Article by:  Sheena Mattingly, HTS Clinical Specialist

ST’s role is going to become exceedingly important under PDPM. This is due to the change in reimbursement which will be focused on patient characteristics rather than therapy minutes. Here are the top 5 things you need to know:

  1. Medical complexity & clinical outcomes are the basis for the new patient-driven payment model (PDPM). SLPs will play an important role in determining SNF payment which will require system optimization for timeliness in order to code the most accurate information.
  2. PDPM does not change coverage criteria for skilled care. SNF care is still only covered if all four of the following are met:
    1. SNF or skilled rehab services are required to be performed by or under the supervision of professional or technical personnel and is ordered by a physician for the condition which the patient received inpatient hospital services.
    2. Skilled services are required daily
    3. Daily skilled services can only be provided on an inpatient basis in a SNF
    4. Services delivered are consistent with the nature of the severity of the illness or injury, medical needs, and accepted standards of medical practice, and are reasonable in duration and quantity
  3. Understanding the components related to the payment model will help with adjustment to the new system. The need for ST is related to the presence of a swallowing disorder, a mechanically altered diet, a ST comorbidity related, and/or cognitive impairment. Combinations of these characteristics produce 12 ST case-mix groups. Our data analytics have observed a trend in need for optimization especially in section K of the MDS. For this reason, we have created tools and resources to help your SLP, dietician, and nursing staff code section K. Please contact us today for more information!
  4. Sections B, C, K, and I are crucial for accurate coding for the ST reimbursement component. Check out our 5 Day Assessment Tool to optimize IDT communication to improve your coding.
  5. CMS will monitor provider practice during PDPM implementation to audit changes in volume and intensity of therapy services, compliance with group & concurrent therapy limit, and coding practices.

Registration NOW OPEN!

We are committed to supporting our partners by offering exclusive PDPM webinar and live trainings in critical areas to foster success as we “Power through PDPM.” Not a partner? Contact us to learn how we’re providing even more value to our partners

 

Supercharge Your MDS:  6-Part Webinar Series

June 14 — Determining Clinical Category & Care Planning for the Complex Resident
June 19 — PDPM: SLP Component & Accurate Reporting of SLP Comorbidities
June 26 — PDPM: NTA Component & Comorbidities
July 10 — PDPM: Section GG & Functional Scoring
July 17 — PDPM: Best Practices for 5-day & IPA Data
July 24 — Transitioning to PDPM & Ensuring Billing Accuracy

New!

July 31 — Supportive Documentation for SNF Level of Care Under PDPM

Article by Cassie Murray, OTR, QCP, IASSC CYB, Chief Operating & Clinical Officer, Healthcare Therapy Services, Inc.

On Friday 4/19, CMS released the pre-publication of the FY 2020 Skilled Nursing Facility Prospective Payment System Proposed Rule. As expected, the Patient-Driven Payment Model is confirmed to go into effect October 1, 2019.
SNF Proposed Payment Updates for FY 2020:

  • Proposed SNF payment update is 2.5% (increase of $887 million from FY2019)
  • The proposed updated Base Rates for the PDPM Components (unadjusted federal per diem rates for urban and rural):

TABLE 3: FY 2020 Unadjusted Federal Rate Per Diem–URBAN

TABLE 4: FY 2020 Unadjusted Federal Rate Per Diem-RURAL

SNF Quality Reporting Program:

  • For FY 2022, CMS proposes the adoption of two process measures:
    • Transfer of Health Information to the Provider-Post-Acute Care.
    • Transfer of Health Information to the Patient-Post-Acute Care.
  • CMS proposes to update specifications for Discharge to the Community SNF QRP Measure to exclude baseline nursing facility residents from the measure.
  • CMS proposes to collect standardized patient assessment data using MDS for all patients regardless of payer source.

PDPM Changes:

  • CMS proposes to change the SNF group therapy definition to match the IRF group therapy definition. This would allow for qualified therapists or assistants to treat two to six patients in a group performing the same or similar activities.
  • CMS proposes that non-substantive updates to ICD-10 codes used in PDPM be made through the PDPM website. Substantive changes would continue to be made through traditional notice and rulemaking processes. Non-substantive updates are to maintain consistency with the most recent ICD-10 code set.
  • CMS proposes updates to the regulation text to coincide with the assessment changes under PDPM:
    • Initial patient assessment regulation would state: “assessment schedule must include performance of an initial patient assessment no later than the 8th day of post-hospital SNF care”.
  • The Optional Interim Payment Assessment would be included in the regulation.

Stakeholder comments will be accepted until June 18, 2019.

Click here to view the CMS Fact Sheet.

Click here to view the FY 2020 Proposed Rule Pre-publication.

  1. Master PDPM Methodology

    Master PDPM methodology and include all staff in job relevant PDPM subject matter trainings. Since we started PDPM training in September 2018, we have seen a trend of key departments who are being left out of the mix. This includes the Admissions teams, floor nurses, social services, medical directors, nurse practitioners, business office and medical records. Needless to say, PDPM will take the village.

    Trainings should Include an intermediate level of PDPM understanding.
    •  ICD-10 Coding
    •  GG Coding
    •  Quick Tip: Coding of the functional status in GG should be based on usual performance and should be determined by IDT collaboration.

     

  2. Ensure Documentation Confidence

    •  Ensure that your nurses are comfortable with the transition from section G to section GG for functional measure coding.
    •  
    Ensure that the nurses are comfortable with documenting their skill. Since nursing has its own component, they have to be able to “own” their nursing skill and document to justify their services.
    •  Ensure confidence in capturing all active diagnosis. This means that you will need to (or already have) rewritten your admissions procedures and utilize preadmission forms to capture NTA items. Our PDPM analysis across the board shows a great opportunity to improve coding to accurately reflect the conditions of our patients.

     

  3. Set-up for MDS Success

    Set MDS up for success. Evaluate the work flow for MDS and gain an accurate picture of job responsibilities. While there are fewer required MDS assessments under PDPM, the time not spent in assessments can be used to ensure accurate and timely coding under PDPM. Business office managers can begin conversations with managed care providers to ascertain any expected changes in reimbursement.

     

  4. Adapt & Modify Processes

    Adapt and modify your current processes to align with PDPM specific conditions and coding. In our pilot sites, HTS and our partners are adding PDPM processes to current operations to prepare and identify best practice prior to October 1st. This can be achieved alongside our current RUG system to give your team more confidence and reduce the “flipping of the PDPM switch” on midnight of September 30th.

    Examples include:
    Changes to your weekly Medicare meeting forms
    •  Changes to your admission processes Begin a 5-day assessment meeting for all Med A patients with each department contributing their PDPM-related information
    •  Establish the IDT approach to selecting the primary diagnosis prior to the skilled stay.
    •  Use the CMS Clinical Category Mapping “Return to Provider Codes” which will be rejected beginning October 1st

     

  5. Restorative Nursing

    Restorative nursing for your skilled patients may be a positive adjunct to therapy services under PDPM.

    Under PDPM, providing two restorative programs for the nursing groups Reduced Physical Function and Behavioral or Cognitive Symptoms will result in an increased nursing CMI.

     

  6. Talk with Your Docs 

    You have from now until October 1st to work with your hospitals and physicians to ensure efficient data collection for the 5-day MDS and optimal information for coding accuracy. This may include a review of how you obtain your data, what EHR is being used and if they are willing to build reports or have the ability to add reports to their standard transfer paperwork. It may be necessary to call a meeting about PDPM to your referral networks and educate doctors and hospitals on the importance of sending this key information. This includes: providing timely discharge summaries, operative reporting, ICD-10 codes, accurate active diagnosis and any specialty information.

     

  7. Know Your Software

    Whether you are using PCC, Matrix, Vision, etc. it is important to know what new functionalities will be available under PDPM.
    •  Know what current PDPM tools and reports are available for you to take utilize now.
    •  Get involved in any PDPM workgroups offered by the software provider to offer feedback and suggestions.
    •  Take advantage of any trainings, modules or alerts of new functions.

by Skilled Nursing News
Starting October 1, skilled nursing facility operators will have no choice but to become proficient with a specific type of medical coding that previously had no bearing on reimbursements — and leading industry voices say there are multiple paths to getting there.

ICD-10 codes, specific diagnosis identifications long used by hospitals, will play a key role in the new Patient-Driven Payment Model (PDPM), and facilities only have a few more months to get staffers up to speed.

Click here to continue reading this article.

Exclusive PDPM Training For HTS Partners

Generate Powerful ICD.10 Coding
We are committed to supporting our partners by offering exclusive PDPM webinar and live trainings in critical areas to foster success as we “Power through PDPM.”

These sessions will review ICD-10-CM coding conventions and official guidelines for coding/reporting to gain knowledge on appropriately assigning ICD-10 codes, a focus on the diagnosis codes that impact reimbursement under the Patient Driven Payment Model (PDPM). Please contact us to register. Not a partner? Contact us to learn how we’re providing even more value to our partners.

Tuesday, April 9 – Evansville
Wednesday, April 10 – Louisville
Wednesday, May 29 – Fort Wayne
Thursday, May 30 – Indianapolis

By: Cassie Murray, OTR, ,QCP, Chief Operating Officer

Site-Specific PDPM Impact

Individual PDPM Meetings with all partner sites: All HTS partner sites received education on PDPM along with their specific PDPM Impact Analysis.

Deep Dive into Data

HTS operations is diving deep into site-specific data in order to establish additional best practices and clinical pathways based on diagnosis category and functional level. HTS is conducting extensive data analysis by site to analyze the following key items: history, patient population, conditions, principle diagnosis, diagnostic category, functional level, the amount of time spent in therapy as well as their functional outcomes. This data gives sound strategic direction to process improvements and clinical positioning to foster success under PDPM.

Therapy GG Coding Analysis

All HTS therapists are certified in the CMS Care Tool, which is the standardized outcome for mobility and self-care. However, we are auditing our therapists’ GG coding to ensure continued confidence that our therapists are accurate and skilled in GG coding.

Current MDS Data Analysis

HTS is partnering with clients to upload actual 2018 MDS data and provide patient-specific analysis to identify opportunities, trends, education, and auditing needs to ensure accuracy incoding and optimize system processes. This information is valuable as we craft a PDPM strategic plan for each community we serve.

Powerful Partnerships

We have collaborated with the nursing and MDS experts from Proactive Medical Review to provide comprehensive training and resources for nursing and other nontherapy departments within the IDT. Together we are offering our Power Through PDPM exclusive training series of monthly trainings to focus on each key component of PDPM preparedness.

Last September through December, HTS provided introductory trainings via a series of PDPM 2-hour live trainings for partner communities and staff. The training covered PDPM fundamentals and methodology accompanied with an action plan for success. A facility specific PDPM impact analysis was completed as a baseline resource for operational readiness.

“I was privileged to be invited to a recent PDPM training in Edmonton conducted by HTS. The information that was provided at the training was focused and well presented. Although, I know there will be changes as the final rule develops in mid-2019, I felt that HTS had done an excellent job summarizing the proposed rule on PDPM and did a great job with the presentation.” – Terry Skaggs, CFO Wells Health System, Owensboro, KY

We would be happy to provide complimentary training. If you would like us to schedule time to meet with your acute care providers and physicians, contact us at info@htstherapy.com.

We are committed to supporting our partners by offering exclusive PDPM webinar and live trainings in critical areas to foster success as we “Power through PDPM.”

January:
PDPM Impact & Facility Action Plan

February:
Effective Systems & Section GG Coding

March:
Light up Your Admissions Process: Systems for Successful PDPM Transition

April-May:
Generate Powerful Coding—ICD.10 Live Trainings

June-July:
Supercharge Your MDS: 6-Part Series

Education on PDPM

HTS is actively scheduling PDPM education for hospitals and physicians to keep valued referral sources and community partners informed on the pending change and how it will affect them and their post-acute partners. More specifically, this education will emphasize how important it is to have accurate, thorough, and timely patient information prior to the admission. By utilizing tools such as CliniSign, which captures an electronic signature of the physician and EMR cross-communication, we are on track to engage all parties in the joint goal of successful implementation of PDPM.

“It’s important that we give our hospitals and physicians early education on PDPM so that they understand the significance of this new reimbursement model and how it will impact care delivery. This also keeps them apprised of any significant provider behavior changes that could negatively impact quality of care and potentially increase preventable hospital readmissions.” -Amanda Green, Executive Director of Strategic Development

We would be happy to provide complimentary training. If you would like us to schedule time to meet with your acute care providers and physicians, contact us at info@htstherapy.com.

By: Cassie Murray, OTR, ,QCP, Chief Operating Officer

It is no secret that PDPM will be a significant change for providers. HTS has successfully traversed reimbursement changes alongside our partners in the past and emerged strong. We were prepared to tackle the challenge while maintaining the highest quality of care. PDPM will be no different. HTS has a plan for success. When our partners succeed under the new SNF reimbursement methodology, we succeed. The core elements of the new model press us, as direct caregivers, to essentially return to our “roots” by focusing all care decisions based on patient conditions and needs.

Revenue will no longer be based on managing therapy minutes, but will be directly aligned with patient care delivery. HTS therapists are passionate about individualized clinical profiles and meeting the care needs associated with specific patient characteristics. This change in philosophy will assist in breaking down the unintentional silos built around departments and is an opportunity to promote collaboration with strategic clinical programs and processes. We understand that the PDPM transition is likely to put an extra level of stress on nursing and MDS—who will be under pressure to understand all of the intricacies of PDPM including coding and special rules such as the interrupted stay policy and variable per diem adjustment. The pressure is definitely on as the nursing role in reimbursement rises to the top of the pile. But not to worry, HTS’s partners will have access to exceptional resources and training opportunities as we navigate this change together.

We remain optimistic that quality care, remarkable customer service, and appropriate reimbursement will be achieved under the new model. As partners in therapy, our clients are confident in our resources and unmatched expertise to navigate this change while working together toward a successful transition from RUGs IV to PDPM.

We would be happy to provide complimentary training. If you would like us to schedule time to meet with your acute care providers and physicians, contact us at info@htstherapy.com.

 


 

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

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.