PDPM – Re-Scripting for our Cast of Characters Feature Presentation 1
PDPM Premiers: October 1, 2019 PDPM revamp of Med A reimbursement from Volume to Value Reimbursement driven by Primary Reason for SNF stay, functional scores, clinical conditions and comorbidities, cognition, depression, swallowing disorders, mechanically altered diets and restorative nursing – No longer days and minutes of rehab 5 Clinical Categories scored individually assigning Case Mix Groups and reimbursement rates for each: PT/ OT/ ST/ Nursing/ NTA Initial MDS establishes reimbursement for entire stay based on total of the 5 clinical categories Intended to Strengthen Care Delivery Process New Core Competencies Required PPS is Gone with the Wind… 2
Star of the Show Leading Roles Re-scripting Editing Key Takeaways Assigning the Director #1 in the Box Office Character Development And the winners will be… Supporting Actors 3
Star of the Show: The Patient 4
Opening Scene PT Dx/ Clinical Category GG Score OT Patient Dx/ Clinical Category GG Score Admission Date Primary reason for SNF stay Dx Prior Surgery Prior Hospital Stay SLP Prior living arrangement Anticipated DC Presence of Acute Neurologic Destination Barriers Conditions, Cog Impairment, Speech comorbidity, Swallowing Disorder, Mechanically Altered Diet Nursing Conditions, treatments or services, depression, GG Score, Restorative Nursing NTA Conditions/Extensive Services from ICD-10 5
Director 6
Interdisciplinary Communication: Collaborative Assessments and Care Delivery IDT Review of Patient • Response to Intervention & progress towards capturing of active conditions, Dx and Initial IDT PDPM • characteristics Component Review PDPM Component Review • Daily, ongoing Review of • Leading to Accurate Determine care • response to Intervention, Admission Assessment by delivery needs by Changes in Condition , day 8 (161 items on MDS Discipline Supportive Documentation, IPA impact reimbursement ) Restorative GG 1 st 3 days “Usual • Day 1-3 Gathering of • • Assessment Need, Safe Nursing Initiation GG Performance & Performance” & Transition Readiness Patient Specific Goals DC goals Baseline care • BIMs / CPS • plan completion Pre-Admission Day 1, Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9< (Day of Admission) Dx capturing of Primary Reason for SNF stay begins preadmission – continually reassess for accuracy and supportive documentation Ongoing Dx Specificity > Clinical Category (68,000 ICD10 codes, 24,000 RTP ) • Gathering of Clinical Conditions and Characteristics - including Pre Admission • Consequence of incomplete assessment = default category •
SNF Pre-Admission Checklist Data Elements PDPM Impact Source Responsible Party Follow Up Date Primary Diagnosis for SNF Admission Active Diagnoses 10020B (For assessing SNF Admission Diagnosis) Diagnosis History MDS Section I (PDPM conditions/comorbidities) - HIV/AIDS (Nursing and NTA Components) History & Physical All Components Discharge Summary All Components Other Key Elements for Classification Surgical History Section J2100-J5000 Coding -- PT/OT/SLP Classification Information to Support Component Classification Significant Consults MDS & Claim High Impact Items Cardiac PT/OT/SLP/Nursing/NTAs Classification Pulmonary 12000; 16200; 16300, O0100E-F, O0400 C0300; C0300A, B and C; C0400; C0400A, B and C; Neurological C0500; C0700; C1000 Gastro-Intestinal See K and O Series in SLP, Nursing and NTAS Psychiatric (i.e. Depression) See Nursing Component Detail Below Other: Therapy Evaluations/Treatment MDS & Claim High Impact Items GG0130A1; GG0130C1; GG0170B1; GG0170C1; PT GG0170C1; GG0170D1, GG0170E1; GG0170F1; GG0170J1; GG0170J1; GG0170K1; J200-J5000 Series GG0130A1; GG0130C1; GG0170B1; GG0170C1; OT GG0170C1; GG0170D1, GG0170E1; GG0170F1; GG0170J1; GG0170J1; GG0170K1; J200-J5000 Series B0100; C0300; C0300A-C; C0400; C0400A-C; C0500; C0700; C1000; GG0130A; GG0130C1, GG0170C1, SLP GG0170D1, GG0170E1, GG0170F1; 14300; 14900; 8 15500; 18000A-J; K0100A-D; K0510C2; O0100E2-F2
SNF Pre-Admission Checklist Data Elements PDPM Impact Source Responsible Party Follow Up Date Nursing MDS & Claim High Impact Items Depression D0100; D0200A - I; D0300; D0500A - J; D0600 Wounds Critical for Special Care/Clinically Complex Services - Pressure Ulcers M0300B1, C1, D1, F1 - Skin/ Ulcer Treatment M1200A - E; M1200G - I - Surgical Wounds J2100 - J5000 Series - Wounds Other 12500 - Other Skin Problems M1030; M1040A - C Infections - Active & History 12000; 12100 Functional Information GG0130A1, GG0130C1, GG0170B1, GG0170C1, GG0170D1, GG0170E1, GG0170F1 B0100; 12900; I4400; I5100; I5200; I5300; I6200; I6300; J1100C; J1550A; J1550B; K0300; K0510A1-2; Ko510B1 - 2; K0710A3; K0710B3; Clinical Conditions, Treatments, or Restorative N0350A - BM1200A - E, G - I; O0100E2 - F2; O0100I2; O0100J2, O0100M2; O0400D2 NTAS MDS & Claim High Impact Items Medications Critical for High Cost Items (i.e. IV) - Medication History Nursing, NTAS - Medication Administration and Treatment Records O0100H2 - Respiratory Administration Records O0100F2; O0100H2; -O0100I2 Wounds 12500 9 Conditions 12900; 15200; 16200; 1800A -J Services K0510A2; K0710A2; K0710B2; O0100I2
Spotlighting Resources PDPM Clinical Categories to ICD-10 Diagnosis Codes Mapping www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html RAI https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/nursinghomequalityinits/mds30raimanual.html GG Functional Scoring Webinar Training https://pac.training/courses/section_gg_2019/story_html5.html Crosswalk Link / CMS PDPM Training www.cms.gov/Medicare/Medicare-fee-for-service-Payment/SNFPPS/PDPM.html 10
PDPM SNF Part A payment will be: • Per Diem Payment Rate • Sum of SIX components; • Five will be adjusted by patient characteristics; • Three will be adjusted by LOS Cms.gov. (2019). Patient Driven Payment Model - Centers for Medicare & Medicaid Services. [online] Available at: https://www.cms.gov/Medicare/Medicare- Fee-for-Service-Payment/SNFPPS/PDPM.html 11
Close Up: PT / OT / ST Therapy Components 12
Therapy: PT/OT – 10 Categories Collapsed into FOUR (4) Major Joint Rep. or Non-Ortho Surgery & Other Orthopedic Medical Management Spinal Surgery Acute Neurologic Non-Surgical Cancer Major Joint Rep. or Non-Orthopedic Orthopedic/ Spinal Surgery Surgery Musculoskeletal Pulmonary Orthopedic Surgery Acute Neurologic (Except MJR or Spinal) Acute Infections Cardiovascular & Coagulations Medical Management 13
Therapy: Section J Adjustment Major Joint Replacement Spinal Surgery New MDS Items: SectionJ: Patient Surgical History: Captures major surgical procedures (from qualifying hospital stay) Which may change PDPM clinical category from I0020B group. Relevant for PT/OT Classification 14
PT/OT PDPM - CMG (TA/TP) CMI Drivers (1.08-1.92) Section GG Function PT OT Case-Mix PT Case-Mix OT Case Mix Clinical Category Score Group Index Index Major Joint Replacement or Spinal Surgery 0-5 TA 1.53 1.49 Major Joint Replacement or Spinal Surgery 6-9 TB 1.70 1.63 Major Joint Replacement or Spinal Surgery 10-23 TC 1.88 1.69 Major Joint Replacement or Spinal Surgery 24 TD 1.92 1.53 Other Orthopedic 0-5 TE 1.42 1.41 Other Orthopedic 6-9 TF 1.61 1.60 Other Orthopedic 10-23 TG 1.67 1.64 Other Orthopedic 24 TH 1.16 1.15 Medical Management 0-5 TI 1.13 1.18 Medical Management 6-9 TJ 1.42 1.45 Medical Management 10-23 TK 1.52 1.54 Medical Management 24 TL 1.09 1.11 Non-Orthopedic Surgery and Acute Neurologic 0-5 TM 1.27 1.30 Non-Orthopedic Surgery and Acute Neurologic 6-9 TN 1.48 1.50 Non-Orthopedic Surgery and Acute Neurologic 10-23 TO 1.55 1.55 Non-Orthopedic Surgery and Acute Neurologic 24 TP 1.08 1.09 15
PT/OT Function Score Section GG Items Included in PT & OT Functional Measure Section GG Item Score GG0130A1 Self-care: Eating 0 - 4 PT / OT Function Score Construction GG0130B1 Self-care: Oral Hygiene 0 - 4 Response Score GG0130C1 Self-care: Toileting Hygiene 0 - 4 05, 06 Set-up assistance, Independent 4 GG0170B1 Mobility: Sit to lying 0 - 4 (average of 2 items) GG0170C1 Mobility: Lying to sitting on side of bed 4 Supervision or touching assistance 3 3 Partial / moderate assistance 2 GG0170D1 Mobility: Sit to stand GG0170E1 Mobility: Chair / bed-to-chair transfer 0 - 4 (average of 3 items) 2 Substantial / maximal assistance 1 GG0170F1 Mobility: Toilet transfer Walking items only: Dependent, Refused, 01, 07, 09, 10, 88 0 N/A, Not Attempted, Resident Cannot Walk* GG0170J1 Mobility: Walk 50 feet with 2 turns 0 - 4 (average of 2 items) GG0170K1 Mobility: Walk 150 feet * Coded based on response to GG0170H1 (does the resident walk?) 16
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