Posts

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.

 

As anticipated, the change to the Patient-Driven Payment Model (PDPM) was finalized to go into effect October 1, 2019 (FY 2020). CMS noted that this allows providers one year to prepare for this fundamental change from the RUG-IV case-mix model to the new PDPM methodology which is based on patient condition and care needs. Preparations will involve staff education and training, internal system transitions, software development, and impact analysis. The final version of PDPM is largely the same as proposed earlier this year.

Additionally, the rule finalizes the 2.4% market basket increase for SNFs as required by the Bipartisan Budget Act of 2018 which will result in an overall increase in Medicare payments to SNFs of $820 million (effective 10/1/18). There were no new measures adopted for the SNF Quality Reporting Program (SNF QRP); however, CMS is including an added factor to consider for removal of measures for the SNF QRP.

CMS will publicly display the four assessment-based quality measures and increase the number of years of data used to display the two claims-based SNF QRP measures from one year to two years (Discharge to the Community and Medicare Spending Per Beneficiary). The SNF Value-Based Purchasing Program using the one claims-based measure (all cause 30-day hospital readmission measure) continues with updates to policies and an adjustment to the scoring methodology and an Extraordinary Circumstances Exception (ECE) policy.


Links for CMS details:

FY 2019 SNF PPS Final Rule Fact Sheet:
www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-07-31-3.html

FY 2019 Final Rule (pre-publication copy):
https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-16570.pdf


This fall HTS will offer extensive education and training for our therapy staff and our partners in multiple locations to prepare for PDPM. Look for upcoming details.

HTS is feeling optimistic as we read the latest reimbursement model change proposed by CMS and released late afternoon on Friday, April 27th. If you haven’t had the chance to dive into RSC-1, this was gearing up to be the biggest reimbursement overhaul since PPS.

The RSC-1 has now been modified and renamed to the Patient-Driven Payment Model (PDPM). The new model is designed to improve the incentives to treat the needs of the whole patient, instead of focusing on the volume of services the patient receives. CMS noted that RCS-1 received considerable feedback expressing concerns with the complexity of RCS-1. As a result, CMS has made significant changes that we are feeling pretty good about. If passed, this would take place starting October 1, 2019 — which means we don’t have much time before it becomes reality.

 

Here are 7 things we know up front about the PDPM changes to note:

  1. PDPM will be Much Less Complex than RSC-1
    Under the RSC-1, there were actually over 130,000 different possible classifications. The PDPM reduces this by nearly 80%. RUGs will certainly be going away, but this may make the reimbursement calculations much less of headache for all parties involved.
  2. Therapy is Detailed in the Discharge PPS Assessment
    A proposed modified section O requires PT, OT and ST details on all PPS discharge assessments for all Medicare A discharges (including those who DC from the facility). Therapy details include: start and end dates, total individual minutes provided, total concurrent minutes provided, total group minutes provided, and total days provided. This may be CMS’s way of safeguarding against underproviding and ensuring that patients receive what they need versus greatly reducing or eliminating necessary therapy services.
  3. PT & OT are Separate Payment Categories
    Under the RSC-1 model, PT and OT were a combined payment and ST was considered separate. Noting the obvious concerns, we are happy that each discipline will receive their own payment classification. Additionally, the new model eliminates the cognitive impairment factor from the PT and OT classification.
  4. Group & Concurrent Allow for a Total of 25%
     Under RSC-1, it was proposed to allow 25% group therapy and 25% concurrent therapy. Under the PDPM, there is a 25% group and concurrent therapy combined allotment.
  5. Section GG is Even MORE Important
     Replacing section G with GG for the functional component is required for PT & OT payment classifications, as well as,nursing case-mix classification. 6 areas are scored and totaled for the functional measure: eating, oral hygiene, toileting, sit-to-lying, lying-to-sitting on bed, sit-to-stand, chair/bed-to-chair, toilet transfer, walk 50 feet with 2 turns, and walk 150 feet. HTS implemented mandatory use of the CARE Tool for all therapists in 2014 to ensure that our outcomes and benchmarks are congruent with CMS.
  6. Reduced Burden of Multiple Assessments
     The reduction in required assessments as proposed with RCS-1 remains in the PDPM. Only 2 PPS assessments are required: 5-day assessment and D/C Assessment. PDPM adds an optional “Interim Payment Assessment” (IPA) which would allow for a resident to be re-classified if criteria are met.
  7. Reduction in Reimbursement with Length of Stay
    PDPM calls for reduction in reimbursement correlating with length of stay for PT, OT, and Non-Therapy Ancillary (NTA) classifications. For PT and OT, days 1-20 would be reimbursed at the full rate. On day 21, a decreasing adjustment factor of 2% is applied every 7 days throughout the remainder of the stay. NTA days 1-3 are reimbursed at an increased adjustment factor of 3. Day 4 through the remainder of the stay, the reimbursement is adjusted to a factor of 1. These adjustments are based on Medicare’s research indicating PT, OT, and NTA costs decrease the longer the resident stays.
Read More About the PDPM:

We Are Optimistic and Committed

We continue to be optimistic considering the enormous changes we are facing with this new payment model. CMS has an open forum and NASL and other groups are already collaborating on the details. CMS posted provider-specific impact data reflecting FY 2017 payment under RUG-IV compared with what the payment would have been under PDPM. After a full review, the total payment was indeed budget neutral.

You may view your SNF’s impact by following the link above (“CMS provided tools”). As we know more information, we will gladly pass it along. We are committed to being good partners in rehabilitation by informing our clients and colleagues with the most up to date information on rehabilitation and post-acute care.


Cassie Murray, OTR, QCP, IASSC CYB
Executive Director of Clinical Services
Healthcare Therapy Services, Inc.
cmurray@htstherapy.com | 800.486.4449 ext 210

HTS is a leading contract therapy and wellness provider in the Midwest. As the trusted authority in post-acute rehabilitation, our clients look to us to not only maintain exceptional clinical collaboration and outcomes, but also to be a trusted partner in helping their organizations perform better. Since 1988, HTS has been an independently owned, trusted, ethical provider of therapy services for senior living communities, home health agencies and hospitals.

Therapist owned and managed, our mission is to provide the very best people and programs to move our clients and employees forward so that together we can provide a “hope and a future” Jeremiah 29:11 to those we serve. We have grown from a single provider (who has been a longstanding client since 1988) to a company employing over 1,800 therapists in the Midwest and Southern states.