[PDF] - Under PDPM Specifics of the PT, OT, and SLP Classifications Kim PDF Document

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Comprehending and Maximizing Under PDPM – Specifics of the PT, OT, and SLP Classifications

Kim Barrows, RN, BSN

President of KB Post-Acute Strategic Specialist

Mary Braun, RN

Nurse Consultant for KB Post-Acute Strategic Specialist

PT and OT Case-Mix Classification Groups

What is important in this classification

group: “The Criteria”

Primary diagnosis for the SNF stay:

Item I0020B

Surgical procedures associated

with the primary dx performed during the preceding hospital stay: J2100-J5000

Functional score: section GG
Variable per diem

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PT and OT Classification Diagnosis

Primary Diagnosis
Step 1: Classifies the resident into a clinical category
Step 2: Adjustments to the clinical category may be made in cases where the

resident received a surgical procedure during the preceding hospital stay associated with that diagnosis.

Section J

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Section J – Cont’d PT/OT Classification Diagnosis

J2100-Recent surgery requiring active SNF care
If no, resident will remain in the default clinical category derived from Section I
If yes, the resident will convert the resident into a surgical primary clinical

PT/OT Classification Diagnosis

Step 3: Based on the primary diagnosis and the occurrence of a surgical intervention the resident is then classified into one of ten clinical categories.

For PT and OT Classification PDPM Clinical Category Major Joint Replacement or Spinal Surgery Non-Orthopedic Surgery Acute Neurologic Non-Surgical Orthopedic/Musculoskeletal Orthopedic Surgery (Except Major Joint Replacement or Spinal Surgery) Medical Management Acute Infections Cancer Pulmonary Cardiovascular and Coagulation

PT/OT Classification Diagnosis

PDPM Clinical Category Major Joint Replacement or Spinal Surgery Major Joint Replacement or Spinal Surgery Non-Orthopedic Surgery Non-Orthopedic Surgery and Acute Neurologic Acute Neurologic Non-Surgical Orthopedic/Musculoskeletal Other Orthopedic Orthopedic Surgery (Except Major Joint Replacement or Spinal Surgery) Medical Management Medical Management Acute Infections Cancer Pulmonary Cardiovascular and Coagulation

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PT/OT Classification Diagnosis

Mapping of the ICD-10 diagnosis and/or surgical procedures that will be used to

classify the resident into one of the ten clinical categories is located on the SNF website:

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html

The spread sheet has 4 columns
ICD-10 DM code - has drop down to sort A - Z or Z - A
Description - has drop down to sort A - Z or Z - A
Default clinical categories- has drop down listing the 10 clinical categories
Return to Provider-invalid primary diagnosis
Will not provide a PDPM classification
The record will reject when submitted

PT/OT Classification Diagnosis

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ICD-10 DM Code Description

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Default Clinical Category Major Procedure During the Prior Inpatient Stay

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PT/OT Classification Diagnosis

S22040S - Wedge compression fracture of fourth thoracic vertebra,

sequela

PT/OT Classification Diagnosis

M80861P - Other osteoporosis with current pathological fracture,

right lower leg, subsequent encounter for fracture with malunion

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PT/OT Classification Diagnosis

M00072 - Staphylococcal arthritis, left ankle and foot

PT/OT Classification Diagnosis

H53121 - Transient visual loss, right eye

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PT/OT Classification Diagnosis

Strategies for Successful ICD-10-CM Barriers
Determine the primary diagnosis as a TEAM
Can start now, day after a new admission meet as a team to determine

the primary diagnosis

Updated ICD-10-CM manuals
Triple Check
Maintain an accurate diagnosis list

PT/OT Classification Diagnosis

Pitfalls leading to Unsuccessful ICD-10-CM coding
Do not use “unspecified” codes
Do not code resolved diagnosis
Incorrect seventh character (for fractures/injuries)
“A”- Initial encounter
“D”- Subsequent encounter
“S”- Sequela
Coding a diagnosis that has not been documented by a physician

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Let’s Run Through Section I Diagnosis Example

Hospital COC has Dx

M84.345S-

Clinical Mapping -

Stress Fracture L finger sequella

Maybe eligible for 1
f 2 orthopedic

Let’s Run Through Section J-Surgery Related Items

Resident admitted to SNF on 10/30/19
Hospital records indicate that resident was involved in MVA

10/20/19 where he sustained multiple bone fx and abdominal

injuries. Major surgeries include:
Surgery to repair comminuted fx of L wrist
ORIF to repair fx bilateral tibia/fibula, lower legs,
Large Bowel Resection (Partial Colectomy)
ORIF to repair fx L clavicle
Resident admitted to SNF for Nursing, PT, OT services

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Coding Section J PT/OT Classification Functional Score

Functional Score
Calculated from Section GG
Functional Score will range 0 - 24
Increasing score now means increased independence
There is no direct relationship between increasing dependence and

increasing payment

Promotes CMS goal of standardizing assessment items across all payment

settings

Also better coordinates payment with other quality initiatives
For the PT/OT components the score is based on 10 items have been highly

related to PT/OT costs per day

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PT/OT Classification Functional Score

2 – Bed Mobility 3 – Transfer Items 1 – Eating Item 1 – Toileting Item 1 – Oral Hygiene Item 2 – Walking Items 10 Items

PT/OT Classification Functional Score Definitions

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Section GG

Self Care Items

Section GG

Mobility

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PT/OT Classification Functional Score PT/OT Classification Functional Score

The two tables the first including the 2 walking items
The second table, excluding the walking items; The additional

response “Resident cannot walk”

Makes it possible for those residents who cannot walk for their assessments

to still calculate a functional score.

Will use:
07 - resident refused
09 - not applicable
10 - not attempted d/t environmental conditions
88 - not attempted due to medical/safety concerns

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PT/OT Classification Functional Score

The final score:
Average score for 2 mobility items
Average score for 3 transfer items
Average score for average of 2 walking items
Score for eating
Score for oral hygiene
Score for toilet hygiene

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Calculating the Functional Score

From the MDS previous slide:
Eating - 3 = 2 pts
Oral hygiene - 3 = 2 pts
Toileting hygiene - 2= 1 pt
Sit to lying - 2= 1 pt
Lying to sitting on side of the bed - 2 = 1 pt
Sit to stand - 3 = 2 pts
Chair/bed-to-chair transfer – 2 = 1 pt
Toilet transfer - 3 = 2 pts
Walk 50 ft with 2 turns - 88 = 0 pts
Walk 150 ft - 88 = 0 pts

Calculating the Functional Score

Eating - 2 pts
Plus
Oral hygiene - 2 pts
Plus
Toilet hygiene - 1 pt
Plus
Average 2 items for bed mobility 1 + 1 = 2 divided by 2 = 1
Average 3 items for transfers 2 + 1 +2 = 5 divided by 3 = 1.6666
Average 2 items for walking 0 + 0 = 0 divided by 2 = 0

Do the Math

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Calculating the Functional Score

2 + 2 + 1 + 1 + 1.67 + 0 = 7.67
Rounded up at the end
Functional score 8.

PT/OT Case Mix Classification Groups

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Putting it all together to get a PT/OT Classification Group

MDS completed, coding included:
Section I-I0200B coded: M97.11XS –
Peri prosthetic fx around internal prosthetic R knee joint sequella.
Clinical category from mapping- Major Joint Replacement or Spinal Surgery
Section J-J2000 coded: yes
Section J-J2100 coded: yes
Section J-J2300: checked
Functional score calculated section GG: 6
What is PT/OT Case Mix Group?
Answer?

Variable Per Diem Adjustment/Factors PT/OT Component

Medicare Payment Days Adjustment Factor 1-20 1.00 21-27 0.98 28-34 0.96 35-41 0.94 42-48 0.92 49-55 0.90 56-62 0.88 63-69 0.86 70-76 0.84 77-83 0.82 84-90 0.80 91-97 0.78 98-100 0.76

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Bonus Question: Variable Per Diem Adjustment

Resident admitted on 10/10/19
5 Day PPS ARD 10/17/19 with PT/OT Classification Group Score: TB
Date is now 10/21/19
With the Variable Per Diem
For Medicare Payment Days, what adjustment factor will be applied to the PT/OT

classification scores?

Adjustment Factor 1.0
(100% of the rate)

Speech/Language Pathology Case-Mix Classification Group

What is important in this classification group. The Criteria:
Clinical Category
Derived from the primary diagnosis (I0020B)
Acute Neurologic
Cognitive Impairment
Presence of SLP related Comorbidity
Mechanically Altered Diet and/or Swallowing Disorder
Section K – Swallowing/Nutritional Status

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Acute Neurologic

SLP Case-Mix Classification Group Cognitive Impairment

Comes from the Cognitive Score
Found in Section C – Cognitive Patterns
BIMS- Brief Interview for Mental Status
Resident Interview - (make every attempt)
Add all the item numbers together
Score range 0-15
CPS- Cognitive Performance Scale
Staff interview (only if resident cannot be interviewed)
Score range 0 - 6
The Cognitive Function Scale combines scores from both scales to cover all

residents

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SLP Case-Mix Classification Group Cognitive Impairment

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CMS has Identified 12 comorbidities which have been found to

directly impact increased costs under SLP

The presence of only of these conditions are required to fulfill the

requirement for resident to qualify under this criteria of the SLP classification

1 out of 12 is all that is required

SLP Case-Mix Classification Group

SLP Related Comorbidities

SLP Case-Mix Classification Group

SLP Related Comorbidities

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Identify SLP Related Comorbidities

Resident admitted to SNF. Information from the hospital transfer

records and include:

S/P MVA
Ventilator Dependent via tracheostomy
Has fractures bilateral tibia and fibula
Has fracture L wrist
Dx include CHF; COPD; Diverticulitis
Dx of apraxia related to endotracheal tube while at hospital

Identify SLP Comorbidities

How many identified?
3
Tracheostomy
Ventilator
Apraxia
Remember only need 1 condition; is sufficient to qualify for the SLP

Comorbidities criteria.

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Identify SLP Comorbidities Identify SLP Comorbidities

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SLP Case Mix Classification

Mechanically Altered Diet Swallowing Disorder Found in Section K

SLP Case Mix Classification

K0510C - Mechanically Altered Diet
Definition in RAI has not changed
Altered texture/consistency of foods
Soft solids
Pureed foods
Ground meats
Thickened Liquids
Mechanically Altered Diet is not necessarily considered also a therapeutic diet.
Enteral feedings are not considered a Mechanically Altered Diet

Mechanically Altered Diet Swallowing Disorder

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DEFINITIONS MECHANICALLY ALTERED DIET A diet specifically prepared to alter the texture or consistency of food to facilitate oral intake. Examples include soft solids, pureed foods, ground meat, and thickened liquids. A mechanically altered diet should not automatically be considered a therapeutic diet.

Section K0510C Identifying a Swallowing Disorder

Within the 7 day look back period it was documented by the 7p-7a

night shift nurse that resident was noted coughing as she was swallowing her 10 pm medications. The night nurse crushed her 6am medications (not contraindicated) and placed in applesauce. Resident tolerated well and no further coughing noted. The nurse reviews residents dx list and notes that does not have an actual swallowing disorder diagnosis

Swallowing disorder?

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Identifying a Mechanically Altered Diet

Within the 7 day look back period it was noted on the physician
rder sheet the resident has order for Regular Diet NAS ground
meats. Thin liquids.
Code Mechanically Altered Diet?

SLP: Bringing All the Criteria Together

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Calculating the SLP Classification Score

Once MDS coding completion noted:
Did not qualify in having an acute neurologic condition
BIMS score of 3
Has dx of Laryngeal Cancer
Noted in documentation that resident has speech and language deficits
Tolerating ordered downgrade diet mechanical soft diet with nectar thickened
liquids. No further choking during meals/medication pass

SLP Classification Score Calculation

Criteria that applies first column:
BIMS score 3 - moderately impaired
Laryngeal Cancer
Speech and Language Deficit
Criteria that applies second column:
Mechanical altered diet

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SLP Classification Score Calculation FY 2020 Unadjusted Federal Rate Per Diem

Urban Rural

Rate Component

PT OT SLP Nursing NTA Non-Case Mix Per Diem Amount $61.16 $56.93 $22.83 $106.64 $80.45 $95.48

Rate Component

PT OT SLP Nursing NTA Non-Case Mix Per Diem Amount $69.72 $64.03 $28.76 $101.88 $76.86 $97.25

www.proactivemedicalreview.com/snf-proposed-payment-updates-for-fy-2020/

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PT/OT
Increase education ICD-10 coding and have updated ICD-10 coding book
Daily meetings after morning meeting to discuss primary diagnosis
Develop check lists for including criteria for each classification component and fill out
ne for each new admission/readmission
Nursing and therapy WORK TOGETHER on section GG
Develop a crosswalk between therapy language and language on MDS in

section GG to make the definitions of levels of assistance more congruent

Accuracy is the key when coding section GG. Even 1 slight error can have a

significant impact on the functional score at the very end with “rounding up”

Strategies for the PT/OT and SLP Components

PT/OT continued
Access to the clinical cross walk spread sheet for all key staff members
Start to convert existing diagnoses to appropriate diagnosis which are

mapped and attached to a PDPM clinical category

Communicate with referring hospitals on the pertinent information needed

with transfer records and COC

Strategies for the PT/OT and SLP Components

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Strategies for the PT/OT and SLP Components

SLP
Educate nursing staff on common hot list of diagnoses that indicate Acute

Neurologic classification

Consider OT/ST to complete the BIMS if applicable during the evaluation
Consider ST to complete check off list of the items listed in K0100 during

evaluation

Have documentation charting template designed for nurses and STNAs to

document any signs/symptoms of swallowing disorders each shift.

Laminate list of the 12 SLP comorbidities for each nurses station and/or med

cart

Enhance Communication between Dietician/SLP/Nursing on ordered diet and

if it constitutes a mechanically altered diet

Thank you!

Questions? Email questions to kbarrows@kb-pass.com

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References

Centers for Medicare & Medicaid Services. (2018). Long-term care facility resident assessment instrument 3.0 user’s manual. Retrieved March 3, 2019,

from https://downloads.cms.gov/files/1-MDS-30-RAI-Manual-v1-16-October-1-2018.pdf

Centers for Medicare & Medicaid Services. (2018). Medicare issues fiscal year 2019 payment & policy changes for skilled nursing facilities. Retrieved

July 31, 2018, from www.cms.gov/newsroom/fact-sheets/medicare-issues-fiscal-year-2019-payment-policy-changes-skilled-nursing-facilities

Centers for Medicare & Medicaid Services. (2019). Patient Driven Payment Model. Retrieved August 31, 2018, from

www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html

Centers for Medicare & Medicaid Services. (2019). Patient Driven Payment Model- Fact sheet: PDPM functional and cognitive scoring. Retrieved

February 14, 2019, from https://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/SNFPPS/Downloads/PDPM_Fact_Sheet_FunctionalCognitiveScoring_Final_v3_508.pdf

Centers for Medicare & Medicaid Services. (2019). Patient Driven Payment Model-Fact sheet: PDPM patient classification. Retrieved February 14,

2019, from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/PDPM_Fact_Sheet_Template_Payment- Overview_v4_508.pdf

Centers for Medicare & Medicaid Services. (2019). PDPM FAQs. Retrieved February 14, 2019, from https://www.cms.gov/Medicare/Medicare-Fee-for-

Service-Payment/SNFPPS/PDPM.html

Centers for Medicare & Medicaid Services. (2019). PDPM ICD-10 mappings: Clinical category. Retrieved February 14, 2019, from

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html

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