RCS 1 Thank you for joining us today! Irene Henrich Director of - - PowerPoint PPT Presentation

RCS 1

Thank you for joining us today!

Irene Henrich

Director of Quality and Compliance ihenrich@careventures.net

RCS 1: Highlights and Timelines

Resident Classification System, Version I

• May 2017 – CMS released the SNF PPS Advance Notice of

Proposed Rulemaking (ANPRM)

• July 2017 – CMS posted a Provider-specific Impact Analysis

representing estimated payments under RCS1

• August 2017 – Deadline for the Comment Period regarding the

Proposed Policy

• October 2018 – Earliest that RCS 1 could become FINAL RULE

(most likely 2019)

• April/May 2018 – Final Rule may be released or announcement
• f postponement ???

Why Replace RUGS?

• RUGS is an index-maximizing system has led to 90% of

residents having payments primarily driven by therapy services.

• CMS’ view that Therapy in SNFs is predicated on financial

considerations as opposed to resident needs.

• Multiple reports and studies published by the OIG and

MedPAC expressing concerns with “thresholding” and Ultra High domination.

• Insufficient Payment for Nursing Services and Ancillary

Services chiefly prescription drugs.

CMS Goals for RCS 1

• To improve targeting of resources to

medically complex beneficiaries

• To reduce incentives for SNFs to deliver

therapy based on financial considerations

• To promote consistency with other

Medicare and PAC payment settings by basing resident classification on clinical information and minimizing the role of the ‘volume’ of service provision in determination of payment

RUGS vs RCS 1

RUGS RCS1

Payment Methodology Index-Maximizing Index-Combining Components 2 case-mix components + 2 non case-mix components 4 case-mix components+ 1 none case-mix component PPS Assessments 5 scheduled PPS assessments- 5-day, 14-day, 30-day, 60-day, 90-day 1 scheduled PPS assessment – 5-day Reimbursement  Rates are constant throughout the patient’s length of stay  Reimbursement Management relies on Therapy Services  Rates decline throughout the patient’s length of stay (front loading)  Reimbursement Management will shift to Nurses and Coders Diagnosis Coding No direct impact on reimbursement Diagnosis Coding will have a direct impact on reimbursement

• Section I8000A of the MDS 3.0

Therapy Provision Reimbursement Engine Outcomes Engine

RCS 1 MDS Assessment Schedule Type

Medicare MDS Assessment Schedule Type Assessment Reference Dates Applicable Standard Medicare Payment Days

5-day Scheduled PPS Assessment Days 1-8 All covered Part A days until Part A discharge Significant Change in Status Assessment (SCSA) No later than 14 days after a significant change in identified ARD of the assessment through Part A discharge PPS Discharge Assessment Equal to the End of Date of Most Recent Medicare Stay (A2400C)  Therapy minutes rendered during the stay will be reported as part D/C Assessment

MDS Changes coming… (October 2018)

• Section I – Primary Diagnosis Category – specific

change that aligns with RCS 1 requirements

• Additional items in Section GG
• Section N - N2001 – Drug Regimen Review

N2003 – Medication Follow-up N2005 – Medication Intervention

RUGS

RCS1

Determination of Payment in RCS 1

PT/OT 30 case-mix groups SLP 18 case-mix groups Nursing 43 case-mix groups (same as RUGS) NTA 6 case-mix groups

• Diagnostic

Information (slide 10)

• Diagnostic Information

(slide 10)

• Clinical information

from SNF stay

• Comorbidities present

(slide 14-16)

• Cognitive Status

(CFS)(slide 11)

• Cognitive Status (CFS)

(slide 11)

• Extensive services

received

• Extensive services

received

• Functional Status

(slide 12)

• SLP-related

comorbidities (slide 13)

• Restorative nursing

services received

• Presence of swallowing

disorder or mechanically altered diet (slide 13)  Variable per diem adjustment  1% every 3rd day after Day 14  Variable per diem adjustment  First 3 days of the stay – 3 % adjustment  For days 4-100 – 1% adjustment

Primary Diagnostic Clinical Categories

RCS1 Primary Diagnosis (10 total) PT/OT Clinical Categories (5 total) SLP Clinical Categories (2 total)

Major Joint Replacement or Spinal Surgery Major Joint Replacement or Spinal Surgery Non-Neurologic Surgical Procedures on Extremities Other Orthopedic Non-Neurologic Non-Ortho Surgery Non-Orthopedic Surgery Non-Neurologic Acute Infections Medical Management Non-Neurologic Cardiovascular and Coagulations Medical Management Non-Neurologic Pulmonary Medical Management Non-Neurologic Non-Surgical Ortho/Musculoskeletal Other Orthopedic Non-Neurologic Acute Neurologic Acute Neurologic Neurologic Cancer Medical Management Non-Neurologic Medical Management Medical Management Non-Neurologic

Cognitive Functional Scale

CFS Levels BIMS score CPS score CFS score Cognitively intact 13-15

• 1

Mildly Impaired 8-12 0-2 2 Moderately Impaired 0-7 3-4 3 Severely Impaired

• 5-6

4

• The Cognitive Functional Scale (CFS) is

utilized in RCS 1 for PT/OT and SLP payment components

• The CFS is calculated based on scores

from two other cognitive measures – Brief Interview for Mental Status (BIMS) and the Cognitive Performance Scale (CPS).

• BIMS is determined from MDS 3.0
• C0200 Repetition of Words
• C0300 Temporal Orientation
• C0400 Recall
• C0500- BIMS Summary
• CPS- all MDS based

Functional Status

• Information needed for PT/OT

component

• 6-point measurement scale
• 3 ADLs considered- ‘late loss’

ADLs – these ADLs predict resource use most accurately

• MDS Section G
• G0110B (transfers)
• G0110I (toileting)
• G0110H (eating)

ADL Self-Performance Score Transfer Toileting Eating Independent +3 +3 +6 Supervision +4 +4 +5 Limited Assist +6 +6 +4 Extensive Assist +5 +5 +3 Total Dependence +2 +2 +2 Activity Occurred 1-2x +1 +1 +1 Activity Did not Occur +0 +0 +0

Speech Co-Morbidities

Speech considerations

Presence of either …

• Swallowing disorder (MDS item

K0100Z)

• Mechanical diet (MDS item

K0510C2) Presence of either …

• SLP related Comorbidity (see

table on right)

• Mild to Severe Cognitive

Impairment (CFS)

MDS Item Description I4300 Aphasia I4500 CVA,TIA, or Stroke I4900 Hemiplegia or Hemiparesis I5500 TBI I8000 Laryngeal Cancer I8000 Dysphagia I8000 ALS I8000 Oral Cancer I8000 Speech and Language Deficits O0100E2 Tracheostomy Care O0100F2 Ventilator or Respirator

NTA Comorbidity Score Calculation

Condition/Extensive Service MDS Item NTA Tier Points HIV/AIDS n/a (SNF claim) Ultra-High 8 Parenteral/IV feeding –High Intensity K0510A2, K0710A2 Very High 7 Parenteral/IV feeding- Low Intensity K0510A2,K0710 A2,K0710B2 High 5 Ventilator/Respirator O0100F2 High 5 IV Medication O0100H2 High 5

NTA Comorbidity Score Calculation

Condition/Extensive Service MDS Item NTA Tier Points Multidrug-Resistant Organism (MDRO) I1700 Medium 2 DM I2900 Medium 2 MS I5200 Medium 2 Asthma, COPD or Chronic Lung Disease I6200 Medium 2 Kidney Transplant Status I8000 Medium 2 Major Organ Transplant Status I8000 Medium 2 Chemotherapy O0100A2 Medium 2 Tracheostomy O0100E2 Medium 2 Transfusion O010012 Medium 2

NTA Comorbidity Score Calculation

Condition/Extensive Service MDS Item NTA Tier Points Suctioning O0100D2 Low 1 Isolation or quarantine for active infectious disease O0100M2 Low 1 Wound Infection (other than foot) I2500 Low 1 Osteomyelitis and Endocarditis I8000 Low 1 DVT/Pulmonary Embolism I8000 Low 1 Stage 4 Pressure Ulcer M0300D1 Low 1 Diabetic Foot Ulcer M1040B Low 1 Radiation O0100B2 Low 1

NTA Case-Mix Classification Groups

NTA Score Range NTA Group NTA Case-Mix Index 11+ NA 3.33 8-10 NB 2.59 6-7 NC 2.02 3-5 ND 1.52 1-2 NE 1.16 NF 0.83

PT/OT Case-Mix Groups

Clinical Category Functional Score Mod/Severe Cog Impairment PT/OT Case-Mix Group Case-Mix Index

Major Joint Replacement or Spinal Surgery 14-18 No TA 1.82 Major Joint Replacement or Spinal Surgery 14-18 Yes TB 1.59 Major Joint Replacement or Spinal Surgery 8-13 No TC 1.73 Major Joint Replacement or Spinal Surgery 8-13 Yes TD 1.45 Major Joint Replacement or Spinal Surgery 0-7 No TE 1.68 Major Joint Replacement or Spinal Surgery 0-7 Yes TF 1.36

PT/OT Case-Mix Groups

Clinical Category Functional Score Mod/Severe Cog Impairment PT/OT Case- Mix Group Case-Mix Index Other Orthopedic 14-18 No TG 1.70 Other Orthopedic 14-18 Yes TH 1.55 Other Orthopedic 8-13 No TI 1.58 Other Orthopedic 8-13 Yes TJ 1.39 Other Orthopedic 0-7 No TK 1.38 Other Orthopedic 0-7 Yes TL 1.14

PT/OT Case-Mix Groups

Clinical Category Functional Score Mod/Severe Cognitive Impairment PT/OT Case-Mix Group Case-Mix Index Acute Neuro 14-18 No TM 1.61 Acute Neuro 14-18 Yes TN 1.48 Acute Neuro 8-13 No TO 1.52 Acute Neuro 8-13 Yes TP 1.36 Acute Neuro 0-7 No TQ 1.47 Acute Neuro 0-7 Yes TR 1.17

PT/OT Case-Mix Groups

Clinical Category Functional Score Mod/Severe Cog Impairment Case-Mix Group Case-Mix Index Non-Ortho Surgery 14-18 No TS 1.82 Non-Ortho Surgery 14-18 Yes TT 1.59 Non-Ortho Surgery 8-13 No TU 1.73 Non-Ortho Surgery 8-13 Yes TV 1.45 Non-Ortho Surgery 0-7 No TW 1.68 Non-Ortho Surgery 0-7 Yes TX 1.36

PT/OT Case-Mix Classification

Clinical Category Functional Score Mod/Severe Cog Impairment Case-Mix Group Case-Mix Index Medical Management 14-18 No T1 1.70 Medical Management 14-18 Yes T2 1.55 Medical Management 8-13 No T3 1.58 Medical Management 8-13 Yes T4 1.39 Medical Management 0-7 No T5 1.38 Medical Management 0-7 Yes T6 1.14

SLP Case-Mix Classification Groups

Clinical Category Presence of Swallowing Disorder

• r Mech Altered Diet

SLP-related comorbidity

• r Mild to Severe Cog

Impairment Case-Mix Group Case-Mix Index Acute Neuro Both Both SA 4.19 Acute Neuro Both Either SB 3.71 Acute Neuro Both Neither SC 3.37 Acute Neuro Either Both SD 3.67 Acute Neuro Either Either SE 3.12 Acute Neuro Either Neither SF 2.54 Acute Neuro Neither Both SG 2.97 Acute Neuro Neither Either SH 2.06 Acute Neuro Neither Neither SI 1.28

SLP Case-Mix Classification Groups

Clinical Category Presence of Swallowing Disorder

• r Mech Altered Diet

SLP-related comorbidity or Mild to Severe Cog Impairment Case-Mix Group Case-Mix Index Non-Neuro Both Both SJ 3.21 Non-Neuro Both Either SK 2.96 Non-Neuro Both Neither SL 2.63 Non-Neuro Either Both SM 2.62 Non-Neuro Either Either SN 2.22 Non-Neuro Either Neither SO 1.70 Non-Neuro Neither Both SP 1.91 Non-Neuro Neither Either SQ 1.38 Non-Neuro Neither Neither SR 0.61

RCS1 Unadjusted Federal Rate Per Diem – Urban and Rural

Nursing NTA PT/OT SLP Non-case-mix Urban $100.91 $76.12 $126.76 $24.14 $90.35 Rural $96.40 $72.72 $141.47 $31.06 $92.02

Impact Analysis by Resident Population

Resident Characteristics Higher Reimbursement Percentage Change (GAIN) Lower Reimbursement Percentage change (LOSS)

Length of SNF stay (Utilization Days) Resident with SNF stays of 1- 15 days 15.9% Resident with stays of 31+ days

• 2.5%

IV Meds during stay Residents with IV Meds 22.9% Residents without IV Meds

• 2.0%

Receipt of Therapy Residents receiving a single therapy 37.3% Residents receiving 3 therapies

• 3.9%

NTA costs during SNF stay Residents with NTA costs of $150 19.2% Resident with lower NTA costs ($10-50)

• 3.2%

NTA Comorbidity Score 11+ 25.9% 7.7%

Impact Analysis by Provider

Provider Characteristics Higher Reimbursement Percentage Change (GAIN) Lower Reimbursement Percentage Change (LOSS)

Bed Size Small Facilities 0-49 beds 6.7% Facilities with 200+ beds

• 0.7%

Location Rural 3.7% Urban

• 0.8%

% of SNF utilization days billed as RU SNFs with 1- 10% of utilization billed as RU 28.4% SNFs with 90- 100% of utilization days billed as RU

• 9.9%

% of SNF stays with 100 day utilization SNFs with 1- 10% of their stays utilizing 100 days 0.3% SNFs with 25- 100% of their stays utilizing 100 days

• 3.9%

Implications of RCS 1

• A HUGE shift in Concept and Operations for Med A Admissions

in the SNF setting

• The magnitude of the change will be felt at all levels –

Nursing, Therapy, Ancillary Services, EMR vendors, MACs

• Volume of Therapy and Mode of Treatment will change

significantly – more group and concurrent therapy are allowed/encouraged with RCS1 (up to 25% of each per resident, per day)

• Part A pricing structures will change for Contracted Therapy

Providers –Per Diem, Per Minute, % of CMI score

• A more balanced therapy and nursing clinical case-mix will

WIN under RCS1 !

How should SNFs prepare for RCS 1?

Learn More, Get Educated, Be Prepared !!!

I. Evaluate the Clinical Capabilities of your current team

Clinical Capabilities Description RCS1 case-mix index

MDS accuracy Identify and capture full spectrum of acuity Nursing, PT/OT, ST, NTA ICD 10 coding To capture the appropriate Primary Diagnostic Category that an admission falls into Nursing, PT/OT, ST, NTA Acuity Manage more medically complex admissions Nursing, NTA Other Clinical Services Respiratory, Restorative Nursing

• II. Evaluate your Interdisciplinary workflows and systems that

impact length of stay and occupancy in your community.

• Does your Admissions team understand and adhere to the expectations

related to LOS ?

• Does your Social Work team understand the expectations related to the LOS

and have the tools to support timely discharges to the next level ?

• Does your Nursing team understand the value of providing and optimizing the

resident’s highest functional level outside of therapy services ? Do they understand how correct documentation impacts reimbursement? *Use resources like the CRITICAL PATHWAYS from Gravity

How should SNFs prepare for RCS 1?

How should SNFs prepare for RCS 1?

• III. Evaluate and Strengthen your

Upstream and Downstream relationships

• To keep information exchange consistent and timely
• To keep your occupancy up and to keep the

referrals/admissions coming

• To facilitate safe transitions to the next level in a timely

manner in order to maintain appropriate LOS and also minimize hospital readmissions

• To have systems in place for appropriate discharge follow up
• To achieve Preferred Provider status

Thank you for participating!

Irene Henrich,

Director of Quality and Compliance ihenrich@careventures.net

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Gravity Healthcare Consulting

www.gravityhealthcareconsulting.com

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Additional more comprehensive training and education

msabo@gravitygealthcareconsulting.com

1-240-803-7999