1. Master PDPM Methodology

   Master PDPM methodology and include all staff in job relevant PDPM subject matter trainings. Since we started PDPM training in September 2018, we have seen a trend of key departments who are being left out of the mix. This includes the Admissions teams, floor nurses, social services, medical directors, nurse practitioners, business office and medical records. Needless to say, PDPM will take the village.

   Trainings should Include an intermediate level of PDPM understanding.
   •  ICD-10 Coding
   •  GG Coding
   •  Quick Tip: Coding of the functional status in GG should be based on usual performance and should be determined by IDT collaboration.

    

2. Ensure Documentation Confidence

   •  Ensure that your nurses are comfortable with the transition from section G to section GG for functional measure coding.
   •  Ensure that the nurses are comfortable with documenting their skill. Since nursing has its own component, they have to be able to “own” their nursing skill and document to justify their services.
   •  Ensure confidence in capturing all active diagnosis. This means that you will need to (or already have) rewritten your admissions procedures and utilize preadmission forms to capture NTA items. Our PDPM analysis across the board shows a great opportunity to improve coding to accurately reflect the conditions of our patients.

    

3. Set-up for MDS Success
   

   Set MDS up for success. Evaluate the work flow for MDS and gain an accurate picture of job responsibilities. While there are fewer required MDS assessments under PDPM, the time not spent in assessments can be used to ensure accurate and timely coding under PDPM. Business office managers can begin conversations with managed care providers to ascertain any expected changes in reimbursement.

    

4. Adapt & Modify Processes
   

   Adapt and modify your current processes to align with PDPM specific conditions and coding. In our pilot sites, HTS and our partners are adding PDPM processes to current operations to prepare and identify best practice prior to October 1st. This can be achieved alongside our current RUG system to give your team more confidence and reduce the “flipping of the PDPM switch” on midnight of September 30th.

   Examples include:
   Changes to your weekly Medicare meeting forms
   •  Changes to your admission processes Begin a 5-day assessment meeting for all Med A patients with each department contributing their PDPM-related information
   •  Establish the IDT approach to selecting the primary diagnosis prior to the skilled stay.
   •  Use the CMS Clinical Category Mapping “Return to Provider Codes” which will be rejected beginning October 1st

    

5. Restorative Nursing
   

   Restorative nursing for your skilled patients may be a positive adjunct to therapy services under PDPM.

   Under PDPM, providing two restorative programs for the nursing groups Reduced Physical Function and Behavioral or Cognitive Symptoms will result in an increased nursing CMI.

    

6. Talk with Your Docs 

   You have from now until October 1st to work with your hospitals and physicians to ensure efficient data collection for the 5-day MDS and optimal information for coding accuracy. This may include a review of how you obtain your data, what EHR is being used and if they are willing to build reports or have the ability to add reports to their standard transfer paperwork. It may be necessary to call a meeting about PDPM to your referral networks and educate doctors and hospitals on the importance of sending this key information. This includes: providing timely discharge summaries, operative reporting, ICD-10 codes, accurate active diagnosis and any specialty information.

    

7. Know Your Software
   

   Whether you are using PCC, Matrix, Vision, etc. it is important to know what new functionalities will be available under PDPM.
   •  Know what current PDPM tools and reports are available for you to take utilize now.
   •  Get involved in any PDPM workgroups offered by the software provider to offer feedback and suggestions.
   •  Take advantage of any trainings, modules or alerts of new functions.

By: Cassie Murray, OTR, ,QCP, Chief Operating Officer

Site-Specific PDPM Impact

Individual PDPM Meetings with all partner sites: All HTS partner sites received education on PDPM along with their specific PDPM Impact Analysis.

Deep Dive into Data

HTS operations is diving deep into site-specific data in order to establish additional best practices and clinical pathways based on diagnosis category and functional level. HTS is conducting extensive data analysis by site to analyze the following key items: history, patient population, conditions, principle diagnosis, diagnostic category, functional level, the amount of time spent in therapy as well as their functional outcomes. This data gives sound strategic direction to process improvements and clinical positioning to foster success under PDPM.

Therapy GG Coding Analysis

All HTS therapists are certified in the CMS Care Tool, which is the standardized outcome for mobility and self-care. However, we are auditing our therapists’ GG coding to ensure continued confidence that our therapists are accurate and skilled in GG coding.

Current MDS Data Analysis

HTS is partnering with clients to upload actual 2018 MDS data and provide patient-specific analysis to identify opportunities, trends, education, and auditing needs to ensure accuracy incoding and optimize system processes. This information is valuable as we craft a PDPM strategic plan for each community we serve.

Powerful Partnerships

We have collaborated with the nursing and MDS experts from Proactive Medical Review to provide comprehensive training and resources for nursing and other nontherapy departments within the IDT. Together we are offering our Power Through PDPM exclusive training series of monthly trainings to focus on each key component of PDPM preparedness.

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.