Feature Presentation 1 PDPM Premiers: October 1, 2019 PDPM revamp - - PowerPoint PPT Presentation

PDPM – Re-Scripting for our Cast of Characters

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Feature Presentation

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…

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PDPM Premiers: October 1, 2019

Star of the Show Re-scripting Assigning the Director Character Development Supporting Actors

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Leading Roles Editing #1 in the Box Office And the winners will be…

Key Takeaways

Star of the Show: The Patient

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Opening Scene

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Patient

Nursing

Conditions, treatments or services, depression, GG Score, Restorative Nursing

NTA

Conditions/Extensive Services from ICD-10

SLP

Presence of Acute Neurologic Conditions, Cog Impairment, Speech comorbidity, Swallowing Disorder, Mechanically Altered Diet

PT

Dx/ Clinical Category GG Score

OT

Dx/ Clinical Category GG Score

Admission Date Primary reason for SNF stay Dx Prior Surgery Prior Hospital Stay Prior living arrangement Anticipated DC Destination Barriers

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Director

Interdisciplinary Communication: Collaborative Assessments and Care Delivery

Dx capturing of Primary Reason for SNF stay begins preadmission – continually reassess for accuracy and supportive documentation

• Initial IDT PDPM

Component Review

• Determine care

delivery needs by Discipline

• GG 1st 3 days “Usual

Performance” & DC goals

• Baseline care

plan

• Day 1-3 Gathering of

GG Performance & Patient Specific Goals

• IDT Review of Patient

Response to Intervention & progress towards capturing

• f active conditions, Dx and

characteristics

• PDPM Component Review

Leading to Accurate Admission Assessment by day 8 (161 items on MDS impact reimbursement)

• 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
• Daily, ongoing Review of

response to Intervention, Changes in Condition, Supportive Documentation, IPA Assessment Need, Safe Transition Readiness

Pre-Admission Day 1,

(Day of Admission)

Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9<

• Restorative

Nursing Initiation

• BIMs / CPS

completion

SNF Pre-Admission Checklist

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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 Neurological C0300; C0300A, B and C; C0400; C0400A, B and C; 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 PT GG0130A1; GG0130C1; GG0170B1; GG0170C1; GG0170C1; GG0170D1, GG0170E1; GG0170F1; GG0170J1; GG0170J1; GG0170K1; J200-J5000 Series OT GG0130A1; GG0130C1; GG0170B1; GG0170C1; GG0170C1; GG0170D1, GG0170E1; GG0170F1; GG0170J1; GG0170J1; GG0170K1; J200-J5000 Series SLP B0100; C0300; C0300A-C; C0400; C0400A-C; C0500; C0700; C1000; GG0130A; GG0130C1, GG0170C1, GG0170D1, GG0170E1, GG0170F1; 14300; 14900; 15500; 18000A-J; K0100A-D; K0510C2; O0100E2-F2

SNF Pre-Admission Checklist

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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 Clinical Conditions, Treatments, or Restorative B0100; 12900; I4400; I5100; I5200; I5300; I6200; I6300; J1100C; J1550A; J1550B; K0300; K0510A1-2; Ko510B1 - 2; K0710A3; K0710B3; 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 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

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PDPM

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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

Close Up: PT / OT / ST Therapy Components

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Therapy: PT/OT – 10 Categories Collapsed into FOUR (4)

Major Joint Rep. or Spinal Surgery Non-Ortho Surgery & Acute Neurologic Medical Management Other Orthopedic Major Joint Rep. or Spinal Surgery Non-Orthopedic Surgery Non-Surgical Orthopedic/ Musculoskeletal Cancer Acute Neurologic Orthopedic Surgery

(Except MJR or Spinal)

Pulmonary Acute Infections Cardiovascular & Coagulations Medical Management 13

Therapy: Section J Adjustment

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

Major Joint Replacement Spinal Surgery

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PT/OT PDPM - CMG (TA/TP) CMI Drivers (1.08-1.92)

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Clinical Category Section GG Function Score PT OT Case-Mix Group PT Case-Mix Index OT Case Mix 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

PT/OT Function Score

16 Section GG Items Included in PT & OT Functional Measure

Section GG Item Score GG0130A1 Self-care: Eating 0 - 4 GG0130B1 Self-care: Oral Hygiene 0 - 4 GG0130C1 Self-care: Toileting Hygiene 0 - 4 GG0170B1 GG0170C1 Mobility: Sit to lying Mobility: Lying to sitting on side of bed 0 - 4 (average of 2 items) GG0170D1 GG0170E1 GG0170F1 Mobility: Sit to stand Mobility: Chair / bed-to-chair transfer Mobility: Toilet transfer 0 - 4 (average of 3 items) GG0170J1 GG0170K1 Mobility: Walk 50 feet with 2 turns Mobility: Walk 150 feet 0 - 4 (average of 2 items)

PT / OT Function Score Construction

Response Score 05, 06 Set-up assistance, Independent 4 4 Supervision or touching assistance 3 3 Partial / moderate assistance 2 2 Substantial / maximal assistance 1 01, 07, 09, 10, 88 Walking items only: Dependent, Refused, N/A, Not Attempted, Resident Cannot Walk*

* Coded based on response to GG0170H1 (does the resident walk?)

Supporting Actors: Nursing, Restorative, Activities, Social Services, Physicians

• PT/ OT recommended interventions towards patient specific functional goals – skilled and unskilled – intensity and duration for IDT feedback
• GG Usual Performance / Goals presented as part of collaborative scoring
• Ongoing response to intervention – treatment modifications, integration into all daily (restorative and activities engagement)
• Skilled group and concurrent delivery and utilization within limit of 25% per discipline
• Identify relevant historical clinical conditions, comorbidities and surgeries
• Understand, Seek out and discuss active comorbidities and active chronic / acute illnesses with an understanding of IPA usage
• Actively participate in safe transition readiness from day 1

Character Development: GG Training and Competency completion for all rehab team members, restorative and CNA’s. ICD10 coding and mapping education for rehab evaluators. Identification of, communication and care plan development based on patient driven skilled vs unskilled needs, ability to integrate with nursing, restorative and activities for a functional patient centered vs days/ minutes approach > “rehab revamp”

Re-scripting > Capture and Communicate as IDT member:

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Lead Role: PT & OT

Therapy: SLP CMG (SA-SL) and CMI (.68 – 4.21)

18 SLP Related Comorbidities

Aphasia Laryngeal Cancer CVA, TIA or Stroke Apraxia Hemiplegia or Hemiparesis Dysphagia Traumatic Brain Injury ALS Tracheostomy Care * Oral Cancers Vent or Respirator Care * Speech & Lang Deficits * while a resident

Presence of acute Neurologic, SLP- Related Comorbidity, or Cognitive Impairment Mechanically Altered Diet or Swallowing Disorder Case-Mix Group CMI

None Neither SA 0.68 None Either SB 1.82 None Both SC 2.67 Any one Neither SD 1.46 Any one Either SE 2.34 Any one Both SF 2.98 Any two Neither SG 2.04 Any two Either SH 2.86 Any two Both SI 3.53 Any three Neither SJ 2.99 Any three Either SK 3.70 Any three Both SL 4.21

Supporting Actors: Dieticians, MDS / Nursing, Physicians, Psychologists

• Re-scripting > Present with standardized tests and assessment to identify:
• Supportive documentation and rationale for clinical category and need for skilled and /or referral interventions
• Qualifying comorbidities
• Need for physician support of active diagnosis
• Cognitive status
• Swallowing disorders
• Modified diet needs
• Character Development: BIMS / CPS education, identification of comorbidities – ability to gain physician involvement as needed.

Collaboration with dietary and nursing on detection of swallowing disorders (section K) and altered diets. ICD10 education on primary reason impacting SNF stay (acute neuro qualifier for SLP) and co-morbidities.

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Lead Role: SLP

Close Up: Nursing Component

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Nursing CMG (ES3-PA1) and CMI (.66 – 4.06)

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Extensive Services Functional GG Score = 0 -14

PDPM/ CMI

Tracheostomy care AND ventilator or respirator (while a resident)

Extensive Services HIPPS ES3 A ES2 B ES1 C ES3 / 4.06

Tracheostomy care OR ventilator or respirator (while a resident)

ES2 / 3.07

Infection Isolation (while a resident)

ES1 / 2.93

Special Care High Functional GG Score = 0 -14 GG Score Depression

PDPM / CMI

Comatose and dependent /activity did not occur 0-5 Depression

HDE2 / 2.40

Septicemia 0-5 No Depression

HDE1 / 1.99

Diabetes with both: 6-14 Depression

HBC2 / 2.24

• daily injections

6-14 No Depression

HBC1 / 1.86

• insulin order changes on 2+ days

Special Care High HIPPS HDE2 D HDE1 E HBC2 F HBC1 G

Quadriplegia with Functional Score <=11 COPD and SOB when lying flat Fever with one of the following:

• pneumonia
• vomiting
• weight loss
• feeding tube with intake requirement

Parenteral/IV feedings – while not or while a resident Respiratory therapy = 7 days Depression criteria is met if the Total Severity Score = or > 10 but not 99

Nursing Case Mix cont.

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Special Care Low Functional GG Score = 0 -14 GG Score Depression PDPM / CMI Cerebral Palsy 0-5 Depression LDE2 / 2.08 Multiple Sclerosis 0-5 No Depression LDE1 / 1.73 Parkinson's Disease and Functional Score <=11 6-14 Depression LBC2 / 1.72 Respiratory failure and oxygen therapy while a resident 6-14 No Depression LBC1 / 1.43 Feeding tube >=51% of calories or 6-50% calories + fluid >=501cc during entire last 7 days (avg across 7 days) Special Care Low HIPPS LDE2 H LDE1 I LBC2 J LBC1 K 2+ Stage 2 pressure ulcers with 2+ skin treatments Stage 3 or 4 pressure ulcer, or unstageable with slough or eschar with 2+ skin treatments 2+ venous/arterial ulcers with 2+ skin treatments Stage 2 pressure ulcer (1) and venous/arterial ulcer (1) with 2+ skin treatments Foot infection, diabetic foot ulcer, or other open lesion of foot with dressings Radiation therapy while a resident Dialysis while a resident Depression criteria is met if the Total Severity Score = or > 10 but not 99

Nursing Case Mix cont.

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Clinically Complex

Functional GG Score = 0 -16 GG Score Depression

PDPM / CMI

Residents with Extensive Services, Special Care High,

• r Special Care Low with Functional Score = 15 OR

16 0-5 Depression

CDE2 / 1.87

Pneumonia 0-5 No Depression

CDE1 / 1.62

Hemiplegia/hemiparesis and Functional Score <=11 6-14 Depression

CBC2 / 1.55

Surgical wounds or open lesion with treatments 15-16 Depression

CA2 / 1.09

Burns 6-14 No Depression

CBC1 / 1.34

Chemotherapy while a resident 15-16 No Depression

CA1 / .94

Oxygen therapy while a resident Special Care High HIPPS CDE2 L CA2 O CDE1 M CBC1 P CBC2 N CA1 Q IV medications while a resident Transfusions while a resident Depression criteria is met if the Total Severity Score = or > 10 but not 99 Behavioral Symptoms & Cognitive Performance Functional GG Score= 11-16 GG Score Restorative PDPM/ CMI Cognitive impairment (BIMS score =/ < 9 or CPS =/ >3) 11-16 >2 restorative nursing BAB2 / 1.04 Hallucinations 11-16 0-1 restorative nursing BAB1 / .99 Delusions Behavioral and Cog HIPPS BAB2 R BAB1 S Physical behavior symptoms toward others Verbal behavior symptoms toward others Other behavioral symptoms not directed toward

• thers

Rejection of care Wandering Restorative Nursing Services Administered for 6 or more days for at least 15 minutes

Nursing Case Mix cont.

25 Reduced Physical Function Functional GG Score = 0-16 GG Score Restorative PDPM / CMI Restorative Count **Count as 1 service if both provided 0-5 >2 restorative nursing PDE2 / 1.57 H0200C, H0500** Urinary toileting program and/or bowel toileting program 0-5 0-1 restorative nursing PDE1 / 1.47 O0500A, B** Passive and/or active range of motion 6-14 >2 restorative nursing PBC2 1.22 O0500C Splint or brace assistance 15--16 >2 restorative nursing PA2 / .71 O0500D, F** Bed mobility and/or walking training 6-14 0-1 restorative nursing PBC1 / 1.13 O0500E Transfer training 15-16 0-1 restorative nursing PA1 / .66 O0500G Dressing and/or grooming training

Reduced Physical Function HIPPS PDE2 T PDE1 U PBC2 V PA2 W PBC1 X PA1 Y

O0500H Eating and/or swallowing training O0500I Amputation/prostheses care O0500J Communication training Provided at least 15 minutes each on 6 out of last 7 days

Nursing Case Mix

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Supporting Characters – CNA’s, Charge Nurses, Restorative, Medication Aides, Therapists, Physicians

• Re-scripting:
• GG vs G: 1st 3 days usual performance capture
• Accurate collection and documentation of clinical information
• Active Diagnosis captured / physician documentation obtained
• Depression
• Restorative Nursing
• Character Development – Documentation skills to support diagnosis and functional scoring, collaboration and communication

between therapies for patient carry over and functional use of skills throughout each day

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Lead Role: Nursing - DON

Close Up: NTA Non Therapy Ancillary Component

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NTA CMG (NA-NF) CMI (.72-3.24)

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Conditions and Extensive Services Used for NTA Component NTA Score Range 12+ Points = NA CMG = 3.24 CMI 9-11 = NB = 2.53 6-8 = NC = 1.84 3-5 = ND = 1.33 1-2 = NE = .96 0 = NF = .72

NTA List

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Condition/Extensive Service Source Points HIV/AIDS SNF Claim 8 Parenteral IV Feeding: Level High MDS Item K0510A2, K0710A2 7 Special Treatments/Programs: Intravenous Medication Post-admit Code MDS Item O0100H2 5 Special Treatments/Programs: Ventilator or Respirator Post-admit Code MDS Item O0100F2 4 Parenteral IV feeding: Level Low MDS Item K0510A2, K0710A2, K0710B2 3 Lung Transplant Status MDS Item I8000 3 Special Treatments/Programs: Transfusion Post-admit Code MDS Item O0100I2 2 Major Organ Transplant Status, Except Lung MDS Item I8000 2 Active Diagnoses: Multiple Sclerosis Code MDS Item I5200 2 Opportunistic Infections MDS Item I8000 2 Active Diagnoses: Asthma COPD Chronic Lung Disease Code MDS Item I6200 2 Bone/Joint/Muscle Infections/Necrosis - Except Aseptic Necrosis of Bone MDS Item I8000 2 Chronic Myeloid Leukemia MDS Item I8000 2 Wound Infection Code MDS Item I2500 2 Active Diagnoses: Diabetes Mellitus (DM) Code MDS Item I2900 2 Endocarditis MDS Item I8000 1 Immune Disorders MDS Item I8000 1 End-Stage Liver Disease MDS Item I8000 1 Other Foot Skin Problems: Diabetic Foot Ulcer Code MDS Item M1040B 1 Narcolepsy and Cataplexy MDS Item I8000 1 Cystic Fibrosis MDS Item I8000 1 Special Treatments/Programs: Tracheostomy Care Post-admit Code MDS Item O0100E2 1 NTA Score Range 12+ Points = NA CMG = 3.24 CMI 9-11 = NB = 2.53 6-8 = NC = 1.84 3-5 = ND = 1.33 1-2 = NE = .96 0 = NF = .72

NTA List

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NTA Score Range 12+ Points = NA CMG = 3.24 CMI 9-11 = NB = 2.53 6-8 = NC = 1.84 3-5 = ND = 1.33 1-2 = NE = .96 0 = NF = .72 Condition/Extensive Service Source Points Active Diagnoses: Multi Drug Resistant Organism (MRDO) Code MDS Section I 1 Special Treatments/Programs: Isolation Post - admit Code MDS Section O 1 Specified Hereditary Metabolic/ Immune Disorders MDS Section I 1 Morbid Obesity MDS Section I 1 Special Treatments/Programs: Radiation Post- Admit code MDS Section O 1 Highest Stage of Unhealed Pressure Ulcer - Stage 4 MDS Section M 1 Psoriatric Arthropathy and Systemic Sclerosis MDS Section I 1 Chronic Pancreatitis MDS Section I 1 Proliferative Diabetic Retinopathy and Vitreous Hemorrhage MDS Section I 1 Other Foot and skin Problems : Foot Infection COde, Other Open Lesion on Foot Code, Except Diabetic Foot Ulcer Code ( (M1040B) MDS Section M 1 Complication of Specified Implanted Device or Graft MDS Section I 1 Bladder and Bowel Appliances: Intermittent Catheterization MDS Section H 1 Inflammatory Bowel Disease MDS Section I 1 Aseptic Necrosis of Bone MDS Section I 1 Special Treatments/Programs: Suctioning Post Admit Code MDS Section O 1 Cardio-Respiratory Failure and Shock MDS Section I 1 Myelodysplastic Syndromes and Myelofibrosis MDS Section I 1 Systemic Lupus Erythematosus, Other Connective Tissue Disorders, and Inflammatory Spondylopathies MDS Section I 1 Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage MDS Section I 1 Nutritional Approaches While a Resident: Feeding Tube MDS Section K 1 Severe Skin Burn or Condition MDS Section I 1 Intractable Epilepsy MDS Section I 1 Active Diagnosis: Malnutrition Code MDS Section I 1 Disorder of Immunity - Except: Rx CC97: Immune Disorders MDS Section I 1 Cirrhosis of Liver MDS Section I 1 Bladder and Bowel Appliances: Ostomy MDS Section I 1 Respiratory Arrest MDS Section I 1 Pulmonary Fibrosis and Other Chronic Lung Disorders MDS Section I 1

NTA

• Lead Actor – MDS Coordinator
• Supporting Actors – Nursing, Physician, Therapists
• Re-scripting –
• Over 50 clinical conditions to be assessed, captured if present with physician diagnosis as needed
• Begin with pre-admission assessment for history of conditions
• Medication Review – indicative of active condition – get back up diagnosis and documentation as needed
• Review with IDT, patient and family leading up to day 8 – monitor beyond day 8 for new conditions and IPA needs
• Character Development – clinical assessment and coding skills, documentation to support active conditions, physician education,

engagement and support, tools and communication

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Qualifying Conditions for Interrupted Stay

Continuation of Stay: The patient returns to the same SNF (not a different SNF); AND: The patient returns within 3 days or less (the “interruption window”) The variable per diem schedule and the assessment schedule continues from the day of the previous discharge. *Source of readmission would not matter.

New Stay: If readmitted to same SNF greater than 3 consecutive days or patient admits to different of SNF, regardless of time between stays = new stay 1. Variable per diem resets to Day 1 2. Assessment schedule resets to Day 1 (New 5-day assessment required)

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Example of Interrupted Stay

DC on Day 3, 6/30/20

Readmit 7/4/2020 New 5-day MDS; Start VPDA Day 1

DC on Day 7, 6/30/20

Readmit 7/2/2020 to different SNF New 5-day MDS; Start VPDA Day 1

DC on Day 7, 6/30/20 Readmit 7/2/2020 Continuation; no MDS; Start VPDA Day 8*

* Subject to considerable comment by stakeholders

1 2 3

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Adjustment Factor PT OT and NTA

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Day 1-3 NTAs variable per-diem adjustment factor of 3x Day 4 – End of Stay NTAs variable per-diem adjustment factor of 1x Day 21 and every 7 days after – PT and OT variable per-diem adjustment rate reduction of 2% Interrupted Stay if > 3 days or admission from another SNF requires an Admission assessment and re-starts the Variable Per Diem count

0.5 1 1.5 2 2.5 3 1-3 4-20 21-27 28-34 35-41 42-48 49-55 56-62 63-69 70-76 77-83 84-90 92-97 98 - 100 PT/OT NTA

PDPM Practice Scoring & Rate Calculations

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• 1. Functional Scoring Practice: (GG)

The IDT collected performance data over the first three days of the Medicare stay. Usual function for eating and oral hygiene was independent with setup help only, while partial/moderate assist was required for sit to lying, lying to sitting, and toilet transfer. Toileting hygiene sit to stand, and bed to chair transfers usual performance required substantial/maximal assist. While able to ambulate 10 feet by day three of the stay, the team determined this progress was made only after therapeutic intervention. Unable to attempt walking greater than 10 feet due to medical condition but has a goal of achieving this by discharge.

PDPM Practice Scoring & Rate Calculations

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Section GG Functional Scoring Worksheet

GG Item#: Description Coding Function Score 0-4 Function Score 0-4 Avg Mobility Scores GG0130A1 Self-care: Eating GG0130C1 Self-care: Toileting Hygiene GG0130B1 *Self-Care: Oral Hygiene * GG0170B1 Mobility: Sit to Lying GG0170C1 Mobility: Lying to sitting on side of bed GG0170D1 Mobility: Sit to Stand GG0170E1 Mobility: Chair<>Bed transfer GG0170F1 Mobility: Toilet transfer GG0170J1 *Mobility: Walk 50' 2 turns * GG0170K1 *Mobility: Walk 150' Total Nsg ** Total PT/OT ** * Included in PT/OT calculation - NA for Nursing

PDPM Practice Scoring & Rate Calculations

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• 2. PT/OT Component Scoring with Rate Calculation

Clinical Category: Non-Orthopedic Surgery GG function score: 16 PT and OT Case-Mix Group (CMG): ___________ PT Case Mix Index (CMI): ___________ OT Case Mix Index (CMI): ________ Total Payment per diem for PT day 1-20: __________Day 21-27: __________ Total Payment per diem for OT day 1-20__________Day 21-27: ___________

PDPM Calculator (Day 1-3)

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Component Urban Base Fed Rate * Rural Base Fed Rate * Case Mix Index Special Adjustors Variable per diem Payment (per diem) PT $60.75 $69.25 X X X = OT $56.55 $63.60 X X X = SLP $22.68 $28.57 X X X = Nursing $105.92 $101.20 X X 1.00** X = NTA $79.91 $76.34 X X X = Non-Case Mix Component $94.84 $96.59 X X X = * Non-wage index adjusted Total Payment

** Except when the resident has HIV/AIDS, then variable per diem adjustment equals 1.18 *** Rates are for FY 2020, from final rule

PDPM Calculator (Day 21-27)

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Component Urban Base Fed Rate * Rural Base Fed Rate * Case Mix Index Special Adjustors Variable per diem Payment (per diem) PT $60.75 $69.25 X X X = OT $56.55 $63.60 X X X = SLP $22.68 $28.57 X X X = Nursing $105.92 $101.20 X X 1.00** X = NTA $79.91 $76.34 X X X = Non-Case Mix Component $94.84 $96.59 X X X = * Non-wage index adjusted Total Payment

** Except when the resident has HIV/AIDS, then variable per diem adjustment equals 1.18 *** Rates are for FY 2020, from final rule

PDPM Practice Scoring Scenario’s

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• 3. SLP Component Scoring with Rate Calculation:

Admitted to SNF s/p traumatic hip fracture. No SLP-related comorbidities receiving a low-salt diet. BIMS interview completed on the eighth day of the Medicare stay scored 15. On the fourth and sixth days of the stay experienced coughing episodes when attempting to swallow medication. The team requested an SLP evaluation on day six. SLP Clinical Category (CMG): __________ SLP Case Mix Index (CMI): __________ SLP Daily Per Diem (Add to PDPM Calculation Worksheet Above): ___________

PDPM Practice Scoring Scenario’s

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• 4. Nursing Component Scoring with Rate Calculation:

Admitted to SNF with exacerbation of COPD. Plans to rehab home. Working with OT and PT five times per week. Complains of shortness of breath daily when walking but denies during rest or when lying flat. During the first three days of stay, section GG performance data was collected, and a nursing function score was determined to be 13. On day six of the stay oxygen saturation levels dropped during therapy; nursing was alerted and provided the ordered PRN 2L of oxygen via nasal cannula for 20 minutes, returning levels back to normal range. Also started on a prompted toileting plan due to developing occasional urinary incontinence during her

• hospitalization. PHQ-9 score of 11, which was completed on day seven of the stay. The 5-Day ARD was also set for day seven.

Nursing Category (Extensive, Special Care High, Special Care Low, Clinically Complex, Behavior Symptoms and Cognitive Performance, Reduced Physical Function): __________ GG Score: __________ Depression Yes/No: __________ Nursing Clinical Category (CMG): __________ Nursing Case Mix Index (CMI): __________ Nursing Per Diem (add to PDPM Rate Calculation Worksheet above): __________

PDPM Practice Scoring Scenario’s

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• 5. NTA- Non-Therapy Ancillary Component Scoring with Rate Calculation:

Admitted to SNF with exacerbation of COPD. No HIV/AIDS and is not receiving parenteral or IV feedings. NTA qualifiers identified: COPD and diabetes mellitus. NTA Point Total: __________ NTA Case Mix Group: __________ NTA Case Mix Index: __________ NTA Per Diem (add to PDPM Calculation Worksheet) –

• Day 1-3: __________
• Day 4+: __________

Total Per Diem from Practice Scenario’s Worksheet: Day 1-3: ____________ Day 4 – 20 variable per diems for PT/OT: _______ NTA: __________ Day 21-27: __________

PDPM Readiness Checklist

“I’ll think about that tomorrow. Tomorrow is another day…. “ - Scarlett O’Hara approach OR  Evaluate care planning team and processes  Ensure Patient Assessment and Coding Skillsets on the team are where they need to be (Section I, K and O)  Should MDS coordinators roles be redefined as clinical care coordinators?  How should standup meetings and daily communication with IDT members be conducted to capture the essential items of the 5 PDPM components and help establish delivery of care  Identify how therapy practices may change to ensure best outcomes for patients  Establish exceptional restorative nursing programs for short stay residents  Discover which clinical capabilities need to be developed or strengthened with resultant staffing implications  Evaluate and develop specialized clinical programs and transition programs  Modify E.H.R to capture changes in condition, swallowing difficulties, restorative care delivery, GG goals…….  Plan for Transition IPA’s Oct 1, 2019  Prepare New Triple Check and Audit Tools

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Patients safely transitioning due to improved collaboration of care toward identified goals and a unified plan of care integrated throughout all departments (decreased episodic cost, improved patient satisfaction) SNFs driving outcomes based on targeting of resources to beneficiary’s individual needs (QM’s, QRP, and 5 Star improvements) PDPM is designed to provide equitable resources to facilities based on patient conditions and characteristics captured and supported in the medical record (delivery of care based on identified need supported by the IDT)

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And the winners will be…

Credits

PRODUCTION COMPANY: Quality Rehab Management PRODUCER: Susan Krall VISUAL EFFECTS: Amie Gerlach ADDITIONAL RESEARCH: 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 [Accessed 15 Mar. 2019]. Federal Register. (2019). Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities (SNF) Final Rule for FY 2019, SNF Value-Based Purchasing Program, and SNF Quality Reporting Program. [online] Available at: https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-16485.pdf

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