities. Often times aphasia in section I4300 of the MDS may be a coding opportunity but also may require querying the physician. Additionally, section K coding best practices could also result in a more accurate SLP case-mix group.
  • Section K coding and optimization requires IDT collaboration. 2017 CMS data analytics revealed that section K coding was also an area of opportunity. In the past many have relied solely on the dietary department for section K coding. We’ve learned the SLP observations are also an important factor when coding section K accurately. For this reason, HTS created a “Quick Reference Optimize Coding in Section K” and “RAI Instructions for Completion of Section K.” Additionally, a webinar is available on the partner portal, “PDPM: SLP Component and Accurate Reporting of SLP Comorbidities.”

As we continue to navigate new waters under the PDPM methodology, we have adapted and modified our systems and processes to assure patient-centered care is at the forefront and best practices are in place. Accurate SLP component coding allows us the opportunity to more accurately depict the patient’s medical status and individualized needs. HTS will continue to provide the resources and tools to achieve IDT collaboration for the best patient outcomes possible so together we can drive quality improvement.


Written By: Sheena Mattingly, M.S., CCC-SLP, RAC-CT, Director of Clinical Outcomes

Article by James M. Berklan, www.mcknights.com

Journalists are supposed to be “words” men and women, but to be honest, I love a good set of numbers as much as anything. Especially when they’re tied to a pertinent analysis.

That’s why I find this period of transition with the Patient Driven Payment Model intoxicating. There’s mystery (Will providers fare well under the drastic overhaul?), cunning (How might providers get the best bang for their buck?) and suspense (What will regulators yank back if they don’t like what they’re seeing?).

And numbers. Lots and lots of numbers.

Wednesday I got a chance to talk initial PDPM numbers with three of the biggest LTC numbers crunchers around, Marc Zimmet, Vince Fedele and Steven Littlehale. We talked about Zimmet Healthcare Services Group’s initial PDPM reimbursement analysis of October Medicare claims.

The overall impression coming out of it? You’re going to be alright, providers. Just as many had predicted, those who did their homework — and vow to keep getting better — should be just fine.

In fact, as colleague Danielle Brown writes in today’s top Daily Update news item, many providers who paid attention in their PDPM educational classes are making, on average, more than $50 more per patient day then they would have under the old RUGs-IV system. When adjusted for one-time exceptions, it’s about half that, but it’s still a big positive. In addition, Zimmet estimates that providers can gain another $40 per patient day more once they get better at coding and, well, simply remembering to claim what they have coming.

While OT and PT therapy pay rates won’t necessarily budge much, better can be had in speech language therapy, nursing and non-therapy ancillary services, Zimmet explained.

A big caveat here: The analysts were clear that theirs was not a random sample and should not be taken as an ironclad predictive argument. The sample included a lot of East Coast clients, and they tended to be on the larger size, but it was still significant and close to what others should be finding.

The biggest worry isn’t so much what PDPM will do to providers’ bottom lines, but, much as I predicted a few weeks ago after talking to a long time marketplace exec: What the Centers for Medicare & Medicaid Services will do to the flow of cash when it eventually recalibrates pay rates. Because we can assume with these kinds of cheery numbers Uncle Sam will want to get back what he feels is rightly his.

Zimmet predicted with “95% confidence” that a rate readjustment will be coming, eventually. Providers will know in “less than a quarter” how finances will shake out, but CMS will likely take about six months before it makes any pronouncements about rate readjustments.

Make no mistake: This is good. It means you’re not getting riffed right now, wondering how to make ends meet. The CMS policy is not going to be budget neutral — but in a good way.

And the best thing of all is, you can do even better at it once you get better at coding and stop leaving money on the table.

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