PDPM WORKSHOP

PDPM ndash Road Map for Success

PDPM WORKSHOP2

1 PDPM Overview

2 Clinical ComponentsMDS Changes

3 ReimbursementBilling

4 Strategies for Success

PDPM WORKSHOP

PDPMOverview

PDPM WORKSHOP

Overview

bullThe Patient-Driven Payment Model (PDPM) is effective October 1 2019bullSpecifications included in the SNF PPS Final Rule

published July 30 2019bullICD-10 captured on MDS will drive clinical classification

which impacts reimbursementbullRehab days and minutes no longer impact paymentbullADL to functional scoring (Section GG)

PDPM WORKSHOP

Overview

bullUnder PDPM there are over 23000 potential payment groupsbullSpecific rate components will vary

throughout the staybullMDS Schedule Changesbull3 day interruption window

PDPM WORKSHOP

RUG IV VS PDPM

6

PDPM WORKSHOP

PDPMComponents amp CharacteristicsbullSherri Robbins Senior Managing

Consultant RN BSN LNHA RAC-CT CLNC ndash BKD LLP

PDPM WORKSHOP

5 CLINICAL PAYMENT DRIVERS

RESIDENT

PT PAYMENT

OT PAYMENT

NTA PAYMENT

SLP PAYMENT

NURSING PAYMENT

NON CASE MIX

8

PDPM WORKSHOP

PDPM Patient Classification

bullPatient classifications are used for each component (PTOTSLPNTA amp Nursing)

bullBreakdown of criteria for each classification

9

Component Criteria

PT Clinical Category Functional Score

OT Clinical Category Functional Score

SLP Presence of Acute Neurologic Condition SLP-related Comorbidity or Cognitive Impairment Mechanically-altered Diet Swallowing Disorder

NTA NTA Conditions Comorbidities Score

Nursing Clinical Condition Needs Functional Score

PDPM WORKSHOP

PDPM Clinical Category

10

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Categories Collapsed to 4 for PT amp OT

PDPM Clinical Category Collapsed PT amp OT Clinical Category

Major Joint Replacement or Spinal Surgery Major Joint Replacement or Spinal Surgery

Non-Orthopedic SurgeryAcute Neurologic

Non-Orthopedic Surgery amp Acute Neurologic

Non-Surgical OrthopedicMusculoskeletalOrthopedic Surgery (Except Major Joint Replacement or Spinal Surgery)

Other Orthopedic

Medical ManagementAcute InfectionsCancerPulmonaryCardiovascular amp Coagulations

Medical Management

PDPM WORKSHOP

PDPM CASE MIX PTOTbullCase mix has two primary elements used to determine classificationo Clinical Category for SNF stay (I0020B)

o Functional Status (Section GG)

12

Clinical CategoryPT amp OT

Function ScorePT amp OT

Case Mix Group PT CMI OT CMI

Major Joint Replacement or Spinal Surgery 0-5 TA 153 149Major Joint Replacement or Spinal Surgery 6-9 TB 170 163Major Joint Replacement or Spinal Surgery 10-23 TC 188 169Major Joint Replacement or Spinal Surgery 24 TD 192 153

Other Orthopedic 0-5 TE 142 141Other Orthopedic 6-9 TF 161 160Other Orthopedic 10-23 TG 167 164Other Orthopedic 24 TH 116 115

Medical Management 0-5 TI 113 118Medical Management 6-9 TJ 142 145Medical Management 10-23 TK 152 154Medical Management 24 TL 109 111

Other Orthopedic 0-5 TM 127 130Other Orthopedic 6-9 TN 148 150Other Orthopedic 10-23 TO 155 155Other Orthopedic 24 TP 108 109

GG

PDPM WORKSHOP

SLP Comorbidities

bullSLP has 12 comorbidities under PDPMoSLP comorbidity flag combines conditions amp services

oOnly the presence of one of the following is required to qualify

13

PDPM WORKSHOP

PDPM Case Mix SLPbullSLP has 3 elementso Clinical Category for SNF Stay- Acute Neurologic or Non-Neurologic

o Presence of Swallowing Disorder and or Mechanically Altered Diet

o Cognitive Status andor Presence of an SLP-related Comorbidity

14

Clinical CategoryPT amp OT

Function ScorePT amp OT

Case Mix Group PT CMI OT CMI

Major Joint Replacement or Spinal Surgery 0-5 TA 153 149Major Joint Replacement or Spinal Surgery 6-9 TB 170 163Major Joint Replacement or Spinal Surgery 10-23 TC 188 169Major Joint Replacement or Spinal Surgery 24 TD 192 153

Other Orthopedic 0-5 TE 142 141Other Orthopedic 6-9 TF 161 160Other Orthopedic 10-23 TG 167 164Other Orthopedic 24 TH 116 115

Medical Management 0-5 TI 113 118Medical Management 6-9 TJ 142 145Medical Management 10-23 TK 152 154Medical Management 24 TL 109 111

Other Orthopedic 0-5 TM 127 130Other Orthopedic 6-9 TN 148 150Other Orthopedic 10-23 TO 155 155Other Orthopedic 24 TP 108 109

GG

PDPM WORKSHOP

SLP Component

bullPresence of oMechanically Altered Diet (Section K)

oSwallowing Disorder (Section K)

PDPM WORKSHOP

MDS Section K

16

PDPM WORKSHOP

Nursing Component

bullSame RUG IV Major CategoriesoExtensive Services

oSpecial Care High

oSpecial Care Low

oClinically Complex

oBehavior Symptoms amp Cognitive Impairment

oReduced Physical Function

PDPM WORKSHOP

Nursing Functional Score

bullMDS Section GG ndash Functional Abilities amp GoalsoAssessed during first three days of admission

oDocuments ldquousual performancerdquo

oFunctional score ranges from zero to 16

Eating Average Bed Mobility

Toilet Hygiene Average Transfer

PDPM WORKSHOP

Nursing CMI

NursingComponent

Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

HBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

NursingComponent

Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

PDPM WORKSHOP

Nursing Component

bullImportant to NoteoNursing component will be increased by 18 for residents with HIVAIDS

o8 points into the NTA count

bull B20 must be on SNF claim

PDPM WORKSHOP

NTA amp Comorbidity CodingbullComorbidity score is a weighted count of comorbidities

o Comorbidities associated with high increases in NTA costs grouped into various point tiers

o Points assigned for each additional comorbidity present with more points awarded for higher-cost tiers

bullComorbidities amp extensive services for NTA classification are derived from a variety of MDS sources with some identified in Item I8000

bullHIVAIDS remains a SNF claim reported adjustment (8 pts)

bullCalculated based on points assigned for 50 MDS items

21

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

PDPM WORKSHOP

NTA Component

bullData Sources

22

HIV AIDS SNF Claim

Bowelbladder appl H0100C H0100D Ostomy catheterization

ParenteralIVtube feed Section K

Ulcers foot skin probs Section M

Special treatmentsext services Section O IV meds ventilator trach suctioning transfusion radiation infection etc

Diagnoses Section I 6 specific diagnoses

Additional active Dx Item I8000 28 specific diagnoses

PDPM WORKSHOP

ConditionExtensive Service Source PointsHIVAIDS SNF Claim 8Parental IV Feeding Level High MDS Item K0510A2 K0710A2 7Special Treatment Programs Intravenous Medication Post-Admit Code MDS Item O0100H2 5Special Treatment Programs Ventilator or Respirator Post-admit Code MDS Item O0100F2 4

Parental IV Feeding Level LowMDS Item K0510A2 K0710A2 K0710B2 3

Lung Transplant Status MDS Item I8000 3Special TreatmentsPrograms Transfusion Post-admit Code MDS Item O0100I2 2Major Organ Transplant Status Except Lung MDS Item I8000 2Active Diagnoses Asthma COPD Chronic Lung Disease Code MDS Item I6200 2BoneJointMuscle InfectionsNecrosis - Except Aseptic Necrosis of Bone MDS Item I8000 2Chronic Myeloid Leukemia MDS Item I8000 2Wound Infection Code MDS Item I2500 2Active Diagnoses Diabetes Mellitus (DM) Code MDS Item I2900 2Endocarditis MDS I8000 1Immune Disorders MDS I8000 1End-Stage Liver Disease MDS I8000 1Other Foot Skin Problems Diabetic Foot Ulcer Code MDS Item M1040B 1Narcolepsy and Cataplexy MDS Item I8000 1Cystic Fibrosis MDS Item I8000 1Special TreatmentsPrograms Tracheostomy Care Post-admit Code MDS Item O00100E2 1Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code MDS Item I1700 1Special TreatmentsPrograms Isolation Post-admit Code MDS Item O0100M2 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsChronic Pancreatitis MDS Item I8000 1Proliferated Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code

MDS Item M1040A M1040B M1040C 1

Complications of Specified Implant Device or Graft MDS Item I8000 1Bladder and Bowel Appliances Intermittent Catheterization MDS Item H0100D 1Inflammatory Bowel Disease MDS Item I1300 1Aseptic Necrosis of Bone MDS Item I8000 1Special TreatmentsPrograms Suctioning Post-admit Code MDS Item O0100D2 1Cardio-Respiratory Failure and Shock MDS Item I8000 1Myelodysplastic Syndromes and Myelofibrosis MDS Item I8000 1Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage MDS Item I8000 1Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Nutritional Approaches While a Resident Feeding Tube MDS Item K0510B2 1Severe Skin Burn or Condition MDS Item I8000 1Intractable Epilepsy MDS Item I8000 1Active Diagnoses Malnutrition code I560 1Disorders of Immunity - Except RxCC97 Immune Disorders MDS Item I8000 1Cirrhosis of Liver MDS Item I8000 1Bladder and Bowel Appliances Ostomy MDS Item H0100C 1Respiratory Arrest MDS Item I8000 1Pulmonary Fibrosis and Other Chronic Lung Disorders MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsSpecified Hereditary MetabolicImmune Disorders MDS Item I8000 1Morbid Obesity MDS Item I8000 1Special TreatmentsPrograms Radiation Post-admit Code MDS Item O0100B2 1Highest Stage of Unhealed Pressure Ulcer - Stage 4 MDS Item M0300D1 1Psoriatic Arthropathy and Systemic Sclerosis MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 184 (NC) X 30 X $44110

Every Point CountsNTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

Every Point Counts

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 253 (NB) X 30 X $60652

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

WORKSHEET

bullNTA Worksheet Calculate the number of NTA points amp payment for the 4 scenarios

28

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient A

29

ConditionExtensive Services NTA Count

Diabetes Mellitus 2

IV Medication 5

Isolation 1

Diabetic Retinopathy 1

Total 9

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient B

30

ConditionExtensive Services NTA Count

COPD 2

Diabetes Mellitus 2

Chronic Pancreatitis 1

Cirrhosis of Liver 1

Total 6

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

31

ConditionExtensive Services Before Fall NTA Count

Diabetes Mellitus 2

Total 2

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

32

ConditionExtensive Services After Fall NTA Count

IV Medication 5

Diabetes Mellitus 2

Endocarditis 1

Total 8

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1
	ConditionExtensive Service		Source		Points
	Specified Hereditary MetabolicImmune Disorders		MDS Item I8000		1
	Morbid Obesity		MDS Item I8000		1
	Special TreatmentsPrograms Radiation Post-admit Code		MDS Item O0100B2		1
	Highest Stage of Unhealed Pressure Ulcer - Stage 4		MDS Item M0300D1		1
	Psoriatic Arthropathy and Systemic Sclerosis		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1

PDPM WORKSHOP2

1 PDPM Overview

2 Clinical ComponentsMDS Changes

3 ReimbursementBilling

4 Strategies for Success

PDPM WORKSHOP

PDPMOverview

PDPM WORKSHOP

Overview

bullThe Patient-Driven Payment Model (PDPM) is effective October 1 2019bullSpecifications included in the SNF PPS Final Rule

published July 30 2019bullICD-10 captured on MDS will drive clinical classification

which impacts reimbursementbullRehab days and minutes no longer impact paymentbullADL to functional scoring (Section GG)

PDPM WORKSHOP

Overview

bullUnder PDPM there are over 23000 potential payment groupsbullSpecific rate components will vary

throughout the staybullMDS Schedule Changesbull3 day interruption window

PDPM WORKSHOP

RUG IV VS PDPM

6

PDPM WORKSHOP

PDPMComponents amp CharacteristicsbullSherri Robbins Senior Managing

Consultant RN BSN LNHA RAC-CT CLNC ndash BKD LLP

PDPM WORKSHOP

5 CLINICAL PAYMENT DRIVERS

RESIDENT

PT PAYMENT

OT PAYMENT

NTA PAYMENT

SLP PAYMENT

NURSING PAYMENT

NON CASE MIX

8

PDPM WORKSHOP

PDPM Patient Classification

bullPatient classifications are used for each component (PTOTSLPNTA amp Nursing)

bullBreakdown of criteria for each classification

9

Component Criteria

PT Clinical Category Functional Score

OT Clinical Category Functional Score

SLP Presence of Acute Neurologic Condition SLP-related Comorbidity or Cognitive Impairment Mechanically-altered Diet Swallowing Disorder

NTA NTA Conditions Comorbidities Score

Nursing Clinical Condition Needs Functional Score

PDPM WORKSHOP

PDPM Clinical Category

10

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Categories Collapsed to 4 for PT amp OT

PDPM Clinical Category Collapsed PT amp OT Clinical Category

Major Joint Replacement or Spinal Surgery Major Joint Replacement or Spinal Surgery

Non-Orthopedic SurgeryAcute Neurologic

Non-Orthopedic Surgery amp Acute Neurologic

Non-Surgical OrthopedicMusculoskeletalOrthopedic Surgery (Except Major Joint Replacement or Spinal Surgery)

Other Orthopedic

Medical ManagementAcute InfectionsCancerPulmonaryCardiovascular amp Coagulations

Medical Management

PDPM WORKSHOP

PDPM CASE MIX PTOTbullCase mix has two primary elements used to determine classificationo Clinical Category for SNF stay (I0020B)

o Functional Status (Section GG)

12

Clinical CategoryPT amp OT

Function ScorePT amp OT

Case Mix Group PT CMI OT CMI

Major Joint Replacement or Spinal Surgery 0-5 TA 153 149Major Joint Replacement or Spinal Surgery 6-9 TB 170 163Major Joint Replacement or Spinal Surgery 10-23 TC 188 169Major Joint Replacement or Spinal Surgery 24 TD 192 153

Other Orthopedic 0-5 TE 142 141Other Orthopedic 6-9 TF 161 160Other Orthopedic 10-23 TG 167 164Other Orthopedic 24 TH 116 115

Medical Management 0-5 TI 113 118Medical Management 6-9 TJ 142 145Medical Management 10-23 TK 152 154Medical Management 24 TL 109 111

Other Orthopedic 0-5 TM 127 130Other Orthopedic 6-9 TN 148 150Other Orthopedic 10-23 TO 155 155Other Orthopedic 24 TP 108 109

GG

PDPM WORKSHOP

SLP Comorbidities

bullSLP has 12 comorbidities under PDPMoSLP comorbidity flag combines conditions amp services

oOnly the presence of one of the following is required to qualify

13

PDPM WORKSHOP

PDPM Case Mix SLPbullSLP has 3 elementso Clinical Category for SNF Stay- Acute Neurologic or Non-Neurologic

o Presence of Swallowing Disorder and or Mechanically Altered Diet

o Cognitive Status andor Presence of an SLP-related Comorbidity

14

Clinical CategoryPT amp OT

Function ScorePT amp OT

Case Mix Group PT CMI OT CMI

Major Joint Replacement or Spinal Surgery 0-5 TA 153 149Major Joint Replacement or Spinal Surgery 6-9 TB 170 163Major Joint Replacement or Spinal Surgery 10-23 TC 188 169Major Joint Replacement or Spinal Surgery 24 TD 192 153

Other Orthopedic 0-5 TE 142 141Other Orthopedic 6-9 TF 161 160Other Orthopedic 10-23 TG 167 164Other Orthopedic 24 TH 116 115

Medical Management 0-5 TI 113 118Medical Management 6-9 TJ 142 145Medical Management 10-23 TK 152 154Medical Management 24 TL 109 111

Other Orthopedic 0-5 TM 127 130Other Orthopedic 6-9 TN 148 150Other Orthopedic 10-23 TO 155 155Other Orthopedic 24 TP 108 109

GG

PDPM WORKSHOP

SLP Component

bullPresence of oMechanically Altered Diet (Section K)

oSwallowing Disorder (Section K)

PDPM WORKSHOP

MDS Section K

16

PDPM WORKSHOP

Nursing Component

bullSame RUG IV Major CategoriesoExtensive Services

oSpecial Care High

oSpecial Care Low

oClinically Complex

oBehavior Symptoms amp Cognitive Impairment

oReduced Physical Function

PDPM WORKSHOP

Nursing Functional Score

bullMDS Section GG ndash Functional Abilities amp GoalsoAssessed during first three days of admission

oDocuments ldquousual performancerdquo

oFunctional score ranges from zero to 16

Eating Average Bed Mobility

Toilet Hygiene Average Transfer

PDPM WORKSHOP

Nursing CMI

NursingComponent

Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

HBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

NursingComponent

Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

PDPM WORKSHOP

Nursing Component

bullImportant to NoteoNursing component will be increased by 18 for residents with HIVAIDS

o8 points into the NTA count

bull B20 must be on SNF claim

PDPM WORKSHOP

NTA amp Comorbidity CodingbullComorbidity score is a weighted count of comorbidities

o Comorbidities associated with high increases in NTA costs grouped into various point tiers

o Points assigned for each additional comorbidity present with more points awarded for higher-cost tiers

bullComorbidities amp extensive services for NTA classification are derived from a variety of MDS sources with some identified in Item I8000

bullHIVAIDS remains a SNF claim reported adjustment (8 pts)

bullCalculated based on points assigned for 50 MDS items

21

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

PDPM WORKSHOP

NTA Component

bullData Sources

22

HIV AIDS SNF Claim

Bowelbladder appl H0100C H0100D Ostomy catheterization

ParenteralIVtube feed Section K

Ulcers foot skin probs Section M

Special treatmentsext services Section O IV meds ventilator trach suctioning transfusion radiation infection etc

Diagnoses Section I 6 specific diagnoses

Additional active Dx Item I8000 28 specific diagnoses

PDPM WORKSHOP

ConditionExtensive Service Source PointsHIVAIDS SNF Claim 8Parental IV Feeding Level High MDS Item K0510A2 K0710A2 7Special Treatment Programs Intravenous Medication Post-Admit Code MDS Item O0100H2 5Special Treatment Programs Ventilator or Respirator Post-admit Code MDS Item O0100F2 4

Parental IV Feeding Level LowMDS Item K0510A2 K0710A2 K0710B2 3

Lung Transplant Status MDS Item I8000 3Special TreatmentsPrograms Transfusion Post-admit Code MDS Item O0100I2 2Major Organ Transplant Status Except Lung MDS Item I8000 2Active Diagnoses Asthma COPD Chronic Lung Disease Code MDS Item I6200 2BoneJointMuscle InfectionsNecrosis - Except Aseptic Necrosis of Bone MDS Item I8000 2Chronic Myeloid Leukemia MDS Item I8000 2Wound Infection Code MDS Item I2500 2Active Diagnoses Diabetes Mellitus (DM) Code MDS Item I2900 2Endocarditis MDS I8000 1Immune Disorders MDS I8000 1End-Stage Liver Disease MDS I8000 1Other Foot Skin Problems Diabetic Foot Ulcer Code MDS Item M1040B 1Narcolepsy and Cataplexy MDS Item I8000 1Cystic Fibrosis MDS Item I8000 1Special TreatmentsPrograms Tracheostomy Care Post-admit Code MDS Item O00100E2 1Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code MDS Item I1700 1Special TreatmentsPrograms Isolation Post-admit Code MDS Item O0100M2 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsChronic Pancreatitis MDS Item I8000 1Proliferated Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code

MDS Item M1040A M1040B M1040C 1

Complications of Specified Implant Device or Graft MDS Item I8000 1Bladder and Bowel Appliances Intermittent Catheterization MDS Item H0100D 1Inflammatory Bowel Disease MDS Item I1300 1Aseptic Necrosis of Bone MDS Item I8000 1Special TreatmentsPrograms Suctioning Post-admit Code MDS Item O0100D2 1Cardio-Respiratory Failure and Shock MDS Item I8000 1Myelodysplastic Syndromes and Myelofibrosis MDS Item I8000 1Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage MDS Item I8000 1Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Nutritional Approaches While a Resident Feeding Tube MDS Item K0510B2 1Severe Skin Burn or Condition MDS Item I8000 1Intractable Epilepsy MDS Item I8000 1Active Diagnoses Malnutrition code I560 1Disorders of Immunity - Except RxCC97 Immune Disorders MDS Item I8000 1Cirrhosis of Liver MDS Item I8000 1Bladder and Bowel Appliances Ostomy MDS Item H0100C 1Respiratory Arrest MDS Item I8000 1Pulmonary Fibrosis and Other Chronic Lung Disorders MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsSpecified Hereditary MetabolicImmune Disorders MDS Item I8000 1Morbid Obesity MDS Item I8000 1Special TreatmentsPrograms Radiation Post-admit Code MDS Item O0100B2 1Highest Stage of Unhealed Pressure Ulcer - Stage 4 MDS Item M0300D1 1Psoriatic Arthropathy and Systemic Sclerosis MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 184 (NC) X 30 X $44110

Every Point CountsNTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

Every Point Counts

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 253 (NB) X 30 X $60652

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

WORKSHEET

bullNTA Worksheet Calculate the number of NTA points amp payment for the 4 scenarios

28

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient A

29

ConditionExtensive Services NTA Count

Diabetes Mellitus 2

IV Medication 5

Isolation 1

Diabetic Retinopathy 1

Total 9

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient B

30

ConditionExtensive Services NTA Count

COPD 2

Diabetes Mellitus 2

Chronic Pancreatitis 1

Cirrhosis of Liver 1

Total 6

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

31

ConditionExtensive Services Before Fall NTA Count

Diabetes Mellitus 2

Total 2

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

32

ConditionExtensive Services After Fall NTA Count

IV Medication 5

Diabetes Mellitus 2

Endocarditis 1

Total 8

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1
	ConditionExtensive Service		Source		Points
	Specified Hereditary MetabolicImmune Disorders		MDS Item I8000		1
	Morbid Obesity		MDS Item I8000		1
	Special TreatmentsPrograms Radiation Post-admit Code		MDS Item O0100B2		1
	Highest Stage of Unhealed Pressure Ulcer - Stage 4		MDS Item M0300D1		1
	Psoriatic Arthropathy and Systemic Sclerosis		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1

PDPM WORKSHOP

PDPMOverview

PDPM WORKSHOP

Overview

bullThe Patient-Driven Payment Model (PDPM) is effective October 1 2019bullSpecifications included in the SNF PPS Final Rule

published July 30 2019bullICD-10 captured on MDS will drive clinical classification

which impacts reimbursementbullRehab days and minutes no longer impact paymentbullADL to functional scoring (Section GG)

PDPM WORKSHOP

Overview

bullUnder PDPM there are over 23000 potential payment groupsbullSpecific rate components will vary

throughout the staybullMDS Schedule Changesbull3 day interruption window

PDPM WORKSHOP

RUG IV VS PDPM

6

PDPM WORKSHOP

PDPMComponents amp CharacteristicsbullSherri Robbins Senior Managing

Consultant RN BSN LNHA RAC-CT CLNC ndash BKD LLP

PDPM WORKSHOP

5 CLINICAL PAYMENT DRIVERS

RESIDENT

PT PAYMENT

OT PAYMENT

NTA PAYMENT

SLP PAYMENT

NURSING PAYMENT

NON CASE MIX

8

PDPM WORKSHOP

PDPM Patient Classification

bullPatient classifications are used for each component (PTOTSLPNTA amp Nursing)

bullBreakdown of criteria for each classification

9

Component Criteria

PT Clinical Category Functional Score

OT Clinical Category Functional Score

SLP Presence of Acute Neurologic Condition SLP-related Comorbidity or Cognitive Impairment Mechanically-altered Diet Swallowing Disorder

NTA NTA Conditions Comorbidities Score

Nursing Clinical Condition Needs Functional Score

PDPM WORKSHOP

PDPM Clinical Category

10

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Categories Collapsed to 4 for PT amp OT

PDPM Clinical Category Collapsed PT amp OT Clinical Category

Major Joint Replacement or Spinal Surgery Major Joint Replacement or Spinal Surgery

Non-Orthopedic SurgeryAcute Neurologic

Non-Orthopedic Surgery amp Acute Neurologic

Non-Surgical OrthopedicMusculoskeletalOrthopedic Surgery (Except Major Joint Replacement or Spinal Surgery)

Other Orthopedic

Medical ManagementAcute InfectionsCancerPulmonaryCardiovascular amp Coagulations

Medical Management

PDPM WORKSHOP

PDPM CASE MIX PTOTbullCase mix has two primary elements used to determine classificationo Clinical Category for SNF stay (I0020B)

o Functional Status (Section GG)

12

Clinical CategoryPT amp OT

Function ScorePT amp OT

Case Mix Group PT CMI OT CMI

Major Joint Replacement or Spinal Surgery 0-5 TA 153 149Major Joint Replacement or Spinal Surgery 6-9 TB 170 163Major Joint Replacement or Spinal Surgery 10-23 TC 188 169Major Joint Replacement or Spinal Surgery 24 TD 192 153

Other Orthopedic 0-5 TE 142 141Other Orthopedic 6-9 TF 161 160Other Orthopedic 10-23 TG 167 164Other Orthopedic 24 TH 116 115

Medical Management 0-5 TI 113 118Medical Management 6-9 TJ 142 145Medical Management 10-23 TK 152 154Medical Management 24 TL 109 111

Other Orthopedic 0-5 TM 127 130Other Orthopedic 6-9 TN 148 150Other Orthopedic 10-23 TO 155 155Other Orthopedic 24 TP 108 109

GG

PDPM WORKSHOP

SLP Comorbidities

bullSLP has 12 comorbidities under PDPMoSLP comorbidity flag combines conditions amp services

oOnly the presence of one of the following is required to qualify

13

PDPM WORKSHOP

PDPM Case Mix SLPbullSLP has 3 elementso Clinical Category for SNF Stay- Acute Neurologic or Non-Neurologic

o Presence of Swallowing Disorder and or Mechanically Altered Diet

o Cognitive Status andor Presence of an SLP-related Comorbidity

14

Clinical CategoryPT amp OT

Function ScorePT amp OT

Case Mix Group PT CMI OT CMI

Major Joint Replacement or Spinal Surgery 0-5 TA 153 149Major Joint Replacement or Spinal Surgery 6-9 TB 170 163Major Joint Replacement or Spinal Surgery 10-23 TC 188 169Major Joint Replacement or Spinal Surgery 24 TD 192 153

Other Orthopedic 0-5 TE 142 141Other Orthopedic 6-9 TF 161 160Other Orthopedic 10-23 TG 167 164Other Orthopedic 24 TH 116 115

Medical Management 0-5 TI 113 118Medical Management 6-9 TJ 142 145Medical Management 10-23 TK 152 154Medical Management 24 TL 109 111

Other Orthopedic 0-5 TM 127 130Other Orthopedic 6-9 TN 148 150Other Orthopedic 10-23 TO 155 155Other Orthopedic 24 TP 108 109

GG

PDPM WORKSHOP

SLP Component

bullPresence of oMechanically Altered Diet (Section K)

oSwallowing Disorder (Section K)

PDPM WORKSHOP

MDS Section K

16

PDPM WORKSHOP

Nursing Component

bullSame RUG IV Major CategoriesoExtensive Services

oSpecial Care High

oSpecial Care Low

oClinically Complex

oBehavior Symptoms amp Cognitive Impairment

oReduced Physical Function

PDPM WORKSHOP

Nursing Functional Score

bullMDS Section GG ndash Functional Abilities amp GoalsoAssessed during first three days of admission

oDocuments ldquousual performancerdquo

oFunctional score ranges from zero to 16

Eating Average Bed Mobility

Toilet Hygiene Average Transfer

PDPM WORKSHOP

Nursing CMI

NursingComponent

Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

HBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

NursingComponent

Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

PDPM WORKSHOP

Nursing Component

bullImportant to NoteoNursing component will be increased by 18 for residents with HIVAIDS

o8 points into the NTA count

bull B20 must be on SNF claim

PDPM WORKSHOP

NTA amp Comorbidity CodingbullComorbidity score is a weighted count of comorbidities

o Comorbidities associated with high increases in NTA costs grouped into various point tiers

o Points assigned for each additional comorbidity present with more points awarded for higher-cost tiers

bullComorbidities amp extensive services for NTA classification are derived from a variety of MDS sources with some identified in Item I8000

bullHIVAIDS remains a SNF claim reported adjustment (8 pts)

bullCalculated based on points assigned for 50 MDS items

21

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

PDPM WORKSHOP

NTA Component

bullData Sources

22

HIV AIDS SNF Claim

Bowelbladder appl H0100C H0100D Ostomy catheterization

ParenteralIVtube feed Section K

Ulcers foot skin probs Section M

Special treatmentsext services Section O IV meds ventilator trach suctioning transfusion radiation infection etc

Diagnoses Section I 6 specific diagnoses

Additional active Dx Item I8000 28 specific diagnoses

PDPM WORKSHOP

ConditionExtensive Service Source PointsHIVAIDS SNF Claim 8Parental IV Feeding Level High MDS Item K0510A2 K0710A2 7Special Treatment Programs Intravenous Medication Post-Admit Code MDS Item O0100H2 5Special Treatment Programs Ventilator or Respirator Post-admit Code MDS Item O0100F2 4

Parental IV Feeding Level LowMDS Item K0510A2 K0710A2 K0710B2 3

Lung Transplant Status MDS Item I8000 3Special TreatmentsPrograms Transfusion Post-admit Code MDS Item O0100I2 2Major Organ Transplant Status Except Lung MDS Item I8000 2Active Diagnoses Asthma COPD Chronic Lung Disease Code MDS Item I6200 2BoneJointMuscle InfectionsNecrosis - Except Aseptic Necrosis of Bone MDS Item I8000 2Chronic Myeloid Leukemia MDS Item I8000 2Wound Infection Code MDS Item I2500 2Active Diagnoses Diabetes Mellitus (DM) Code MDS Item I2900 2Endocarditis MDS I8000 1Immune Disorders MDS I8000 1End-Stage Liver Disease MDS I8000 1Other Foot Skin Problems Diabetic Foot Ulcer Code MDS Item M1040B 1Narcolepsy and Cataplexy MDS Item I8000 1Cystic Fibrosis MDS Item I8000 1Special TreatmentsPrograms Tracheostomy Care Post-admit Code MDS Item O00100E2 1Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code MDS Item I1700 1Special TreatmentsPrograms Isolation Post-admit Code MDS Item O0100M2 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsChronic Pancreatitis MDS Item I8000 1Proliferated Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code

MDS Item M1040A M1040B M1040C 1

Complications of Specified Implant Device or Graft MDS Item I8000 1Bladder and Bowel Appliances Intermittent Catheterization MDS Item H0100D 1Inflammatory Bowel Disease MDS Item I1300 1Aseptic Necrosis of Bone MDS Item I8000 1Special TreatmentsPrograms Suctioning Post-admit Code MDS Item O0100D2 1Cardio-Respiratory Failure and Shock MDS Item I8000 1Myelodysplastic Syndromes and Myelofibrosis MDS Item I8000 1Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage MDS Item I8000 1Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Nutritional Approaches While a Resident Feeding Tube MDS Item K0510B2 1Severe Skin Burn or Condition MDS Item I8000 1Intractable Epilepsy MDS Item I8000 1Active Diagnoses Malnutrition code I560 1Disorders of Immunity - Except RxCC97 Immune Disorders MDS Item I8000 1Cirrhosis of Liver MDS Item I8000 1Bladder and Bowel Appliances Ostomy MDS Item H0100C 1Respiratory Arrest MDS Item I8000 1Pulmonary Fibrosis and Other Chronic Lung Disorders MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsSpecified Hereditary MetabolicImmune Disorders MDS Item I8000 1Morbid Obesity MDS Item I8000 1Special TreatmentsPrograms Radiation Post-admit Code MDS Item O0100B2 1Highest Stage of Unhealed Pressure Ulcer - Stage 4 MDS Item M0300D1 1Psoriatic Arthropathy and Systemic Sclerosis MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 184 (NC) X 30 X $44110

Every Point CountsNTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

Every Point Counts

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 253 (NB) X 30 X $60652

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

WORKSHEET

bullNTA Worksheet Calculate the number of NTA points amp payment for the 4 scenarios

28

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient A

29

ConditionExtensive Services NTA Count

Diabetes Mellitus 2

IV Medication 5

Isolation 1

Diabetic Retinopathy 1

Total 9

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient B

30

ConditionExtensive Services NTA Count

COPD 2

Diabetes Mellitus 2

Chronic Pancreatitis 1

Cirrhosis of Liver 1

Total 6

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

31

ConditionExtensive Services Before Fall NTA Count

Diabetes Mellitus 2

Total 2

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

32

ConditionExtensive Services After Fall NTA Count

IV Medication 5

Diabetes Mellitus 2

Endocarditis 1

Total 8

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1
	ConditionExtensive Service		Source		Points
	Specified Hereditary MetabolicImmune Disorders		MDS Item I8000		1
	Morbid Obesity		MDS Item I8000		1
	Special TreatmentsPrograms Radiation Post-admit Code		MDS Item O0100B2		1
	Highest Stage of Unhealed Pressure Ulcer - Stage 4		MDS Item M0300D1		1
	Psoriatic Arthropathy and Systemic Sclerosis		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1

PDPM WORKSHOP

Overview

bullThe Patient-Driven Payment Model (PDPM) is effective October 1 2019bullSpecifications included in the SNF PPS Final Rule

published July 30 2019bullICD-10 captured on MDS will drive clinical classification

which impacts reimbursementbullRehab days and minutes no longer impact paymentbullADL to functional scoring (Section GG)

PDPM WORKSHOP

Overview

bullUnder PDPM there are over 23000 potential payment groupsbullSpecific rate components will vary

throughout the staybullMDS Schedule Changesbull3 day interruption window

PDPM WORKSHOP

RUG IV VS PDPM

6

PDPM WORKSHOP

PDPMComponents amp CharacteristicsbullSherri Robbins Senior Managing

Consultant RN BSN LNHA RAC-CT CLNC ndash BKD LLP

PDPM WORKSHOP

5 CLINICAL PAYMENT DRIVERS

RESIDENT

PT PAYMENT

OT PAYMENT

NTA PAYMENT

SLP PAYMENT

NURSING PAYMENT

NON CASE MIX

8

PDPM WORKSHOP

PDPM Patient Classification

bullPatient classifications are used for each component (PTOTSLPNTA amp Nursing)

bullBreakdown of criteria for each classification

9

Component Criteria

PT Clinical Category Functional Score

OT Clinical Category Functional Score

SLP Presence of Acute Neurologic Condition SLP-related Comorbidity or Cognitive Impairment Mechanically-altered Diet Swallowing Disorder

NTA NTA Conditions Comorbidities Score

Nursing Clinical Condition Needs Functional Score

PDPM WORKSHOP

PDPM Clinical Category

10

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Categories Collapsed to 4 for PT amp OT

PDPM Clinical Category Collapsed PT amp OT Clinical Category

Major Joint Replacement or Spinal Surgery Major Joint Replacement or Spinal Surgery

Non-Orthopedic SurgeryAcute Neurologic

Non-Orthopedic Surgery amp Acute Neurologic

Non-Surgical OrthopedicMusculoskeletalOrthopedic Surgery (Except Major Joint Replacement or Spinal Surgery)

Other Orthopedic

Medical ManagementAcute InfectionsCancerPulmonaryCardiovascular amp Coagulations

Medical Management

PDPM WORKSHOP

PDPM CASE MIX PTOTbullCase mix has two primary elements used to determine classificationo Clinical Category for SNF stay (I0020B)

o Functional Status (Section GG)

12

Clinical CategoryPT amp OT

Function ScorePT amp OT

Case Mix Group PT CMI OT CMI

Major Joint Replacement or Spinal Surgery 0-5 TA 153 149Major Joint Replacement or Spinal Surgery 6-9 TB 170 163Major Joint Replacement or Spinal Surgery 10-23 TC 188 169Major Joint Replacement or Spinal Surgery 24 TD 192 153

Other Orthopedic 0-5 TE 142 141Other Orthopedic 6-9 TF 161 160Other Orthopedic 10-23 TG 167 164Other Orthopedic 24 TH 116 115

Medical Management 0-5 TI 113 118Medical Management 6-9 TJ 142 145Medical Management 10-23 TK 152 154Medical Management 24 TL 109 111

Other Orthopedic 0-5 TM 127 130Other Orthopedic 6-9 TN 148 150Other Orthopedic 10-23 TO 155 155Other Orthopedic 24 TP 108 109

GG

PDPM WORKSHOP

SLP Comorbidities

bullSLP has 12 comorbidities under PDPMoSLP comorbidity flag combines conditions amp services

oOnly the presence of one of the following is required to qualify

13

PDPM WORKSHOP

PDPM Case Mix SLPbullSLP has 3 elementso Clinical Category for SNF Stay- Acute Neurologic or Non-Neurologic

o Presence of Swallowing Disorder and or Mechanically Altered Diet

o Cognitive Status andor Presence of an SLP-related Comorbidity

14

Clinical CategoryPT amp OT

Function ScorePT amp OT

Case Mix Group PT CMI OT CMI

Major Joint Replacement or Spinal Surgery 0-5 TA 153 149Major Joint Replacement or Spinal Surgery 6-9 TB 170 163Major Joint Replacement or Spinal Surgery 10-23 TC 188 169Major Joint Replacement or Spinal Surgery 24 TD 192 153

Other Orthopedic 0-5 TE 142 141Other Orthopedic 6-9 TF 161 160Other Orthopedic 10-23 TG 167 164Other Orthopedic 24 TH 116 115

Medical Management 0-5 TI 113 118Medical Management 6-9 TJ 142 145Medical Management 10-23 TK 152 154Medical Management 24 TL 109 111

Other Orthopedic 0-5 TM 127 130Other Orthopedic 6-9 TN 148 150Other Orthopedic 10-23 TO 155 155Other Orthopedic 24 TP 108 109

GG

PDPM WORKSHOP

SLP Component

bullPresence of oMechanically Altered Diet (Section K)

oSwallowing Disorder (Section K)

PDPM WORKSHOP

MDS Section K

16

PDPM WORKSHOP

Nursing Component

bullSame RUG IV Major CategoriesoExtensive Services

oSpecial Care High

oSpecial Care Low

oClinically Complex

oBehavior Symptoms amp Cognitive Impairment

oReduced Physical Function

PDPM WORKSHOP

Nursing Functional Score

bullMDS Section GG ndash Functional Abilities amp GoalsoAssessed during first three days of admission

oDocuments ldquousual performancerdquo

oFunctional score ranges from zero to 16

Eating Average Bed Mobility

Toilet Hygiene Average Transfer

PDPM WORKSHOP

Nursing CMI

NursingComponent

Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

HBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

NursingComponent

Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

PDPM WORKSHOP

Nursing Component

bullImportant to NoteoNursing component will be increased by 18 for residents with HIVAIDS

o8 points into the NTA count

bull B20 must be on SNF claim

PDPM WORKSHOP

NTA amp Comorbidity CodingbullComorbidity score is a weighted count of comorbidities

o Comorbidities associated with high increases in NTA costs grouped into various point tiers

o Points assigned for each additional comorbidity present with more points awarded for higher-cost tiers

bullComorbidities amp extensive services for NTA classification are derived from a variety of MDS sources with some identified in Item I8000

bullHIVAIDS remains a SNF claim reported adjustment (8 pts)

bullCalculated based on points assigned for 50 MDS items

21

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

PDPM WORKSHOP

NTA Component

bullData Sources

22

HIV AIDS SNF Claim

Bowelbladder appl H0100C H0100D Ostomy catheterization

ParenteralIVtube feed Section K

Ulcers foot skin probs Section M

Special treatmentsext services Section O IV meds ventilator trach suctioning transfusion radiation infection etc

Diagnoses Section I 6 specific diagnoses

Additional active Dx Item I8000 28 specific diagnoses

PDPM WORKSHOP

ConditionExtensive Service Source PointsHIVAIDS SNF Claim 8Parental IV Feeding Level High MDS Item K0510A2 K0710A2 7Special Treatment Programs Intravenous Medication Post-Admit Code MDS Item O0100H2 5Special Treatment Programs Ventilator or Respirator Post-admit Code MDS Item O0100F2 4

Parental IV Feeding Level LowMDS Item K0510A2 K0710A2 K0710B2 3

Lung Transplant Status MDS Item I8000 3Special TreatmentsPrograms Transfusion Post-admit Code MDS Item O0100I2 2Major Organ Transplant Status Except Lung MDS Item I8000 2Active Diagnoses Asthma COPD Chronic Lung Disease Code MDS Item I6200 2BoneJointMuscle InfectionsNecrosis - Except Aseptic Necrosis of Bone MDS Item I8000 2Chronic Myeloid Leukemia MDS Item I8000 2Wound Infection Code MDS Item I2500 2Active Diagnoses Diabetes Mellitus (DM) Code MDS Item I2900 2Endocarditis MDS I8000 1Immune Disorders MDS I8000 1End-Stage Liver Disease MDS I8000 1Other Foot Skin Problems Diabetic Foot Ulcer Code MDS Item M1040B 1Narcolepsy and Cataplexy MDS Item I8000 1Cystic Fibrosis MDS Item I8000 1Special TreatmentsPrograms Tracheostomy Care Post-admit Code MDS Item O00100E2 1Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code MDS Item I1700 1Special TreatmentsPrograms Isolation Post-admit Code MDS Item O0100M2 1

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PDPM WORKSHOP

ConditionExtensive Service Source PointsChronic Pancreatitis MDS Item I8000 1Proliferated Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code

MDS Item M1040A M1040B M1040C 1

Complications of Specified Implant Device or Graft MDS Item I8000 1Bladder and Bowel Appliances Intermittent Catheterization MDS Item H0100D 1Inflammatory Bowel Disease MDS Item I1300 1Aseptic Necrosis of Bone MDS Item I8000 1Special TreatmentsPrograms Suctioning Post-admit Code MDS Item O0100D2 1Cardio-Respiratory Failure and Shock MDS Item I8000 1Myelodysplastic Syndromes and Myelofibrosis MDS Item I8000 1Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage MDS Item I8000 1Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Nutritional Approaches While a Resident Feeding Tube MDS Item K0510B2 1Severe Skin Burn or Condition MDS Item I8000 1Intractable Epilepsy MDS Item I8000 1Active Diagnoses Malnutrition code I560 1Disorders of Immunity - Except RxCC97 Immune Disorders MDS Item I8000 1Cirrhosis of Liver MDS Item I8000 1Bladder and Bowel Appliances Ostomy MDS Item H0100C 1Respiratory Arrest MDS Item I8000 1Pulmonary Fibrosis and Other Chronic Lung Disorders MDS Item I8000 1

Sheet1

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PDPM WORKSHOP

ConditionExtensive Service Source PointsSpecified Hereditary MetabolicImmune Disorders MDS Item I8000 1Morbid Obesity MDS Item I8000 1Special TreatmentsPrograms Radiation Post-admit Code MDS Item O0100B2 1Highest Stage of Unhealed Pressure Ulcer - Stage 4 MDS Item M0300D1 1Psoriatic Arthropathy and Systemic Sclerosis MDS Item I8000 1

Sheet1

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PDPM WORKSHOP

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 184 (NC) X 30 X $44110

Every Point CountsNTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

Every Point Counts

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 253 (NB) X 30 X $60652

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

WORKSHEET

bullNTA Worksheet Calculate the number of NTA points amp payment for the 4 scenarios

28

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient A

29

ConditionExtensive Services NTA Count

Diabetes Mellitus 2

IV Medication 5

Isolation 1

Diabetic Retinopathy 1

Total 9

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient B

30

ConditionExtensive Services NTA Count

COPD 2

Diabetes Mellitus 2

Chronic Pancreatitis 1

Cirrhosis of Liver 1

Total 6

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

31

ConditionExtensive Services Before Fall NTA Count

Diabetes Mellitus 2

Total 2

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

32

ConditionExtensive Services After Fall NTA Count

IV Medication 5

Diabetes Mellitus 2

Endocarditis 1

Total 8

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1
	ConditionExtensive Service		Source		Points
	Specified Hereditary MetabolicImmune Disorders		MDS Item I8000		1
	Morbid Obesity		MDS Item I8000		1
	Special TreatmentsPrograms Radiation Post-admit Code		MDS Item O0100B2		1
	Highest Stage of Unhealed Pressure Ulcer - Stage 4		MDS Item M0300D1		1
	Psoriatic Arthropathy and Systemic Sclerosis		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1

PDPM WORKSHOP

Overview

bullUnder PDPM there are over 23000 potential payment groupsbullSpecific rate components will vary

throughout the staybullMDS Schedule Changesbull3 day interruption window

PDPM WORKSHOP

RUG IV VS PDPM

6

PDPM WORKSHOP

PDPMComponents amp CharacteristicsbullSherri Robbins Senior Managing

Consultant RN BSN LNHA RAC-CT CLNC ndash BKD LLP

PDPM WORKSHOP

5 CLINICAL PAYMENT DRIVERS

RESIDENT

PT PAYMENT

OT PAYMENT

NTA PAYMENT

SLP PAYMENT

NURSING PAYMENT

NON CASE MIX

8

PDPM WORKSHOP

PDPM Patient Classification

bullPatient classifications are used for each component (PTOTSLPNTA amp Nursing)

bullBreakdown of criteria for each classification

9

Component Criteria

PT Clinical Category Functional Score

OT Clinical Category Functional Score

SLP Presence of Acute Neurologic Condition SLP-related Comorbidity or Cognitive Impairment Mechanically-altered Diet Swallowing Disorder

NTA NTA Conditions Comorbidities Score

Nursing Clinical Condition Needs Functional Score

PDPM WORKSHOP

PDPM Clinical Category

10

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Categories Collapsed to 4 for PT amp OT

PDPM Clinical Category Collapsed PT amp OT Clinical Category

Major Joint Replacement or Spinal Surgery Major Joint Replacement or Spinal Surgery

Non-Orthopedic SurgeryAcute Neurologic

Non-Orthopedic Surgery amp Acute Neurologic

Non-Surgical OrthopedicMusculoskeletalOrthopedic Surgery (Except Major Joint Replacement or Spinal Surgery)

Other Orthopedic

Medical ManagementAcute InfectionsCancerPulmonaryCardiovascular amp Coagulations

Medical Management

PDPM WORKSHOP

PDPM CASE MIX PTOTbullCase mix has two primary elements used to determine classificationo Clinical Category for SNF stay (I0020B)

o Functional Status (Section GG)

12

Clinical CategoryPT amp OT

Function ScorePT amp OT

Case Mix Group PT CMI OT CMI

Major Joint Replacement or Spinal Surgery 0-5 TA 153 149Major Joint Replacement or Spinal Surgery 6-9 TB 170 163Major Joint Replacement or Spinal Surgery 10-23 TC 188 169Major Joint Replacement or Spinal Surgery 24 TD 192 153

Other Orthopedic 0-5 TE 142 141Other Orthopedic 6-9 TF 161 160Other Orthopedic 10-23 TG 167 164Other Orthopedic 24 TH 116 115

Medical Management 0-5 TI 113 118Medical Management 6-9 TJ 142 145Medical Management 10-23 TK 152 154Medical Management 24 TL 109 111

Other Orthopedic 0-5 TM 127 130Other Orthopedic 6-9 TN 148 150Other Orthopedic 10-23 TO 155 155Other Orthopedic 24 TP 108 109

GG

PDPM WORKSHOP

SLP Comorbidities

bullSLP has 12 comorbidities under PDPMoSLP comorbidity flag combines conditions amp services

oOnly the presence of one of the following is required to qualify

13

PDPM WORKSHOP

PDPM Case Mix SLPbullSLP has 3 elementso Clinical Category for SNF Stay- Acute Neurologic or Non-Neurologic

o Presence of Swallowing Disorder and or Mechanically Altered Diet

o Cognitive Status andor Presence of an SLP-related Comorbidity

14

Clinical CategoryPT amp OT

Function ScorePT amp OT

Case Mix Group PT CMI OT CMI

Major Joint Replacement or Spinal Surgery 0-5 TA 153 149Major Joint Replacement or Spinal Surgery 6-9 TB 170 163Major Joint Replacement or Spinal Surgery 10-23 TC 188 169Major Joint Replacement or Spinal Surgery 24 TD 192 153

Other Orthopedic 0-5 TE 142 141Other Orthopedic 6-9 TF 161 160Other Orthopedic 10-23 TG 167 164Other Orthopedic 24 TH 116 115

Medical Management 0-5 TI 113 118Medical Management 6-9 TJ 142 145Medical Management 10-23 TK 152 154Medical Management 24 TL 109 111

Other Orthopedic 0-5 TM 127 130Other Orthopedic 6-9 TN 148 150Other Orthopedic 10-23 TO 155 155Other Orthopedic 24 TP 108 109

GG

PDPM WORKSHOP

SLP Component

bullPresence of oMechanically Altered Diet (Section K)

oSwallowing Disorder (Section K)

PDPM WORKSHOP

MDS Section K

16

PDPM WORKSHOP

Nursing Component

bullSame RUG IV Major CategoriesoExtensive Services

oSpecial Care High

oSpecial Care Low

oClinically Complex

oBehavior Symptoms amp Cognitive Impairment

oReduced Physical Function

PDPM WORKSHOP

Nursing Functional Score

bullMDS Section GG ndash Functional Abilities amp GoalsoAssessed during first three days of admission

oDocuments ldquousual performancerdquo

oFunctional score ranges from zero to 16

Eating Average Bed Mobility

Toilet Hygiene Average Transfer

PDPM WORKSHOP

Nursing CMI

NursingComponent

Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

HBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

NursingComponent

Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

PDPM WORKSHOP

Nursing Component

bullImportant to NoteoNursing component will be increased by 18 for residents with HIVAIDS

o8 points into the NTA count

bull B20 must be on SNF claim

PDPM WORKSHOP

NTA amp Comorbidity CodingbullComorbidity score is a weighted count of comorbidities

o Comorbidities associated with high increases in NTA costs grouped into various point tiers

o Points assigned for each additional comorbidity present with more points awarded for higher-cost tiers

bullComorbidities amp extensive services for NTA classification are derived from a variety of MDS sources with some identified in Item I8000

bullHIVAIDS remains a SNF claim reported adjustment (8 pts)

bullCalculated based on points assigned for 50 MDS items

21

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

PDPM WORKSHOP

NTA Component

bullData Sources

22

HIV AIDS SNF Claim

Bowelbladder appl H0100C H0100D Ostomy catheterization

ParenteralIVtube feed Section K

Ulcers foot skin probs Section M

Special treatmentsext services Section O IV meds ventilator trach suctioning transfusion radiation infection etc

Diagnoses Section I 6 specific diagnoses

Additional active Dx Item I8000 28 specific diagnoses

PDPM WORKSHOP

ConditionExtensive Service Source PointsHIVAIDS SNF Claim 8Parental IV Feeding Level High MDS Item K0510A2 K0710A2 7Special Treatment Programs Intravenous Medication Post-Admit Code MDS Item O0100H2 5Special Treatment Programs Ventilator or Respirator Post-admit Code MDS Item O0100F2 4

Parental IV Feeding Level LowMDS Item K0510A2 K0710A2 K0710B2 3

Lung Transplant Status MDS Item I8000 3Special TreatmentsPrograms Transfusion Post-admit Code MDS Item O0100I2 2Major Organ Transplant Status Except Lung MDS Item I8000 2Active Diagnoses Asthma COPD Chronic Lung Disease Code MDS Item I6200 2BoneJointMuscle InfectionsNecrosis - Except Aseptic Necrosis of Bone MDS Item I8000 2Chronic Myeloid Leukemia MDS Item I8000 2Wound Infection Code MDS Item I2500 2Active Diagnoses Diabetes Mellitus (DM) Code MDS Item I2900 2Endocarditis MDS I8000 1Immune Disorders MDS I8000 1End-Stage Liver Disease MDS I8000 1Other Foot Skin Problems Diabetic Foot Ulcer Code MDS Item M1040B 1Narcolepsy and Cataplexy MDS Item I8000 1Cystic Fibrosis MDS Item I8000 1Special TreatmentsPrograms Tracheostomy Care Post-admit Code MDS Item O00100E2 1Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code MDS Item I1700 1Special TreatmentsPrograms Isolation Post-admit Code MDS Item O0100M2 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsChronic Pancreatitis MDS Item I8000 1Proliferated Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code

MDS Item M1040A M1040B M1040C 1

Complications of Specified Implant Device or Graft MDS Item I8000 1Bladder and Bowel Appliances Intermittent Catheterization MDS Item H0100D 1Inflammatory Bowel Disease MDS Item I1300 1Aseptic Necrosis of Bone MDS Item I8000 1Special TreatmentsPrograms Suctioning Post-admit Code MDS Item O0100D2 1Cardio-Respiratory Failure and Shock MDS Item I8000 1Myelodysplastic Syndromes and Myelofibrosis MDS Item I8000 1Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage MDS Item I8000 1Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Nutritional Approaches While a Resident Feeding Tube MDS Item K0510B2 1Severe Skin Burn or Condition MDS Item I8000 1Intractable Epilepsy MDS Item I8000 1Active Diagnoses Malnutrition code I560 1Disorders of Immunity - Except RxCC97 Immune Disorders MDS Item I8000 1Cirrhosis of Liver MDS Item I8000 1Bladder and Bowel Appliances Ostomy MDS Item H0100C 1Respiratory Arrest MDS Item I8000 1Pulmonary Fibrosis and Other Chronic Lung Disorders MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsSpecified Hereditary MetabolicImmune Disorders MDS Item I8000 1Morbid Obesity MDS Item I8000 1Special TreatmentsPrograms Radiation Post-admit Code MDS Item O0100B2 1Highest Stage of Unhealed Pressure Ulcer - Stage 4 MDS Item M0300D1 1Psoriatic Arthropathy and Systemic Sclerosis MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 184 (NC) X 30 X $44110

Every Point CountsNTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

Every Point Counts

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 253 (NB) X 30 X $60652

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

WORKSHEET

bullNTA Worksheet Calculate the number of NTA points amp payment for the 4 scenarios

28

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient A

29

ConditionExtensive Services NTA Count

Diabetes Mellitus 2

IV Medication 5

Isolation 1

Diabetic Retinopathy 1

Total 9

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient B

30

ConditionExtensive Services NTA Count

COPD 2

Diabetes Mellitus 2

Chronic Pancreatitis 1

Cirrhosis of Liver 1

Total 6

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

31

ConditionExtensive Services Before Fall NTA Count

Diabetes Mellitus 2

Total 2

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

32

ConditionExtensive Services After Fall NTA Count

IV Medication 5

Diabetes Mellitus 2

Endocarditis 1

Total 8

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1
	ConditionExtensive Service		Source		Points
	Specified Hereditary MetabolicImmune Disorders		MDS Item I8000		1
	Morbid Obesity		MDS Item I8000		1
	Special TreatmentsPrograms Radiation Post-admit Code		MDS Item O0100B2		1
	Highest Stage of Unhealed Pressure Ulcer - Stage 4		MDS Item M0300D1		1
	Psoriatic Arthropathy and Systemic Sclerosis		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1

PDPM WORKSHOP

RUG IV VS PDPM

6

PDPM WORKSHOP

PDPMComponents amp CharacteristicsbullSherri Robbins Senior Managing

Consultant RN BSN LNHA RAC-CT CLNC ndash BKD LLP

PDPM WORKSHOP

5 CLINICAL PAYMENT DRIVERS

RESIDENT

PT PAYMENT

OT PAYMENT

NTA PAYMENT

SLP PAYMENT

NURSING PAYMENT

NON CASE MIX

8

PDPM WORKSHOP

PDPM Patient Classification

bullPatient classifications are used for each component (PTOTSLPNTA amp Nursing)

bullBreakdown of criteria for each classification

9

Component Criteria

PT Clinical Category Functional Score

OT Clinical Category Functional Score

SLP Presence of Acute Neurologic Condition SLP-related Comorbidity or Cognitive Impairment Mechanically-altered Diet Swallowing Disorder

NTA NTA Conditions Comorbidities Score

Nursing Clinical Condition Needs Functional Score

PDPM WORKSHOP

PDPM Clinical Category

10

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Categories Collapsed to 4 for PT amp OT

PDPM Clinical Category Collapsed PT amp OT Clinical Category

Major Joint Replacement or Spinal Surgery Major Joint Replacement or Spinal Surgery

Non-Orthopedic SurgeryAcute Neurologic

Non-Orthopedic Surgery amp Acute Neurologic

Non-Surgical OrthopedicMusculoskeletalOrthopedic Surgery (Except Major Joint Replacement or Spinal Surgery)

Other Orthopedic

Medical ManagementAcute InfectionsCancerPulmonaryCardiovascular amp Coagulations

Medical Management

PDPM WORKSHOP

PDPM CASE MIX PTOTbullCase mix has two primary elements used to determine classificationo Clinical Category for SNF stay (I0020B)

o Functional Status (Section GG)

12

Clinical CategoryPT amp OT

Function ScorePT amp OT

Case Mix Group PT CMI OT CMI

Major Joint Replacement or Spinal Surgery 0-5 TA 153 149Major Joint Replacement or Spinal Surgery 6-9 TB 170 163Major Joint Replacement or Spinal Surgery 10-23 TC 188 169Major Joint Replacement or Spinal Surgery 24 TD 192 153

Other Orthopedic 0-5 TE 142 141Other Orthopedic 6-9 TF 161 160Other Orthopedic 10-23 TG 167 164Other Orthopedic 24 TH 116 115

Medical Management 0-5 TI 113 118Medical Management 6-9 TJ 142 145Medical Management 10-23 TK 152 154Medical Management 24 TL 109 111

Other Orthopedic 0-5 TM 127 130Other Orthopedic 6-9 TN 148 150Other Orthopedic 10-23 TO 155 155Other Orthopedic 24 TP 108 109

GG

PDPM WORKSHOP

SLP Comorbidities

bullSLP has 12 comorbidities under PDPMoSLP comorbidity flag combines conditions amp services

oOnly the presence of one of the following is required to qualify

13

PDPM WORKSHOP

PDPM Case Mix SLPbullSLP has 3 elementso Clinical Category for SNF Stay- Acute Neurologic or Non-Neurologic

o Presence of Swallowing Disorder and or Mechanically Altered Diet

o Cognitive Status andor Presence of an SLP-related Comorbidity

14

Clinical CategoryPT amp OT

Function ScorePT amp OT

Case Mix Group PT CMI OT CMI

Major Joint Replacement or Spinal Surgery 0-5 TA 153 149Major Joint Replacement or Spinal Surgery 6-9 TB 170 163Major Joint Replacement or Spinal Surgery 10-23 TC 188 169Major Joint Replacement or Spinal Surgery 24 TD 192 153

Other Orthopedic 0-5 TE 142 141Other Orthopedic 6-9 TF 161 160Other Orthopedic 10-23 TG 167 164Other Orthopedic 24 TH 116 115

Medical Management 0-5 TI 113 118Medical Management 6-9 TJ 142 145Medical Management 10-23 TK 152 154Medical Management 24 TL 109 111

Other Orthopedic 0-5 TM 127 130Other Orthopedic 6-9 TN 148 150Other Orthopedic 10-23 TO 155 155Other Orthopedic 24 TP 108 109

GG

PDPM WORKSHOP

SLP Component

bullPresence of oMechanically Altered Diet (Section K)

oSwallowing Disorder (Section K)

PDPM WORKSHOP

MDS Section K

16

PDPM WORKSHOP

Nursing Component

bullSame RUG IV Major CategoriesoExtensive Services

oSpecial Care High

oSpecial Care Low

oClinically Complex

oBehavior Symptoms amp Cognitive Impairment

oReduced Physical Function

PDPM WORKSHOP

Nursing Functional Score

bullMDS Section GG ndash Functional Abilities amp GoalsoAssessed during first three days of admission

oDocuments ldquousual performancerdquo

oFunctional score ranges from zero to 16

Eating Average Bed Mobility

Toilet Hygiene Average Transfer

PDPM WORKSHOP

Nursing CMI

NursingComponent

Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

HBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

NursingComponent

Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

PDPM WORKSHOP

Nursing Component

bullImportant to NoteoNursing component will be increased by 18 for residents with HIVAIDS

o8 points into the NTA count

bull B20 must be on SNF claim

PDPM WORKSHOP

NTA amp Comorbidity CodingbullComorbidity score is a weighted count of comorbidities

o Comorbidities associated with high increases in NTA costs grouped into various point tiers

o Points assigned for each additional comorbidity present with more points awarded for higher-cost tiers

bullComorbidities amp extensive services for NTA classification are derived from a variety of MDS sources with some identified in Item I8000

bullHIVAIDS remains a SNF claim reported adjustment (8 pts)

bullCalculated based on points assigned for 50 MDS items

21

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

PDPM WORKSHOP

NTA Component

bullData Sources

22

HIV AIDS SNF Claim

Bowelbladder appl H0100C H0100D Ostomy catheterization

ParenteralIVtube feed Section K

Ulcers foot skin probs Section M

Special treatmentsext services Section O IV meds ventilator trach suctioning transfusion radiation infection etc

Diagnoses Section I 6 specific diagnoses

Additional active Dx Item I8000 28 specific diagnoses

PDPM WORKSHOP

ConditionExtensive Service Source PointsHIVAIDS SNF Claim 8Parental IV Feeding Level High MDS Item K0510A2 K0710A2 7Special Treatment Programs Intravenous Medication Post-Admit Code MDS Item O0100H2 5Special Treatment Programs Ventilator or Respirator Post-admit Code MDS Item O0100F2 4

Parental IV Feeding Level LowMDS Item K0510A2 K0710A2 K0710B2 3

Lung Transplant Status MDS Item I8000 3Special TreatmentsPrograms Transfusion Post-admit Code MDS Item O0100I2 2Major Organ Transplant Status Except Lung MDS Item I8000 2Active Diagnoses Asthma COPD Chronic Lung Disease Code MDS Item I6200 2BoneJointMuscle InfectionsNecrosis - Except Aseptic Necrosis of Bone MDS Item I8000 2Chronic Myeloid Leukemia MDS Item I8000 2Wound Infection Code MDS Item I2500 2Active Diagnoses Diabetes Mellitus (DM) Code MDS Item I2900 2Endocarditis MDS I8000 1Immune Disorders MDS I8000 1End-Stage Liver Disease MDS I8000 1Other Foot Skin Problems Diabetic Foot Ulcer Code MDS Item M1040B 1Narcolepsy and Cataplexy MDS Item I8000 1Cystic Fibrosis MDS Item I8000 1Special TreatmentsPrograms Tracheostomy Care Post-admit Code MDS Item O00100E2 1Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code MDS Item I1700 1Special TreatmentsPrograms Isolation Post-admit Code MDS Item O0100M2 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsChronic Pancreatitis MDS Item I8000 1Proliferated Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code

MDS Item M1040A M1040B M1040C 1

Complications of Specified Implant Device or Graft MDS Item I8000 1Bladder and Bowel Appliances Intermittent Catheterization MDS Item H0100D 1Inflammatory Bowel Disease MDS Item I1300 1Aseptic Necrosis of Bone MDS Item I8000 1Special TreatmentsPrograms Suctioning Post-admit Code MDS Item O0100D2 1Cardio-Respiratory Failure and Shock MDS Item I8000 1Myelodysplastic Syndromes and Myelofibrosis MDS Item I8000 1Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage MDS Item I8000 1Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Nutritional Approaches While a Resident Feeding Tube MDS Item K0510B2 1Severe Skin Burn or Condition MDS Item I8000 1Intractable Epilepsy MDS Item I8000 1Active Diagnoses Malnutrition code I560 1Disorders of Immunity - Except RxCC97 Immune Disorders MDS Item I8000 1Cirrhosis of Liver MDS Item I8000 1Bladder and Bowel Appliances Ostomy MDS Item H0100C 1Respiratory Arrest MDS Item I8000 1Pulmonary Fibrosis and Other Chronic Lung Disorders MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsSpecified Hereditary MetabolicImmune Disorders MDS Item I8000 1Morbid Obesity MDS Item I8000 1Special TreatmentsPrograms Radiation Post-admit Code MDS Item O0100B2 1Highest Stage of Unhealed Pressure Ulcer - Stage 4 MDS Item M0300D1 1Psoriatic Arthropathy and Systemic Sclerosis MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 184 (NC) X 30 X $44110

Every Point CountsNTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

Every Point Counts

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 253 (NB) X 30 X $60652

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

WORKSHEET

bullNTA Worksheet Calculate the number of NTA points amp payment for the 4 scenarios

28

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient A

29

ConditionExtensive Services NTA Count

Diabetes Mellitus 2

IV Medication 5

Isolation 1

Diabetic Retinopathy 1

Total 9

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient B

30

ConditionExtensive Services NTA Count

COPD 2

Diabetes Mellitus 2

Chronic Pancreatitis 1

Cirrhosis of Liver 1

Total 6

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

31

ConditionExtensive Services Before Fall NTA Count

Diabetes Mellitus 2

Total 2

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

32

ConditionExtensive Services After Fall NTA Count

IV Medication 5

Diabetes Mellitus 2

Endocarditis 1

Total 8

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1
	ConditionExtensive Service		Source		Points
	Specified Hereditary MetabolicImmune Disorders		MDS Item I8000		1
	Morbid Obesity		MDS Item I8000		1
	Special TreatmentsPrograms Radiation Post-admit Code		MDS Item O0100B2		1
	Highest Stage of Unhealed Pressure Ulcer - Stage 4		MDS Item M0300D1		1
	Psoriatic Arthropathy and Systemic Sclerosis		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1

PDPM WORKSHOP

PDPMComponents amp CharacteristicsbullSherri Robbins Senior Managing

Consultant RN BSN LNHA RAC-CT CLNC ndash BKD LLP

PDPM WORKSHOP

5 CLINICAL PAYMENT DRIVERS

RESIDENT

PT PAYMENT

OT PAYMENT

NTA PAYMENT

SLP PAYMENT

NURSING PAYMENT

NON CASE MIX

8

PDPM WORKSHOP

PDPM Patient Classification

bullPatient classifications are used for each component (PTOTSLPNTA amp Nursing)

bullBreakdown of criteria for each classification

9

Component Criteria

PT Clinical Category Functional Score

OT Clinical Category Functional Score

SLP Presence of Acute Neurologic Condition SLP-related Comorbidity or Cognitive Impairment Mechanically-altered Diet Swallowing Disorder

NTA NTA Conditions Comorbidities Score

Nursing Clinical Condition Needs Functional Score

PDPM WORKSHOP

PDPM Clinical Category

10

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Categories Collapsed to 4 for PT amp OT

PDPM Clinical Category Collapsed PT amp OT Clinical Category

Major Joint Replacement or Spinal Surgery Major Joint Replacement or Spinal Surgery

Non-Orthopedic SurgeryAcute Neurologic

Non-Orthopedic Surgery amp Acute Neurologic

Non-Surgical OrthopedicMusculoskeletalOrthopedic Surgery (Except Major Joint Replacement or Spinal Surgery)

Other Orthopedic

Medical ManagementAcute InfectionsCancerPulmonaryCardiovascular amp Coagulations

Medical Management

PDPM WORKSHOP

PDPM CASE MIX PTOTbullCase mix has two primary elements used to determine classificationo Clinical Category for SNF stay (I0020B)

o Functional Status (Section GG)

12

Clinical CategoryPT amp OT

Function ScorePT amp OT

Case Mix Group PT CMI OT CMI

Major Joint Replacement or Spinal Surgery 0-5 TA 153 149Major Joint Replacement or Spinal Surgery 6-9 TB 170 163Major Joint Replacement or Spinal Surgery 10-23 TC 188 169Major Joint Replacement or Spinal Surgery 24 TD 192 153

Other Orthopedic 0-5 TE 142 141Other Orthopedic 6-9 TF 161 160Other Orthopedic 10-23 TG 167 164Other Orthopedic 24 TH 116 115

Medical Management 0-5 TI 113 118Medical Management 6-9 TJ 142 145Medical Management 10-23 TK 152 154Medical Management 24 TL 109 111

Other Orthopedic 0-5 TM 127 130Other Orthopedic 6-9 TN 148 150Other Orthopedic 10-23 TO 155 155Other Orthopedic 24 TP 108 109

GG

PDPM WORKSHOP

SLP Comorbidities

bullSLP has 12 comorbidities under PDPMoSLP comorbidity flag combines conditions amp services

oOnly the presence of one of the following is required to qualify

13

PDPM WORKSHOP

PDPM Case Mix SLPbullSLP has 3 elementso Clinical Category for SNF Stay- Acute Neurologic or Non-Neurologic

o Presence of Swallowing Disorder and or Mechanically Altered Diet

o Cognitive Status andor Presence of an SLP-related Comorbidity

14

Clinical CategoryPT amp OT

Function ScorePT amp OT

Case Mix Group PT CMI OT CMI

Major Joint Replacement or Spinal Surgery 0-5 TA 153 149Major Joint Replacement or Spinal Surgery 6-9 TB 170 163Major Joint Replacement or Spinal Surgery 10-23 TC 188 169Major Joint Replacement or Spinal Surgery 24 TD 192 153

Other Orthopedic 0-5 TE 142 141Other Orthopedic 6-9 TF 161 160Other Orthopedic 10-23 TG 167 164Other Orthopedic 24 TH 116 115

Medical Management 0-5 TI 113 118Medical Management 6-9 TJ 142 145Medical Management 10-23 TK 152 154Medical Management 24 TL 109 111

Other Orthopedic 0-5 TM 127 130Other Orthopedic 6-9 TN 148 150Other Orthopedic 10-23 TO 155 155Other Orthopedic 24 TP 108 109

GG

PDPM WORKSHOP

SLP Component

bullPresence of oMechanically Altered Diet (Section K)

oSwallowing Disorder (Section K)

PDPM WORKSHOP

MDS Section K

16

PDPM WORKSHOP

Nursing Component

bullSame RUG IV Major CategoriesoExtensive Services

oSpecial Care High

oSpecial Care Low

oClinically Complex

oBehavior Symptoms amp Cognitive Impairment

oReduced Physical Function

PDPM WORKSHOP

Nursing Functional Score

bullMDS Section GG ndash Functional Abilities amp GoalsoAssessed during first three days of admission

oDocuments ldquousual performancerdquo

oFunctional score ranges from zero to 16

Eating Average Bed Mobility

Toilet Hygiene Average Transfer

PDPM WORKSHOP

Nursing CMI

NursingComponent

Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

HBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

NursingComponent

Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

PDPM WORKSHOP

Nursing Component

bullImportant to NoteoNursing component will be increased by 18 for residents with HIVAIDS

o8 points into the NTA count

bull B20 must be on SNF claim

PDPM WORKSHOP

NTA amp Comorbidity CodingbullComorbidity score is a weighted count of comorbidities

o Comorbidities associated with high increases in NTA costs grouped into various point tiers

o Points assigned for each additional comorbidity present with more points awarded for higher-cost tiers

bullComorbidities amp extensive services for NTA classification are derived from a variety of MDS sources with some identified in Item I8000

bullHIVAIDS remains a SNF claim reported adjustment (8 pts)

bullCalculated based on points assigned for 50 MDS items

21

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

PDPM WORKSHOP

NTA Component

bullData Sources

22

HIV AIDS SNF Claim

Bowelbladder appl H0100C H0100D Ostomy catheterization

ParenteralIVtube feed Section K

Ulcers foot skin probs Section M

Special treatmentsext services Section O IV meds ventilator trach suctioning transfusion radiation infection etc

Diagnoses Section I 6 specific diagnoses

Additional active Dx Item I8000 28 specific diagnoses

PDPM WORKSHOP

ConditionExtensive Service Source PointsHIVAIDS SNF Claim 8Parental IV Feeding Level High MDS Item K0510A2 K0710A2 7Special Treatment Programs Intravenous Medication Post-Admit Code MDS Item O0100H2 5Special Treatment Programs Ventilator or Respirator Post-admit Code MDS Item O0100F2 4

Parental IV Feeding Level LowMDS Item K0510A2 K0710A2 K0710B2 3

Lung Transplant Status MDS Item I8000 3Special TreatmentsPrograms Transfusion Post-admit Code MDS Item O0100I2 2Major Organ Transplant Status Except Lung MDS Item I8000 2Active Diagnoses Asthma COPD Chronic Lung Disease Code MDS Item I6200 2BoneJointMuscle InfectionsNecrosis - Except Aseptic Necrosis of Bone MDS Item I8000 2Chronic Myeloid Leukemia MDS Item I8000 2Wound Infection Code MDS Item I2500 2Active Diagnoses Diabetes Mellitus (DM) Code MDS Item I2900 2Endocarditis MDS I8000 1Immune Disorders MDS I8000 1End-Stage Liver Disease MDS I8000 1Other Foot Skin Problems Diabetic Foot Ulcer Code MDS Item M1040B 1Narcolepsy and Cataplexy MDS Item I8000 1Cystic Fibrosis MDS Item I8000 1Special TreatmentsPrograms Tracheostomy Care Post-admit Code MDS Item O00100E2 1Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code MDS Item I1700 1Special TreatmentsPrograms Isolation Post-admit Code MDS Item O0100M2 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsChronic Pancreatitis MDS Item I8000 1Proliferated Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code

MDS Item M1040A M1040B M1040C 1

Complications of Specified Implant Device or Graft MDS Item I8000 1Bladder and Bowel Appliances Intermittent Catheterization MDS Item H0100D 1Inflammatory Bowel Disease MDS Item I1300 1Aseptic Necrosis of Bone MDS Item I8000 1Special TreatmentsPrograms Suctioning Post-admit Code MDS Item O0100D2 1Cardio-Respiratory Failure and Shock MDS Item I8000 1Myelodysplastic Syndromes and Myelofibrosis MDS Item I8000 1Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage MDS Item I8000 1Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Nutritional Approaches While a Resident Feeding Tube MDS Item K0510B2 1Severe Skin Burn or Condition MDS Item I8000 1Intractable Epilepsy MDS Item I8000 1Active Diagnoses Malnutrition code I560 1Disorders of Immunity - Except RxCC97 Immune Disorders MDS Item I8000 1Cirrhosis of Liver MDS Item I8000 1Bladder and Bowel Appliances Ostomy MDS Item H0100C 1Respiratory Arrest MDS Item I8000 1Pulmonary Fibrosis and Other Chronic Lung Disorders MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsSpecified Hereditary MetabolicImmune Disorders MDS Item I8000 1Morbid Obesity MDS Item I8000 1Special TreatmentsPrograms Radiation Post-admit Code MDS Item O0100B2 1Highest Stage of Unhealed Pressure Ulcer - Stage 4 MDS Item M0300D1 1Psoriatic Arthropathy and Systemic Sclerosis MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 184 (NC) X 30 X $44110

Every Point CountsNTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

Every Point Counts

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 253 (NB) X 30 X $60652

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

WORKSHEET

bullNTA Worksheet Calculate the number of NTA points amp payment for the 4 scenarios

28

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient A

29

ConditionExtensive Services NTA Count

Diabetes Mellitus 2

IV Medication 5

Isolation 1

Diabetic Retinopathy 1

Total 9

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient B

30

ConditionExtensive Services NTA Count

COPD 2

Diabetes Mellitus 2

Chronic Pancreatitis 1

Cirrhosis of Liver 1

Total 6

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

31

ConditionExtensive Services Before Fall NTA Count

Diabetes Mellitus 2

Total 2

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

32

ConditionExtensive Services After Fall NTA Count

IV Medication 5

Diabetes Mellitus 2

Endocarditis 1

Total 8

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1
	ConditionExtensive Service		Source		Points
	Specified Hereditary MetabolicImmune Disorders		MDS Item I8000		1
	Morbid Obesity		MDS Item I8000		1
	Special TreatmentsPrograms Radiation Post-admit Code		MDS Item O0100B2		1
	Highest Stage of Unhealed Pressure Ulcer - Stage 4		MDS Item M0300D1		1
	Psoriatic Arthropathy and Systemic Sclerosis		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1

PDPM WORKSHOP

5 CLINICAL PAYMENT DRIVERS

RESIDENT

PT PAYMENT

OT PAYMENT

NTA PAYMENT

SLP PAYMENT

NURSING PAYMENT

NON CASE MIX

8

PDPM WORKSHOP

PDPM Patient Classification

bullPatient classifications are used for each component (PTOTSLPNTA amp Nursing)

bullBreakdown of criteria for each classification

9

Component Criteria

PT Clinical Category Functional Score

OT Clinical Category Functional Score

SLP Presence of Acute Neurologic Condition SLP-related Comorbidity or Cognitive Impairment Mechanically-altered Diet Swallowing Disorder

NTA NTA Conditions Comorbidities Score

Nursing Clinical Condition Needs Functional Score

PDPM WORKSHOP

PDPM Clinical Category

10

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Categories Collapsed to 4 for PT amp OT

PDPM Clinical Category Collapsed PT amp OT Clinical Category

Major Joint Replacement or Spinal Surgery Major Joint Replacement or Spinal Surgery

Non-Orthopedic SurgeryAcute Neurologic

Non-Orthopedic Surgery amp Acute Neurologic

Non-Surgical OrthopedicMusculoskeletalOrthopedic Surgery (Except Major Joint Replacement or Spinal Surgery)

Other Orthopedic

Medical ManagementAcute InfectionsCancerPulmonaryCardiovascular amp Coagulations

Medical Management

PDPM WORKSHOP

PDPM CASE MIX PTOTbullCase mix has two primary elements used to determine classificationo Clinical Category for SNF stay (I0020B)

o Functional Status (Section GG)

12

Clinical CategoryPT amp OT

Function ScorePT amp OT

Case Mix Group PT CMI OT CMI

Major Joint Replacement or Spinal Surgery 0-5 TA 153 149Major Joint Replacement or Spinal Surgery 6-9 TB 170 163Major Joint Replacement or Spinal Surgery 10-23 TC 188 169Major Joint Replacement or Spinal Surgery 24 TD 192 153

Other Orthopedic 0-5 TE 142 141Other Orthopedic 6-9 TF 161 160Other Orthopedic 10-23 TG 167 164Other Orthopedic 24 TH 116 115

Medical Management 0-5 TI 113 118Medical Management 6-9 TJ 142 145Medical Management 10-23 TK 152 154Medical Management 24 TL 109 111

Other Orthopedic 0-5 TM 127 130Other Orthopedic 6-9 TN 148 150Other Orthopedic 10-23 TO 155 155Other Orthopedic 24 TP 108 109

GG

PDPM WORKSHOP

SLP Comorbidities

bullSLP has 12 comorbidities under PDPMoSLP comorbidity flag combines conditions amp services

oOnly the presence of one of the following is required to qualify

13

PDPM WORKSHOP

PDPM Case Mix SLPbullSLP has 3 elementso Clinical Category for SNF Stay- Acute Neurologic or Non-Neurologic

o Presence of Swallowing Disorder and or Mechanically Altered Diet

o Cognitive Status andor Presence of an SLP-related Comorbidity

14

Clinical CategoryPT amp OT

Function ScorePT amp OT

Case Mix Group PT CMI OT CMI

Major Joint Replacement or Spinal Surgery 0-5 TA 153 149Major Joint Replacement or Spinal Surgery 6-9 TB 170 163Major Joint Replacement or Spinal Surgery 10-23 TC 188 169Major Joint Replacement or Spinal Surgery 24 TD 192 153

Other Orthopedic 0-5 TE 142 141Other Orthopedic 6-9 TF 161 160Other Orthopedic 10-23 TG 167 164Other Orthopedic 24 TH 116 115

Medical Management 0-5 TI 113 118Medical Management 6-9 TJ 142 145Medical Management 10-23 TK 152 154Medical Management 24 TL 109 111

Other Orthopedic 0-5 TM 127 130Other Orthopedic 6-9 TN 148 150Other Orthopedic 10-23 TO 155 155Other Orthopedic 24 TP 108 109

GG

PDPM WORKSHOP

SLP Component

bullPresence of oMechanically Altered Diet (Section K)

oSwallowing Disorder (Section K)

PDPM WORKSHOP

MDS Section K

16

PDPM WORKSHOP

Nursing Component

bullSame RUG IV Major CategoriesoExtensive Services

oSpecial Care High

oSpecial Care Low

oClinically Complex

oBehavior Symptoms amp Cognitive Impairment

oReduced Physical Function

PDPM WORKSHOP

Nursing Functional Score

bullMDS Section GG ndash Functional Abilities amp GoalsoAssessed during first three days of admission

oDocuments ldquousual performancerdquo

oFunctional score ranges from zero to 16

Eating Average Bed Mobility

Toilet Hygiene Average Transfer

PDPM WORKSHOP

Nursing CMI

NursingComponent

Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

HBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

NursingComponent

Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

PDPM WORKSHOP

Nursing Component

bullImportant to NoteoNursing component will be increased by 18 for residents with HIVAIDS

o8 points into the NTA count

bull B20 must be on SNF claim

PDPM WORKSHOP

NTA amp Comorbidity CodingbullComorbidity score is a weighted count of comorbidities

o Comorbidities associated with high increases in NTA costs grouped into various point tiers

o Points assigned for each additional comorbidity present with more points awarded for higher-cost tiers

bullComorbidities amp extensive services for NTA classification are derived from a variety of MDS sources with some identified in Item I8000

bullHIVAIDS remains a SNF claim reported adjustment (8 pts)

bullCalculated based on points assigned for 50 MDS items

21

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

PDPM WORKSHOP

NTA Component

bullData Sources

22

HIV AIDS SNF Claim

Bowelbladder appl H0100C H0100D Ostomy catheterization

ParenteralIVtube feed Section K

Ulcers foot skin probs Section M

Special treatmentsext services Section O IV meds ventilator trach suctioning transfusion radiation infection etc

Diagnoses Section I 6 specific diagnoses

Additional active Dx Item I8000 28 specific diagnoses

PDPM WORKSHOP

ConditionExtensive Service Source PointsHIVAIDS SNF Claim 8Parental IV Feeding Level High MDS Item K0510A2 K0710A2 7Special Treatment Programs Intravenous Medication Post-Admit Code MDS Item O0100H2 5Special Treatment Programs Ventilator or Respirator Post-admit Code MDS Item O0100F2 4

Parental IV Feeding Level LowMDS Item K0510A2 K0710A2 K0710B2 3

Lung Transplant Status MDS Item I8000 3Special TreatmentsPrograms Transfusion Post-admit Code MDS Item O0100I2 2Major Organ Transplant Status Except Lung MDS Item I8000 2Active Diagnoses Asthma COPD Chronic Lung Disease Code MDS Item I6200 2BoneJointMuscle InfectionsNecrosis - Except Aseptic Necrosis of Bone MDS Item I8000 2Chronic Myeloid Leukemia MDS Item I8000 2Wound Infection Code MDS Item I2500 2Active Diagnoses Diabetes Mellitus (DM) Code MDS Item I2900 2Endocarditis MDS I8000 1Immune Disorders MDS I8000 1End-Stage Liver Disease MDS I8000 1Other Foot Skin Problems Diabetic Foot Ulcer Code MDS Item M1040B 1Narcolepsy and Cataplexy MDS Item I8000 1Cystic Fibrosis MDS Item I8000 1Special TreatmentsPrograms Tracheostomy Care Post-admit Code MDS Item O00100E2 1Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code MDS Item I1700 1Special TreatmentsPrograms Isolation Post-admit Code MDS Item O0100M2 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsChronic Pancreatitis MDS Item I8000 1Proliferated Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code

MDS Item M1040A M1040B M1040C 1

Complications of Specified Implant Device or Graft MDS Item I8000 1Bladder and Bowel Appliances Intermittent Catheterization MDS Item H0100D 1Inflammatory Bowel Disease MDS Item I1300 1Aseptic Necrosis of Bone MDS Item I8000 1Special TreatmentsPrograms Suctioning Post-admit Code MDS Item O0100D2 1Cardio-Respiratory Failure and Shock MDS Item I8000 1Myelodysplastic Syndromes and Myelofibrosis MDS Item I8000 1Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage MDS Item I8000 1Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Nutritional Approaches While a Resident Feeding Tube MDS Item K0510B2 1Severe Skin Burn or Condition MDS Item I8000 1Intractable Epilepsy MDS Item I8000 1Active Diagnoses Malnutrition code I560 1Disorders of Immunity - Except RxCC97 Immune Disorders MDS Item I8000 1Cirrhosis of Liver MDS Item I8000 1Bladder and Bowel Appliances Ostomy MDS Item H0100C 1Respiratory Arrest MDS Item I8000 1Pulmonary Fibrosis and Other Chronic Lung Disorders MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsSpecified Hereditary MetabolicImmune Disorders MDS Item I8000 1Morbid Obesity MDS Item I8000 1Special TreatmentsPrograms Radiation Post-admit Code MDS Item O0100B2 1Highest Stage of Unhealed Pressure Ulcer - Stage 4 MDS Item M0300D1 1Psoriatic Arthropathy and Systemic Sclerosis MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 184 (NC) X 30 X $44110

Every Point CountsNTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

Every Point Counts

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 253 (NB) X 30 X $60652

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

WORKSHEET

bullNTA Worksheet Calculate the number of NTA points amp payment for the 4 scenarios

28

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient A

29

ConditionExtensive Services NTA Count

Diabetes Mellitus 2

IV Medication 5

Isolation 1

Diabetic Retinopathy 1

Total 9

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient B

30

ConditionExtensive Services NTA Count

COPD 2

Diabetes Mellitus 2

Chronic Pancreatitis 1

Cirrhosis of Liver 1

Total 6

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

31

ConditionExtensive Services Before Fall NTA Count

Diabetes Mellitus 2

Total 2

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

32

ConditionExtensive Services After Fall NTA Count

IV Medication 5

Diabetes Mellitus 2

Endocarditis 1

Total 8

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1
	ConditionExtensive Service		Source		Points
	Specified Hereditary MetabolicImmune Disorders		MDS Item I8000		1
	Morbid Obesity		MDS Item I8000		1
	Special TreatmentsPrograms Radiation Post-admit Code		MDS Item O0100B2		1
	Highest Stage of Unhealed Pressure Ulcer - Stage 4		MDS Item M0300D1		1
	Psoriatic Arthropathy and Systemic Sclerosis		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1

PDPM WORKSHOP

PDPM Patient Classification

bullPatient classifications are used for each component (PTOTSLPNTA amp Nursing)

bullBreakdown of criteria for each classification

9

Component Criteria

PT Clinical Category Functional Score

OT Clinical Category Functional Score

SLP Presence of Acute Neurologic Condition SLP-related Comorbidity or Cognitive Impairment Mechanically-altered Diet Swallowing Disorder

NTA NTA Conditions Comorbidities Score

Nursing Clinical Condition Needs Functional Score

PDPM WORKSHOP

PDPM Clinical Category

10

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Categories Collapsed to 4 for PT amp OT

PDPM Clinical Category Collapsed PT amp OT Clinical Category

Major Joint Replacement or Spinal Surgery Major Joint Replacement or Spinal Surgery

Non-Orthopedic SurgeryAcute Neurologic

Non-Orthopedic Surgery amp Acute Neurologic

Non-Surgical OrthopedicMusculoskeletalOrthopedic Surgery (Except Major Joint Replacement or Spinal Surgery)

Other Orthopedic

Medical ManagementAcute InfectionsCancerPulmonaryCardiovascular amp Coagulations

Medical Management

PDPM WORKSHOP

PDPM CASE MIX PTOTbullCase mix has two primary elements used to determine classificationo Clinical Category for SNF stay (I0020B)

o Functional Status (Section GG)

12

Clinical CategoryPT amp OT

Function ScorePT amp OT

Case Mix Group PT CMI OT CMI

Major Joint Replacement or Spinal Surgery 0-5 TA 153 149Major Joint Replacement or Spinal Surgery 6-9 TB 170 163Major Joint Replacement or Spinal Surgery 10-23 TC 188 169Major Joint Replacement or Spinal Surgery 24 TD 192 153

Other Orthopedic 0-5 TE 142 141Other Orthopedic 6-9 TF 161 160Other Orthopedic 10-23 TG 167 164Other Orthopedic 24 TH 116 115

Medical Management 0-5 TI 113 118Medical Management 6-9 TJ 142 145Medical Management 10-23 TK 152 154Medical Management 24 TL 109 111

Other Orthopedic 0-5 TM 127 130Other Orthopedic 6-9 TN 148 150Other Orthopedic 10-23 TO 155 155Other Orthopedic 24 TP 108 109

GG

PDPM WORKSHOP

SLP Comorbidities

bullSLP has 12 comorbidities under PDPMoSLP comorbidity flag combines conditions amp services

oOnly the presence of one of the following is required to qualify

13

PDPM WORKSHOP

PDPM Case Mix SLPbullSLP has 3 elementso Clinical Category for SNF Stay- Acute Neurologic or Non-Neurologic

o Presence of Swallowing Disorder and or Mechanically Altered Diet

o Cognitive Status andor Presence of an SLP-related Comorbidity

14

Clinical CategoryPT amp OT

Function ScorePT amp OT

Case Mix Group PT CMI OT CMI

Major Joint Replacement or Spinal Surgery 0-5 TA 153 149Major Joint Replacement or Spinal Surgery 6-9 TB 170 163Major Joint Replacement or Spinal Surgery 10-23 TC 188 169Major Joint Replacement or Spinal Surgery 24 TD 192 153

Other Orthopedic 0-5 TE 142 141Other Orthopedic 6-9 TF 161 160Other Orthopedic 10-23 TG 167 164Other Orthopedic 24 TH 116 115

Medical Management 0-5 TI 113 118Medical Management 6-9 TJ 142 145Medical Management 10-23 TK 152 154Medical Management 24 TL 109 111

Other Orthopedic 0-5 TM 127 130Other Orthopedic 6-9 TN 148 150Other Orthopedic 10-23 TO 155 155Other Orthopedic 24 TP 108 109

GG

PDPM WORKSHOP

SLP Component

bullPresence of oMechanically Altered Diet (Section K)

oSwallowing Disorder (Section K)

PDPM WORKSHOP

MDS Section K

16

PDPM WORKSHOP

Nursing Component

bullSame RUG IV Major CategoriesoExtensive Services

oSpecial Care High

oSpecial Care Low

oClinically Complex

oBehavior Symptoms amp Cognitive Impairment

oReduced Physical Function

PDPM WORKSHOP

Nursing Functional Score

bullMDS Section GG ndash Functional Abilities amp GoalsoAssessed during first three days of admission

oDocuments ldquousual performancerdquo

oFunctional score ranges from zero to 16

Eating Average Bed Mobility

Toilet Hygiene Average Transfer

PDPM WORKSHOP

Nursing CMI

NursingComponent

Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

HBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

NursingComponent

Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

PDPM WORKSHOP

Nursing Component

bullImportant to NoteoNursing component will be increased by 18 for residents with HIVAIDS

o8 points into the NTA count

bull B20 must be on SNF claim

PDPM WORKSHOP

NTA amp Comorbidity CodingbullComorbidity score is a weighted count of comorbidities

o Comorbidities associated with high increases in NTA costs grouped into various point tiers

o Points assigned for each additional comorbidity present with more points awarded for higher-cost tiers

bullComorbidities amp extensive services for NTA classification are derived from a variety of MDS sources with some identified in Item I8000

bullHIVAIDS remains a SNF claim reported adjustment (8 pts)

bullCalculated based on points assigned for 50 MDS items

21

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

PDPM WORKSHOP

NTA Component

bullData Sources

22

HIV AIDS SNF Claim

Bowelbladder appl H0100C H0100D Ostomy catheterization

ParenteralIVtube feed Section K

Ulcers foot skin probs Section M

Special treatmentsext services Section O IV meds ventilator trach suctioning transfusion radiation infection etc

Diagnoses Section I 6 specific diagnoses

Additional active Dx Item I8000 28 specific diagnoses

PDPM WORKSHOP

ConditionExtensive Service Source PointsHIVAIDS SNF Claim 8Parental IV Feeding Level High MDS Item K0510A2 K0710A2 7Special Treatment Programs Intravenous Medication Post-Admit Code MDS Item O0100H2 5Special Treatment Programs Ventilator or Respirator Post-admit Code MDS Item O0100F2 4

Parental IV Feeding Level LowMDS Item K0510A2 K0710A2 K0710B2 3

Lung Transplant Status MDS Item I8000 3Special TreatmentsPrograms Transfusion Post-admit Code MDS Item O0100I2 2Major Organ Transplant Status Except Lung MDS Item I8000 2Active Diagnoses Asthma COPD Chronic Lung Disease Code MDS Item I6200 2BoneJointMuscle InfectionsNecrosis - Except Aseptic Necrosis of Bone MDS Item I8000 2Chronic Myeloid Leukemia MDS Item I8000 2Wound Infection Code MDS Item I2500 2Active Diagnoses Diabetes Mellitus (DM) Code MDS Item I2900 2Endocarditis MDS I8000 1Immune Disorders MDS I8000 1End-Stage Liver Disease MDS I8000 1Other Foot Skin Problems Diabetic Foot Ulcer Code MDS Item M1040B 1Narcolepsy and Cataplexy MDS Item I8000 1Cystic Fibrosis MDS Item I8000 1Special TreatmentsPrograms Tracheostomy Care Post-admit Code MDS Item O00100E2 1Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code MDS Item I1700 1Special TreatmentsPrograms Isolation Post-admit Code MDS Item O0100M2 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsChronic Pancreatitis MDS Item I8000 1Proliferated Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code

MDS Item M1040A M1040B M1040C 1

Complications of Specified Implant Device or Graft MDS Item I8000 1Bladder and Bowel Appliances Intermittent Catheterization MDS Item H0100D 1Inflammatory Bowel Disease MDS Item I1300 1Aseptic Necrosis of Bone MDS Item I8000 1Special TreatmentsPrograms Suctioning Post-admit Code MDS Item O0100D2 1Cardio-Respiratory Failure and Shock MDS Item I8000 1Myelodysplastic Syndromes and Myelofibrosis MDS Item I8000 1Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage MDS Item I8000 1Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Nutritional Approaches While a Resident Feeding Tube MDS Item K0510B2 1Severe Skin Burn or Condition MDS Item I8000 1Intractable Epilepsy MDS Item I8000 1Active Diagnoses Malnutrition code I560 1Disorders of Immunity - Except RxCC97 Immune Disorders MDS Item I8000 1Cirrhosis of Liver MDS Item I8000 1Bladder and Bowel Appliances Ostomy MDS Item H0100C 1Respiratory Arrest MDS Item I8000 1Pulmonary Fibrosis and Other Chronic Lung Disorders MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsSpecified Hereditary MetabolicImmune Disorders MDS Item I8000 1Morbid Obesity MDS Item I8000 1Special TreatmentsPrograms Radiation Post-admit Code MDS Item O0100B2 1Highest Stage of Unhealed Pressure Ulcer - Stage 4 MDS Item M0300D1 1Psoriatic Arthropathy and Systemic Sclerosis MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 184 (NC) X 30 X $44110

Every Point CountsNTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

Every Point Counts

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 253 (NB) X 30 X $60652

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

WORKSHEET

bullNTA Worksheet Calculate the number of NTA points amp payment for the 4 scenarios

28

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient A

29

ConditionExtensive Services NTA Count

Diabetes Mellitus 2

IV Medication 5

Isolation 1

Diabetic Retinopathy 1

Total 9

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient B

30

ConditionExtensive Services NTA Count

COPD 2

Diabetes Mellitus 2

Chronic Pancreatitis 1

Cirrhosis of Liver 1

Total 6

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

31

ConditionExtensive Services Before Fall NTA Count

Diabetes Mellitus 2

Total 2

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

32

ConditionExtensive Services After Fall NTA Count

IV Medication 5

Diabetes Mellitus 2

Endocarditis 1

Total 8

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1
	ConditionExtensive Service		Source		Points
	Specified Hereditary MetabolicImmune Disorders		MDS Item I8000		1
	Morbid Obesity		MDS Item I8000		1
	Special TreatmentsPrograms Radiation Post-admit Code		MDS Item O0100B2		1
	Highest Stage of Unhealed Pressure Ulcer - Stage 4		MDS Item M0300D1		1
	Psoriatic Arthropathy and Systemic Sclerosis		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1

PDPM WORKSHOP

PDPM Clinical Category

10

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Categories Collapsed to 4 for PT amp OT

PDPM Clinical Category Collapsed PT amp OT Clinical Category

Major Joint Replacement or Spinal Surgery Major Joint Replacement or Spinal Surgery

Non-Orthopedic SurgeryAcute Neurologic

Non-Orthopedic Surgery amp Acute Neurologic

Non-Surgical OrthopedicMusculoskeletalOrthopedic Surgery (Except Major Joint Replacement or Spinal Surgery)

Other Orthopedic

Medical ManagementAcute InfectionsCancerPulmonaryCardiovascular amp Coagulations

Medical Management

PDPM WORKSHOP

PDPM CASE MIX PTOTbullCase mix has two primary elements used to determine classificationo Clinical Category for SNF stay (I0020B)

o Functional Status (Section GG)

12

Clinical CategoryPT amp OT

Function ScorePT amp OT

Case Mix Group PT CMI OT CMI

Major Joint Replacement or Spinal Surgery 0-5 TA 153 149Major Joint Replacement or Spinal Surgery 6-9 TB 170 163Major Joint Replacement or Spinal Surgery 10-23 TC 188 169Major Joint Replacement or Spinal Surgery 24 TD 192 153

Other Orthopedic 0-5 TE 142 141Other Orthopedic 6-9 TF 161 160Other Orthopedic 10-23 TG 167 164Other Orthopedic 24 TH 116 115

Medical Management 0-5 TI 113 118Medical Management 6-9 TJ 142 145Medical Management 10-23 TK 152 154Medical Management 24 TL 109 111

Other Orthopedic 0-5 TM 127 130Other Orthopedic 6-9 TN 148 150Other Orthopedic 10-23 TO 155 155Other Orthopedic 24 TP 108 109

GG

PDPM WORKSHOP

SLP Comorbidities

bullSLP has 12 comorbidities under PDPMoSLP comorbidity flag combines conditions amp services

oOnly the presence of one of the following is required to qualify

13

PDPM WORKSHOP

PDPM Case Mix SLPbullSLP has 3 elementso Clinical Category for SNF Stay- Acute Neurologic or Non-Neurologic

o Presence of Swallowing Disorder and or Mechanically Altered Diet

o Cognitive Status andor Presence of an SLP-related Comorbidity

14

Clinical CategoryPT amp OT

Function ScorePT amp OT

Case Mix Group PT CMI OT CMI

Major Joint Replacement or Spinal Surgery 0-5 TA 153 149Major Joint Replacement or Spinal Surgery 6-9 TB 170 163Major Joint Replacement or Spinal Surgery 10-23 TC 188 169Major Joint Replacement or Spinal Surgery 24 TD 192 153

Other Orthopedic 0-5 TE 142 141Other Orthopedic 6-9 TF 161 160Other Orthopedic 10-23 TG 167 164Other Orthopedic 24 TH 116 115

Medical Management 0-5 TI 113 118Medical Management 6-9 TJ 142 145Medical Management 10-23 TK 152 154Medical Management 24 TL 109 111

Other Orthopedic 0-5 TM 127 130Other Orthopedic 6-9 TN 148 150Other Orthopedic 10-23 TO 155 155Other Orthopedic 24 TP 108 109

GG

PDPM WORKSHOP

SLP Component

bullPresence of oMechanically Altered Diet (Section K)

oSwallowing Disorder (Section K)

PDPM WORKSHOP

MDS Section K

16

PDPM WORKSHOP

Nursing Component

bullSame RUG IV Major CategoriesoExtensive Services

oSpecial Care High

oSpecial Care Low

oClinically Complex

oBehavior Symptoms amp Cognitive Impairment

oReduced Physical Function

PDPM WORKSHOP

Nursing Functional Score

bullMDS Section GG ndash Functional Abilities amp GoalsoAssessed during first three days of admission

oDocuments ldquousual performancerdquo

oFunctional score ranges from zero to 16

Eating Average Bed Mobility

Toilet Hygiene Average Transfer

PDPM WORKSHOP

Nursing CMI

NursingComponent

Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

HBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

NursingComponent

Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

PDPM WORKSHOP

Nursing Component

bullImportant to NoteoNursing component will be increased by 18 for residents with HIVAIDS

o8 points into the NTA count

bull B20 must be on SNF claim

PDPM WORKSHOP

NTA amp Comorbidity CodingbullComorbidity score is a weighted count of comorbidities

o Comorbidities associated with high increases in NTA costs grouped into various point tiers

o Points assigned for each additional comorbidity present with more points awarded for higher-cost tiers

bullComorbidities amp extensive services for NTA classification are derived from a variety of MDS sources with some identified in Item I8000

bullHIVAIDS remains a SNF claim reported adjustment (8 pts)

bullCalculated based on points assigned for 50 MDS items

21

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

PDPM WORKSHOP

NTA Component

bullData Sources

22

HIV AIDS SNF Claim

Bowelbladder appl H0100C H0100D Ostomy catheterization

ParenteralIVtube feed Section K

Ulcers foot skin probs Section M

Special treatmentsext services Section O IV meds ventilator trach suctioning transfusion radiation infection etc

Diagnoses Section I 6 specific diagnoses

Additional active Dx Item I8000 28 specific diagnoses

PDPM WORKSHOP

ConditionExtensive Service Source PointsHIVAIDS SNF Claim 8Parental IV Feeding Level High MDS Item K0510A2 K0710A2 7Special Treatment Programs Intravenous Medication Post-Admit Code MDS Item O0100H2 5Special Treatment Programs Ventilator or Respirator Post-admit Code MDS Item O0100F2 4

Parental IV Feeding Level LowMDS Item K0510A2 K0710A2 K0710B2 3

Lung Transplant Status MDS Item I8000 3Special TreatmentsPrograms Transfusion Post-admit Code MDS Item O0100I2 2Major Organ Transplant Status Except Lung MDS Item I8000 2Active Diagnoses Asthma COPD Chronic Lung Disease Code MDS Item I6200 2BoneJointMuscle InfectionsNecrosis - Except Aseptic Necrosis of Bone MDS Item I8000 2Chronic Myeloid Leukemia MDS Item I8000 2Wound Infection Code MDS Item I2500 2Active Diagnoses Diabetes Mellitus (DM) Code MDS Item I2900 2Endocarditis MDS I8000 1Immune Disorders MDS I8000 1End-Stage Liver Disease MDS I8000 1Other Foot Skin Problems Diabetic Foot Ulcer Code MDS Item M1040B 1Narcolepsy and Cataplexy MDS Item I8000 1Cystic Fibrosis MDS Item I8000 1Special TreatmentsPrograms Tracheostomy Care Post-admit Code MDS Item O00100E2 1Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code MDS Item I1700 1Special TreatmentsPrograms Isolation Post-admit Code MDS Item O0100M2 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsChronic Pancreatitis MDS Item I8000 1Proliferated Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code

MDS Item M1040A M1040B M1040C 1

Complications of Specified Implant Device or Graft MDS Item I8000 1Bladder and Bowel Appliances Intermittent Catheterization MDS Item H0100D 1Inflammatory Bowel Disease MDS Item I1300 1Aseptic Necrosis of Bone MDS Item I8000 1Special TreatmentsPrograms Suctioning Post-admit Code MDS Item O0100D2 1Cardio-Respiratory Failure and Shock MDS Item I8000 1Myelodysplastic Syndromes and Myelofibrosis MDS Item I8000 1Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage MDS Item I8000 1Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Nutritional Approaches While a Resident Feeding Tube MDS Item K0510B2 1Severe Skin Burn or Condition MDS Item I8000 1Intractable Epilepsy MDS Item I8000 1Active Diagnoses Malnutrition code I560 1Disorders of Immunity - Except RxCC97 Immune Disorders MDS Item I8000 1Cirrhosis of Liver MDS Item I8000 1Bladder and Bowel Appliances Ostomy MDS Item H0100C 1Respiratory Arrest MDS Item I8000 1Pulmonary Fibrosis and Other Chronic Lung Disorders MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsSpecified Hereditary MetabolicImmune Disorders MDS Item I8000 1Morbid Obesity MDS Item I8000 1Special TreatmentsPrograms Radiation Post-admit Code MDS Item O0100B2 1Highest Stage of Unhealed Pressure Ulcer - Stage 4 MDS Item M0300D1 1Psoriatic Arthropathy and Systemic Sclerosis MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 184 (NC) X 30 X $44110

Every Point CountsNTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

Every Point Counts

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 253 (NB) X 30 X $60652

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

WORKSHEET

bullNTA Worksheet Calculate the number of NTA points amp payment for the 4 scenarios

28

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient A

29

ConditionExtensive Services NTA Count

Diabetes Mellitus 2

IV Medication 5

Isolation 1

Diabetic Retinopathy 1

Total 9

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient B

30

ConditionExtensive Services NTA Count

COPD 2

Diabetes Mellitus 2

Chronic Pancreatitis 1

Cirrhosis of Liver 1

Total 6

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

31

ConditionExtensive Services Before Fall NTA Count

Diabetes Mellitus 2

Total 2

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

32

ConditionExtensive Services After Fall NTA Count

IV Medication 5

Diabetes Mellitus 2

Endocarditis 1

Total 8

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1
	ConditionExtensive Service		Source		Points
	Specified Hereditary MetabolicImmune Disorders		MDS Item I8000		1
	Morbid Obesity		MDS Item I8000		1
	Special TreatmentsPrograms Radiation Post-admit Code		MDS Item O0100B2		1
	Highest Stage of Unhealed Pressure Ulcer - Stage 4		MDS Item M0300D1		1
	Psoriatic Arthropathy and Systemic Sclerosis		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1

PDPM WORKSHOP

Clinical Categories Collapsed to 4 for PT amp OT

PDPM Clinical Category Collapsed PT amp OT Clinical Category

Major Joint Replacement or Spinal Surgery Major Joint Replacement or Spinal Surgery

Non-Orthopedic SurgeryAcute Neurologic

Non-Orthopedic Surgery amp Acute Neurologic

Non-Surgical OrthopedicMusculoskeletalOrthopedic Surgery (Except Major Joint Replacement or Spinal Surgery)

Other Orthopedic

Medical ManagementAcute InfectionsCancerPulmonaryCardiovascular amp Coagulations

Medical Management

PDPM WORKSHOP

PDPM CASE MIX PTOTbullCase mix has two primary elements used to determine classificationo Clinical Category for SNF stay (I0020B)

o Functional Status (Section GG)

12

Clinical CategoryPT amp OT

Function ScorePT amp OT

Case Mix Group PT CMI OT CMI

Major Joint Replacement or Spinal Surgery 0-5 TA 153 149Major Joint Replacement or Spinal Surgery 6-9 TB 170 163Major Joint Replacement or Spinal Surgery 10-23 TC 188 169Major Joint Replacement or Spinal Surgery 24 TD 192 153

Other Orthopedic 0-5 TE 142 141Other Orthopedic 6-9 TF 161 160Other Orthopedic 10-23 TG 167 164Other Orthopedic 24 TH 116 115

Medical Management 0-5 TI 113 118Medical Management 6-9 TJ 142 145Medical Management 10-23 TK 152 154Medical Management 24 TL 109 111

Other Orthopedic 0-5 TM 127 130Other Orthopedic 6-9 TN 148 150Other Orthopedic 10-23 TO 155 155Other Orthopedic 24 TP 108 109

GG

PDPM WORKSHOP

SLP Comorbidities

bullSLP has 12 comorbidities under PDPMoSLP comorbidity flag combines conditions amp services

oOnly the presence of one of the following is required to qualify

13

PDPM WORKSHOP

PDPM Case Mix SLPbullSLP has 3 elementso Clinical Category for SNF Stay- Acute Neurologic or Non-Neurologic

o Presence of Swallowing Disorder and or Mechanically Altered Diet

o Cognitive Status andor Presence of an SLP-related Comorbidity

14

Clinical CategoryPT amp OT

Function ScorePT amp OT

Case Mix Group PT CMI OT CMI

Major Joint Replacement or Spinal Surgery 0-5 TA 153 149Major Joint Replacement or Spinal Surgery 6-9 TB 170 163Major Joint Replacement or Spinal Surgery 10-23 TC 188 169Major Joint Replacement or Spinal Surgery 24 TD 192 153

Other Orthopedic 0-5 TE 142 141Other Orthopedic 6-9 TF 161 160Other Orthopedic 10-23 TG 167 164Other Orthopedic 24 TH 116 115

Medical Management 0-5 TI 113 118Medical Management 6-9 TJ 142 145Medical Management 10-23 TK 152 154Medical Management 24 TL 109 111

Other Orthopedic 0-5 TM 127 130Other Orthopedic 6-9 TN 148 150Other Orthopedic 10-23 TO 155 155Other Orthopedic 24 TP 108 109

GG

PDPM WORKSHOP

SLP Component

bullPresence of oMechanically Altered Diet (Section K)

oSwallowing Disorder (Section K)

PDPM WORKSHOP

MDS Section K

16

PDPM WORKSHOP

Nursing Component

bullSame RUG IV Major CategoriesoExtensive Services

oSpecial Care High

oSpecial Care Low

oClinically Complex

oBehavior Symptoms amp Cognitive Impairment

oReduced Physical Function

PDPM WORKSHOP

Nursing Functional Score

bullMDS Section GG ndash Functional Abilities amp GoalsoAssessed during first three days of admission

oDocuments ldquousual performancerdquo

oFunctional score ranges from zero to 16

Eating Average Bed Mobility

Toilet Hygiene Average Transfer

PDPM WORKSHOP

Nursing CMI

NursingComponent

Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

HBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

NursingComponent

Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

PDPM WORKSHOP

Nursing Component

bullImportant to NoteoNursing component will be increased by 18 for residents with HIVAIDS

o8 points into the NTA count

bull B20 must be on SNF claim

PDPM WORKSHOP

NTA amp Comorbidity CodingbullComorbidity score is a weighted count of comorbidities

o Comorbidities associated with high increases in NTA costs grouped into various point tiers

o Points assigned for each additional comorbidity present with more points awarded for higher-cost tiers

bullComorbidities amp extensive services for NTA classification are derived from a variety of MDS sources with some identified in Item I8000

bullHIVAIDS remains a SNF claim reported adjustment (8 pts)

bullCalculated based on points assigned for 50 MDS items

21

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

PDPM WORKSHOP

NTA Component

bullData Sources

22

HIV AIDS SNF Claim

Bowelbladder appl H0100C H0100D Ostomy catheterization

ParenteralIVtube feed Section K

Ulcers foot skin probs Section M

Special treatmentsext services Section O IV meds ventilator trach suctioning transfusion radiation infection etc

Diagnoses Section I 6 specific diagnoses

Additional active Dx Item I8000 28 specific diagnoses

PDPM WORKSHOP

ConditionExtensive Service Source PointsHIVAIDS SNF Claim 8Parental IV Feeding Level High MDS Item K0510A2 K0710A2 7Special Treatment Programs Intravenous Medication Post-Admit Code MDS Item O0100H2 5Special Treatment Programs Ventilator or Respirator Post-admit Code MDS Item O0100F2 4

Parental IV Feeding Level LowMDS Item K0510A2 K0710A2 K0710B2 3

Lung Transplant Status MDS Item I8000 3Special TreatmentsPrograms Transfusion Post-admit Code MDS Item O0100I2 2Major Organ Transplant Status Except Lung MDS Item I8000 2Active Diagnoses Asthma COPD Chronic Lung Disease Code MDS Item I6200 2BoneJointMuscle InfectionsNecrosis - Except Aseptic Necrosis of Bone MDS Item I8000 2Chronic Myeloid Leukemia MDS Item I8000 2Wound Infection Code MDS Item I2500 2Active Diagnoses Diabetes Mellitus (DM) Code MDS Item I2900 2Endocarditis MDS I8000 1Immune Disorders MDS I8000 1End-Stage Liver Disease MDS I8000 1Other Foot Skin Problems Diabetic Foot Ulcer Code MDS Item M1040B 1Narcolepsy and Cataplexy MDS Item I8000 1Cystic Fibrosis MDS Item I8000 1Special TreatmentsPrograms Tracheostomy Care Post-admit Code MDS Item O00100E2 1Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code MDS Item I1700 1Special TreatmentsPrograms Isolation Post-admit Code MDS Item O0100M2 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsChronic Pancreatitis MDS Item I8000 1Proliferated Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code

MDS Item M1040A M1040B M1040C 1

Complications of Specified Implant Device or Graft MDS Item I8000 1Bladder and Bowel Appliances Intermittent Catheterization MDS Item H0100D 1Inflammatory Bowel Disease MDS Item I1300 1Aseptic Necrosis of Bone MDS Item I8000 1Special TreatmentsPrograms Suctioning Post-admit Code MDS Item O0100D2 1Cardio-Respiratory Failure and Shock MDS Item I8000 1Myelodysplastic Syndromes and Myelofibrosis MDS Item I8000 1Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage MDS Item I8000 1Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Nutritional Approaches While a Resident Feeding Tube MDS Item K0510B2 1Severe Skin Burn or Condition MDS Item I8000 1Intractable Epilepsy MDS Item I8000 1Active Diagnoses Malnutrition code I560 1Disorders of Immunity - Except RxCC97 Immune Disorders MDS Item I8000 1Cirrhosis of Liver MDS Item I8000 1Bladder and Bowel Appliances Ostomy MDS Item H0100C 1Respiratory Arrest MDS Item I8000 1Pulmonary Fibrosis and Other Chronic Lung Disorders MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsSpecified Hereditary MetabolicImmune Disorders MDS Item I8000 1Morbid Obesity MDS Item I8000 1Special TreatmentsPrograms Radiation Post-admit Code MDS Item O0100B2 1Highest Stage of Unhealed Pressure Ulcer - Stage 4 MDS Item M0300D1 1Psoriatic Arthropathy and Systemic Sclerosis MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 184 (NC) X 30 X $44110

Every Point CountsNTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

Every Point Counts

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 253 (NB) X 30 X $60652

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

WORKSHEET

bullNTA Worksheet Calculate the number of NTA points amp payment for the 4 scenarios

28

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient A

29

ConditionExtensive Services NTA Count

Diabetes Mellitus 2

IV Medication 5

Isolation 1

Diabetic Retinopathy 1

Total 9

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient B

30

ConditionExtensive Services NTA Count

COPD 2

Diabetes Mellitus 2

Chronic Pancreatitis 1

Cirrhosis of Liver 1

Total 6

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

31

ConditionExtensive Services Before Fall NTA Count

Diabetes Mellitus 2

Total 2

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

32

ConditionExtensive Services After Fall NTA Count

IV Medication 5

Diabetes Mellitus 2

Endocarditis 1

Total 8

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1
	ConditionExtensive Service		Source		Points
	Specified Hereditary MetabolicImmune Disorders		MDS Item I8000		1
	Morbid Obesity		MDS Item I8000		1
	Special TreatmentsPrograms Radiation Post-admit Code		MDS Item O0100B2		1
	Highest Stage of Unhealed Pressure Ulcer - Stage 4		MDS Item M0300D1		1
	Psoriatic Arthropathy and Systemic Sclerosis		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1

PDPM WORKSHOP

PDPM CASE MIX PTOTbullCase mix has two primary elements used to determine classificationo Clinical Category for SNF stay (I0020B)

o Functional Status (Section GG)

12

Clinical CategoryPT amp OT

Function ScorePT amp OT

Case Mix Group PT CMI OT CMI

Major Joint Replacement or Spinal Surgery 0-5 TA 153 149Major Joint Replacement or Spinal Surgery 6-9 TB 170 163Major Joint Replacement or Spinal Surgery 10-23 TC 188 169Major Joint Replacement or Spinal Surgery 24 TD 192 153

Other Orthopedic 0-5 TE 142 141Other Orthopedic 6-9 TF 161 160Other Orthopedic 10-23 TG 167 164Other Orthopedic 24 TH 116 115

Medical Management 0-5 TI 113 118Medical Management 6-9 TJ 142 145Medical Management 10-23 TK 152 154Medical Management 24 TL 109 111

Other Orthopedic 0-5 TM 127 130Other Orthopedic 6-9 TN 148 150Other Orthopedic 10-23 TO 155 155Other Orthopedic 24 TP 108 109

GG

PDPM WORKSHOP

SLP Comorbidities

bullSLP has 12 comorbidities under PDPMoSLP comorbidity flag combines conditions amp services

oOnly the presence of one of the following is required to qualify

13

PDPM WORKSHOP

PDPM Case Mix SLPbullSLP has 3 elementso Clinical Category for SNF Stay- Acute Neurologic or Non-Neurologic

o Presence of Swallowing Disorder and or Mechanically Altered Diet

o Cognitive Status andor Presence of an SLP-related Comorbidity

14

Clinical CategoryPT amp OT

Function ScorePT amp OT

Case Mix Group PT CMI OT CMI

Major Joint Replacement or Spinal Surgery 0-5 TA 153 149Major Joint Replacement or Spinal Surgery 6-9 TB 170 163Major Joint Replacement or Spinal Surgery 10-23 TC 188 169Major Joint Replacement or Spinal Surgery 24 TD 192 153

Other Orthopedic 0-5 TE 142 141Other Orthopedic 6-9 TF 161 160Other Orthopedic 10-23 TG 167 164Other Orthopedic 24 TH 116 115

Medical Management 0-5 TI 113 118Medical Management 6-9 TJ 142 145Medical Management 10-23 TK 152 154Medical Management 24 TL 109 111

Other Orthopedic 0-5 TM 127 130Other Orthopedic 6-9 TN 148 150Other Orthopedic 10-23 TO 155 155Other Orthopedic 24 TP 108 109

GG

PDPM WORKSHOP

SLP Component

bullPresence of oMechanically Altered Diet (Section K)

oSwallowing Disorder (Section K)

PDPM WORKSHOP

MDS Section K

16

PDPM WORKSHOP

Nursing Component

bullSame RUG IV Major CategoriesoExtensive Services

oSpecial Care High

oSpecial Care Low

oClinically Complex

oBehavior Symptoms amp Cognitive Impairment

oReduced Physical Function

PDPM WORKSHOP

Nursing Functional Score

bullMDS Section GG ndash Functional Abilities amp GoalsoAssessed during first three days of admission

oDocuments ldquousual performancerdquo

oFunctional score ranges from zero to 16

Eating Average Bed Mobility

Toilet Hygiene Average Transfer

PDPM WORKSHOP

Nursing CMI

NursingComponent

Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

HBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

NursingComponent

Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

PDPM WORKSHOP

Nursing Component

bullImportant to NoteoNursing component will be increased by 18 for residents with HIVAIDS

o8 points into the NTA count

bull B20 must be on SNF claim

PDPM WORKSHOP

NTA amp Comorbidity CodingbullComorbidity score is a weighted count of comorbidities

o Comorbidities associated with high increases in NTA costs grouped into various point tiers

o Points assigned for each additional comorbidity present with more points awarded for higher-cost tiers

bullComorbidities amp extensive services for NTA classification are derived from a variety of MDS sources with some identified in Item I8000

bullHIVAIDS remains a SNF claim reported adjustment (8 pts)

bullCalculated based on points assigned for 50 MDS items

21

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

PDPM WORKSHOP

NTA Component

bullData Sources

22

HIV AIDS SNF Claim

Bowelbladder appl H0100C H0100D Ostomy catheterization

ParenteralIVtube feed Section K

Ulcers foot skin probs Section M

Special treatmentsext services Section O IV meds ventilator trach suctioning transfusion radiation infection etc

Diagnoses Section I 6 specific diagnoses

Additional active Dx Item I8000 28 specific diagnoses

PDPM WORKSHOP

ConditionExtensive Service Source PointsHIVAIDS SNF Claim 8Parental IV Feeding Level High MDS Item K0510A2 K0710A2 7Special Treatment Programs Intravenous Medication Post-Admit Code MDS Item O0100H2 5Special Treatment Programs Ventilator or Respirator Post-admit Code MDS Item O0100F2 4

Parental IV Feeding Level LowMDS Item K0510A2 K0710A2 K0710B2 3

Lung Transplant Status MDS Item I8000 3Special TreatmentsPrograms Transfusion Post-admit Code MDS Item O0100I2 2Major Organ Transplant Status Except Lung MDS Item I8000 2Active Diagnoses Asthma COPD Chronic Lung Disease Code MDS Item I6200 2BoneJointMuscle InfectionsNecrosis - Except Aseptic Necrosis of Bone MDS Item I8000 2Chronic Myeloid Leukemia MDS Item I8000 2Wound Infection Code MDS Item I2500 2Active Diagnoses Diabetes Mellitus (DM) Code MDS Item I2900 2Endocarditis MDS I8000 1Immune Disorders MDS I8000 1End-Stage Liver Disease MDS I8000 1Other Foot Skin Problems Diabetic Foot Ulcer Code MDS Item M1040B 1Narcolepsy and Cataplexy MDS Item I8000 1Cystic Fibrosis MDS Item I8000 1Special TreatmentsPrograms Tracheostomy Care Post-admit Code MDS Item O00100E2 1Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code MDS Item I1700 1Special TreatmentsPrograms Isolation Post-admit Code MDS Item O0100M2 1

Sheet1

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PDPM WORKSHOP

ConditionExtensive Service Source PointsChronic Pancreatitis MDS Item I8000 1Proliferated Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code

MDS Item M1040A M1040B M1040C 1

Complications of Specified Implant Device or Graft MDS Item I8000 1Bladder and Bowel Appliances Intermittent Catheterization MDS Item H0100D 1Inflammatory Bowel Disease MDS Item I1300 1Aseptic Necrosis of Bone MDS Item I8000 1Special TreatmentsPrograms Suctioning Post-admit Code MDS Item O0100D2 1Cardio-Respiratory Failure and Shock MDS Item I8000 1Myelodysplastic Syndromes and Myelofibrosis MDS Item I8000 1Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage MDS Item I8000 1Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Nutritional Approaches While a Resident Feeding Tube MDS Item K0510B2 1Severe Skin Burn or Condition MDS Item I8000 1Intractable Epilepsy MDS Item I8000 1Active Diagnoses Malnutrition code I560 1Disorders of Immunity - Except RxCC97 Immune Disorders MDS Item I8000 1Cirrhosis of Liver MDS Item I8000 1Bladder and Bowel Appliances Ostomy MDS Item H0100C 1Respiratory Arrest MDS Item I8000 1Pulmonary Fibrosis and Other Chronic Lung Disorders MDS Item I8000 1

Sheet1

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PDPM WORKSHOP

ConditionExtensive Service Source PointsSpecified Hereditary MetabolicImmune Disorders MDS Item I8000 1Morbid Obesity MDS Item I8000 1Special TreatmentsPrograms Radiation Post-admit Code MDS Item O0100B2 1Highest Stage of Unhealed Pressure Ulcer - Stage 4 MDS Item M0300D1 1Psoriatic Arthropathy and Systemic Sclerosis MDS Item I8000 1

Sheet1

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PDPM WORKSHOP

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 184 (NC) X 30 X $44110

Every Point CountsNTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

Every Point Counts

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 253 (NB) X 30 X $60652

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

WORKSHEET

bullNTA Worksheet Calculate the number of NTA points amp payment for the 4 scenarios

28

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient A

29

ConditionExtensive Services NTA Count

Diabetes Mellitus 2

IV Medication 5

Isolation 1

Diabetic Retinopathy 1

Total 9

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient B

30

ConditionExtensive Services NTA Count

COPD 2

Diabetes Mellitus 2

Chronic Pancreatitis 1

Cirrhosis of Liver 1

Total 6

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

31

ConditionExtensive Services Before Fall NTA Count

Diabetes Mellitus 2

Total 2

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

32

ConditionExtensive Services After Fall NTA Count

IV Medication 5

Diabetes Mellitus 2

Endocarditis 1

Total 8

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1
	ConditionExtensive Service		Source		Points
	Specified Hereditary MetabolicImmune Disorders		MDS Item I8000		1
	Morbid Obesity		MDS Item I8000		1
	Special TreatmentsPrograms Radiation Post-admit Code		MDS Item O0100B2		1
	Highest Stage of Unhealed Pressure Ulcer - Stage 4		MDS Item M0300D1		1
	Psoriatic Arthropathy and Systemic Sclerosis		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1

PDPM WORKSHOP

SLP Comorbidities

bullSLP has 12 comorbidities under PDPMoSLP comorbidity flag combines conditions amp services

oOnly the presence of one of the following is required to qualify

13

PDPM WORKSHOP

PDPM Case Mix SLPbullSLP has 3 elementso Clinical Category for SNF Stay- Acute Neurologic or Non-Neurologic

o Presence of Swallowing Disorder and or Mechanically Altered Diet

o Cognitive Status andor Presence of an SLP-related Comorbidity

14

Clinical CategoryPT amp OT

Function ScorePT amp OT

Case Mix Group PT CMI OT CMI

Major Joint Replacement or Spinal Surgery 0-5 TA 153 149Major Joint Replacement or Spinal Surgery 6-9 TB 170 163Major Joint Replacement or Spinal Surgery 10-23 TC 188 169Major Joint Replacement or Spinal Surgery 24 TD 192 153

Other Orthopedic 0-5 TE 142 141Other Orthopedic 6-9 TF 161 160Other Orthopedic 10-23 TG 167 164Other Orthopedic 24 TH 116 115

Medical Management 0-5 TI 113 118Medical Management 6-9 TJ 142 145Medical Management 10-23 TK 152 154Medical Management 24 TL 109 111

Other Orthopedic 0-5 TM 127 130Other Orthopedic 6-9 TN 148 150Other Orthopedic 10-23 TO 155 155Other Orthopedic 24 TP 108 109

GG

PDPM WORKSHOP

SLP Component

bullPresence of oMechanically Altered Diet (Section K)

oSwallowing Disorder (Section K)

PDPM WORKSHOP

MDS Section K

16

PDPM WORKSHOP

Nursing Component

bullSame RUG IV Major CategoriesoExtensive Services

oSpecial Care High

oSpecial Care Low

oClinically Complex

oBehavior Symptoms amp Cognitive Impairment

oReduced Physical Function

PDPM WORKSHOP

Nursing Functional Score

bullMDS Section GG ndash Functional Abilities amp GoalsoAssessed during first three days of admission

oDocuments ldquousual performancerdquo

oFunctional score ranges from zero to 16

Eating Average Bed Mobility

Toilet Hygiene Average Transfer

PDPM WORKSHOP

Nursing CMI

NursingComponent

Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

HBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

NursingComponent

Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

PDPM WORKSHOP

Nursing Component

bullImportant to NoteoNursing component will be increased by 18 for residents with HIVAIDS

o8 points into the NTA count

bull B20 must be on SNF claim

PDPM WORKSHOP

NTA amp Comorbidity CodingbullComorbidity score is a weighted count of comorbidities

o Comorbidities associated with high increases in NTA costs grouped into various point tiers

o Points assigned for each additional comorbidity present with more points awarded for higher-cost tiers

bullComorbidities amp extensive services for NTA classification are derived from a variety of MDS sources with some identified in Item I8000

bullHIVAIDS remains a SNF claim reported adjustment (8 pts)

bullCalculated based on points assigned for 50 MDS items

21

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

PDPM WORKSHOP

NTA Component

bullData Sources

22

HIV AIDS SNF Claim

Bowelbladder appl H0100C H0100D Ostomy catheterization

ParenteralIVtube feed Section K

Ulcers foot skin probs Section M

Special treatmentsext services Section O IV meds ventilator trach suctioning transfusion radiation infection etc

Diagnoses Section I 6 specific diagnoses

Additional active Dx Item I8000 28 specific diagnoses

PDPM WORKSHOP

ConditionExtensive Service Source PointsHIVAIDS SNF Claim 8Parental IV Feeding Level High MDS Item K0510A2 K0710A2 7Special Treatment Programs Intravenous Medication Post-Admit Code MDS Item O0100H2 5Special Treatment Programs Ventilator or Respirator Post-admit Code MDS Item O0100F2 4

Parental IV Feeding Level LowMDS Item K0510A2 K0710A2 K0710B2 3

Lung Transplant Status MDS Item I8000 3Special TreatmentsPrograms Transfusion Post-admit Code MDS Item O0100I2 2Major Organ Transplant Status Except Lung MDS Item I8000 2Active Diagnoses Asthma COPD Chronic Lung Disease Code MDS Item I6200 2BoneJointMuscle InfectionsNecrosis - Except Aseptic Necrosis of Bone MDS Item I8000 2Chronic Myeloid Leukemia MDS Item I8000 2Wound Infection Code MDS Item I2500 2Active Diagnoses Diabetes Mellitus (DM) Code MDS Item I2900 2Endocarditis MDS I8000 1Immune Disorders MDS I8000 1End-Stage Liver Disease MDS I8000 1Other Foot Skin Problems Diabetic Foot Ulcer Code MDS Item M1040B 1Narcolepsy and Cataplexy MDS Item I8000 1Cystic Fibrosis MDS Item I8000 1Special TreatmentsPrograms Tracheostomy Care Post-admit Code MDS Item O00100E2 1Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code MDS Item I1700 1Special TreatmentsPrograms Isolation Post-admit Code MDS Item O0100M2 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsChronic Pancreatitis MDS Item I8000 1Proliferated Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code

MDS Item M1040A M1040B M1040C 1

Complications of Specified Implant Device or Graft MDS Item I8000 1Bladder and Bowel Appliances Intermittent Catheterization MDS Item H0100D 1Inflammatory Bowel Disease MDS Item I1300 1Aseptic Necrosis of Bone MDS Item I8000 1Special TreatmentsPrograms Suctioning Post-admit Code MDS Item O0100D2 1Cardio-Respiratory Failure and Shock MDS Item I8000 1Myelodysplastic Syndromes and Myelofibrosis MDS Item I8000 1Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage MDS Item I8000 1Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Nutritional Approaches While a Resident Feeding Tube MDS Item K0510B2 1Severe Skin Burn or Condition MDS Item I8000 1Intractable Epilepsy MDS Item I8000 1Active Diagnoses Malnutrition code I560 1Disorders of Immunity - Except RxCC97 Immune Disorders MDS Item I8000 1Cirrhosis of Liver MDS Item I8000 1Bladder and Bowel Appliances Ostomy MDS Item H0100C 1Respiratory Arrest MDS Item I8000 1Pulmonary Fibrosis and Other Chronic Lung Disorders MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsSpecified Hereditary MetabolicImmune Disorders MDS Item I8000 1Morbid Obesity MDS Item I8000 1Special TreatmentsPrograms Radiation Post-admit Code MDS Item O0100B2 1Highest Stage of Unhealed Pressure Ulcer - Stage 4 MDS Item M0300D1 1Psoriatic Arthropathy and Systemic Sclerosis MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 184 (NC) X 30 X $44110

Every Point CountsNTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

Every Point Counts

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 253 (NB) X 30 X $60652

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

WORKSHEET

bullNTA Worksheet Calculate the number of NTA points amp payment for the 4 scenarios

28

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient A

29

ConditionExtensive Services NTA Count

Diabetes Mellitus 2

IV Medication 5

Isolation 1

Diabetic Retinopathy 1

Total 9

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient B

30

ConditionExtensive Services NTA Count

COPD 2

Diabetes Mellitus 2

Chronic Pancreatitis 1

Cirrhosis of Liver 1

Total 6

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

31

ConditionExtensive Services Before Fall NTA Count

Diabetes Mellitus 2

Total 2

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

32

ConditionExtensive Services After Fall NTA Count

IV Medication 5

Diabetes Mellitus 2

Endocarditis 1

Total 8

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1
	ConditionExtensive Service		Source		Points
	Specified Hereditary MetabolicImmune Disorders		MDS Item I8000		1
	Morbid Obesity		MDS Item I8000		1
	Special TreatmentsPrograms Radiation Post-admit Code		MDS Item O0100B2		1
	Highest Stage of Unhealed Pressure Ulcer - Stage 4		MDS Item M0300D1		1
	Psoriatic Arthropathy and Systemic Sclerosis		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1

PDPM WORKSHOP

PDPM Case Mix SLPbullSLP has 3 elementso Clinical Category for SNF Stay- Acute Neurologic or Non-Neurologic

o Presence of Swallowing Disorder and or Mechanically Altered Diet

o Cognitive Status andor Presence of an SLP-related Comorbidity

14

Clinical CategoryPT amp OT

Function ScorePT amp OT

Case Mix Group PT CMI OT CMI

Major Joint Replacement or Spinal Surgery 0-5 TA 153 149Major Joint Replacement or Spinal Surgery 6-9 TB 170 163Major Joint Replacement or Spinal Surgery 10-23 TC 188 169Major Joint Replacement or Spinal Surgery 24 TD 192 153

Other Orthopedic 0-5 TE 142 141Other Orthopedic 6-9 TF 161 160Other Orthopedic 10-23 TG 167 164Other Orthopedic 24 TH 116 115

Medical Management 0-5 TI 113 118Medical Management 6-9 TJ 142 145Medical Management 10-23 TK 152 154Medical Management 24 TL 109 111

Other Orthopedic 0-5 TM 127 130Other Orthopedic 6-9 TN 148 150Other Orthopedic 10-23 TO 155 155Other Orthopedic 24 TP 108 109

GG

PDPM WORKSHOP

SLP Component

bullPresence of oMechanically Altered Diet (Section K)

oSwallowing Disorder (Section K)

PDPM WORKSHOP

MDS Section K

16

PDPM WORKSHOP

Nursing Component

bullSame RUG IV Major CategoriesoExtensive Services

oSpecial Care High

oSpecial Care Low

oClinically Complex

oBehavior Symptoms amp Cognitive Impairment

oReduced Physical Function

PDPM WORKSHOP

Nursing Functional Score

bullMDS Section GG ndash Functional Abilities amp GoalsoAssessed during first three days of admission

oDocuments ldquousual performancerdquo

oFunctional score ranges from zero to 16

Eating Average Bed Mobility

Toilet Hygiene Average Transfer

PDPM WORKSHOP

Nursing CMI

NursingComponent

Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

HBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

NursingComponent

Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

PDPM WORKSHOP

Nursing Component

bullImportant to NoteoNursing component will be increased by 18 for residents with HIVAIDS

o8 points into the NTA count

bull B20 must be on SNF claim

PDPM WORKSHOP

NTA amp Comorbidity CodingbullComorbidity score is a weighted count of comorbidities

o Comorbidities associated with high increases in NTA costs grouped into various point tiers

o Points assigned for each additional comorbidity present with more points awarded for higher-cost tiers

bullComorbidities amp extensive services for NTA classification are derived from a variety of MDS sources with some identified in Item I8000

bullHIVAIDS remains a SNF claim reported adjustment (8 pts)

bullCalculated based on points assigned for 50 MDS items

21

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

PDPM WORKSHOP

NTA Component

bullData Sources

22

HIV AIDS SNF Claim

Bowelbladder appl H0100C H0100D Ostomy catheterization

ParenteralIVtube feed Section K

Ulcers foot skin probs Section M

Special treatmentsext services Section O IV meds ventilator trach suctioning transfusion radiation infection etc

Diagnoses Section I 6 specific diagnoses

Additional active Dx Item I8000 28 specific diagnoses

PDPM WORKSHOP

ConditionExtensive Service Source PointsHIVAIDS SNF Claim 8Parental IV Feeding Level High MDS Item K0510A2 K0710A2 7Special Treatment Programs Intravenous Medication Post-Admit Code MDS Item O0100H2 5Special Treatment Programs Ventilator or Respirator Post-admit Code MDS Item O0100F2 4

Parental IV Feeding Level LowMDS Item K0510A2 K0710A2 K0710B2 3

Lung Transplant Status MDS Item I8000 3Special TreatmentsPrograms Transfusion Post-admit Code MDS Item O0100I2 2Major Organ Transplant Status Except Lung MDS Item I8000 2Active Diagnoses Asthma COPD Chronic Lung Disease Code MDS Item I6200 2BoneJointMuscle InfectionsNecrosis - Except Aseptic Necrosis of Bone MDS Item I8000 2Chronic Myeloid Leukemia MDS Item I8000 2Wound Infection Code MDS Item I2500 2Active Diagnoses Diabetes Mellitus (DM) Code MDS Item I2900 2Endocarditis MDS I8000 1Immune Disorders MDS I8000 1End-Stage Liver Disease MDS I8000 1Other Foot Skin Problems Diabetic Foot Ulcer Code MDS Item M1040B 1Narcolepsy and Cataplexy MDS Item I8000 1Cystic Fibrosis MDS Item I8000 1Special TreatmentsPrograms Tracheostomy Care Post-admit Code MDS Item O00100E2 1Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code MDS Item I1700 1Special TreatmentsPrograms Isolation Post-admit Code MDS Item O0100M2 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsChronic Pancreatitis MDS Item I8000 1Proliferated Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code

MDS Item M1040A M1040B M1040C 1

Complications of Specified Implant Device or Graft MDS Item I8000 1Bladder and Bowel Appliances Intermittent Catheterization MDS Item H0100D 1Inflammatory Bowel Disease MDS Item I1300 1Aseptic Necrosis of Bone MDS Item I8000 1Special TreatmentsPrograms Suctioning Post-admit Code MDS Item O0100D2 1Cardio-Respiratory Failure and Shock MDS Item I8000 1Myelodysplastic Syndromes and Myelofibrosis MDS Item I8000 1Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage MDS Item I8000 1Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Nutritional Approaches While a Resident Feeding Tube MDS Item K0510B2 1Severe Skin Burn or Condition MDS Item I8000 1Intractable Epilepsy MDS Item I8000 1Active Diagnoses Malnutrition code I560 1Disorders of Immunity - Except RxCC97 Immune Disorders MDS Item I8000 1Cirrhosis of Liver MDS Item I8000 1Bladder and Bowel Appliances Ostomy MDS Item H0100C 1Respiratory Arrest MDS Item I8000 1Pulmonary Fibrosis and Other Chronic Lung Disorders MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsSpecified Hereditary MetabolicImmune Disorders MDS Item I8000 1Morbid Obesity MDS Item I8000 1Special TreatmentsPrograms Radiation Post-admit Code MDS Item O0100B2 1Highest Stage of Unhealed Pressure Ulcer - Stage 4 MDS Item M0300D1 1Psoriatic Arthropathy and Systemic Sclerosis MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 184 (NC) X 30 X $44110

Every Point CountsNTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

Every Point Counts

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 253 (NB) X 30 X $60652

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

WORKSHEET

bullNTA Worksheet Calculate the number of NTA points amp payment for the 4 scenarios

28

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient A

29

ConditionExtensive Services NTA Count

Diabetes Mellitus 2

IV Medication 5

Isolation 1

Diabetic Retinopathy 1

Total 9

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient B

30

ConditionExtensive Services NTA Count

COPD 2

Diabetes Mellitus 2

Chronic Pancreatitis 1

Cirrhosis of Liver 1

Total 6

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

31

ConditionExtensive Services Before Fall NTA Count

Diabetes Mellitus 2

Total 2

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

32

ConditionExtensive Services After Fall NTA Count

IV Medication 5

Diabetes Mellitus 2

Endocarditis 1

Total 8

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1
	ConditionExtensive Service		Source		Points
	Specified Hereditary MetabolicImmune Disorders		MDS Item I8000		1
	Morbid Obesity		MDS Item I8000		1
	Special TreatmentsPrograms Radiation Post-admit Code		MDS Item O0100B2		1
	Highest Stage of Unhealed Pressure Ulcer - Stage 4		MDS Item M0300D1		1
	Psoriatic Arthropathy and Systemic Sclerosis		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1

PDPM WORKSHOP

SLP Component

bullPresence of oMechanically Altered Diet (Section K)

oSwallowing Disorder (Section K)

PDPM WORKSHOP

MDS Section K

16

PDPM WORKSHOP

Nursing Component

bullSame RUG IV Major CategoriesoExtensive Services

oSpecial Care High

oSpecial Care Low

oClinically Complex

oBehavior Symptoms amp Cognitive Impairment

oReduced Physical Function

PDPM WORKSHOP

Nursing Functional Score

bullMDS Section GG ndash Functional Abilities amp GoalsoAssessed during first three days of admission

oDocuments ldquousual performancerdquo

oFunctional score ranges from zero to 16

Eating Average Bed Mobility

Toilet Hygiene Average Transfer

PDPM WORKSHOP

Nursing CMI

NursingComponent

Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

HBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

NursingComponent

Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

PDPM WORKSHOP

Nursing Component

bullImportant to NoteoNursing component will be increased by 18 for residents with HIVAIDS

o8 points into the NTA count

bull B20 must be on SNF claim

PDPM WORKSHOP

NTA amp Comorbidity CodingbullComorbidity score is a weighted count of comorbidities

o Comorbidities associated with high increases in NTA costs grouped into various point tiers

o Points assigned for each additional comorbidity present with more points awarded for higher-cost tiers

bullComorbidities amp extensive services for NTA classification are derived from a variety of MDS sources with some identified in Item I8000

bullHIVAIDS remains a SNF claim reported adjustment (8 pts)

bullCalculated based on points assigned for 50 MDS items

21

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

PDPM WORKSHOP

NTA Component

bullData Sources

22

HIV AIDS SNF Claim

Bowelbladder appl H0100C H0100D Ostomy catheterization

ParenteralIVtube feed Section K

Ulcers foot skin probs Section M

Special treatmentsext services Section O IV meds ventilator trach suctioning transfusion radiation infection etc

Diagnoses Section I 6 specific diagnoses

Additional active Dx Item I8000 28 specific diagnoses

PDPM WORKSHOP

ConditionExtensive Service Source PointsHIVAIDS SNF Claim 8Parental IV Feeding Level High MDS Item K0510A2 K0710A2 7Special Treatment Programs Intravenous Medication Post-Admit Code MDS Item O0100H2 5Special Treatment Programs Ventilator or Respirator Post-admit Code MDS Item O0100F2 4

Parental IV Feeding Level LowMDS Item K0510A2 K0710A2 K0710B2 3

Lung Transplant Status MDS Item I8000 3Special TreatmentsPrograms Transfusion Post-admit Code MDS Item O0100I2 2Major Organ Transplant Status Except Lung MDS Item I8000 2Active Diagnoses Asthma COPD Chronic Lung Disease Code MDS Item I6200 2BoneJointMuscle InfectionsNecrosis - Except Aseptic Necrosis of Bone MDS Item I8000 2Chronic Myeloid Leukemia MDS Item I8000 2Wound Infection Code MDS Item I2500 2Active Diagnoses Diabetes Mellitus (DM) Code MDS Item I2900 2Endocarditis MDS I8000 1Immune Disorders MDS I8000 1End-Stage Liver Disease MDS I8000 1Other Foot Skin Problems Diabetic Foot Ulcer Code MDS Item M1040B 1Narcolepsy and Cataplexy MDS Item I8000 1Cystic Fibrosis MDS Item I8000 1Special TreatmentsPrograms Tracheostomy Care Post-admit Code MDS Item O00100E2 1Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code MDS Item I1700 1Special TreatmentsPrograms Isolation Post-admit Code MDS Item O0100M2 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsChronic Pancreatitis MDS Item I8000 1Proliferated Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code

MDS Item M1040A M1040B M1040C 1

Complications of Specified Implant Device or Graft MDS Item I8000 1Bladder and Bowel Appliances Intermittent Catheterization MDS Item H0100D 1Inflammatory Bowel Disease MDS Item I1300 1Aseptic Necrosis of Bone MDS Item I8000 1Special TreatmentsPrograms Suctioning Post-admit Code MDS Item O0100D2 1Cardio-Respiratory Failure and Shock MDS Item I8000 1Myelodysplastic Syndromes and Myelofibrosis MDS Item I8000 1Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage MDS Item I8000 1Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Nutritional Approaches While a Resident Feeding Tube MDS Item K0510B2 1Severe Skin Burn or Condition MDS Item I8000 1Intractable Epilepsy MDS Item I8000 1Active Diagnoses Malnutrition code I560 1Disorders of Immunity - Except RxCC97 Immune Disorders MDS Item I8000 1Cirrhosis of Liver MDS Item I8000 1Bladder and Bowel Appliances Ostomy MDS Item H0100C 1Respiratory Arrest MDS Item I8000 1Pulmonary Fibrosis and Other Chronic Lung Disorders MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsSpecified Hereditary MetabolicImmune Disorders MDS Item I8000 1Morbid Obesity MDS Item I8000 1Special TreatmentsPrograms Radiation Post-admit Code MDS Item O0100B2 1Highest Stage of Unhealed Pressure Ulcer - Stage 4 MDS Item M0300D1 1Psoriatic Arthropathy and Systemic Sclerosis MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 184 (NC) X 30 X $44110

Every Point CountsNTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

Every Point Counts

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 253 (NB) X 30 X $60652

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

WORKSHEET

bullNTA Worksheet Calculate the number of NTA points amp payment for the 4 scenarios

28

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient A

29

ConditionExtensive Services NTA Count

Diabetes Mellitus 2

IV Medication 5

Isolation 1

Diabetic Retinopathy 1

Total 9

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient B

30

ConditionExtensive Services NTA Count

COPD 2

Diabetes Mellitus 2

Chronic Pancreatitis 1

Cirrhosis of Liver 1

Total 6

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

31

ConditionExtensive Services Before Fall NTA Count

Diabetes Mellitus 2

Total 2

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

32

ConditionExtensive Services After Fall NTA Count

IV Medication 5

Diabetes Mellitus 2

Endocarditis 1

Total 8

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1
	ConditionExtensive Service		Source		Points
	Specified Hereditary MetabolicImmune Disorders		MDS Item I8000		1
	Morbid Obesity		MDS Item I8000		1
	Special TreatmentsPrograms Radiation Post-admit Code		MDS Item O0100B2		1
	Highest Stage of Unhealed Pressure Ulcer - Stage 4		MDS Item M0300D1		1
	Psoriatic Arthropathy and Systemic Sclerosis		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1

PDPM WORKSHOP

MDS Section K

16

PDPM WORKSHOP

Nursing Component

bullSame RUG IV Major CategoriesoExtensive Services

oSpecial Care High

oSpecial Care Low

oClinically Complex

oBehavior Symptoms amp Cognitive Impairment

oReduced Physical Function

PDPM WORKSHOP

Nursing Functional Score

bullMDS Section GG ndash Functional Abilities amp GoalsoAssessed during first three days of admission

oDocuments ldquousual performancerdquo

oFunctional score ranges from zero to 16

Eating Average Bed Mobility

Toilet Hygiene Average Transfer

PDPM WORKSHOP

Nursing CMI

NursingComponent

Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

HBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

NursingComponent

Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

PDPM WORKSHOP

Nursing Component

bullImportant to NoteoNursing component will be increased by 18 for residents with HIVAIDS

o8 points into the NTA count

bull B20 must be on SNF claim

PDPM WORKSHOP

NTA amp Comorbidity CodingbullComorbidity score is a weighted count of comorbidities

o Comorbidities associated with high increases in NTA costs grouped into various point tiers

o Points assigned for each additional comorbidity present with more points awarded for higher-cost tiers

bullComorbidities amp extensive services for NTA classification are derived from a variety of MDS sources with some identified in Item I8000

bullHIVAIDS remains a SNF claim reported adjustment (8 pts)

bullCalculated based on points assigned for 50 MDS items

21

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

PDPM WORKSHOP

NTA Component

bullData Sources

22

HIV AIDS SNF Claim

Bowelbladder appl H0100C H0100D Ostomy catheterization

ParenteralIVtube feed Section K

Ulcers foot skin probs Section M

Special treatmentsext services Section O IV meds ventilator trach suctioning transfusion radiation infection etc

Diagnoses Section I 6 specific diagnoses

Additional active Dx Item I8000 28 specific diagnoses

PDPM WORKSHOP

ConditionExtensive Service Source PointsHIVAIDS SNF Claim 8Parental IV Feeding Level High MDS Item K0510A2 K0710A2 7Special Treatment Programs Intravenous Medication Post-Admit Code MDS Item O0100H2 5Special Treatment Programs Ventilator or Respirator Post-admit Code MDS Item O0100F2 4

Parental IV Feeding Level LowMDS Item K0510A2 K0710A2 K0710B2 3

Lung Transplant Status MDS Item I8000 3Special TreatmentsPrograms Transfusion Post-admit Code MDS Item O0100I2 2Major Organ Transplant Status Except Lung MDS Item I8000 2Active Diagnoses Asthma COPD Chronic Lung Disease Code MDS Item I6200 2BoneJointMuscle InfectionsNecrosis - Except Aseptic Necrosis of Bone MDS Item I8000 2Chronic Myeloid Leukemia MDS Item I8000 2Wound Infection Code MDS Item I2500 2Active Diagnoses Diabetes Mellitus (DM) Code MDS Item I2900 2Endocarditis MDS I8000 1Immune Disorders MDS I8000 1End-Stage Liver Disease MDS I8000 1Other Foot Skin Problems Diabetic Foot Ulcer Code MDS Item M1040B 1Narcolepsy and Cataplexy MDS Item I8000 1Cystic Fibrosis MDS Item I8000 1Special TreatmentsPrograms Tracheostomy Care Post-admit Code MDS Item O00100E2 1Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code MDS Item I1700 1Special TreatmentsPrograms Isolation Post-admit Code MDS Item O0100M2 1

Sheet1

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PDPM WORKSHOP

ConditionExtensive Service Source PointsChronic Pancreatitis MDS Item I8000 1Proliferated Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code

MDS Item M1040A M1040B M1040C 1

Complications of Specified Implant Device or Graft MDS Item I8000 1Bladder and Bowel Appliances Intermittent Catheterization MDS Item H0100D 1Inflammatory Bowel Disease MDS Item I1300 1Aseptic Necrosis of Bone MDS Item I8000 1Special TreatmentsPrograms Suctioning Post-admit Code MDS Item O0100D2 1Cardio-Respiratory Failure and Shock MDS Item I8000 1Myelodysplastic Syndromes and Myelofibrosis MDS Item I8000 1Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage MDS Item I8000 1Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Nutritional Approaches While a Resident Feeding Tube MDS Item K0510B2 1Severe Skin Burn or Condition MDS Item I8000 1Intractable Epilepsy MDS Item I8000 1Active Diagnoses Malnutrition code I560 1Disorders of Immunity - Except RxCC97 Immune Disorders MDS Item I8000 1Cirrhosis of Liver MDS Item I8000 1Bladder and Bowel Appliances Ostomy MDS Item H0100C 1Respiratory Arrest MDS Item I8000 1Pulmonary Fibrosis and Other Chronic Lung Disorders MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsSpecified Hereditary MetabolicImmune Disorders MDS Item I8000 1Morbid Obesity MDS Item I8000 1Special TreatmentsPrograms Radiation Post-admit Code MDS Item O0100B2 1Highest Stage of Unhealed Pressure Ulcer - Stage 4 MDS Item M0300D1 1Psoriatic Arthropathy and Systemic Sclerosis MDS Item I8000 1

Sheet1

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PDPM WORKSHOP

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 184 (NC) X 30 X $44110

Every Point CountsNTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

Every Point Counts

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 253 (NB) X 30 X $60652

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

WORKSHEET

bullNTA Worksheet Calculate the number of NTA points amp payment for the 4 scenarios

28

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient A

29

ConditionExtensive Services NTA Count

Diabetes Mellitus 2

IV Medication 5

Isolation 1

Diabetic Retinopathy 1

Total 9

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient B

30

ConditionExtensive Services NTA Count

COPD 2

Diabetes Mellitus 2

Chronic Pancreatitis 1

Cirrhosis of Liver 1

Total 6

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

31

ConditionExtensive Services Before Fall NTA Count

Diabetes Mellitus 2

Total 2

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

32

ConditionExtensive Services After Fall NTA Count

IV Medication 5

Diabetes Mellitus 2

Endocarditis 1

Total 8

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1
	ConditionExtensive Service		Source		Points
	Specified Hereditary MetabolicImmune Disorders		MDS Item I8000		1
	Morbid Obesity		MDS Item I8000		1
	Special TreatmentsPrograms Radiation Post-admit Code		MDS Item O0100B2		1
	Highest Stage of Unhealed Pressure Ulcer - Stage 4		MDS Item M0300D1		1
	Psoriatic Arthropathy and Systemic Sclerosis		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1

PDPM WORKSHOP

Nursing Component

bullSame RUG IV Major CategoriesoExtensive Services

oSpecial Care High

oSpecial Care Low

oClinically Complex

oBehavior Symptoms amp Cognitive Impairment

oReduced Physical Function

PDPM WORKSHOP

Nursing Functional Score

bullMDS Section GG ndash Functional Abilities amp GoalsoAssessed during first three days of admission

oDocuments ldquousual performancerdquo

oFunctional score ranges from zero to 16

Eating Average Bed Mobility

Toilet Hygiene Average Transfer

PDPM WORKSHOP

Nursing CMI

NursingComponent

Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

HBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

NursingComponent

Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

PDPM WORKSHOP

Nursing Component

bullImportant to NoteoNursing component will be increased by 18 for residents with HIVAIDS

o8 points into the NTA count

bull B20 must be on SNF claim

PDPM WORKSHOP

NTA amp Comorbidity CodingbullComorbidity score is a weighted count of comorbidities

o Comorbidities associated with high increases in NTA costs grouped into various point tiers

o Points assigned for each additional comorbidity present with more points awarded for higher-cost tiers

bullComorbidities amp extensive services for NTA classification are derived from a variety of MDS sources with some identified in Item I8000

bullHIVAIDS remains a SNF claim reported adjustment (8 pts)

bullCalculated based on points assigned for 50 MDS items

21

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

PDPM WORKSHOP

NTA Component

bullData Sources

22

HIV AIDS SNF Claim

Bowelbladder appl H0100C H0100D Ostomy catheterization

ParenteralIVtube feed Section K

Ulcers foot skin probs Section M

Special treatmentsext services Section O IV meds ventilator trach suctioning transfusion radiation infection etc

Diagnoses Section I 6 specific diagnoses

Additional active Dx Item I8000 28 specific diagnoses

PDPM WORKSHOP

ConditionExtensive Service Source PointsHIVAIDS SNF Claim 8Parental IV Feeding Level High MDS Item K0510A2 K0710A2 7Special Treatment Programs Intravenous Medication Post-Admit Code MDS Item O0100H2 5Special Treatment Programs Ventilator or Respirator Post-admit Code MDS Item O0100F2 4

Parental IV Feeding Level LowMDS Item K0510A2 K0710A2 K0710B2 3

Lung Transplant Status MDS Item I8000 3Special TreatmentsPrograms Transfusion Post-admit Code MDS Item O0100I2 2Major Organ Transplant Status Except Lung MDS Item I8000 2Active Diagnoses Asthma COPD Chronic Lung Disease Code MDS Item I6200 2BoneJointMuscle InfectionsNecrosis - Except Aseptic Necrosis of Bone MDS Item I8000 2Chronic Myeloid Leukemia MDS Item I8000 2Wound Infection Code MDS Item I2500 2Active Diagnoses Diabetes Mellitus (DM) Code MDS Item I2900 2Endocarditis MDS I8000 1Immune Disorders MDS I8000 1End-Stage Liver Disease MDS I8000 1Other Foot Skin Problems Diabetic Foot Ulcer Code MDS Item M1040B 1Narcolepsy and Cataplexy MDS Item I8000 1Cystic Fibrosis MDS Item I8000 1Special TreatmentsPrograms Tracheostomy Care Post-admit Code MDS Item O00100E2 1Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code MDS Item I1700 1Special TreatmentsPrograms Isolation Post-admit Code MDS Item O0100M2 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsChronic Pancreatitis MDS Item I8000 1Proliferated Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code

MDS Item M1040A M1040B M1040C 1

Complications of Specified Implant Device or Graft MDS Item I8000 1Bladder and Bowel Appliances Intermittent Catheterization MDS Item H0100D 1Inflammatory Bowel Disease MDS Item I1300 1Aseptic Necrosis of Bone MDS Item I8000 1Special TreatmentsPrograms Suctioning Post-admit Code MDS Item O0100D2 1Cardio-Respiratory Failure and Shock MDS Item I8000 1Myelodysplastic Syndromes and Myelofibrosis MDS Item I8000 1Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage MDS Item I8000 1Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Nutritional Approaches While a Resident Feeding Tube MDS Item K0510B2 1Severe Skin Burn or Condition MDS Item I8000 1Intractable Epilepsy MDS Item I8000 1Active Diagnoses Malnutrition code I560 1Disorders of Immunity - Except RxCC97 Immune Disorders MDS Item I8000 1Cirrhosis of Liver MDS Item I8000 1Bladder and Bowel Appliances Ostomy MDS Item H0100C 1Respiratory Arrest MDS Item I8000 1Pulmonary Fibrosis and Other Chronic Lung Disorders MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsSpecified Hereditary MetabolicImmune Disorders MDS Item I8000 1Morbid Obesity MDS Item I8000 1Special TreatmentsPrograms Radiation Post-admit Code MDS Item O0100B2 1Highest Stage of Unhealed Pressure Ulcer - Stage 4 MDS Item M0300D1 1Psoriatic Arthropathy and Systemic Sclerosis MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 184 (NC) X 30 X $44110

Every Point CountsNTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

Every Point Counts

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 253 (NB) X 30 X $60652

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

WORKSHEET

bullNTA Worksheet Calculate the number of NTA points amp payment for the 4 scenarios

28

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient A

29

ConditionExtensive Services NTA Count

Diabetes Mellitus 2

IV Medication 5

Isolation 1

Diabetic Retinopathy 1

Total 9

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient B

30

ConditionExtensive Services NTA Count

COPD 2

Diabetes Mellitus 2

Chronic Pancreatitis 1

Cirrhosis of Liver 1

Total 6

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

31

ConditionExtensive Services Before Fall NTA Count

Diabetes Mellitus 2

Total 2

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

32

ConditionExtensive Services After Fall NTA Count

IV Medication 5

Diabetes Mellitus 2

Endocarditis 1

Total 8

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1
	ConditionExtensive Service		Source		Points
	Specified Hereditary MetabolicImmune Disorders		MDS Item I8000		1
	Morbid Obesity		MDS Item I8000		1
	Special TreatmentsPrograms Radiation Post-admit Code		MDS Item O0100B2		1
	Highest Stage of Unhealed Pressure Ulcer - Stage 4		MDS Item M0300D1		1
	Psoriatic Arthropathy and Systemic Sclerosis		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1

PDPM WORKSHOP

Nursing Functional Score

bullMDS Section GG ndash Functional Abilities amp GoalsoAssessed during first three days of admission

oDocuments ldquousual performancerdquo

oFunctional score ranges from zero to 16

Eating Average Bed Mobility

Toilet Hygiene Average Transfer

PDPM WORKSHOP

Nursing CMI

NursingComponent

Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

HBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

NursingComponent

Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

PDPM WORKSHOP

Nursing Component

bullImportant to NoteoNursing component will be increased by 18 for residents with HIVAIDS

o8 points into the NTA count

bull B20 must be on SNF claim

PDPM WORKSHOP

NTA amp Comorbidity CodingbullComorbidity score is a weighted count of comorbidities

o Comorbidities associated with high increases in NTA costs grouped into various point tiers

o Points assigned for each additional comorbidity present with more points awarded for higher-cost tiers

bullComorbidities amp extensive services for NTA classification are derived from a variety of MDS sources with some identified in Item I8000

bullHIVAIDS remains a SNF claim reported adjustment (8 pts)

bullCalculated based on points assigned for 50 MDS items

21

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

PDPM WORKSHOP

NTA Component

bullData Sources

22

HIV AIDS SNF Claim

Bowelbladder appl H0100C H0100D Ostomy catheterization

ParenteralIVtube feed Section K

Ulcers foot skin probs Section M

Special treatmentsext services Section O IV meds ventilator trach suctioning transfusion radiation infection etc

Diagnoses Section I 6 specific diagnoses

Additional active Dx Item I8000 28 specific diagnoses

PDPM WORKSHOP

ConditionExtensive Service Source PointsHIVAIDS SNF Claim 8Parental IV Feeding Level High MDS Item K0510A2 K0710A2 7Special Treatment Programs Intravenous Medication Post-Admit Code MDS Item O0100H2 5Special Treatment Programs Ventilator or Respirator Post-admit Code MDS Item O0100F2 4

Parental IV Feeding Level LowMDS Item K0510A2 K0710A2 K0710B2 3

Lung Transplant Status MDS Item I8000 3Special TreatmentsPrograms Transfusion Post-admit Code MDS Item O0100I2 2Major Organ Transplant Status Except Lung MDS Item I8000 2Active Diagnoses Asthma COPD Chronic Lung Disease Code MDS Item I6200 2BoneJointMuscle InfectionsNecrosis - Except Aseptic Necrosis of Bone MDS Item I8000 2Chronic Myeloid Leukemia MDS Item I8000 2Wound Infection Code MDS Item I2500 2Active Diagnoses Diabetes Mellitus (DM) Code MDS Item I2900 2Endocarditis MDS I8000 1Immune Disorders MDS I8000 1End-Stage Liver Disease MDS I8000 1Other Foot Skin Problems Diabetic Foot Ulcer Code MDS Item M1040B 1Narcolepsy and Cataplexy MDS Item I8000 1Cystic Fibrosis MDS Item I8000 1Special TreatmentsPrograms Tracheostomy Care Post-admit Code MDS Item O00100E2 1Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code MDS Item I1700 1Special TreatmentsPrograms Isolation Post-admit Code MDS Item O0100M2 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsChronic Pancreatitis MDS Item I8000 1Proliferated Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code

MDS Item M1040A M1040B M1040C 1

Complications of Specified Implant Device or Graft MDS Item I8000 1Bladder and Bowel Appliances Intermittent Catheterization MDS Item H0100D 1Inflammatory Bowel Disease MDS Item I1300 1Aseptic Necrosis of Bone MDS Item I8000 1Special TreatmentsPrograms Suctioning Post-admit Code MDS Item O0100D2 1Cardio-Respiratory Failure and Shock MDS Item I8000 1Myelodysplastic Syndromes and Myelofibrosis MDS Item I8000 1Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage MDS Item I8000 1Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Nutritional Approaches While a Resident Feeding Tube MDS Item K0510B2 1Severe Skin Burn or Condition MDS Item I8000 1Intractable Epilepsy MDS Item I8000 1Active Diagnoses Malnutrition code I560 1Disorders of Immunity - Except RxCC97 Immune Disorders MDS Item I8000 1Cirrhosis of Liver MDS Item I8000 1Bladder and Bowel Appliances Ostomy MDS Item H0100C 1Respiratory Arrest MDS Item I8000 1Pulmonary Fibrosis and Other Chronic Lung Disorders MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsSpecified Hereditary MetabolicImmune Disorders MDS Item I8000 1Morbid Obesity MDS Item I8000 1Special TreatmentsPrograms Radiation Post-admit Code MDS Item O0100B2 1Highest Stage of Unhealed Pressure Ulcer - Stage 4 MDS Item M0300D1 1Psoriatic Arthropathy and Systemic Sclerosis MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 184 (NC) X 30 X $44110

Every Point CountsNTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

Every Point Counts

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 253 (NB) X 30 X $60652

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

WORKSHEET

bullNTA Worksheet Calculate the number of NTA points amp payment for the 4 scenarios

28

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient A

29

ConditionExtensive Services NTA Count

Diabetes Mellitus 2

IV Medication 5

Isolation 1

Diabetic Retinopathy 1

Total 9

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient B

30

ConditionExtensive Services NTA Count

COPD 2

Diabetes Mellitus 2

Chronic Pancreatitis 1

Cirrhosis of Liver 1

Total 6

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

31

ConditionExtensive Services Before Fall NTA Count

Diabetes Mellitus 2

Total 2

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

32

ConditionExtensive Services After Fall NTA Count

IV Medication 5

Diabetes Mellitus 2

Endocarditis 1

Total 8

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1
	ConditionExtensive Service		Source		Points
	Specified Hereditary MetabolicImmune Disorders		MDS Item I8000		1
	Morbid Obesity		MDS Item I8000		1
	Special TreatmentsPrograms Radiation Post-admit Code		MDS Item O0100B2		1
	Highest Stage of Unhealed Pressure Ulcer - Stage 4		MDS Item M0300D1		1
	Psoriatic Arthropathy and Systemic Sclerosis		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1

PDPM WORKSHOP

Nursing CMI

NursingComponent

Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

HBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

NursingComponent

Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

PDPM WORKSHOP

Nursing Component

bullImportant to NoteoNursing component will be increased by 18 for residents with HIVAIDS

o8 points into the NTA count

bull B20 must be on SNF claim

PDPM WORKSHOP

NTA amp Comorbidity CodingbullComorbidity score is a weighted count of comorbidities

o Comorbidities associated with high increases in NTA costs grouped into various point tiers

o Points assigned for each additional comorbidity present with more points awarded for higher-cost tiers

bullComorbidities amp extensive services for NTA classification are derived from a variety of MDS sources with some identified in Item I8000

bullHIVAIDS remains a SNF claim reported adjustment (8 pts)

bullCalculated based on points assigned for 50 MDS items

21

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

PDPM WORKSHOP

NTA Component

bullData Sources

22

HIV AIDS SNF Claim

Bowelbladder appl H0100C H0100D Ostomy catheterization

ParenteralIVtube feed Section K

Ulcers foot skin probs Section M

Special treatmentsext services Section O IV meds ventilator trach suctioning transfusion radiation infection etc

Diagnoses Section I 6 specific diagnoses

Additional active Dx Item I8000 28 specific diagnoses

PDPM WORKSHOP

ConditionExtensive Service Source PointsHIVAIDS SNF Claim 8Parental IV Feeding Level High MDS Item K0510A2 K0710A2 7Special Treatment Programs Intravenous Medication Post-Admit Code MDS Item O0100H2 5Special Treatment Programs Ventilator or Respirator Post-admit Code MDS Item O0100F2 4

Parental IV Feeding Level LowMDS Item K0510A2 K0710A2 K0710B2 3

Lung Transplant Status MDS Item I8000 3Special TreatmentsPrograms Transfusion Post-admit Code MDS Item O0100I2 2Major Organ Transplant Status Except Lung MDS Item I8000 2Active Diagnoses Asthma COPD Chronic Lung Disease Code MDS Item I6200 2BoneJointMuscle InfectionsNecrosis - Except Aseptic Necrosis of Bone MDS Item I8000 2Chronic Myeloid Leukemia MDS Item I8000 2Wound Infection Code MDS Item I2500 2Active Diagnoses Diabetes Mellitus (DM) Code MDS Item I2900 2Endocarditis MDS I8000 1Immune Disorders MDS I8000 1End-Stage Liver Disease MDS I8000 1Other Foot Skin Problems Diabetic Foot Ulcer Code MDS Item M1040B 1Narcolepsy and Cataplexy MDS Item I8000 1Cystic Fibrosis MDS Item I8000 1Special TreatmentsPrograms Tracheostomy Care Post-admit Code MDS Item O00100E2 1Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code MDS Item I1700 1Special TreatmentsPrograms Isolation Post-admit Code MDS Item O0100M2 1

Sheet1

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Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsChronic Pancreatitis MDS Item I8000 1Proliferated Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code

MDS Item M1040A M1040B M1040C 1

Complications of Specified Implant Device or Graft MDS Item I8000 1Bladder and Bowel Appliances Intermittent Catheterization MDS Item H0100D 1Inflammatory Bowel Disease MDS Item I1300 1Aseptic Necrosis of Bone MDS Item I8000 1Special TreatmentsPrograms Suctioning Post-admit Code MDS Item O0100D2 1Cardio-Respiratory Failure and Shock MDS Item I8000 1Myelodysplastic Syndromes and Myelofibrosis MDS Item I8000 1Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage MDS Item I8000 1Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Nutritional Approaches While a Resident Feeding Tube MDS Item K0510B2 1Severe Skin Burn or Condition MDS Item I8000 1Intractable Epilepsy MDS Item I8000 1Active Diagnoses Malnutrition code I560 1Disorders of Immunity - Except RxCC97 Immune Disorders MDS Item I8000 1Cirrhosis of Liver MDS Item I8000 1Bladder and Bowel Appliances Ostomy MDS Item H0100C 1Respiratory Arrest MDS Item I8000 1Pulmonary Fibrosis and Other Chronic Lung Disorders MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsSpecified Hereditary MetabolicImmune Disorders MDS Item I8000 1Morbid Obesity MDS Item I8000 1Special TreatmentsPrograms Radiation Post-admit Code MDS Item O0100B2 1Highest Stage of Unhealed Pressure Ulcer - Stage 4 MDS Item M0300D1 1Psoriatic Arthropathy and Systemic Sclerosis MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 184 (NC) X 30 X $44110

Every Point CountsNTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

Every Point Counts

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 253 (NB) X 30 X $60652

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

WORKSHEET

bullNTA Worksheet Calculate the number of NTA points amp payment for the 4 scenarios

28

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient A

29

ConditionExtensive Services NTA Count

Diabetes Mellitus 2

IV Medication 5

Isolation 1

Diabetic Retinopathy 1

Total 9

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient B

30

ConditionExtensive Services NTA Count

COPD 2

Diabetes Mellitus 2

Chronic Pancreatitis 1

Cirrhosis of Liver 1

Total 6

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

31

ConditionExtensive Services Before Fall NTA Count

Diabetes Mellitus 2

Total 2

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

32

ConditionExtensive Services After Fall NTA Count

IV Medication 5

Diabetes Mellitus 2

Endocarditis 1

Total 8

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1
	ConditionExtensive Service		Source		Points
	Specified Hereditary MetabolicImmune Disorders		MDS Item I8000		1
	Morbid Obesity		MDS Item I8000		1
	Special TreatmentsPrograms Radiation Post-admit Code		MDS Item O0100B2		1
	Highest Stage of Unhealed Pressure Ulcer - Stage 4		MDS Item M0300D1		1
	Psoriatic Arthropathy and Systemic Sclerosis		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1

PDPM WORKSHOP

Nursing Component

bullImportant to NoteoNursing component will be increased by 18 for residents with HIVAIDS

o8 points into the NTA count

bull B20 must be on SNF claim

PDPM WORKSHOP

NTA amp Comorbidity CodingbullComorbidity score is a weighted count of comorbidities

o Comorbidities associated with high increases in NTA costs grouped into various point tiers

o Points assigned for each additional comorbidity present with more points awarded for higher-cost tiers

bullComorbidities amp extensive services for NTA classification are derived from a variety of MDS sources with some identified in Item I8000

bullHIVAIDS remains a SNF claim reported adjustment (8 pts)

bullCalculated based on points assigned for 50 MDS items

21

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

PDPM WORKSHOP

NTA Component

bullData Sources

22

HIV AIDS SNF Claim

Bowelbladder appl H0100C H0100D Ostomy catheterization

ParenteralIVtube feed Section K

Ulcers foot skin probs Section M

Special treatmentsext services Section O IV meds ventilator trach suctioning transfusion radiation infection etc

Diagnoses Section I 6 specific diagnoses

Additional active Dx Item I8000 28 specific diagnoses

PDPM WORKSHOP

ConditionExtensive Service Source PointsHIVAIDS SNF Claim 8Parental IV Feeding Level High MDS Item K0510A2 K0710A2 7Special Treatment Programs Intravenous Medication Post-Admit Code MDS Item O0100H2 5Special Treatment Programs Ventilator or Respirator Post-admit Code MDS Item O0100F2 4

Parental IV Feeding Level LowMDS Item K0510A2 K0710A2 K0710B2 3

Lung Transplant Status MDS Item I8000 3Special TreatmentsPrograms Transfusion Post-admit Code MDS Item O0100I2 2Major Organ Transplant Status Except Lung MDS Item I8000 2Active Diagnoses Asthma COPD Chronic Lung Disease Code MDS Item I6200 2BoneJointMuscle InfectionsNecrosis - Except Aseptic Necrosis of Bone MDS Item I8000 2Chronic Myeloid Leukemia MDS Item I8000 2Wound Infection Code MDS Item I2500 2Active Diagnoses Diabetes Mellitus (DM) Code MDS Item I2900 2Endocarditis MDS I8000 1Immune Disorders MDS I8000 1End-Stage Liver Disease MDS I8000 1Other Foot Skin Problems Diabetic Foot Ulcer Code MDS Item M1040B 1Narcolepsy and Cataplexy MDS Item I8000 1Cystic Fibrosis MDS Item I8000 1Special TreatmentsPrograms Tracheostomy Care Post-admit Code MDS Item O00100E2 1Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code MDS Item I1700 1Special TreatmentsPrograms Isolation Post-admit Code MDS Item O0100M2 1

Sheet1

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PDPM WORKSHOP

ConditionExtensive Service Source PointsChronic Pancreatitis MDS Item I8000 1Proliferated Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code

MDS Item M1040A M1040B M1040C 1

Complications of Specified Implant Device or Graft MDS Item I8000 1Bladder and Bowel Appliances Intermittent Catheterization MDS Item H0100D 1Inflammatory Bowel Disease MDS Item I1300 1Aseptic Necrosis of Bone MDS Item I8000 1Special TreatmentsPrograms Suctioning Post-admit Code MDS Item O0100D2 1Cardio-Respiratory Failure and Shock MDS Item I8000 1Myelodysplastic Syndromes and Myelofibrosis MDS Item I8000 1Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage MDS Item I8000 1Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Nutritional Approaches While a Resident Feeding Tube MDS Item K0510B2 1Severe Skin Burn or Condition MDS Item I8000 1Intractable Epilepsy MDS Item I8000 1Active Diagnoses Malnutrition code I560 1Disorders of Immunity - Except RxCC97 Immune Disorders MDS Item I8000 1Cirrhosis of Liver MDS Item I8000 1Bladder and Bowel Appliances Ostomy MDS Item H0100C 1Respiratory Arrest MDS Item I8000 1Pulmonary Fibrosis and Other Chronic Lung Disorders MDS Item I8000 1

Sheet1

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PDPM WORKSHOP

ConditionExtensive Service Source PointsSpecified Hereditary MetabolicImmune Disorders MDS Item I8000 1Morbid Obesity MDS Item I8000 1Special TreatmentsPrograms Radiation Post-admit Code MDS Item O0100B2 1Highest Stage of Unhealed Pressure Ulcer - Stage 4 MDS Item M0300D1 1Psoriatic Arthropathy and Systemic Sclerosis MDS Item I8000 1

Sheet1

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Sheet3

PDPM WORKSHOP

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 184 (NC) X 30 X $44110

Every Point CountsNTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

Every Point Counts

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 253 (NB) X 30 X $60652

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

WORKSHEET

bullNTA Worksheet Calculate the number of NTA points amp payment for the 4 scenarios

28

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient A

29

ConditionExtensive Services NTA Count

Diabetes Mellitus 2

IV Medication 5

Isolation 1

Diabetic Retinopathy 1

Total 9

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient B

30

ConditionExtensive Services NTA Count

COPD 2

Diabetes Mellitus 2

Chronic Pancreatitis 1

Cirrhosis of Liver 1

Total 6

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

31

ConditionExtensive Services Before Fall NTA Count

Diabetes Mellitus 2

Total 2

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

32

ConditionExtensive Services After Fall NTA Count

IV Medication 5

Diabetes Mellitus 2

Endocarditis 1

Total 8

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1
	ConditionExtensive Service		Source		Points
	Specified Hereditary MetabolicImmune Disorders		MDS Item I8000		1
	Morbid Obesity		MDS Item I8000		1
	Special TreatmentsPrograms Radiation Post-admit Code		MDS Item O0100B2		1
	Highest Stage of Unhealed Pressure Ulcer - Stage 4		MDS Item M0300D1		1
	Psoriatic Arthropathy and Systemic Sclerosis		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1

PDPM WORKSHOP

NTA amp Comorbidity CodingbullComorbidity score is a weighted count of comorbidities

o Comorbidities associated with high increases in NTA costs grouped into various point tiers

o Points assigned for each additional comorbidity present with more points awarded for higher-cost tiers

bullComorbidities amp extensive services for NTA classification are derived from a variety of MDS sources with some identified in Item I8000

bullHIVAIDS remains a SNF claim reported adjustment (8 pts)

bullCalculated based on points assigned for 50 MDS items

21

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

PDPM WORKSHOP

NTA Component

bullData Sources

22

HIV AIDS SNF Claim

Bowelbladder appl H0100C H0100D Ostomy catheterization

ParenteralIVtube feed Section K

Ulcers foot skin probs Section M

Special treatmentsext services Section O IV meds ventilator trach suctioning transfusion radiation infection etc

Diagnoses Section I 6 specific diagnoses

Additional active Dx Item I8000 28 specific diagnoses

PDPM WORKSHOP

ConditionExtensive Service Source PointsHIVAIDS SNF Claim 8Parental IV Feeding Level High MDS Item K0510A2 K0710A2 7Special Treatment Programs Intravenous Medication Post-Admit Code MDS Item O0100H2 5Special Treatment Programs Ventilator or Respirator Post-admit Code MDS Item O0100F2 4

Parental IV Feeding Level LowMDS Item K0510A2 K0710A2 K0710B2 3

Lung Transplant Status MDS Item I8000 3Special TreatmentsPrograms Transfusion Post-admit Code MDS Item O0100I2 2Major Organ Transplant Status Except Lung MDS Item I8000 2Active Diagnoses Asthma COPD Chronic Lung Disease Code MDS Item I6200 2BoneJointMuscle InfectionsNecrosis - Except Aseptic Necrosis of Bone MDS Item I8000 2Chronic Myeloid Leukemia MDS Item I8000 2Wound Infection Code MDS Item I2500 2Active Diagnoses Diabetes Mellitus (DM) Code MDS Item I2900 2Endocarditis MDS I8000 1Immune Disorders MDS I8000 1End-Stage Liver Disease MDS I8000 1Other Foot Skin Problems Diabetic Foot Ulcer Code MDS Item M1040B 1Narcolepsy and Cataplexy MDS Item I8000 1Cystic Fibrosis MDS Item I8000 1Special TreatmentsPrograms Tracheostomy Care Post-admit Code MDS Item O00100E2 1Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code MDS Item I1700 1Special TreatmentsPrograms Isolation Post-admit Code MDS Item O0100M2 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsChronic Pancreatitis MDS Item I8000 1Proliferated Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code

MDS Item M1040A M1040B M1040C 1

Complications of Specified Implant Device or Graft MDS Item I8000 1Bladder and Bowel Appliances Intermittent Catheterization MDS Item H0100D 1Inflammatory Bowel Disease MDS Item I1300 1Aseptic Necrosis of Bone MDS Item I8000 1Special TreatmentsPrograms Suctioning Post-admit Code MDS Item O0100D2 1Cardio-Respiratory Failure and Shock MDS Item I8000 1Myelodysplastic Syndromes and Myelofibrosis MDS Item I8000 1Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage MDS Item I8000 1Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Nutritional Approaches While a Resident Feeding Tube MDS Item K0510B2 1Severe Skin Burn or Condition MDS Item I8000 1Intractable Epilepsy MDS Item I8000 1Active Diagnoses Malnutrition code I560 1Disorders of Immunity - Except RxCC97 Immune Disorders MDS Item I8000 1Cirrhosis of Liver MDS Item I8000 1Bladder and Bowel Appliances Ostomy MDS Item H0100C 1Respiratory Arrest MDS Item I8000 1Pulmonary Fibrosis and Other Chronic Lung Disorders MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsSpecified Hereditary MetabolicImmune Disorders MDS Item I8000 1Morbid Obesity MDS Item I8000 1Special TreatmentsPrograms Radiation Post-admit Code MDS Item O0100B2 1Highest Stage of Unhealed Pressure Ulcer - Stage 4 MDS Item M0300D1 1Psoriatic Arthropathy and Systemic Sclerosis MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 184 (NC) X 30 X $44110

Every Point CountsNTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

Every Point Counts

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 253 (NB) X 30 X $60652

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

WORKSHEET

bullNTA Worksheet Calculate the number of NTA points amp payment for the 4 scenarios

28

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient A

29

ConditionExtensive Services NTA Count

Diabetes Mellitus 2

IV Medication 5

Isolation 1

Diabetic Retinopathy 1

Total 9

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient B

30

ConditionExtensive Services NTA Count

COPD 2

Diabetes Mellitus 2

Chronic Pancreatitis 1

Cirrhosis of Liver 1

Total 6

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

31

ConditionExtensive Services Before Fall NTA Count

Diabetes Mellitus 2

Total 2

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

32

ConditionExtensive Services After Fall NTA Count

IV Medication 5

Diabetes Mellitus 2

Endocarditis 1

Total 8

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1
	ConditionExtensive Service		Source		Points
	Specified Hereditary MetabolicImmune Disorders		MDS Item I8000		1
	Morbid Obesity		MDS Item I8000		1
	Special TreatmentsPrograms Radiation Post-admit Code		MDS Item O0100B2		1
	Highest Stage of Unhealed Pressure Ulcer - Stage 4		MDS Item M0300D1		1
	Psoriatic Arthropathy and Systemic Sclerosis		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1

PDPM WORKSHOP

NTA Component

bullData Sources

22

HIV AIDS SNF Claim

Bowelbladder appl H0100C H0100D Ostomy catheterization

ParenteralIVtube feed Section K

Ulcers foot skin probs Section M

Special treatmentsext services Section O IV meds ventilator trach suctioning transfusion radiation infection etc

Diagnoses Section I 6 specific diagnoses

Additional active Dx Item I8000 28 specific diagnoses

PDPM WORKSHOP

ConditionExtensive Service Source PointsHIVAIDS SNF Claim 8Parental IV Feeding Level High MDS Item K0510A2 K0710A2 7Special Treatment Programs Intravenous Medication Post-Admit Code MDS Item O0100H2 5Special Treatment Programs Ventilator or Respirator Post-admit Code MDS Item O0100F2 4

Parental IV Feeding Level LowMDS Item K0510A2 K0710A2 K0710B2 3

Lung Transplant Status MDS Item I8000 3Special TreatmentsPrograms Transfusion Post-admit Code MDS Item O0100I2 2Major Organ Transplant Status Except Lung MDS Item I8000 2Active Diagnoses Asthma COPD Chronic Lung Disease Code MDS Item I6200 2BoneJointMuscle InfectionsNecrosis - Except Aseptic Necrosis of Bone MDS Item I8000 2Chronic Myeloid Leukemia MDS Item I8000 2Wound Infection Code MDS Item I2500 2Active Diagnoses Diabetes Mellitus (DM) Code MDS Item I2900 2Endocarditis MDS I8000 1Immune Disorders MDS I8000 1End-Stage Liver Disease MDS I8000 1Other Foot Skin Problems Diabetic Foot Ulcer Code MDS Item M1040B 1Narcolepsy and Cataplexy MDS Item I8000 1Cystic Fibrosis MDS Item I8000 1Special TreatmentsPrograms Tracheostomy Care Post-admit Code MDS Item O00100E2 1Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code MDS Item I1700 1Special TreatmentsPrograms Isolation Post-admit Code MDS Item O0100M2 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsChronic Pancreatitis MDS Item I8000 1Proliferated Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code

MDS Item M1040A M1040B M1040C 1

Complications of Specified Implant Device or Graft MDS Item I8000 1Bladder and Bowel Appliances Intermittent Catheterization MDS Item H0100D 1Inflammatory Bowel Disease MDS Item I1300 1Aseptic Necrosis of Bone MDS Item I8000 1Special TreatmentsPrograms Suctioning Post-admit Code MDS Item O0100D2 1Cardio-Respiratory Failure and Shock MDS Item I8000 1Myelodysplastic Syndromes and Myelofibrosis MDS Item I8000 1Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage MDS Item I8000 1Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Nutritional Approaches While a Resident Feeding Tube MDS Item K0510B2 1Severe Skin Burn or Condition MDS Item I8000 1Intractable Epilepsy MDS Item I8000 1Active Diagnoses Malnutrition code I560 1Disorders of Immunity - Except RxCC97 Immune Disorders MDS Item I8000 1Cirrhosis of Liver MDS Item I8000 1Bladder and Bowel Appliances Ostomy MDS Item H0100C 1Respiratory Arrest MDS Item I8000 1Pulmonary Fibrosis and Other Chronic Lung Disorders MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsSpecified Hereditary MetabolicImmune Disorders MDS Item I8000 1Morbid Obesity MDS Item I8000 1Special TreatmentsPrograms Radiation Post-admit Code MDS Item O0100B2 1Highest Stage of Unhealed Pressure Ulcer - Stage 4 MDS Item M0300D1 1Psoriatic Arthropathy and Systemic Sclerosis MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 184 (NC) X 30 X $44110

Every Point CountsNTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

Every Point Counts

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 253 (NB) X 30 X $60652

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

WORKSHEET

bullNTA Worksheet Calculate the number of NTA points amp payment for the 4 scenarios

28

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient A

29

ConditionExtensive Services NTA Count

Diabetes Mellitus 2

IV Medication 5

Isolation 1

Diabetic Retinopathy 1

Total 9

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient B

30

ConditionExtensive Services NTA Count

COPD 2

Diabetes Mellitus 2

Chronic Pancreatitis 1

Cirrhosis of Liver 1

Total 6

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

31

ConditionExtensive Services Before Fall NTA Count

Diabetes Mellitus 2

Total 2

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

32

ConditionExtensive Services After Fall NTA Count

IV Medication 5

Diabetes Mellitus 2

Endocarditis 1

Total 8

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1
	ConditionExtensive Service		Source		Points
	Specified Hereditary MetabolicImmune Disorders		MDS Item I8000		1
	Morbid Obesity		MDS Item I8000		1
	Special TreatmentsPrograms Radiation Post-admit Code		MDS Item O0100B2		1
	Highest Stage of Unhealed Pressure Ulcer - Stage 4		MDS Item M0300D1		1
	Psoriatic Arthropathy and Systemic Sclerosis		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1

PDPM WORKSHOP

ConditionExtensive Service Source PointsHIVAIDS SNF Claim 8Parental IV Feeding Level High MDS Item K0510A2 K0710A2 7Special Treatment Programs Intravenous Medication Post-Admit Code MDS Item O0100H2 5Special Treatment Programs Ventilator or Respirator Post-admit Code MDS Item O0100F2 4

Parental IV Feeding Level LowMDS Item K0510A2 K0710A2 K0710B2 3

Lung Transplant Status MDS Item I8000 3Special TreatmentsPrograms Transfusion Post-admit Code MDS Item O0100I2 2Major Organ Transplant Status Except Lung MDS Item I8000 2Active Diagnoses Asthma COPD Chronic Lung Disease Code MDS Item I6200 2BoneJointMuscle InfectionsNecrosis - Except Aseptic Necrosis of Bone MDS Item I8000 2Chronic Myeloid Leukemia MDS Item I8000 2Wound Infection Code MDS Item I2500 2Active Diagnoses Diabetes Mellitus (DM) Code MDS Item I2900 2Endocarditis MDS I8000 1Immune Disorders MDS I8000 1End-Stage Liver Disease MDS I8000 1Other Foot Skin Problems Diabetic Foot Ulcer Code MDS Item M1040B 1Narcolepsy and Cataplexy MDS Item I8000 1Cystic Fibrosis MDS Item I8000 1Special TreatmentsPrograms Tracheostomy Care Post-admit Code MDS Item O00100E2 1Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code MDS Item I1700 1Special TreatmentsPrograms Isolation Post-admit Code MDS Item O0100M2 1

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PDPM WORKSHOP

ConditionExtensive Service Source PointsChronic Pancreatitis MDS Item I8000 1Proliferated Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code

MDS Item M1040A M1040B M1040C 1

Complications of Specified Implant Device or Graft MDS Item I8000 1Bladder and Bowel Appliances Intermittent Catheterization MDS Item H0100D 1Inflammatory Bowel Disease MDS Item I1300 1Aseptic Necrosis of Bone MDS Item I8000 1Special TreatmentsPrograms Suctioning Post-admit Code MDS Item O0100D2 1Cardio-Respiratory Failure and Shock MDS Item I8000 1Myelodysplastic Syndromes and Myelofibrosis MDS Item I8000 1Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage MDS Item I8000 1Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Nutritional Approaches While a Resident Feeding Tube MDS Item K0510B2 1Severe Skin Burn or Condition MDS Item I8000 1Intractable Epilepsy MDS Item I8000 1Active Diagnoses Malnutrition code I560 1Disorders of Immunity - Except RxCC97 Immune Disorders MDS Item I8000 1Cirrhosis of Liver MDS Item I8000 1Bladder and Bowel Appliances Ostomy MDS Item H0100C 1Respiratory Arrest MDS Item I8000 1Pulmonary Fibrosis and Other Chronic Lung Disorders MDS Item I8000 1

Sheet1

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PDPM WORKSHOP

ConditionExtensive Service Source PointsSpecified Hereditary MetabolicImmune Disorders MDS Item I8000 1Morbid Obesity MDS Item I8000 1Special TreatmentsPrograms Radiation Post-admit Code MDS Item O0100B2 1Highest Stage of Unhealed Pressure Ulcer - Stage 4 MDS Item M0300D1 1Psoriatic Arthropathy and Systemic Sclerosis MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 184 (NC) X 30 X $44110

Every Point CountsNTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

Every Point Counts

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 253 (NB) X 30 X $60652

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

WORKSHEET

bullNTA Worksheet Calculate the number of NTA points amp payment for the 4 scenarios

28

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient A

29

ConditionExtensive Services NTA Count

Diabetes Mellitus 2

IV Medication 5

Isolation 1

Diabetic Retinopathy 1

Total 9

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient B

30

ConditionExtensive Services NTA Count

COPD 2

Diabetes Mellitus 2

Chronic Pancreatitis 1

Cirrhosis of Liver 1

Total 6

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

31

ConditionExtensive Services Before Fall NTA Count

Diabetes Mellitus 2

Total 2

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

32

ConditionExtensive Services After Fall NTA Count

IV Medication 5

Diabetes Mellitus 2

Endocarditis 1

Total 8

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1
	ConditionExtensive Service		Source		Points
	Specified Hereditary MetabolicImmune Disorders		MDS Item I8000		1
	Morbid Obesity		MDS Item I8000		1
	Special TreatmentsPrograms Radiation Post-admit Code		MDS Item O0100B2		1
	Highest Stage of Unhealed Pressure Ulcer - Stage 4		MDS Item M0300D1		1
	Psoriatic Arthropathy and Systemic Sclerosis		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1

PDPM WORKSHOP

ConditionExtensive Service Source PointsChronic Pancreatitis MDS Item I8000 1Proliferated Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code

MDS Item M1040A M1040B M1040C 1

Complications of Specified Implant Device or Graft MDS Item I8000 1Bladder and Bowel Appliances Intermittent Catheterization MDS Item H0100D 1Inflammatory Bowel Disease MDS Item I1300 1Aseptic Necrosis of Bone MDS Item I8000 1Special TreatmentsPrograms Suctioning Post-admit Code MDS Item O0100D2 1Cardio-Respiratory Failure and Shock MDS Item I8000 1Myelodysplastic Syndromes and Myelofibrosis MDS Item I8000 1Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage MDS Item I8000 1Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1Nutritional Approaches While a Resident Feeding Tube MDS Item K0510B2 1Severe Skin Burn or Condition MDS Item I8000 1Intractable Epilepsy MDS Item I8000 1Active Diagnoses Malnutrition code I560 1Disorders of Immunity - Except RxCC97 Immune Disorders MDS Item I8000 1Cirrhosis of Liver MDS Item I8000 1Bladder and Bowel Appliances Ostomy MDS Item H0100C 1Respiratory Arrest MDS Item I8000 1Pulmonary Fibrosis and Other Chronic Lung Disorders MDS Item I8000 1

Sheet1

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Sheet3

PDPM WORKSHOP

ConditionExtensive Service Source PointsSpecified Hereditary MetabolicImmune Disorders MDS Item I8000 1Morbid Obesity MDS Item I8000 1Special TreatmentsPrograms Radiation Post-admit Code MDS Item O0100B2 1Highest Stage of Unhealed Pressure Ulcer - Stage 4 MDS Item M0300D1 1Psoriatic Arthropathy and Systemic Sclerosis MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 184 (NC) X 30 X $44110

Every Point CountsNTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

Every Point Counts

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 253 (NB) X 30 X $60652

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

WORKSHEET

bullNTA Worksheet Calculate the number of NTA points amp payment for the 4 scenarios

28

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient A

29

ConditionExtensive Services NTA Count

Diabetes Mellitus 2

IV Medication 5

Isolation 1

Diabetic Retinopathy 1

Total 9

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient B

30

ConditionExtensive Services NTA Count

COPD 2

Diabetes Mellitus 2

Chronic Pancreatitis 1

Cirrhosis of Liver 1

Total 6

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

31

ConditionExtensive Services Before Fall NTA Count

Diabetes Mellitus 2

Total 2

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

32

ConditionExtensive Services After Fall NTA Count

IV Medication 5

Diabetes Mellitus 2

Endocarditis 1

Total 8

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1
	ConditionExtensive Service		Source		Points
	Specified Hereditary MetabolicImmune Disorders		MDS Item I8000		1
	Morbid Obesity		MDS Item I8000		1
	Special TreatmentsPrograms Radiation Post-admit Code		MDS Item O0100B2		1
	Highest Stage of Unhealed Pressure Ulcer - Stage 4		MDS Item M0300D1		1
	Psoriatic Arthropathy and Systemic Sclerosis		MDS Item I8000		1

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1

PDPM WORKSHOP

ConditionExtensive Service Source PointsSpecified Hereditary MetabolicImmune Disorders MDS Item I8000 1Morbid Obesity MDS Item I8000 1Special TreatmentsPrograms Radiation Post-admit Code MDS Item O0100B2 1Highest Stage of Unhealed Pressure Ulcer - Stage 4 MDS Item M0300D1 1Psoriatic Arthropathy and Systemic Sclerosis MDS Item I8000 1

Sheet1

Sheet2

Sheet3

PDPM WORKSHOP

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 184 (NC) X 30 X $44110

Every Point CountsNTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

Every Point Counts

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 253 (NB) X 30 X $60652

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

WORKSHEET

bullNTA Worksheet Calculate the number of NTA points amp payment for the 4 scenarios

28

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient A

29

ConditionExtensive Services NTA Count

Diabetes Mellitus 2

IV Medication 5

Isolation 1

Diabetic Retinopathy 1

Total 9

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient B

30

ConditionExtensive Services NTA Count

COPD 2

Diabetes Mellitus 2

Chronic Pancreatitis 1

Cirrhosis of Liver 1

Total 6

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

31

ConditionExtensive Services Before Fall NTA Count

Diabetes Mellitus 2

Total 2

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

32

ConditionExtensive Services After Fall NTA Count

IV Medication 5

Diabetes Mellitus 2

Endocarditis 1

Total 8

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

	Clinical Category		Example			Clinical Category		Example
	Major JointSpinal Surgery		Cancer			Medical Management		Z483 aftercare following surgery for neoplasm
	Non-Surgical OrthopedicMusculoskeletal		Pulmonary			Non Orthopedic Surgery		S31829D unspecified open wound of L buttock subsequent encounter
	Orthopedic Surgery (Except for Major Joint Replacement or Spinal Surgery		Cardiovascular and Coagulations			Pulmonary		J9611 Chronic Respiratory failure with hypoxia
	Acute Infections		Acute Neurologic			Acute Infection		A4151 Sepsis due to E Coli
	Medical Management		Non-Orthopedic Surgery			Acute Neurologic		I639 Cerebral Infarction unspecified
				Major JointSpinal Surgery		Z471 aftercare following joint replacement surgery
				CVCoagulations		I951 Orthostatic Hypertension
				Orthopedic Surgery		Z4789 Encounter for other orthopedic aftercare
				Non surgical OrthopedicMusculoskeletal		T84021S Dislocation of internal L hip prosthesis- sequela
				Cancer		All forms of cancer blood tissue bone
	ConditionExtensive Service		Source		Points
	HIVAIDS		SNF Claim		8
	Parental IV Feeding Level High		MDS Item K0510A2 K0710A2		7
	Special Treatment Programs Intravenous Medication Post-Admit Code		MDS Item O0100H2		5
	Special Treatment Programs Ventilator or Respirator Post-admit Code		MDS Item O0100F2		4
	Parental IV Feeding Level Low		MDS Item K0510A2 K0710A2 K0710B2		3
	Lung Transplant Status		MDS Item I8000		3
	Special TreatmentsPrograms Transfusion Post-admit Code		MDS Item O0100I2		2
	Major Organ Transplant Status Except Lung		MDS Item I8000		2
	Active Diagnoses Asthma COPD Chronic Lung Disease Code		MDS Item I6200		2
	BoneJointMuscle InfectionsNecrosis - 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 I8000		1
	Immune Disorders		MDS I8000		1
	End-Stage Liver Disease		MDS 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 TreatmentsPrograms Tracheostomy Care Post-admit Code		MDS Item O00100E2		1
	Active Diagnoses Multi-Drug Resistant Organism (MDRO) Code		MDS Item I1700		1
	Special TreatmentsPrograms Isolation Post-admit Code		MDS Item O0100M2		1
	ConditionExtensive Service		Source		Points
	Chronic Pancreatitis		MDS Item I8000		1
	Proliferated Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Other Foot Skin Problems Foot Infection Code Other Open Lesion on Foot Code Except Diabetic Foot Ulcer Code		MDS Item M1040A M1040B M1040C		1
	Complications of Specified Implant Device or Graft		MDS Item I8000		1
	Bladder and Bowel Appliances Intermittent Catheterization		MDS Item H0100D		1
	Inflammatory Bowel Disease		MDS Item I1300		1
	Aseptic Necrosis of Bone		MDS Item I8000		1
	Special TreatmentsPrograms Suctioning Post-admit Code		MDS Item O0100D2		1
	Cardio-Respiratory Failure and Shock		MDS Item I8000		1
	Myelodysplastic Syndromes and Myelofibrosis		MDS Item I8000		1
	Systemic Lupus Erythematosus Other Connective Tissue Disorders and Inflammatory Hemorrhage		MDS Item I8000		1
	Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage		MDS Item I8000		1
	Nutritional Approaches While a Resident Feeding Tube		MDS Item K0510B2		1
	Severe Skin Burn or Condition		MDS Item I8000		1
	Intractable Epilepsy		MDS Item I8000		1
	Active Diagnoses Malnutrition code		I560		1
	Disorders of Immunity - Except RxCC97 Immune Disorders		MDS Item I8000		1
	Cirrhosis of Liver		MDS Item I8000		1
	Bladder and Bowel Appliances Ostomy		MDS Item H0100C		1
	Respiratory Arrest		MDS Item I8000		1
	Pulmonary Fibrosis and Other Chronic Lung Disorders		MDS Item I8000		1
	ConditionExtensive Service		Source		Points
	Specified Hereditary MetabolicImmune Disorders		MDS Item I8000		1
	Morbid Obesity		MDS Item I8000		1
	Special TreatmentsPrograms Radiation Post-admit Code		MDS Item O0100B2		1
	Highest Stage of Unhealed Pressure Ulcer - Stage 4		MDS Item M0300D1		1
	Psoriatic Arthropathy and Systemic Sclerosis		MDS Item I8000		1

PDPM WORKSHOP

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 184 (NC) X 30 X $44110

Every Point CountsNTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

Every Point Counts

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 253 (NB) X 30 X $60652

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

WORKSHEET

bullNTA Worksheet Calculate the number of NTA points amp payment for the 4 scenarios

28

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient A

29

ConditionExtensive Services NTA Count

Diabetes Mellitus 2

IV Medication 5

Isolation 1

Diabetic Retinopathy 1

Total 9

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient B

30

ConditionExtensive Services NTA Count

COPD 2

Diabetes Mellitus 2

Chronic Pancreatitis 1

Cirrhosis of Liver 1

Total 6

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

31

ConditionExtensive Services Before Fall NTA Count

Diabetes Mellitus 2

Total 2

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

32

ConditionExtensive Services After Fall NTA Count

IV Medication 5

Diabetes Mellitus 2

Endocarditis 1

Total 8

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

PDPM WORKSHOP

Every Point Counts

Component Urban Base Rate CMI Variable Adjustment Factor Per Diem(for 1st 3 days of stay)

NTA $7991 X 253 (NB) X 30 X $60652

NTA Score Range NTA Case Mix Group NTA Case Mix Index12+ NA 3249-11 NB 2536-8 NC 1843-5 ND 1331-2 NE 0960 NF 072

TABLE 12 FY 2019 PDPM Unadjusted Rate Per Diem - UrbanRate

Component Nursing NTA PT OT SLP Non Case-Mix

Per Diem Amount

$10592 $7991 $6075 $5655 $2268 $9484

PDPM WORKSHOP

WORKSHEET

bullNTA Worksheet Calculate the number of NTA points amp payment for the 4 scenarios

28

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient A

29

ConditionExtensive Services NTA Count

Diabetes Mellitus 2

IV Medication 5

Isolation 1

Diabetic Retinopathy 1

Total 9

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient B

30

ConditionExtensive Services NTA Count

COPD 2

Diabetes Mellitus 2

Chronic Pancreatitis 1

Cirrhosis of Liver 1

Total 6

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

31

ConditionExtensive Services Before Fall NTA Count

Diabetes Mellitus 2

Total 2

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

32

ConditionExtensive Services After Fall NTA Count

IV Medication 5

Diabetes Mellitus 2

Endocarditis 1

Total 8

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

PDPM WORKSHOP

WORKSHEET

bullNTA Worksheet Calculate the number of NTA points amp payment for the 4 scenarios

28

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient A

29

ConditionExtensive Services NTA Count

Diabetes Mellitus 2

IV Medication 5

Isolation 1

Diabetic Retinopathy 1

Total 9

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient B

30

ConditionExtensive Services NTA Count

COPD 2

Diabetes Mellitus 2

Chronic Pancreatitis 1

Cirrhosis of Liver 1

Total 6

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

31

ConditionExtensive Services Before Fall NTA Count

Diabetes Mellitus 2

Total 2

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

32

ConditionExtensive Services After Fall NTA Count

IV Medication 5

Diabetes Mellitus 2

Endocarditis 1

Total 8

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient A

29

ConditionExtensive Services NTA Count

Diabetes Mellitus 2

IV Medication 5

Isolation 1

Diabetic Retinopathy 1

Total 9

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient B

30

ConditionExtensive Services NTA Count

COPD 2

Diabetes Mellitus 2

Chronic Pancreatitis 1

Cirrhosis of Liver 1

Total 6

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

31

ConditionExtensive Services Before Fall NTA Count

Diabetes Mellitus 2

Total 2

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

32

ConditionExtensive Services After Fall NTA Count

IV Medication 5

Diabetes Mellitus 2

Endocarditis 1

Total 8

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient B

30

ConditionExtensive Services NTA Count

COPD 2

Diabetes Mellitus 2

Chronic Pancreatitis 1

Cirrhosis of Liver 1

Total 6

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

31

ConditionExtensive Services Before Fall NTA Count

Diabetes Mellitus 2

Total 2

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

32

ConditionExtensive Services After Fall NTA Count

IV Medication 5

Diabetes Mellitus 2

Endocarditis 1

Total 8

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

31

ConditionExtensive Services Before Fall NTA Count

Diabetes Mellitus 2

Total 2

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

32

ConditionExtensive Services After Fall NTA Count

IV Medication 5

Diabetes Mellitus 2

Endocarditis 1

Total 8

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

PDPM WORKSHOP

NTA Scenarios

bullNTA Patient C

32

ConditionExtensive Services After Fall NTA Count

IV Medication 5

Diabetes Mellitus 2

Endocarditis 1

Total 8

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

PDPM WORKSHOP

NTA Payment Scenario

Patient NTA Count CMG CMI NTA Payment

A 9 NB 253 $20217

B 6 NC 184 $14703

C before fall 2 NE 096 $7671

After Fall 8 NC 184 $14703

33

Updated for Urban rate in FY20

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

PDPM WORKSHOP

ICD-10 Coding

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

PDPM WORKSHOP

ICD-10 Fundamentals

bull Replaced ICD-9 codes as of October 1 2015bull Expanded number of potential codes from 13000+ to

70000+bull Also expanded from 4-digit to 6-digit coding to allow for far

more specificity includingoLaterality (M24461 ndash Recurrent dislocation right knee)oMore specific condition details (L89221 ndash Pressure ulcer of left hip

stage 1)oCombinations of conditions (I25110 - Atherosclerotic heart disease of

native coronary artery with unstable angina pectoris)

35

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

PDPM WORKSHOP

PDPM Clinical Category

36

bull Clinical categories are assigned based on the primary diagnosis for the stay

bull NEW MDS item I0020B (ldquoI-20-Brdquo) is used to then map to one of the PDPM clinical categories

bull Section J (Surgical Procedures) of MDS used to further adjust clinical classifications if applicable

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

PDPM WORKSHOP

Clinical Category

bullhttpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentSNFPPSPDPMhtml

37

PDPM WORKSHOP

10 Steps to Correct Coding

bullStep 1 Identify the reason for the visit or encounter (ie a sign symptom diagnosis andor condition)

bullStep 2 After selecting the reason for the encounter always consult the alphabetic index before verifying code selection in the tabular section

bullStep 3 Locate the main term entry

bullStep 4 Read cross-reference listed with the main term or the subterm

bullStep 5 Review entries for modifiers

38

PDPM WORKSHOP

10 Steps to Correct Coding

bullStep 6 Interpret abbreviations cross-references default codes additional character and brackets

bullStep 7 Choose a potential code and locate it in the tabular list

bullStep 8 Determine whether the code is a the highest level of specificity

bullStep 9 Assign the code

bullStep 10 Sequence codes correctly

39

PDPM WORKSHOP

Example

bullAspiration pneumonia

40

PDPM WORKSHOP

Aspiration Pneumonia

bullDiagnosis Pneumonia due aspiration of tube feeding

bullStep 1 The reason for the encounter was the condition Aspiration Pneumonia

bullStep 2 Consult the Alphabetic Index

41

PDPM WORKSHOP

bullStep 3

Locate the main term entry

Aspiration Pneumonia

bkdcomPDPM42

PDPM WORKSHOP

bullStep 4

Read cross-reference listed with the main term or the sub-term

Aspiration Pneumonia

bkdcomPDPM43

PDPM WORKSHOP

bullStep 5

Review entries for modifiers

Aspiration Pneumonia

PDPM WORKSHOP

Aspiration Pneumonia

bullStep 6

Go to Tabular List

PDPM WORKSHOP

Aspiration Pneumonia

bullStep 7 Locate Code

PDPM WORKSHOP

Aspiration Pneumonia

PDPM WORKSHOP

Aspiration Pneumonia

bullStep 8 Read through the subcategory codes under J69 and note that the fourth character is required to specify solid or liquids that caused the pneumonia Locate the Pneumonitis due to inhalation of food and vomit J690

bullStep 9 Assign code J690 Pneumonitis due to inhalation of food and vomit

bullStep 10 Be sure to add the associated foreign body in respiratory tract code T17910D

PDPM WORKSHOP

Which ICD-10 Codes Map to a PDPM Clinical Category

49

PDPM WORKSHOP

50

RTPRTP

RTPRTP

Medical ManagementNon-Surgical Ortho Musculoskeletal

RTPRTP

RTP

RTP

Which ICD-10 Codes Map to a PDPM Clinical Category

PDPM WORKSHOP

Patient Surgical History ndashItems J2100 ndash J5000 (New Items)

bull These items are used to capture any major surgical procedures that occurred during the inpatient hospital stay that immediately preceded the SNF admission (ie the qualifying hospital stay)

Section J ndashPast Surgical Categories

51

PDPM WORKSHOP

Section J ndash Past Surgical Categories

52

PDPM WORKSHOP

53

MDS Sample ndash Section I (Active Diagnoses)

PDPM WORKSHOP

54

Section I ndash Continued

PDPM WORKSHOP

Section GG

PDPM WORKSHOP

Functional Scoring under PDPM

bull ldquoReversedrdquo scoring between RUG vs PDPMbull RUG-IV Section G with a higher score means increased dependence

bull PDPM Section GG with a higher score means increased independence

bullPayment Differences related to Function between RUG vs PDPMbull RUG-IV payments increase with dependence within a given RUG

bull PDPM has no consistent relationship between increased dependence amp increased payments (differs for Therapy amp Nursing)

bull For the PT amp OT component payment for three clinical categories is lower for the most amp least dependent patients (who are less likely to require high amounts of therapy) amp higher for those in between (who are more likely to require high amounts of therapy)

56

PDPM WORKSHOP

Nursing Component

bullPDPM uses the same basic structure as RUG-IV except for the following changes o Function score based on Section GG of the MDS 30

o Collapsed functional nursing groups from 43 to 25

57

PDPM WORKSHOP

58

Section GG0130 -Self Care

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

59

Section GG0170 -Mobility

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

60

PDPM WORKSHOP

Why Does This Matter

bull Therapy amp nursing use different languagebull Therapy ratings may not accurately reflect the residents

ldquousual performancerdquo because residents may act differently in therapy than they do on the unit

61

PDPM WORKSHOP

Usual Performance RAI Manual page GG-9

bull A residentrsquos functional status can be impacted by the environment or situations encountered at the facilitybull Observing the residentrsquos interactions with others in different

locations amp circumstances is important for a comprehensive understanding of the residentrsquos functional statusbull If the residentrsquos functional status varies record the

residentrsquos usual ability to perform each activity bull Do not record the residentrsquos best performance amp do not

record the residentrsquos worst performance but rather record the residentrsquos usual performance

62

PDPM WORKSHOP

Patient Case Study

bull Mr L lives with his wife in a one-level home which is accessed by 3 steps bull Prior to a recent fall Mr L was independent with self-care

activities including bathing dressing toileting amp eating bull He was able to ambulate about the house without problem with

the use of a cane bullWhen ascending amp descending the external steps of the house

Mr L would hold onto rails to ensure his balance bull Mr L prepares his own daily medications amp takes turns with his

wife to ensure the bills are paid amp grocery shopping is done

63

PDPM WORKSHOP

OT Evaluation

64

EATING

Receiving a no added salt regular consistency diet Independent opening containers amp cutting up meat once the tray is set before him Discharge goal is to remain independent with eating

ORAL HYGIENE

Edentulous wears full dentures Able to remove dentures to soak clean amp replace in mouth once needed items are set up Once activity is complete staff put away items It is anticipated he will not require assistance of any type with oral hygiene by discharge

TOILETING HYGIENE

Uses toilet to void amp have bowel movements Once standing before toilet requires steadying assistance from one helper as he pulls down his pants amp underwear After elimination requires staff to wipe amp clean Contact guard assistance is needed to stand amp readjust clothing Expected that he will perform perineal hygiene amp management of clothing with supervision Per clinical staff documentation required substantialmax assistance with toileting hygiene on 7 of the 9 observed shifts in the first 3 days of his stay Interview with staff indicate that he required staff to wipe amp clean him assist him to stand amp to pull up his pants amp underwear after elimination

PDPM WORKSHOP

PT Evaluation

65

ROLL LEFT amp RIGHT

Requires therapist to position pillow between legs to prevent adduction of the affected extremity amp then to assist him to roll side to side in bed Therapist provided more than half of the effort Therapy goal states it is expected that he will be independent with bed mobility including being able to roll left amp right at discharge

SIT TO LYING

Requires assistance of 1 therapist to support trunk amp lift both legs back into bed Did contribute a small amount of effort as he used his right arm to lower himself to a supine position Therapy goal is for him to be independent with this activity by discharge

LYLYING TO SITTINGON SIDE OF BED

Able to bring his left leg off the bed amp assist with pushing up with right arm Required assist to bring right leg off the side of the bed amp needed to be fully supported to come to a sitting position Helper provided more than half the effort Therapy goal is for Mr L to be independent with this activity by discharge

PDPM WORKSHOP

Case Study Scoring

bull Use handouts to complete taskbull Please work in groups at your tablebull Items to code on Admission5-PPS Assessmento GG0130 Self Care Items (just 3 areas covered)

o GG0170 Mobility Items (just 3 areas covered)

o Discharge goals for one Self Care amp Mobility Item

PDPM WORKSHOP

Admission5-Day PPS AssessmentGG0130 Self-Care

PDPM WORKSHOP

GG0130 Self-Care

68

ITEM 1 ADMISSION PERFORMANCE

2 DISCHARGE GOAL

GG0130A Eating 06 Independent 06 Independent

GG0130B Oral Hygiene 05 Setup or Clean-up Assistance

06 Independent

GG0130C Toileting Hygiene 02 SubstantialMaximal Assistance

04 Supervision or Touching Assistance

GG0130E ShowerBath Self NA NA

GG0130F Upper Body Dressing NA NA

GG0130G Lower Body Dressing NA NA

GG0130H Putting onTaking off Footwear

NA NA

PDPM WORKSHOP

GG0130A Eating

bull Admission Performance Coding = 06 Independent

bull Rationale Mr L was able to open containers cut meat amp eat without assistance on admission

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to remain independent with eating on discharge

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

10 Steps to Correct Coding

bullStep 6 Interpret abbreviations cross-references default codes additional character and brackets

bullStep 7 Choose a potential code and locate it in the tabular list

bullStep 8 Determine whether the code is a the highest level of specificity

bullStep 9 Assign the code

bullStep 10 Sequence codes correctly

39

PDPM WORKSHOP

Example

bullAspiration pneumonia

40

PDPM WORKSHOP

Aspiration Pneumonia

bullDiagnosis Pneumonia due aspiration of tube feeding

bullStep 1 The reason for the encounter was the condition Aspiration Pneumonia

bullStep 2 Consult the Alphabetic Index

41

PDPM WORKSHOP

bullStep 3

Locate the main term entry

Aspiration Pneumonia

bkdcomPDPM42

PDPM WORKSHOP

bullStep 4

Read cross-reference listed with the main term or the sub-term

Aspiration Pneumonia

bkdcomPDPM43

PDPM WORKSHOP

bullStep 5

Review entries for modifiers

Aspiration Pneumonia

PDPM WORKSHOP

Aspiration Pneumonia

bullStep 6

Go to Tabular List

PDPM WORKSHOP

Aspiration Pneumonia

bullStep 7 Locate Code

PDPM WORKSHOP

Aspiration Pneumonia

PDPM WORKSHOP

Aspiration Pneumonia

bullStep 8 Read through the subcategory codes under J69 and note that the fourth character is required to specify solid or liquids that caused the pneumonia Locate the Pneumonitis due to inhalation of food and vomit J690

bullStep 9 Assign code J690 Pneumonitis due to inhalation of food and vomit

bullStep 10 Be sure to add the associated foreign body in respiratory tract code T17910D

PDPM WORKSHOP

Which ICD-10 Codes Map to a PDPM Clinical Category

49

PDPM WORKSHOP

50

RTPRTP

RTPRTP

Medical ManagementNon-Surgical Ortho Musculoskeletal

RTPRTP

RTP

RTP

Which ICD-10 Codes Map to a PDPM Clinical Category

PDPM WORKSHOP

Patient Surgical History ndashItems J2100 ndash J5000 (New Items)

bull These items are used to capture any major surgical procedures that occurred during the inpatient hospital stay that immediately preceded the SNF admission (ie the qualifying hospital stay)

Section J ndashPast Surgical Categories

51

PDPM WORKSHOP

Section J ndash Past Surgical Categories

52

PDPM WORKSHOP

53

MDS Sample ndash Section I (Active Diagnoses)

PDPM WORKSHOP

54

Section I ndash Continued

PDPM WORKSHOP

Section GG

PDPM WORKSHOP

Functional Scoring under PDPM

bull ldquoReversedrdquo scoring between RUG vs PDPMbull RUG-IV Section G with a higher score means increased dependence

bull PDPM Section GG with a higher score means increased independence

bullPayment Differences related to Function between RUG vs PDPMbull RUG-IV payments increase with dependence within a given RUG

bull PDPM has no consistent relationship between increased dependence amp increased payments (differs for Therapy amp Nursing)

bull For the PT amp OT component payment for three clinical categories is lower for the most amp least dependent patients (who are less likely to require high amounts of therapy) amp higher for those in between (who are more likely to require high amounts of therapy)

56

PDPM WORKSHOP

Nursing Component

bullPDPM uses the same basic structure as RUG-IV except for the following changes o Function score based on Section GG of the MDS 30

o Collapsed functional nursing groups from 43 to 25

57

PDPM WORKSHOP

58

Section GG0130 -Self Care

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

59

Section GG0170 -Mobility

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

60

PDPM WORKSHOP

Why Does This Matter

bull Therapy amp nursing use different languagebull Therapy ratings may not accurately reflect the residents

ldquousual performancerdquo because residents may act differently in therapy than they do on the unit

61

PDPM WORKSHOP

Usual Performance RAI Manual page GG-9

bull A residentrsquos functional status can be impacted by the environment or situations encountered at the facilitybull Observing the residentrsquos interactions with others in different

locations amp circumstances is important for a comprehensive understanding of the residentrsquos functional statusbull If the residentrsquos functional status varies record the

residentrsquos usual ability to perform each activity bull Do not record the residentrsquos best performance amp do not

record the residentrsquos worst performance but rather record the residentrsquos usual performance

62

PDPM WORKSHOP

Patient Case Study

bull Mr L lives with his wife in a one-level home which is accessed by 3 steps bull Prior to a recent fall Mr L was independent with self-care

activities including bathing dressing toileting amp eating bull He was able to ambulate about the house without problem with

the use of a cane bullWhen ascending amp descending the external steps of the house

Mr L would hold onto rails to ensure his balance bull Mr L prepares his own daily medications amp takes turns with his

wife to ensure the bills are paid amp grocery shopping is done

63

PDPM WORKSHOP

OT Evaluation

64

EATING

Receiving a no added salt regular consistency diet Independent opening containers amp cutting up meat once the tray is set before him Discharge goal is to remain independent with eating

ORAL HYGIENE

Edentulous wears full dentures Able to remove dentures to soak clean amp replace in mouth once needed items are set up Once activity is complete staff put away items It is anticipated he will not require assistance of any type with oral hygiene by discharge

TOILETING HYGIENE

Uses toilet to void amp have bowel movements Once standing before toilet requires steadying assistance from one helper as he pulls down his pants amp underwear After elimination requires staff to wipe amp clean Contact guard assistance is needed to stand amp readjust clothing Expected that he will perform perineal hygiene amp management of clothing with supervision Per clinical staff documentation required substantialmax assistance with toileting hygiene on 7 of the 9 observed shifts in the first 3 days of his stay Interview with staff indicate that he required staff to wipe amp clean him assist him to stand amp to pull up his pants amp underwear after elimination

PDPM WORKSHOP

PT Evaluation

65

ROLL LEFT amp RIGHT

Requires therapist to position pillow between legs to prevent adduction of the affected extremity amp then to assist him to roll side to side in bed Therapist provided more than half of the effort Therapy goal states it is expected that he will be independent with bed mobility including being able to roll left amp right at discharge

SIT TO LYING

Requires assistance of 1 therapist to support trunk amp lift both legs back into bed Did contribute a small amount of effort as he used his right arm to lower himself to a supine position Therapy goal is for him to be independent with this activity by discharge

LYLYING TO SITTINGON SIDE OF BED

Able to bring his left leg off the bed amp assist with pushing up with right arm Required assist to bring right leg off the side of the bed amp needed to be fully supported to come to a sitting position Helper provided more than half the effort Therapy goal is for Mr L to be independent with this activity by discharge

PDPM WORKSHOP

Case Study Scoring

bull Use handouts to complete taskbull Please work in groups at your tablebull Items to code on Admission5-PPS Assessmento GG0130 Self Care Items (just 3 areas covered)

o GG0170 Mobility Items (just 3 areas covered)

o Discharge goals for one Self Care amp Mobility Item

PDPM WORKSHOP

Admission5-Day PPS AssessmentGG0130 Self-Care

PDPM WORKSHOP

GG0130 Self-Care

68

ITEM 1 ADMISSION PERFORMANCE

2 DISCHARGE GOAL

GG0130A Eating 06 Independent 06 Independent

GG0130B Oral Hygiene 05 Setup or Clean-up Assistance

06 Independent

GG0130C Toileting Hygiene 02 SubstantialMaximal Assistance

04 Supervision or Touching Assistance

GG0130E ShowerBath Self NA NA

GG0130F Upper Body Dressing NA NA

GG0130G Lower Body Dressing NA NA

GG0130H Putting onTaking off Footwear

NA NA

PDPM WORKSHOP

GG0130A Eating

bull Admission Performance Coding = 06 Independent

bull Rationale Mr L was able to open containers cut meat amp eat without assistance on admission

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to remain independent with eating on discharge

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Example

bullAspiration pneumonia

40

PDPM WORKSHOP

Aspiration Pneumonia

bullDiagnosis Pneumonia due aspiration of tube feeding

bullStep 1 The reason for the encounter was the condition Aspiration Pneumonia

bullStep 2 Consult the Alphabetic Index

41

PDPM WORKSHOP

bullStep 3

Locate the main term entry

Aspiration Pneumonia

bkdcomPDPM42

PDPM WORKSHOP

bullStep 4

Read cross-reference listed with the main term or the sub-term

Aspiration Pneumonia

bkdcomPDPM43

PDPM WORKSHOP

bullStep 5

Review entries for modifiers

Aspiration Pneumonia

PDPM WORKSHOP

Aspiration Pneumonia

bullStep 6

Go to Tabular List

PDPM WORKSHOP

Aspiration Pneumonia

bullStep 7 Locate Code

PDPM WORKSHOP

Aspiration Pneumonia

PDPM WORKSHOP

Aspiration Pneumonia

bullStep 8 Read through the subcategory codes under J69 and note that the fourth character is required to specify solid or liquids that caused the pneumonia Locate the Pneumonitis due to inhalation of food and vomit J690

bullStep 9 Assign code J690 Pneumonitis due to inhalation of food and vomit

bullStep 10 Be sure to add the associated foreign body in respiratory tract code T17910D

PDPM WORKSHOP

Which ICD-10 Codes Map to a PDPM Clinical Category

49

PDPM WORKSHOP

50

RTPRTP

RTPRTP

Medical ManagementNon-Surgical Ortho Musculoskeletal

RTPRTP

RTP

RTP

Which ICD-10 Codes Map to a PDPM Clinical Category

PDPM WORKSHOP

Patient Surgical History ndashItems J2100 ndash J5000 (New Items)

bull These items are used to capture any major surgical procedures that occurred during the inpatient hospital stay that immediately preceded the SNF admission (ie the qualifying hospital stay)

Section J ndashPast Surgical Categories

51

PDPM WORKSHOP

Section J ndash Past Surgical Categories

52

PDPM WORKSHOP

53

MDS Sample ndash Section I (Active Diagnoses)

PDPM WORKSHOP

54

Section I ndash Continued

PDPM WORKSHOP

Section GG

PDPM WORKSHOP

Functional Scoring under PDPM

bull ldquoReversedrdquo scoring between RUG vs PDPMbull RUG-IV Section G with a higher score means increased dependence

bull PDPM Section GG with a higher score means increased independence

bullPayment Differences related to Function between RUG vs PDPMbull RUG-IV payments increase with dependence within a given RUG

bull PDPM has no consistent relationship between increased dependence amp increased payments (differs for Therapy amp Nursing)

bull For the PT amp OT component payment for three clinical categories is lower for the most amp least dependent patients (who are less likely to require high amounts of therapy) amp higher for those in between (who are more likely to require high amounts of therapy)

56

PDPM WORKSHOP

Nursing Component

bullPDPM uses the same basic structure as RUG-IV except for the following changes o Function score based on Section GG of the MDS 30

o Collapsed functional nursing groups from 43 to 25

57

PDPM WORKSHOP

58

Section GG0130 -Self Care

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

59

Section GG0170 -Mobility

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

60

PDPM WORKSHOP

Why Does This Matter

bull Therapy amp nursing use different languagebull Therapy ratings may not accurately reflect the residents

ldquousual performancerdquo because residents may act differently in therapy than they do on the unit

61

PDPM WORKSHOP

Usual Performance RAI Manual page GG-9

bull A residentrsquos functional status can be impacted by the environment or situations encountered at the facilitybull Observing the residentrsquos interactions with others in different

locations amp circumstances is important for a comprehensive understanding of the residentrsquos functional statusbull If the residentrsquos functional status varies record the

residentrsquos usual ability to perform each activity bull Do not record the residentrsquos best performance amp do not

record the residentrsquos worst performance but rather record the residentrsquos usual performance

62

PDPM WORKSHOP

Patient Case Study

bull Mr L lives with his wife in a one-level home which is accessed by 3 steps bull Prior to a recent fall Mr L was independent with self-care

activities including bathing dressing toileting amp eating bull He was able to ambulate about the house without problem with

the use of a cane bullWhen ascending amp descending the external steps of the house

Mr L would hold onto rails to ensure his balance bull Mr L prepares his own daily medications amp takes turns with his

wife to ensure the bills are paid amp grocery shopping is done

63

PDPM WORKSHOP

OT Evaluation

64

EATING

Receiving a no added salt regular consistency diet Independent opening containers amp cutting up meat once the tray is set before him Discharge goal is to remain independent with eating

ORAL HYGIENE

Edentulous wears full dentures Able to remove dentures to soak clean amp replace in mouth once needed items are set up Once activity is complete staff put away items It is anticipated he will not require assistance of any type with oral hygiene by discharge

TOILETING HYGIENE

Uses toilet to void amp have bowel movements Once standing before toilet requires steadying assistance from one helper as he pulls down his pants amp underwear After elimination requires staff to wipe amp clean Contact guard assistance is needed to stand amp readjust clothing Expected that he will perform perineal hygiene amp management of clothing with supervision Per clinical staff documentation required substantialmax assistance with toileting hygiene on 7 of the 9 observed shifts in the first 3 days of his stay Interview with staff indicate that he required staff to wipe amp clean him assist him to stand amp to pull up his pants amp underwear after elimination

PDPM WORKSHOP

PT Evaluation

65

ROLL LEFT amp RIGHT

Requires therapist to position pillow between legs to prevent adduction of the affected extremity amp then to assist him to roll side to side in bed Therapist provided more than half of the effort Therapy goal states it is expected that he will be independent with bed mobility including being able to roll left amp right at discharge

SIT TO LYING

Requires assistance of 1 therapist to support trunk amp lift both legs back into bed Did contribute a small amount of effort as he used his right arm to lower himself to a supine position Therapy goal is for him to be independent with this activity by discharge

LYLYING TO SITTINGON SIDE OF BED

Able to bring his left leg off the bed amp assist with pushing up with right arm Required assist to bring right leg off the side of the bed amp needed to be fully supported to come to a sitting position Helper provided more than half the effort Therapy goal is for Mr L to be independent with this activity by discharge

PDPM WORKSHOP

Case Study Scoring

bull Use handouts to complete taskbull Please work in groups at your tablebull Items to code on Admission5-PPS Assessmento GG0130 Self Care Items (just 3 areas covered)

o GG0170 Mobility Items (just 3 areas covered)

o Discharge goals for one Self Care amp Mobility Item

PDPM WORKSHOP

Admission5-Day PPS AssessmentGG0130 Self-Care

PDPM WORKSHOP

GG0130 Self-Care

68

ITEM 1 ADMISSION PERFORMANCE

2 DISCHARGE GOAL

GG0130A Eating 06 Independent 06 Independent

GG0130B Oral Hygiene 05 Setup or Clean-up Assistance

06 Independent

GG0130C Toileting Hygiene 02 SubstantialMaximal Assistance

04 Supervision or Touching Assistance

GG0130E ShowerBath Self NA NA

GG0130F Upper Body Dressing NA NA

GG0130G Lower Body Dressing NA NA

GG0130H Putting onTaking off Footwear

NA NA

PDPM WORKSHOP

GG0130A Eating

bull Admission Performance Coding = 06 Independent

bull Rationale Mr L was able to open containers cut meat amp eat without assistance on admission

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to remain independent with eating on discharge

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Aspiration Pneumonia

bullDiagnosis Pneumonia due aspiration of tube feeding

bullStep 1 The reason for the encounter was the condition Aspiration Pneumonia

bullStep 2 Consult the Alphabetic Index

41

PDPM WORKSHOP

bullStep 3

Locate the main term entry

Aspiration Pneumonia

bkdcomPDPM42

PDPM WORKSHOP

bullStep 4

Read cross-reference listed with the main term or the sub-term

Aspiration Pneumonia

bkdcomPDPM43

PDPM WORKSHOP

bullStep 5

Review entries for modifiers

Aspiration Pneumonia

PDPM WORKSHOP

Aspiration Pneumonia

bullStep 6

Go to Tabular List

PDPM WORKSHOP

Aspiration Pneumonia

bullStep 7 Locate Code

PDPM WORKSHOP

Aspiration Pneumonia

PDPM WORKSHOP

Aspiration Pneumonia

bullStep 8 Read through the subcategory codes under J69 and note that the fourth character is required to specify solid or liquids that caused the pneumonia Locate the Pneumonitis due to inhalation of food and vomit J690

bullStep 9 Assign code J690 Pneumonitis due to inhalation of food and vomit

bullStep 10 Be sure to add the associated foreign body in respiratory tract code T17910D

PDPM WORKSHOP

Which ICD-10 Codes Map to a PDPM Clinical Category

49

PDPM WORKSHOP

50

RTPRTP

RTPRTP

Medical ManagementNon-Surgical Ortho Musculoskeletal

RTPRTP

RTP

RTP

Which ICD-10 Codes Map to a PDPM Clinical Category

PDPM WORKSHOP

Patient Surgical History ndashItems J2100 ndash J5000 (New Items)

bull These items are used to capture any major surgical procedures that occurred during the inpatient hospital stay that immediately preceded the SNF admission (ie the qualifying hospital stay)

Section J ndashPast Surgical Categories

51

PDPM WORKSHOP

Section J ndash Past Surgical Categories

52

PDPM WORKSHOP

53

MDS Sample ndash Section I (Active Diagnoses)

PDPM WORKSHOP

54

Section I ndash Continued

PDPM WORKSHOP

Section GG

PDPM WORKSHOP

Functional Scoring under PDPM

bull ldquoReversedrdquo scoring between RUG vs PDPMbull RUG-IV Section G with a higher score means increased dependence

bull PDPM Section GG with a higher score means increased independence

bullPayment Differences related to Function between RUG vs PDPMbull RUG-IV payments increase with dependence within a given RUG

bull PDPM has no consistent relationship between increased dependence amp increased payments (differs for Therapy amp Nursing)

bull For the PT amp OT component payment for three clinical categories is lower for the most amp least dependent patients (who are less likely to require high amounts of therapy) amp higher for those in between (who are more likely to require high amounts of therapy)

56

PDPM WORKSHOP

Nursing Component

bullPDPM uses the same basic structure as RUG-IV except for the following changes o Function score based on Section GG of the MDS 30

o Collapsed functional nursing groups from 43 to 25

57

PDPM WORKSHOP

58

Section GG0130 -Self Care

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

59

Section GG0170 -Mobility

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

60

PDPM WORKSHOP

Why Does This Matter

bull Therapy amp nursing use different languagebull Therapy ratings may not accurately reflect the residents

ldquousual performancerdquo because residents may act differently in therapy than they do on the unit

61

PDPM WORKSHOP

Usual Performance RAI Manual page GG-9

bull A residentrsquos functional status can be impacted by the environment or situations encountered at the facilitybull Observing the residentrsquos interactions with others in different

locations amp circumstances is important for a comprehensive understanding of the residentrsquos functional statusbull If the residentrsquos functional status varies record the

residentrsquos usual ability to perform each activity bull Do not record the residentrsquos best performance amp do not

record the residentrsquos worst performance but rather record the residentrsquos usual performance

62

PDPM WORKSHOP

Patient Case Study

bull Mr L lives with his wife in a one-level home which is accessed by 3 steps bull Prior to a recent fall Mr L was independent with self-care

activities including bathing dressing toileting amp eating bull He was able to ambulate about the house without problem with

the use of a cane bullWhen ascending amp descending the external steps of the house

Mr L would hold onto rails to ensure his balance bull Mr L prepares his own daily medications amp takes turns with his

wife to ensure the bills are paid amp grocery shopping is done

63

PDPM WORKSHOP

OT Evaluation

64

EATING

Receiving a no added salt regular consistency diet Independent opening containers amp cutting up meat once the tray is set before him Discharge goal is to remain independent with eating

ORAL HYGIENE

Edentulous wears full dentures Able to remove dentures to soak clean amp replace in mouth once needed items are set up Once activity is complete staff put away items It is anticipated he will not require assistance of any type with oral hygiene by discharge

TOILETING HYGIENE

Uses toilet to void amp have bowel movements Once standing before toilet requires steadying assistance from one helper as he pulls down his pants amp underwear After elimination requires staff to wipe amp clean Contact guard assistance is needed to stand amp readjust clothing Expected that he will perform perineal hygiene amp management of clothing with supervision Per clinical staff documentation required substantialmax assistance with toileting hygiene on 7 of the 9 observed shifts in the first 3 days of his stay Interview with staff indicate that he required staff to wipe amp clean him assist him to stand amp to pull up his pants amp underwear after elimination

PDPM WORKSHOP

PT Evaluation

65

ROLL LEFT amp RIGHT

Requires therapist to position pillow between legs to prevent adduction of the affected extremity amp then to assist him to roll side to side in bed Therapist provided more than half of the effort Therapy goal states it is expected that he will be independent with bed mobility including being able to roll left amp right at discharge

SIT TO LYING

Requires assistance of 1 therapist to support trunk amp lift both legs back into bed Did contribute a small amount of effort as he used his right arm to lower himself to a supine position Therapy goal is for him to be independent with this activity by discharge

LYLYING TO SITTINGON SIDE OF BED

Able to bring his left leg off the bed amp assist with pushing up with right arm Required assist to bring right leg off the side of the bed amp needed to be fully supported to come to a sitting position Helper provided more than half the effort Therapy goal is for Mr L to be independent with this activity by discharge

PDPM WORKSHOP

Case Study Scoring

bull Use handouts to complete taskbull Please work in groups at your tablebull Items to code on Admission5-PPS Assessmento GG0130 Self Care Items (just 3 areas covered)

o GG0170 Mobility Items (just 3 areas covered)

o Discharge goals for one Self Care amp Mobility Item

PDPM WORKSHOP

Admission5-Day PPS AssessmentGG0130 Self-Care

PDPM WORKSHOP

GG0130 Self-Care

68

ITEM 1 ADMISSION PERFORMANCE

2 DISCHARGE GOAL

GG0130A Eating 06 Independent 06 Independent

GG0130B Oral Hygiene 05 Setup or Clean-up Assistance

06 Independent

GG0130C Toileting Hygiene 02 SubstantialMaximal Assistance

04 Supervision or Touching Assistance

GG0130E ShowerBath Self NA NA

GG0130F Upper Body Dressing NA NA

GG0130G Lower Body Dressing NA NA

GG0130H Putting onTaking off Footwear

NA NA

PDPM WORKSHOP

GG0130A Eating

bull Admission Performance Coding = 06 Independent

bull Rationale Mr L was able to open containers cut meat amp eat without assistance on admission

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to remain independent with eating on discharge

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

bullStep 3

Locate the main term entry

Aspiration Pneumonia

bkdcomPDPM42

PDPM WORKSHOP

bullStep 4

Read cross-reference listed with the main term or the sub-term

Aspiration Pneumonia

bkdcomPDPM43

PDPM WORKSHOP

bullStep 5

Review entries for modifiers

Aspiration Pneumonia

PDPM WORKSHOP

Aspiration Pneumonia

bullStep 6

Go to Tabular List

PDPM WORKSHOP

Aspiration Pneumonia

bullStep 7 Locate Code

PDPM WORKSHOP

Aspiration Pneumonia

PDPM WORKSHOP

Aspiration Pneumonia

bullStep 8 Read through the subcategory codes under J69 and note that the fourth character is required to specify solid or liquids that caused the pneumonia Locate the Pneumonitis due to inhalation of food and vomit J690

bullStep 9 Assign code J690 Pneumonitis due to inhalation of food and vomit

bullStep 10 Be sure to add the associated foreign body in respiratory tract code T17910D

PDPM WORKSHOP

Which ICD-10 Codes Map to a PDPM Clinical Category

49

PDPM WORKSHOP

50

RTPRTP

RTPRTP

Medical ManagementNon-Surgical Ortho Musculoskeletal

RTPRTP

RTP

RTP

Which ICD-10 Codes Map to a PDPM Clinical Category

PDPM WORKSHOP

Patient Surgical History ndashItems J2100 ndash J5000 (New Items)

bull These items are used to capture any major surgical procedures that occurred during the inpatient hospital stay that immediately preceded the SNF admission (ie the qualifying hospital stay)

Section J ndashPast Surgical Categories

51

PDPM WORKSHOP

Section J ndash Past Surgical Categories

52

PDPM WORKSHOP

53

MDS Sample ndash Section I (Active Diagnoses)

PDPM WORKSHOP

54

Section I ndash Continued

PDPM WORKSHOP

Section GG

PDPM WORKSHOP

Functional Scoring under PDPM

bull ldquoReversedrdquo scoring between RUG vs PDPMbull RUG-IV Section G with a higher score means increased dependence

bull PDPM Section GG with a higher score means increased independence

bullPayment Differences related to Function between RUG vs PDPMbull RUG-IV payments increase with dependence within a given RUG

bull PDPM has no consistent relationship between increased dependence amp increased payments (differs for Therapy amp Nursing)

bull For the PT amp OT component payment for three clinical categories is lower for the most amp least dependent patients (who are less likely to require high amounts of therapy) amp higher for those in between (who are more likely to require high amounts of therapy)

56

PDPM WORKSHOP

Nursing Component

bullPDPM uses the same basic structure as RUG-IV except for the following changes o Function score based on Section GG of the MDS 30

o Collapsed functional nursing groups from 43 to 25

57

PDPM WORKSHOP

58

Section GG0130 -Self Care

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

59

Section GG0170 -Mobility

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

60

PDPM WORKSHOP

Why Does This Matter

bull Therapy amp nursing use different languagebull Therapy ratings may not accurately reflect the residents

ldquousual performancerdquo because residents may act differently in therapy than they do on the unit

61

PDPM WORKSHOP

Usual Performance RAI Manual page GG-9

bull A residentrsquos functional status can be impacted by the environment or situations encountered at the facilitybull Observing the residentrsquos interactions with others in different

locations amp circumstances is important for a comprehensive understanding of the residentrsquos functional statusbull If the residentrsquos functional status varies record the

residentrsquos usual ability to perform each activity bull Do not record the residentrsquos best performance amp do not

record the residentrsquos worst performance but rather record the residentrsquos usual performance

62

PDPM WORKSHOP

Patient Case Study

bull Mr L lives with his wife in a one-level home which is accessed by 3 steps bull Prior to a recent fall Mr L was independent with self-care

activities including bathing dressing toileting amp eating bull He was able to ambulate about the house without problem with

the use of a cane bullWhen ascending amp descending the external steps of the house

Mr L would hold onto rails to ensure his balance bull Mr L prepares his own daily medications amp takes turns with his

wife to ensure the bills are paid amp grocery shopping is done

63

PDPM WORKSHOP

OT Evaluation

64

EATING

Receiving a no added salt regular consistency diet Independent opening containers amp cutting up meat once the tray is set before him Discharge goal is to remain independent with eating

ORAL HYGIENE

Edentulous wears full dentures Able to remove dentures to soak clean amp replace in mouth once needed items are set up Once activity is complete staff put away items It is anticipated he will not require assistance of any type with oral hygiene by discharge

TOILETING HYGIENE

Uses toilet to void amp have bowel movements Once standing before toilet requires steadying assistance from one helper as he pulls down his pants amp underwear After elimination requires staff to wipe amp clean Contact guard assistance is needed to stand amp readjust clothing Expected that he will perform perineal hygiene amp management of clothing with supervision Per clinical staff documentation required substantialmax assistance with toileting hygiene on 7 of the 9 observed shifts in the first 3 days of his stay Interview with staff indicate that he required staff to wipe amp clean him assist him to stand amp to pull up his pants amp underwear after elimination

PDPM WORKSHOP

PT Evaluation

65

ROLL LEFT amp RIGHT

Requires therapist to position pillow between legs to prevent adduction of the affected extremity amp then to assist him to roll side to side in bed Therapist provided more than half of the effort Therapy goal states it is expected that he will be independent with bed mobility including being able to roll left amp right at discharge

SIT TO LYING

Requires assistance of 1 therapist to support trunk amp lift both legs back into bed Did contribute a small amount of effort as he used his right arm to lower himself to a supine position Therapy goal is for him to be independent with this activity by discharge

LYLYING TO SITTINGON SIDE OF BED

Able to bring his left leg off the bed amp assist with pushing up with right arm Required assist to bring right leg off the side of the bed amp needed to be fully supported to come to a sitting position Helper provided more than half the effort Therapy goal is for Mr L to be independent with this activity by discharge

PDPM WORKSHOP

Case Study Scoring

bull Use handouts to complete taskbull Please work in groups at your tablebull Items to code on Admission5-PPS Assessmento GG0130 Self Care Items (just 3 areas covered)

o GG0170 Mobility Items (just 3 areas covered)

o Discharge goals for one Self Care amp Mobility Item

PDPM WORKSHOP

Admission5-Day PPS AssessmentGG0130 Self-Care

PDPM WORKSHOP

GG0130 Self-Care

68

ITEM 1 ADMISSION PERFORMANCE

2 DISCHARGE GOAL

GG0130A Eating 06 Independent 06 Independent

GG0130B Oral Hygiene 05 Setup or Clean-up Assistance

06 Independent

GG0130C Toileting Hygiene 02 SubstantialMaximal Assistance

04 Supervision or Touching Assistance

GG0130E ShowerBath Self NA NA

GG0130F Upper Body Dressing NA NA

GG0130G Lower Body Dressing NA NA

GG0130H Putting onTaking off Footwear

NA NA

PDPM WORKSHOP

GG0130A Eating

bull Admission Performance Coding = 06 Independent

bull Rationale Mr L was able to open containers cut meat amp eat without assistance on admission

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to remain independent with eating on discharge

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

bullStep 4

Read cross-reference listed with the main term or the sub-term

Aspiration Pneumonia

bkdcomPDPM43

PDPM WORKSHOP

bullStep 5

Review entries for modifiers

Aspiration Pneumonia

PDPM WORKSHOP

Aspiration Pneumonia

bullStep 6

Go to Tabular List

PDPM WORKSHOP

Aspiration Pneumonia

bullStep 7 Locate Code

PDPM WORKSHOP

Aspiration Pneumonia

PDPM WORKSHOP

Aspiration Pneumonia

bullStep 8 Read through the subcategory codes under J69 and note that the fourth character is required to specify solid or liquids that caused the pneumonia Locate the Pneumonitis due to inhalation of food and vomit J690

bullStep 9 Assign code J690 Pneumonitis due to inhalation of food and vomit

bullStep 10 Be sure to add the associated foreign body in respiratory tract code T17910D

PDPM WORKSHOP

Which ICD-10 Codes Map to a PDPM Clinical Category

49

PDPM WORKSHOP

50

RTPRTP

RTPRTP

Medical ManagementNon-Surgical Ortho Musculoskeletal

RTPRTP

RTP

RTP

Which ICD-10 Codes Map to a PDPM Clinical Category

PDPM WORKSHOP

Patient Surgical History ndashItems J2100 ndash J5000 (New Items)

bull These items are used to capture any major surgical procedures that occurred during the inpatient hospital stay that immediately preceded the SNF admission (ie the qualifying hospital stay)

Section J ndashPast Surgical Categories

51

PDPM WORKSHOP

Section J ndash Past Surgical Categories

52

PDPM WORKSHOP

53

MDS Sample ndash Section I (Active Diagnoses)

PDPM WORKSHOP

54

Section I ndash Continued

PDPM WORKSHOP

Section GG

PDPM WORKSHOP

Functional Scoring under PDPM

bull ldquoReversedrdquo scoring between RUG vs PDPMbull RUG-IV Section G with a higher score means increased dependence

bull PDPM Section GG with a higher score means increased independence

bullPayment Differences related to Function between RUG vs PDPMbull RUG-IV payments increase with dependence within a given RUG

bull PDPM has no consistent relationship between increased dependence amp increased payments (differs for Therapy amp Nursing)

bull For the PT amp OT component payment for three clinical categories is lower for the most amp least dependent patients (who are less likely to require high amounts of therapy) amp higher for those in between (who are more likely to require high amounts of therapy)

56

PDPM WORKSHOP

Nursing Component

bullPDPM uses the same basic structure as RUG-IV except for the following changes o Function score based on Section GG of the MDS 30

o Collapsed functional nursing groups from 43 to 25

57

PDPM WORKSHOP

58

Section GG0130 -Self Care

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

59

Section GG0170 -Mobility

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

60

PDPM WORKSHOP

Why Does This Matter

bull Therapy amp nursing use different languagebull Therapy ratings may not accurately reflect the residents

ldquousual performancerdquo because residents may act differently in therapy than they do on the unit

61

PDPM WORKSHOP

Usual Performance RAI Manual page GG-9

bull A residentrsquos functional status can be impacted by the environment or situations encountered at the facilitybull Observing the residentrsquos interactions with others in different

locations amp circumstances is important for a comprehensive understanding of the residentrsquos functional statusbull If the residentrsquos functional status varies record the

residentrsquos usual ability to perform each activity bull Do not record the residentrsquos best performance amp do not

record the residentrsquos worst performance but rather record the residentrsquos usual performance

62

PDPM WORKSHOP

Patient Case Study

bull Mr L lives with his wife in a one-level home which is accessed by 3 steps bull Prior to a recent fall Mr L was independent with self-care

activities including bathing dressing toileting amp eating bull He was able to ambulate about the house without problem with

the use of a cane bullWhen ascending amp descending the external steps of the house

Mr L would hold onto rails to ensure his balance bull Mr L prepares his own daily medications amp takes turns with his

wife to ensure the bills are paid amp grocery shopping is done

63

PDPM WORKSHOP

OT Evaluation

64

EATING

Receiving a no added salt regular consistency diet Independent opening containers amp cutting up meat once the tray is set before him Discharge goal is to remain independent with eating

ORAL HYGIENE

Edentulous wears full dentures Able to remove dentures to soak clean amp replace in mouth once needed items are set up Once activity is complete staff put away items It is anticipated he will not require assistance of any type with oral hygiene by discharge

TOILETING HYGIENE

Uses toilet to void amp have bowel movements Once standing before toilet requires steadying assistance from one helper as he pulls down his pants amp underwear After elimination requires staff to wipe amp clean Contact guard assistance is needed to stand amp readjust clothing Expected that he will perform perineal hygiene amp management of clothing with supervision Per clinical staff documentation required substantialmax assistance with toileting hygiene on 7 of the 9 observed shifts in the first 3 days of his stay Interview with staff indicate that he required staff to wipe amp clean him assist him to stand amp to pull up his pants amp underwear after elimination

PDPM WORKSHOP

PT Evaluation

65

ROLL LEFT amp RIGHT

Requires therapist to position pillow between legs to prevent adduction of the affected extremity amp then to assist him to roll side to side in bed Therapist provided more than half of the effort Therapy goal states it is expected that he will be independent with bed mobility including being able to roll left amp right at discharge

SIT TO LYING

Requires assistance of 1 therapist to support trunk amp lift both legs back into bed Did contribute a small amount of effort as he used his right arm to lower himself to a supine position Therapy goal is for him to be independent with this activity by discharge

LYLYING TO SITTINGON SIDE OF BED

Able to bring his left leg off the bed amp assist with pushing up with right arm Required assist to bring right leg off the side of the bed amp needed to be fully supported to come to a sitting position Helper provided more than half the effort Therapy goal is for Mr L to be independent with this activity by discharge

PDPM WORKSHOP

Case Study Scoring

bull Use handouts to complete taskbull Please work in groups at your tablebull Items to code on Admission5-PPS Assessmento GG0130 Self Care Items (just 3 areas covered)

o GG0170 Mobility Items (just 3 areas covered)

o Discharge goals for one Self Care amp Mobility Item

PDPM WORKSHOP

Admission5-Day PPS AssessmentGG0130 Self-Care

PDPM WORKSHOP

GG0130 Self-Care

68

ITEM 1 ADMISSION PERFORMANCE

2 DISCHARGE GOAL

GG0130A Eating 06 Independent 06 Independent

GG0130B Oral Hygiene 05 Setup or Clean-up Assistance

06 Independent

GG0130C Toileting Hygiene 02 SubstantialMaximal Assistance

04 Supervision or Touching Assistance

GG0130E ShowerBath Self NA NA

GG0130F Upper Body Dressing NA NA

GG0130G Lower Body Dressing NA NA

GG0130H Putting onTaking off Footwear

NA NA

PDPM WORKSHOP

GG0130A Eating

bull Admission Performance Coding = 06 Independent

bull Rationale Mr L was able to open containers cut meat amp eat without assistance on admission

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to remain independent with eating on discharge

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

bullStep 5

Review entries for modifiers

Aspiration Pneumonia

PDPM WORKSHOP

Aspiration Pneumonia

bullStep 6

Go to Tabular List

PDPM WORKSHOP

Aspiration Pneumonia

bullStep 7 Locate Code

PDPM WORKSHOP

Aspiration Pneumonia

PDPM WORKSHOP

Aspiration Pneumonia

bullStep 8 Read through the subcategory codes under J69 and note that the fourth character is required to specify solid or liquids that caused the pneumonia Locate the Pneumonitis due to inhalation of food and vomit J690

bullStep 9 Assign code J690 Pneumonitis due to inhalation of food and vomit

bullStep 10 Be sure to add the associated foreign body in respiratory tract code T17910D

PDPM WORKSHOP

Which ICD-10 Codes Map to a PDPM Clinical Category

49

PDPM WORKSHOP

50

RTPRTP

RTPRTP

Medical ManagementNon-Surgical Ortho Musculoskeletal

RTPRTP

RTP

RTP

Which ICD-10 Codes Map to a PDPM Clinical Category

PDPM WORKSHOP

Patient Surgical History ndashItems J2100 ndash J5000 (New Items)

bull These items are used to capture any major surgical procedures that occurred during the inpatient hospital stay that immediately preceded the SNF admission (ie the qualifying hospital stay)

Section J ndashPast Surgical Categories

51

PDPM WORKSHOP

Section J ndash Past Surgical Categories

52

PDPM WORKSHOP

53

MDS Sample ndash Section I (Active Diagnoses)

PDPM WORKSHOP

54

Section I ndash Continued

PDPM WORKSHOP

Section GG

PDPM WORKSHOP

Functional Scoring under PDPM

bull ldquoReversedrdquo scoring between RUG vs PDPMbull RUG-IV Section G with a higher score means increased dependence

bull PDPM Section GG with a higher score means increased independence

bullPayment Differences related to Function between RUG vs PDPMbull RUG-IV payments increase with dependence within a given RUG

bull PDPM has no consistent relationship between increased dependence amp increased payments (differs for Therapy amp Nursing)

bull For the PT amp OT component payment for three clinical categories is lower for the most amp least dependent patients (who are less likely to require high amounts of therapy) amp higher for those in between (who are more likely to require high amounts of therapy)

56

PDPM WORKSHOP

Nursing Component

bullPDPM uses the same basic structure as RUG-IV except for the following changes o Function score based on Section GG of the MDS 30

o Collapsed functional nursing groups from 43 to 25

57

PDPM WORKSHOP

58

Section GG0130 -Self Care

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

59

Section GG0170 -Mobility

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

60

PDPM WORKSHOP

Why Does This Matter

bull Therapy amp nursing use different languagebull Therapy ratings may not accurately reflect the residents

ldquousual performancerdquo because residents may act differently in therapy than they do on the unit

61

PDPM WORKSHOP

Usual Performance RAI Manual page GG-9

bull A residentrsquos functional status can be impacted by the environment or situations encountered at the facilitybull Observing the residentrsquos interactions with others in different

locations amp circumstances is important for a comprehensive understanding of the residentrsquos functional statusbull If the residentrsquos functional status varies record the

residentrsquos usual ability to perform each activity bull Do not record the residentrsquos best performance amp do not

record the residentrsquos worst performance but rather record the residentrsquos usual performance

62

PDPM WORKSHOP

Patient Case Study

bull Mr L lives with his wife in a one-level home which is accessed by 3 steps bull Prior to a recent fall Mr L was independent with self-care

activities including bathing dressing toileting amp eating bull He was able to ambulate about the house without problem with

the use of a cane bullWhen ascending amp descending the external steps of the house

Mr L would hold onto rails to ensure his balance bull Mr L prepares his own daily medications amp takes turns with his

wife to ensure the bills are paid amp grocery shopping is done

63

PDPM WORKSHOP

OT Evaluation

64

EATING

Receiving a no added salt regular consistency diet Independent opening containers amp cutting up meat once the tray is set before him Discharge goal is to remain independent with eating

ORAL HYGIENE

Edentulous wears full dentures Able to remove dentures to soak clean amp replace in mouth once needed items are set up Once activity is complete staff put away items It is anticipated he will not require assistance of any type with oral hygiene by discharge

TOILETING HYGIENE

Uses toilet to void amp have bowel movements Once standing before toilet requires steadying assistance from one helper as he pulls down his pants amp underwear After elimination requires staff to wipe amp clean Contact guard assistance is needed to stand amp readjust clothing Expected that he will perform perineal hygiene amp management of clothing with supervision Per clinical staff documentation required substantialmax assistance with toileting hygiene on 7 of the 9 observed shifts in the first 3 days of his stay Interview with staff indicate that he required staff to wipe amp clean him assist him to stand amp to pull up his pants amp underwear after elimination

PDPM WORKSHOP

PT Evaluation

65

ROLL LEFT amp RIGHT

Requires therapist to position pillow between legs to prevent adduction of the affected extremity amp then to assist him to roll side to side in bed Therapist provided more than half of the effort Therapy goal states it is expected that he will be independent with bed mobility including being able to roll left amp right at discharge

SIT TO LYING

Requires assistance of 1 therapist to support trunk amp lift both legs back into bed Did contribute a small amount of effort as he used his right arm to lower himself to a supine position Therapy goal is for him to be independent with this activity by discharge

LYLYING TO SITTINGON SIDE OF BED

Able to bring his left leg off the bed amp assist with pushing up with right arm Required assist to bring right leg off the side of the bed amp needed to be fully supported to come to a sitting position Helper provided more than half the effort Therapy goal is for Mr L to be independent with this activity by discharge

PDPM WORKSHOP

Case Study Scoring

bull Use handouts to complete taskbull Please work in groups at your tablebull Items to code on Admission5-PPS Assessmento GG0130 Self Care Items (just 3 areas covered)

o GG0170 Mobility Items (just 3 areas covered)

o Discharge goals for one Self Care amp Mobility Item

PDPM WORKSHOP

Admission5-Day PPS AssessmentGG0130 Self-Care

PDPM WORKSHOP

GG0130 Self-Care

68

ITEM 1 ADMISSION PERFORMANCE

2 DISCHARGE GOAL

GG0130A Eating 06 Independent 06 Independent

GG0130B Oral Hygiene 05 Setup or Clean-up Assistance

06 Independent

GG0130C Toileting Hygiene 02 SubstantialMaximal Assistance

04 Supervision or Touching Assistance

GG0130E ShowerBath Self NA NA

GG0130F Upper Body Dressing NA NA

GG0130G Lower Body Dressing NA NA

GG0130H Putting onTaking off Footwear

NA NA

PDPM WORKSHOP

GG0130A Eating

bull Admission Performance Coding = 06 Independent

bull Rationale Mr L was able to open containers cut meat amp eat without assistance on admission

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to remain independent with eating on discharge

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Aspiration Pneumonia

bullStep 6

Go to Tabular List

PDPM WORKSHOP

Aspiration Pneumonia

bullStep 7 Locate Code

PDPM WORKSHOP

Aspiration Pneumonia

PDPM WORKSHOP

Aspiration Pneumonia

bullStep 8 Read through the subcategory codes under J69 and note that the fourth character is required to specify solid or liquids that caused the pneumonia Locate the Pneumonitis due to inhalation of food and vomit J690

bullStep 9 Assign code J690 Pneumonitis due to inhalation of food and vomit

bullStep 10 Be sure to add the associated foreign body in respiratory tract code T17910D

PDPM WORKSHOP

Which ICD-10 Codes Map to a PDPM Clinical Category

49

PDPM WORKSHOP

50

RTPRTP

RTPRTP

Medical ManagementNon-Surgical Ortho Musculoskeletal

RTPRTP

RTP

RTP

Which ICD-10 Codes Map to a PDPM Clinical Category

PDPM WORKSHOP

Patient Surgical History ndashItems J2100 ndash J5000 (New Items)

bull These items are used to capture any major surgical procedures that occurred during the inpatient hospital stay that immediately preceded the SNF admission (ie the qualifying hospital stay)

Section J ndashPast Surgical Categories

51

PDPM WORKSHOP

Section J ndash Past Surgical Categories

52

PDPM WORKSHOP

53

MDS Sample ndash Section I (Active Diagnoses)

PDPM WORKSHOP

54

Section I ndash Continued

PDPM WORKSHOP

Section GG

PDPM WORKSHOP

Functional Scoring under PDPM

bull ldquoReversedrdquo scoring between RUG vs PDPMbull RUG-IV Section G with a higher score means increased dependence

bull PDPM Section GG with a higher score means increased independence

bullPayment Differences related to Function between RUG vs PDPMbull RUG-IV payments increase with dependence within a given RUG

bull PDPM has no consistent relationship between increased dependence amp increased payments (differs for Therapy amp Nursing)

bull For the PT amp OT component payment for three clinical categories is lower for the most amp least dependent patients (who are less likely to require high amounts of therapy) amp higher for those in between (who are more likely to require high amounts of therapy)

56

PDPM WORKSHOP

Nursing Component

bullPDPM uses the same basic structure as RUG-IV except for the following changes o Function score based on Section GG of the MDS 30

o Collapsed functional nursing groups from 43 to 25

57

PDPM WORKSHOP

58

Section GG0130 -Self Care

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

59

Section GG0170 -Mobility

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

60

PDPM WORKSHOP

Why Does This Matter

bull Therapy amp nursing use different languagebull Therapy ratings may not accurately reflect the residents

ldquousual performancerdquo because residents may act differently in therapy than they do on the unit

61

PDPM WORKSHOP

Usual Performance RAI Manual page GG-9

bull A residentrsquos functional status can be impacted by the environment or situations encountered at the facilitybull Observing the residentrsquos interactions with others in different

locations amp circumstances is important for a comprehensive understanding of the residentrsquos functional statusbull If the residentrsquos functional status varies record the

residentrsquos usual ability to perform each activity bull Do not record the residentrsquos best performance amp do not

record the residentrsquos worst performance but rather record the residentrsquos usual performance

62

PDPM WORKSHOP

Patient Case Study

bull Mr L lives with his wife in a one-level home which is accessed by 3 steps bull Prior to a recent fall Mr L was independent with self-care

activities including bathing dressing toileting amp eating bull He was able to ambulate about the house without problem with

the use of a cane bullWhen ascending amp descending the external steps of the house

Mr L would hold onto rails to ensure his balance bull Mr L prepares his own daily medications amp takes turns with his

wife to ensure the bills are paid amp grocery shopping is done

63

PDPM WORKSHOP

OT Evaluation

64

EATING

Receiving a no added salt regular consistency diet Independent opening containers amp cutting up meat once the tray is set before him Discharge goal is to remain independent with eating

ORAL HYGIENE

Edentulous wears full dentures Able to remove dentures to soak clean amp replace in mouth once needed items are set up Once activity is complete staff put away items It is anticipated he will not require assistance of any type with oral hygiene by discharge

TOILETING HYGIENE

Uses toilet to void amp have bowel movements Once standing before toilet requires steadying assistance from one helper as he pulls down his pants amp underwear After elimination requires staff to wipe amp clean Contact guard assistance is needed to stand amp readjust clothing Expected that he will perform perineal hygiene amp management of clothing with supervision Per clinical staff documentation required substantialmax assistance with toileting hygiene on 7 of the 9 observed shifts in the first 3 days of his stay Interview with staff indicate that he required staff to wipe amp clean him assist him to stand amp to pull up his pants amp underwear after elimination

PDPM WORKSHOP

PT Evaluation

65

ROLL LEFT amp RIGHT

Requires therapist to position pillow between legs to prevent adduction of the affected extremity amp then to assist him to roll side to side in bed Therapist provided more than half of the effort Therapy goal states it is expected that he will be independent with bed mobility including being able to roll left amp right at discharge

SIT TO LYING

Requires assistance of 1 therapist to support trunk amp lift both legs back into bed Did contribute a small amount of effort as he used his right arm to lower himself to a supine position Therapy goal is for him to be independent with this activity by discharge

LYLYING TO SITTINGON SIDE OF BED

Able to bring his left leg off the bed amp assist with pushing up with right arm Required assist to bring right leg off the side of the bed amp needed to be fully supported to come to a sitting position Helper provided more than half the effort Therapy goal is for Mr L to be independent with this activity by discharge

PDPM WORKSHOP

Case Study Scoring

bull Use handouts to complete taskbull Please work in groups at your tablebull Items to code on Admission5-PPS Assessmento GG0130 Self Care Items (just 3 areas covered)

o GG0170 Mobility Items (just 3 areas covered)

o Discharge goals for one Self Care amp Mobility Item

PDPM WORKSHOP

Admission5-Day PPS AssessmentGG0130 Self-Care

PDPM WORKSHOP

GG0130 Self-Care

68

ITEM 1 ADMISSION PERFORMANCE

2 DISCHARGE GOAL

GG0130A Eating 06 Independent 06 Independent

GG0130B Oral Hygiene 05 Setup or Clean-up Assistance

06 Independent

GG0130C Toileting Hygiene 02 SubstantialMaximal Assistance

04 Supervision or Touching Assistance

GG0130E ShowerBath Self NA NA

GG0130F Upper Body Dressing NA NA

GG0130G Lower Body Dressing NA NA

GG0130H Putting onTaking off Footwear

NA NA

PDPM WORKSHOP

GG0130A Eating

bull Admission Performance Coding = 06 Independent

bull Rationale Mr L was able to open containers cut meat amp eat without assistance on admission

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to remain independent with eating on discharge

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Aspiration Pneumonia

bullStep 7 Locate Code

PDPM WORKSHOP

Aspiration Pneumonia

PDPM WORKSHOP

Aspiration Pneumonia

bullStep 8 Read through the subcategory codes under J69 and note that the fourth character is required to specify solid or liquids that caused the pneumonia Locate the Pneumonitis due to inhalation of food and vomit J690

bullStep 9 Assign code J690 Pneumonitis due to inhalation of food and vomit

bullStep 10 Be sure to add the associated foreign body in respiratory tract code T17910D

PDPM WORKSHOP

Which ICD-10 Codes Map to a PDPM Clinical Category

49

PDPM WORKSHOP

50

RTPRTP

RTPRTP

Medical ManagementNon-Surgical Ortho Musculoskeletal

RTPRTP

RTP

RTP

Which ICD-10 Codes Map to a PDPM Clinical Category

PDPM WORKSHOP

Patient Surgical History ndashItems J2100 ndash J5000 (New Items)

bull These items are used to capture any major surgical procedures that occurred during the inpatient hospital stay that immediately preceded the SNF admission (ie the qualifying hospital stay)

Section J ndashPast Surgical Categories

51

PDPM WORKSHOP

Section J ndash Past Surgical Categories

52

PDPM WORKSHOP

53

MDS Sample ndash Section I (Active Diagnoses)

PDPM WORKSHOP

54

Section I ndash Continued

PDPM WORKSHOP

Section GG

PDPM WORKSHOP

Functional Scoring under PDPM

bull ldquoReversedrdquo scoring between RUG vs PDPMbull RUG-IV Section G with a higher score means increased dependence

bull PDPM Section GG with a higher score means increased independence

bullPayment Differences related to Function between RUG vs PDPMbull RUG-IV payments increase with dependence within a given RUG

bull PDPM has no consistent relationship between increased dependence amp increased payments (differs for Therapy amp Nursing)

bull For the PT amp OT component payment for three clinical categories is lower for the most amp least dependent patients (who are less likely to require high amounts of therapy) amp higher for those in between (who are more likely to require high amounts of therapy)

56

PDPM WORKSHOP

Nursing Component

bullPDPM uses the same basic structure as RUG-IV except for the following changes o Function score based on Section GG of the MDS 30

o Collapsed functional nursing groups from 43 to 25

57

PDPM WORKSHOP

58

Section GG0130 -Self Care

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

59

Section GG0170 -Mobility

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

60

PDPM WORKSHOP

Why Does This Matter

bull Therapy amp nursing use different languagebull Therapy ratings may not accurately reflect the residents

ldquousual performancerdquo because residents may act differently in therapy than they do on the unit

61

PDPM WORKSHOP

Usual Performance RAI Manual page GG-9

bull A residentrsquos functional status can be impacted by the environment or situations encountered at the facilitybull Observing the residentrsquos interactions with others in different

locations amp circumstances is important for a comprehensive understanding of the residentrsquos functional statusbull If the residentrsquos functional status varies record the

residentrsquos usual ability to perform each activity bull Do not record the residentrsquos best performance amp do not

record the residentrsquos worst performance but rather record the residentrsquos usual performance

62

PDPM WORKSHOP

Patient Case Study

bull Mr L lives with his wife in a one-level home which is accessed by 3 steps bull Prior to a recent fall Mr L was independent with self-care

activities including bathing dressing toileting amp eating bull He was able to ambulate about the house without problem with

the use of a cane bullWhen ascending amp descending the external steps of the house

Mr L would hold onto rails to ensure his balance bull Mr L prepares his own daily medications amp takes turns with his

wife to ensure the bills are paid amp grocery shopping is done

63

PDPM WORKSHOP

OT Evaluation

64

EATING

Receiving a no added salt regular consistency diet Independent opening containers amp cutting up meat once the tray is set before him Discharge goal is to remain independent with eating

ORAL HYGIENE

Edentulous wears full dentures Able to remove dentures to soak clean amp replace in mouth once needed items are set up Once activity is complete staff put away items It is anticipated he will not require assistance of any type with oral hygiene by discharge

TOILETING HYGIENE

Uses toilet to void amp have bowel movements Once standing before toilet requires steadying assistance from one helper as he pulls down his pants amp underwear After elimination requires staff to wipe amp clean Contact guard assistance is needed to stand amp readjust clothing Expected that he will perform perineal hygiene amp management of clothing with supervision Per clinical staff documentation required substantialmax assistance with toileting hygiene on 7 of the 9 observed shifts in the first 3 days of his stay Interview with staff indicate that he required staff to wipe amp clean him assist him to stand amp to pull up his pants amp underwear after elimination

PDPM WORKSHOP

PT Evaluation

65

ROLL LEFT amp RIGHT

Requires therapist to position pillow between legs to prevent adduction of the affected extremity amp then to assist him to roll side to side in bed Therapist provided more than half of the effort Therapy goal states it is expected that he will be independent with bed mobility including being able to roll left amp right at discharge

SIT TO LYING

Requires assistance of 1 therapist to support trunk amp lift both legs back into bed Did contribute a small amount of effort as he used his right arm to lower himself to a supine position Therapy goal is for him to be independent with this activity by discharge

LYLYING TO SITTINGON SIDE OF BED

Able to bring his left leg off the bed amp assist with pushing up with right arm Required assist to bring right leg off the side of the bed amp needed to be fully supported to come to a sitting position Helper provided more than half the effort Therapy goal is for Mr L to be independent with this activity by discharge

PDPM WORKSHOP

Case Study Scoring

bull Use handouts to complete taskbull Please work in groups at your tablebull Items to code on Admission5-PPS Assessmento GG0130 Self Care Items (just 3 areas covered)

o GG0170 Mobility Items (just 3 areas covered)

o Discharge goals for one Self Care amp Mobility Item

PDPM WORKSHOP

Admission5-Day PPS AssessmentGG0130 Self-Care

PDPM WORKSHOP

GG0130 Self-Care

68

ITEM 1 ADMISSION PERFORMANCE

2 DISCHARGE GOAL

GG0130A Eating 06 Independent 06 Independent

GG0130B Oral Hygiene 05 Setup or Clean-up Assistance

06 Independent

GG0130C Toileting Hygiene 02 SubstantialMaximal Assistance

04 Supervision or Touching Assistance

GG0130E ShowerBath Self NA NA

GG0130F Upper Body Dressing NA NA

GG0130G Lower Body Dressing NA NA

GG0130H Putting onTaking off Footwear

NA NA

PDPM WORKSHOP

GG0130A Eating

bull Admission Performance Coding = 06 Independent

bull Rationale Mr L was able to open containers cut meat amp eat without assistance on admission

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to remain independent with eating on discharge

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Aspiration Pneumonia

PDPM WORKSHOP

Aspiration Pneumonia

bullStep 8 Read through the subcategory codes under J69 and note that the fourth character is required to specify solid or liquids that caused the pneumonia Locate the Pneumonitis due to inhalation of food and vomit J690

bullStep 9 Assign code J690 Pneumonitis due to inhalation of food and vomit

bullStep 10 Be sure to add the associated foreign body in respiratory tract code T17910D

PDPM WORKSHOP

Which ICD-10 Codes Map to a PDPM Clinical Category

49

PDPM WORKSHOP

50

RTPRTP

RTPRTP

Medical ManagementNon-Surgical Ortho Musculoskeletal

RTPRTP

RTP

RTP

Which ICD-10 Codes Map to a PDPM Clinical Category

PDPM WORKSHOP

Patient Surgical History ndashItems J2100 ndash J5000 (New Items)

bull These items are used to capture any major surgical procedures that occurred during the inpatient hospital stay that immediately preceded the SNF admission (ie the qualifying hospital stay)

Section J ndashPast Surgical Categories

51

PDPM WORKSHOP

Section J ndash Past Surgical Categories

52

PDPM WORKSHOP

53

MDS Sample ndash Section I (Active Diagnoses)

PDPM WORKSHOP

54

Section I ndash Continued

PDPM WORKSHOP

Section GG

PDPM WORKSHOP

Functional Scoring under PDPM

bull ldquoReversedrdquo scoring between RUG vs PDPMbull RUG-IV Section G with a higher score means increased dependence

bull PDPM Section GG with a higher score means increased independence

bullPayment Differences related to Function between RUG vs PDPMbull RUG-IV payments increase with dependence within a given RUG

bull PDPM has no consistent relationship between increased dependence amp increased payments (differs for Therapy amp Nursing)

bull For the PT amp OT component payment for three clinical categories is lower for the most amp least dependent patients (who are less likely to require high amounts of therapy) amp higher for those in between (who are more likely to require high amounts of therapy)

56

PDPM WORKSHOP

Nursing Component

bullPDPM uses the same basic structure as RUG-IV except for the following changes o Function score based on Section GG of the MDS 30

o Collapsed functional nursing groups from 43 to 25

57

PDPM WORKSHOP

58

Section GG0130 -Self Care

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

59

Section GG0170 -Mobility

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

60

PDPM WORKSHOP

Why Does This Matter

bull Therapy amp nursing use different languagebull Therapy ratings may not accurately reflect the residents

ldquousual performancerdquo because residents may act differently in therapy than they do on the unit

61

PDPM WORKSHOP

Usual Performance RAI Manual page GG-9

bull A residentrsquos functional status can be impacted by the environment or situations encountered at the facilitybull Observing the residentrsquos interactions with others in different

locations amp circumstances is important for a comprehensive understanding of the residentrsquos functional statusbull If the residentrsquos functional status varies record the

residentrsquos usual ability to perform each activity bull Do not record the residentrsquos best performance amp do not

record the residentrsquos worst performance but rather record the residentrsquos usual performance

62

PDPM WORKSHOP

Patient Case Study

bull Mr L lives with his wife in a one-level home which is accessed by 3 steps bull Prior to a recent fall Mr L was independent with self-care

activities including bathing dressing toileting amp eating bull He was able to ambulate about the house without problem with

the use of a cane bullWhen ascending amp descending the external steps of the house

Mr L would hold onto rails to ensure his balance bull Mr L prepares his own daily medications amp takes turns with his

wife to ensure the bills are paid amp grocery shopping is done

63

PDPM WORKSHOP

OT Evaluation

64

EATING

Receiving a no added salt regular consistency diet Independent opening containers amp cutting up meat once the tray is set before him Discharge goal is to remain independent with eating

ORAL HYGIENE

Edentulous wears full dentures Able to remove dentures to soak clean amp replace in mouth once needed items are set up Once activity is complete staff put away items It is anticipated he will not require assistance of any type with oral hygiene by discharge

TOILETING HYGIENE

Uses toilet to void amp have bowel movements Once standing before toilet requires steadying assistance from one helper as he pulls down his pants amp underwear After elimination requires staff to wipe amp clean Contact guard assistance is needed to stand amp readjust clothing Expected that he will perform perineal hygiene amp management of clothing with supervision Per clinical staff documentation required substantialmax assistance with toileting hygiene on 7 of the 9 observed shifts in the first 3 days of his stay Interview with staff indicate that he required staff to wipe amp clean him assist him to stand amp to pull up his pants amp underwear after elimination

PDPM WORKSHOP

PT Evaluation

65

ROLL LEFT amp RIGHT

Requires therapist to position pillow between legs to prevent adduction of the affected extremity amp then to assist him to roll side to side in bed Therapist provided more than half of the effort Therapy goal states it is expected that he will be independent with bed mobility including being able to roll left amp right at discharge

SIT TO LYING

Requires assistance of 1 therapist to support trunk amp lift both legs back into bed Did contribute a small amount of effort as he used his right arm to lower himself to a supine position Therapy goal is for him to be independent with this activity by discharge

LYLYING TO SITTINGON SIDE OF BED

Able to bring his left leg off the bed amp assist with pushing up with right arm Required assist to bring right leg off the side of the bed amp needed to be fully supported to come to a sitting position Helper provided more than half the effort Therapy goal is for Mr L to be independent with this activity by discharge

PDPM WORKSHOP

Case Study Scoring

bull Use handouts to complete taskbull Please work in groups at your tablebull Items to code on Admission5-PPS Assessmento GG0130 Self Care Items (just 3 areas covered)

o GG0170 Mobility Items (just 3 areas covered)

o Discharge goals for one Self Care amp Mobility Item

PDPM WORKSHOP

Admission5-Day PPS AssessmentGG0130 Self-Care

PDPM WORKSHOP

GG0130 Self-Care

68

ITEM 1 ADMISSION PERFORMANCE

2 DISCHARGE GOAL

GG0130A Eating 06 Independent 06 Independent

GG0130B Oral Hygiene 05 Setup or Clean-up Assistance

06 Independent

GG0130C Toileting Hygiene 02 SubstantialMaximal Assistance

04 Supervision or Touching Assistance

GG0130E ShowerBath Self NA NA

GG0130F Upper Body Dressing NA NA

GG0130G Lower Body Dressing NA NA

GG0130H Putting onTaking off Footwear

NA NA

PDPM WORKSHOP

GG0130A Eating

bull Admission Performance Coding = 06 Independent

bull Rationale Mr L was able to open containers cut meat amp eat without assistance on admission

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to remain independent with eating on discharge

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Aspiration Pneumonia

bullStep 8 Read through the subcategory codes under J69 and note that the fourth character is required to specify solid or liquids that caused the pneumonia Locate the Pneumonitis due to inhalation of food and vomit J690

bullStep 9 Assign code J690 Pneumonitis due to inhalation of food and vomit

bullStep 10 Be sure to add the associated foreign body in respiratory tract code T17910D

PDPM WORKSHOP

Which ICD-10 Codes Map to a PDPM Clinical Category

49

PDPM WORKSHOP

50

RTPRTP

RTPRTP

Medical ManagementNon-Surgical Ortho Musculoskeletal

RTPRTP

RTP

RTP

Which ICD-10 Codes Map to a PDPM Clinical Category

PDPM WORKSHOP

Patient Surgical History ndashItems J2100 ndash J5000 (New Items)

bull These items are used to capture any major surgical procedures that occurred during the inpatient hospital stay that immediately preceded the SNF admission (ie the qualifying hospital stay)

Section J ndashPast Surgical Categories

51

PDPM WORKSHOP

Section J ndash Past Surgical Categories

52

PDPM WORKSHOP

53

MDS Sample ndash Section I (Active Diagnoses)

PDPM WORKSHOP

54

Section I ndash Continued

PDPM WORKSHOP

Section GG

PDPM WORKSHOP

Functional Scoring under PDPM

bull ldquoReversedrdquo scoring between RUG vs PDPMbull RUG-IV Section G with a higher score means increased dependence

bull PDPM Section GG with a higher score means increased independence

bullPayment Differences related to Function between RUG vs PDPMbull RUG-IV payments increase with dependence within a given RUG

bull PDPM has no consistent relationship between increased dependence amp increased payments (differs for Therapy amp Nursing)

bull For the PT amp OT component payment for three clinical categories is lower for the most amp least dependent patients (who are less likely to require high amounts of therapy) amp higher for those in between (who are more likely to require high amounts of therapy)

56

PDPM WORKSHOP

Nursing Component

bullPDPM uses the same basic structure as RUG-IV except for the following changes o Function score based on Section GG of the MDS 30

o Collapsed functional nursing groups from 43 to 25

57

PDPM WORKSHOP

58

Section GG0130 -Self Care

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

59

Section GG0170 -Mobility

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

60

PDPM WORKSHOP

Why Does This Matter

bull Therapy amp nursing use different languagebull Therapy ratings may not accurately reflect the residents

ldquousual performancerdquo because residents may act differently in therapy than they do on the unit

61

PDPM WORKSHOP

Usual Performance RAI Manual page GG-9

bull A residentrsquos functional status can be impacted by the environment or situations encountered at the facilitybull Observing the residentrsquos interactions with others in different

locations amp circumstances is important for a comprehensive understanding of the residentrsquos functional statusbull If the residentrsquos functional status varies record the

residentrsquos usual ability to perform each activity bull Do not record the residentrsquos best performance amp do not

record the residentrsquos worst performance but rather record the residentrsquos usual performance

62

PDPM WORKSHOP

Patient Case Study

bull Mr L lives with his wife in a one-level home which is accessed by 3 steps bull Prior to a recent fall Mr L was independent with self-care

activities including bathing dressing toileting amp eating bull He was able to ambulate about the house without problem with

the use of a cane bullWhen ascending amp descending the external steps of the house

Mr L would hold onto rails to ensure his balance bull Mr L prepares his own daily medications amp takes turns with his

wife to ensure the bills are paid amp grocery shopping is done

63

PDPM WORKSHOP

OT Evaluation

64

EATING

Receiving a no added salt regular consistency diet Independent opening containers amp cutting up meat once the tray is set before him Discharge goal is to remain independent with eating

ORAL HYGIENE

Edentulous wears full dentures Able to remove dentures to soak clean amp replace in mouth once needed items are set up Once activity is complete staff put away items It is anticipated he will not require assistance of any type with oral hygiene by discharge

TOILETING HYGIENE

Uses toilet to void amp have bowel movements Once standing before toilet requires steadying assistance from one helper as he pulls down his pants amp underwear After elimination requires staff to wipe amp clean Contact guard assistance is needed to stand amp readjust clothing Expected that he will perform perineal hygiene amp management of clothing with supervision Per clinical staff documentation required substantialmax assistance with toileting hygiene on 7 of the 9 observed shifts in the first 3 days of his stay Interview with staff indicate that he required staff to wipe amp clean him assist him to stand amp to pull up his pants amp underwear after elimination

PDPM WORKSHOP

PT Evaluation

65

ROLL LEFT amp RIGHT

Requires therapist to position pillow between legs to prevent adduction of the affected extremity amp then to assist him to roll side to side in bed Therapist provided more than half of the effort Therapy goal states it is expected that he will be independent with bed mobility including being able to roll left amp right at discharge

SIT TO LYING

Requires assistance of 1 therapist to support trunk amp lift both legs back into bed Did contribute a small amount of effort as he used his right arm to lower himself to a supine position Therapy goal is for him to be independent with this activity by discharge

LYLYING TO SITTINGON SIDE OF BED

Able to bring his left leg off the bed amp assist with pushing up with right arm Required assist to bring right leg off the side of the bed amp needed to be fully supported to come to a sitting position Helper provided more than half the effort Therapy goal is for Mr L to be independent with this activity by discharge

PDPM WORKSHOP

Case Study Scoring

bull Use handouts to complete taskbull Please work in groups at your tablebull Items to code on Admission5-PPS Assessmento GG0130 Self Care Items (just 3 areas covered)

o GG0170 Mobility Items (just 3 areas covered)

o Discharge goals for one Self Care amp Mobility Item

PDPM WORKSHOP

Admission5-Day PPS AssessmentGG0130 Self-Care

PDPM WORKSHOP

GG0130 Self-Care

68

ITEM 1 ADMISSION PERFORMANCE

2 DISCHARGE GOAL

GG0130A Eating 06 Independent 06 Independent

GG0130B Oral Hygiene 05 Setup or Clean-up Assistance

06 Independent

GG0130C Toileting Hygiene 02 SubstantialMaximal Assistance

04 Supervision or Touching Assistance

GG0130E ShowerBath Self NA NA

GG0130F Upper Body Dressing NA NA

GG0130G Lower Body Dressing NA NA

GG0130H Putting onTaking off Footwear

NA NA

PDPM WORKSHOP

GG0130A Eating

bull Admission Performance Coding = 06 Independent

bull Rationale Mr L was able to open containers cut meat amp eat without assistance on admission

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to remain independent with eating on discharge

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Which ICD-10 Codes Map to a PDPM Clinical Category

49

PDPM WORKSHOP

50

RTPRTP

RTPRTP

Medical ManagementNon-Surgical Ortho Musculoskeletal

RTPRTP

RTP

RTP

Which ICD-10 Codes Map to a PDPM Clinical Category

PDPM WORKSHOP

Patient Surgical History ndashItems J2100 ndash J5000 (New Items)

bull These items are used to capture any major surgical procedures that occurred during the inpatient hospital stay that immediately preceded the SNF admission (ie the qualifying hospital stay)

Section J ndashPast Surgical Categories

51

PDPM WORKSHOP

Section J ndash Past Surgical Categories

52

PDPM WORKSHOP

53

MDS Sample ndash Section I (Active Diagnoses)

PDPM WORKSHOP

54

Section I ndash Continued

PDPM WORKSHOP

Section GG

PDPM WORKSHOP

Functional Scoring under PDPM

bull ldquoReversedrdquo scoring between RUG vs PDPMbull RUG-IV Section G with a higher score means increased dependence

bull PDPM Section GG with a higher score means increased independence

bullPayment Differences related to Function between RUG vs PDPMbull RUG-IV payments increase with dependence within a given RUG

bull PDPM has no consistent relationship between increased dependence amp increased payments (differs for Therapy amp Nursing)

bull For the PT amp OT component payment for three clinical categories is lower for the most amp least dependent patients (who are less likely to require high amounts of therapy) amp higher for those in between (who are more likely to require high amounts of therapy)

56

PDPM WORKSHOP

Nursing Component

bullPDPM uses the same basic structure as RUG-IV except for the following changes o Function score based on Section GG of the MDS 30

o Collapsed functional nursing groups from 43 to 25

57

PDPM WORKSHOP

58

Section GG0130 -Self Care

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

59

Section GG0170 -Mobility

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

60

PDPM WORKSHOP

Why Does This Matter

bull Therapy amp nursing use different languagebull Therapy ratings may not accurately reflect the residents

ldquousual performancerdquo because residents may act differently in therapy than they do on the unit

61

PDPM WORKSHOP

Usual Performance RAI Manual page GG-9

bull A residentrsquos functional status can be impacted by the environment or situations encountered at the facilitybull Observing the residentrsquos interactions with others in different

locations amp circumstances is important for a comprehensive understanding of the residentrsquos functional statusbull If the residentrsquos functional status varies record the

residentrsquos usual ability to perform each activity bull Do not record the residentrsquos best performance amp do not

record the residentrsquos worst performance but rather record the residentrsquos usual performance

62

PDPM WORKSHOP

Patient Case Study

bull Mr L lives with his wife in a one-level home which is accessed by 3 steps bull Prior to a recent fall Mr L was independent with self-care

activities including bathing dressing toileting amp eating bull He was able to ambulate about the house without problem with

the use of a cane bullWhen ascending amp descending the external steps of the house

Mr L would hold onto rails to ensure his balance bull Mr L prepares his own daily medications amp takes turns with his

wife to ensure the bills are paid amp grocery shopping is done

63

PDPM WORKSHOP

OT Evaluation

64

EATING

Receiving a no added salt regular consistency diet Independent opening containers amp cutting up meat once the tray is set before him Discharge goal is to remain independent with eating

ORAL HYGIENE

Edentulous wears full dentures Able to remove dentures to soak clean amp replace in mouth once needed items are set up Once activity is complete staff put away items It is anticipated he will not require assistance of any type with oral hygiene by discharge

TOILETING HYGIENE

Uses toilet to void amp have bowel movements Once standing before toilet requires steadying assistance from one helper as he pulls down his pants amp underwear After elimination requires staff to wipe amp clean Contact guard assistance is needed to stand amp readjust clothing Expected that he will perform perineal hygiene amp management of clothing with supervision Per clinical staff documentation required substantialmax assistance with toileting hygiene on 7 of the 9 observed shifts in the first 3 days of his stay Interview with staff indicate that he required staff to wipe amp clean him assist him to stand amp to pull up his pants amp underwear after elimination

PDPM WORKSHOP

PT Evaluation

65

ROLL LEFT amp RIGHT

Requires therapist to position pillow between legs to prevent adduction of the affected extremity amp then to assist him to roll side to side in bed Therapist provided more than half of the effort Therapy goal states it is expected that he will be independent with bed mobility including being able to roll left amp right at discharge

SIT TO LYING

Requires assistance of 1 therapist to support trunk amp lift both legs back into bed Did contribute a small amount of effort as he used his right arm to lower himself to a supine position Therapy goal is for him to be independent with this activity by discharge

LYLYING TO SITTINGON SIDE OF BED

Able to bring his left leg off the bed amp assist with pushing up with right arm Required assist to bring right leg off the side of the bed amp needed to be fully supported to come to a sitting position Helper provided more than half the effort Therapy goal is for Mr L to be independent with this activity by discharge

PDPM WORKSHOP

Case Study Scoring

bull Use handouts to complete taskbull Please work in groups at your tablebull Items to code on Admission5-PPS Assessmento GG0130 Self Care Items (just 3 areas covered)

o GG0170 Mobility Items (just 3 areas covered)

o Discharge goals for one Self Care amp Mobility Item

PDPM WORKSHOP

Admission5-Day PPS AssessmentGG0130 Self-Care

PDPM WORKSHOP

GG0130 Self-Care

68

ITEM 1 ADMISSION PERFORMANCE

2 DISCHARGE GOAL

GG0130A Eating 06 Independent 06 Independent

GG0130B Oral Hygiene 05 Setup or Clean-up Assistance

06 Independent

GG0130C Toileting Hygiene 02 SubstantialMaximal Assistance

04 Supervision or Touching Assistance

GG0130E ShowerBath Self NA NA

GG0130F Upper Body Dressing NA NA

GG0130G Lower Body Dressing NA NA

GG0130H Putting onTaking off Footwear

NA NA

PDPM WORKSHOP

GG0130A Eating

bull Admission Performance Coding = 06 Independent

bull Rationale Mr L was able to open containers cut meat amp eat without assistance on admission

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to remain independent with eating on discharge

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

50

RTPRTP

RTPRTP

Medical ManagementNon-Surgical Ortho Musculoskeletal

RTPRTP

RTP

RTP

Which ICD-10 Codes Map to a PDPM Clinical Category

PDPM WORKSHOP

Patient Surgical History ndashItems J2100 ndash J5000 (New Items)

bull These items are used to capture any major surgical procedures that occurred during the inpatient hospital stay that immediately preceded the SNF admission (ie the qualifying hospital stay)

Section J ndashPast Surgical Categories

51

PDPM WORKSHOP

Section J ndash Past Surgical Categories

52

PDPM WORKSHOP

53

MDS Sample ndash Section I (Active Diagnoses)

PDPM WORKSHOP

54

Section I ndash Continued

PDPM WORKSHOP

Section GG

PDPM WORKSHOP

Functional Scoring under PDPM

bull ldquoReversedrdquo scoring between RUG vs PDPMbull RUG-IV Section G with a higher score means increased dependence

bull PDPM Section GG with a higher score means increased independence

bullPayment Differences related to Function between RUG vs PDPMbull RUG-IV payments increase with dependence within a given RUG

bull PDPM has no consistent relationship between increased dependence amp increased payments (differs for Therapy amp Nursing)

bull For the PT amp OT component payment for three clinical categories is lower for the most amp least dependent patients (who are less likely to require high amounts of therapy) amp higher for those in between (who are more likely to require high amounts of therapy)

56

PDPM WORKSHOP

Nursing Component

bullPDPM uses the same basic structure as RUG-IV except for the following changes o Function score based on Section GG of the MDS 30

o Collapsed functional nursing groups from 43 to 25

57

PDPM WORKSHOP

58

Section GG0130 -Self Care

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

59

Section GG0170 -Mobility

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

60

PDPM WORKSHOP

Why Does This Matter

bull Therapy amp nursing use different languagebull Therapy ratings may not accurately reflect the residents

ldquousual performancerdquo because residents may act differently in therapy than they do on the unit

61

PDPM WORKSHOP

Usual Performance RAI Manual page GG-9

bull A residentrsquos functional status can be impacted by the environment or situations encountered at the facilitybull Observing the residentrsquos interactions with others in different

locations amp circumstances is important for a comprehensive understanding of the residentrsquos functional statusbull If the residentrsquos functional status varies record the

residentrsquos usual ability to perform each activity bull Do not record the residentrsquos best performance amp do not

record the residentrsquos worst performance but rather record the residentrsquos usual performance

62

PDPM WORKSHOP

Patient Case Study

bull Mr L lives with his wife in a one-level home which is accessed by 3 steps bull Prior to a recent fall Mr L was independent with self-care

activities including bathing dressing toileting amp eating bull He was able to ambulate about the house without problem with

the use of a cane bullWhen ascending amp descending the external steps of the house

Mr L would hold onto rails to ensure his balance bull Mr L prepares his own daily medications amp takes turns with his

wife to ensure the bills are paid amp grocery shopping is done

63

PDPM WORKSHOP

OT Evaluation

64

EATING

Receiving a no added salt regular consistency diet Independent opening containers amp cutting up meat once the tray is set before him Discharge goal is to remain independent with eating

ORAL HYGIENE

Edentulous wears full dentures Able to remove dentures to soak clean amp replace in mouth once needed items are set up Once activity is complete staff put away items It is anticipated he will not require assistance of any type with oral hygiene by discharge

TOILETING HYGIENE

Uses toilet to void amp have bowel movements Once standing before toilet requires steadying assistance from one helper as he pulls down his pants amp underwear After elimination requires staff to wipe amp clean Contact guard assistance is needed to stand amp readjust clothing Expected that he will perform perineal hygiene amp management of clothing with supervision Per clinical staff documentation required substantialmax assistance with toileting hygiene on 7 of the 9 observed shifts in the first 3 days of his stay Interview with staff indicate that he required staff to wipe amp clean him assist him to stand amp to pull up his pants amp underwear after elimination

PDPM WORKSHOP

PT Evaluation

65

ROLL LEFT amp RIGHT

Requires therapist to position pillow between legs to prevent adduction of the affected extremity amp then to assist him to roll side to side in bed Therapist provided more than half of the effort Therapy goal states it is expected that he will be independent with bed mobility including being able to roll left amp right at discharge

SIT TO LYING

Requires assistance of 1 therapist to support trunk amp lift both legs back into bed Did contribute a small amount of effort as he used his right arm to lower himself to a supine position Therapy goal is for him to be independent with this activity by discharge

LYLYING TO SITTINGON SIDE OF BED

Able to bring his left leg off the bed amp assist with pushing up with right arm Required assist to bring right leg off the side of the bed amp needed to be fully supported to come to a sitting position Helper provided more than half the effort Therapy goal is for Mr L to be independent with this activity by discharge

PDPM WORKSHOP

Case Study Scoring

bull Use handouts to complete taskbull Please work in groups at your tablebull Items to code on Admission5-PPS Assessmento GG0130 Self Care Items (just 3 areas covered)

o GG0170 Mobility Items (just 3 areas covered)

o Discharge goals for one Self Care amp Mobility Item

PDPM WORKSHOP

Admission5-Day PPS AssessmentGG0130 Self-Care

PDPM WORKSHOP

GG0130 Self-Care

68

ITEM 1 ADMISSION PERFORMANCE

2 DISCHARGE GOAL

GG0130A Eating 06 Independent 06 Independent

GG0130B Oral Hygiene 05 Setup or Clean-up Assistance

06 Independent

GG0130C Toileting Hygiene 02 SubstantialMaximal Assistance

04 Supervision or Touching Assistance

GG0130E ShowerBath Self NA NA

GG0130F Upper Body Dressing NA NA

GG0130G Lower Body Dressing NA NA

GG0130H Putting onTaking off Footwear

NA NA

PDPM WORKSHOP

GG0130A Eating

bull Admission Performance Coding = 06 Independent

bull Rationale Mr L was able to open containers cut meat amp eat without assistance on admission

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to remain independent with eating on discharge

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Patient Surgical History ndashItems J2100 ndash J5000 (New Items)

bull These items are used to capture any major surgical procedures that occurred during the inpatient hospital stay that immediately preceded the SNF admission (ie the qualifying hospital stay)

Section J ndashPast Surgical Categories

51

PDPM WORKSHOP

Section J ndash Past Surgical Categories

52

PDPM WORKSHOP

53

MDS Sample ndash Section I (Active Diagnoses)

PDPM WORKSHOP

54

Section I ndash Continued

PDPM WORKSHOP

Section GG

PDPM WORKSHOP

Functional Scoring under PDPM

bull ldquoReversedrdquo scoring between RUG vs PDPMbull RUG-IV Section G with a higher score means increased dependence

bull PDPM Section GG with a higher score means increased independence

bullPayment Differences related to Function between RUG vs PDPMbull RUG-IV payments increase with dependence within a given RUG

bull PDPM has no consistent relationship between increased dependence amp increased payments (differs for Therapy amp Nursing)

bull For the PT amp OT component payment for three clinical categories is lower for the most amp least dependent patients (who are less likely to require high amounts of therapy) amp higher for those in between (who are more likely to require high amounts of therapy)

56

PDPM WORKSHOP

Nursing Component

bullPDPM uses the same basic structure as RUG-IV except for the following changes o Function score based on Section GG of the MDS 30

o Collapsed functional nursing groups from 43 to 25

57

PDPM WORKSHOP

58

Section GG0130 -Self Care

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

59

Section GG0170 -Mobility

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

60

PDPM WORKSHOP

Why Does This Matter

bull Therapy amp nursing use different languagebull Therapy ratings may not accurately reflect the residents

ldquousual performancerdquo because residents may act differently in therapy than they do on the unit

61

PDPM WORKSHOP

Usual Performance RAI Manual page GG-9

bull A residentrsquos functional status can be impacted by the environment or situations encountered at the facilitybull Observing the residentrsquos interactions with others in different

locations amp circumstances is important for a comprehensive understanding of the residentrsquos functional statusbull If the residentrsquos functional status varies record the

residentrsquos usual ability to perform each activity bull Do not record the residentrsquos best performance amp do not

record the residentrsquos worst performance but rather record the residentrsquos usual performance

62

PDPM WORKSHOP

Patient Case Study

bull Mr L lives with his wife in a one-level home which is accessed by 3 steps bull Prior to a recent fall Mr L was independent with self-care

activities including bathing dressing toileting amp eating bull He was able to ambulate about the house without problem with

the use of a cane bullWhen ascending amp descending the external steps of the house

Mr L would hold onto rails to ensure his balance bull Mr L prepares his own daily medications amp takes turns with his

wife to ensure the bills are paid amp grocery shopping is done

63

PDPM WORKSHOP

OT Evaluation

64

EATING

Receiving a no added salt regular consistency diet Independent opening containers amp cutting up meat once the tray is set before him Discharge goal is to remain independent with eating

ORAL HYGIENE

Edentulous wears full dentures Able to remove dentures to soak clean amp replace in mouth once needed items are set up Once activity is complete staff put away items It is anticipated he will not require assistance of any type with oral hygiene by discharge

TOILETING HYGIENE

Uses toilet to void amp have bowel movements Once standing before toilet requires steadying assistance from one helper as he pulls down his pants amp underwear After elimination requires staff to wipe amp clean Contact guard assistance is needed to stand amp readjust clothing Expected that he will perform perineal hygiene amp management of clothing with supervision Per clinical staff documentation required substantialmax assistance with toileting hygiene on 7 of the 9 observed shifts in the first 3 days of his stay Interview with staff indicate that he required staff to wipe amp clean him assist him to stand amp to pull up his pants amp underwear after elimination

PDPM WORKSHOP

PT Evaluation

65

ROLL LEFT amp RIGHT

Requires therapist to position pillow between legs to prevent adduction of the affected extremity amp then to assist him to roll side to side in bed Therapist provided more than half of the effort Therapy goal states it is expected that he will be independent with bed mobility including being able to roll left amp right at discharge

SIT TO LYING

Requires assistance of 1 therapist to support trunk amp lift both legs back into bed Did contribute a small amount of effort as he used his right arm to lower himself to a supine position Therapy goal is for him to be independent with this activity by discharge

LYLYING TO SITTINGON SIDE OF BED

Able to bring his left leg off the bed amp assist with pushing up with right arm Required assist to bring right leg off the side of the bed amp needed to be fully supported to come to a sitting position Helper provided more than half the effort Therapy goal is for Mr L to be independent with this activity by discharge

PDPM WORKSHOP

Case Study Scoring

bull Use handouts to complete taskbull Please work in groups at your tablebull Items to code on Admission5-PPS Assessmento GG0130 Self Care Items (just 3 areas covered)

o GG0170 Mobility Items (just 3 areas covered)

o Discharge goals for one Self Care amp Mobility Item

PDPM WORKSHOP

Admission5-Day PPS AssessmentGG0130 Self-Care

PDPM WORKSHOP

GG0130 Self-Care

68

ITEM 1 ADMISSION PERFORMANCE

2 DISCHARGE GOAL

GG0130A Eating 06 Independent 06 Independent

GG0130B Oral Hygiene 05 Setup or Clean-up Assistance

06 Independent

GG0130C Toileting Hygiene 02 SubstantialMaximal Assistance

04 Supervision or Touching Assistance

GG0130E ShowerBath Self NA NA

GG0130F Upper Body Dressing NA NA

GG0130G Lower Body Dressing NA NA

GG0130H Putting onTaking off Footwear

NA NA

PDPM WORKSHOP

GG0130A Eating

bull Admission Performance Coding = 06 Independent

bull Rationale Mr L was able to open containers cut meat amp eat without assistance on admission

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to remain independent with eating on discharge

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Section J ndash Past Surgical Categories

52

PDPM WORKSHOP

53

MDS Sample ndash Section I (Active Diagnoses)

PDPM WORKSHOP

54

Section I ndash Continued

PDPM WORKSHOP

Section GG

PDPM WORKSHOP

Functional Scoring under PDPM

bull ldquoReversedrdquo scoring between RUG vs PDPMbull RUG-IV Section G with a higher score means increased dependence

bull PDPM Section GG with a higher score means increased independence

bullPayment Differences related to Function between RUG vs PDPMbull RUG-IV payments increase with dependence within a given RUG

bull PDPM has no consistent relationship between increased dependence amp increased payments (differs for Therapy amp Nursing)

bull For the PT amp OT component payment for three clinical categories is lower for the most amp least dependent patients (who are less likely to require high amounts of therapy) amp higher for those in between (who are more likely to require high amounts of therapy)

56

PDPM WORKSHOP

Nursing Component

bullPDPM uses the same basic structure as RUG-IV except for the following changes o Function score based on Section GG of the MDS 30

o Collapsed functional nursing groups from 43 to 25

57

PDPM WORKSHOP

58

Section GG0130 -Self Care

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

59

Section GG0170 -Mobility

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

60

PDPM WORKSHOP

Why Does This Matter

bull Therapy amp nursing use different languagebull Therapy ratings may not accurately reflect the residents

ldquousual performancerdquo because residents may act differently in therapy than they do on the unit

61

PDPM WORKSHOP

Usual Performance RAI Manual page GG-9

bull A residentrsquos functional status can be impacted by the environment or situations encountered at the facilitybull Observing the residentrsquos interactions with others in different

locations amp circumstances is important for a comprehensive understanding of the residentrsquos functional statusbull If the residentrsquos functional status varies record the

residentrsquos usual ability to perform each activity bull Do not record the residentrsquos best performance amp do not

record the residentrsquos worst performance but rather record the residentrsquos usual performance

62

PDPM WORKSHOP

Patient Case Study

bull Mr L lives with his wife in a one-level home which is accessed by 3 steps bull Prior to a recent fall Mr L was independent with self-care

activities including bathing dressing toileting amp eating bull He was able to ambulate about the house without problem with

the use of a cane bullWhen ascending amp descending the external steps of the house

Mr L would hold onto rails to ensure his balance bull Mr L prepares his own daily medications amp takes turns with his

wife to ensure the bills are paid amp grocery shopping is done

63

PDPM WORKSHOP

OT Evaluation

64

EATING

Receiving a no added salt regular consistency diet Independent opening containers amp cutting up meat once the tray is set before him Discharge goal is to remain independent with eating

ORAL HYGIENE

Edentulous wears full dentures Able to remove dentures to soak clean amp replace in mouth once needed items are set up Once activity is complete staff put away items It is anticipated he will not require assistance of any type with oral hygiene by discharge

TOILETING HYGIENE

Uses toilet to void amp have bowel movements Once standing before toilet requires steadying assistance from one helper as he pulls down his pants amp underwear After elimination requires staff to wipe amp clean Contact guard assistance is needed to stand amp readjust clothing Expected that he will perform perineal hygiene amp management of clothing with supervision Per clinical staff documentation required substantialmax assistance with toileting hygiene on 7 of the 9 observed shifts in the first 3 days of his stay Interview with staff indicate that he required staff to wipe amp clean him assist him to stand amp to pull up his pants amp underwear after elimination

PDPM WORKSHOP

PT Evaluation

65

ROLL LEFT amp RIGHT

Requires therapist to position pillow between legs to prevent adduction of the affected extremity amp then to assist him to roll side to side in bed Therapist provided more than half of the effort Therapy goal states it is expected that he will be independent with bed mobility including being able to roll left amp right at discharge

SIT TO LYING

Requires assistance of 1 therapist to support trunk amp lift both legs back into bed Did contribute a small amount of effort as he used his right arm to lower himself to a supine position Therapy goal is for him to be independent with this activity by discharge

LYLYING TO SITTINGON SIDE OF BED

Able to bring his left leg off the bed amp assist with pushing up with right arm Required assist to bring right leg off the side of the bed amp needed to be fully supported to come to a sitting position Helper provided more than half the effort Therapy goal is for Mr L to be independent with this activity by discharge

PDPM WORKSHOP

Case Study Scoring

bull Use handouts to complete taskbull Please work in groups at your tablebull Items to code on Admission5-PPS Assessmento GG0130 Self Care Items (just 3 areas covered)

o GG0170 Mobility Items (just 3 areas covered)

o Discharge goals for one Self Care amp Mobility Item

PDPM WORKSHOP

Admission5-Day PPS AssessmentGG0130 Self-Care

PDPM WORKSHOP

GG0130 Self-Care

68

ITEM 1 ADMISSION PERFORMANCE

2 DISCHARGE GOAL

GG0130A Eating 06 Independent 06 Independent

GG0130B Oral Hygiene 05 Setup or Clean-up Assistance

06 Independent

GG0130C Toileting Hygiene 02 SubstantialMaximal Assistance

04 Supervision or Touching Assistance

GG0130E ShowerBath Self NA NA

GG0130F Upper Body Dressing NA NA

GG0130G Lower Body Dressing NA NA

GG0130H Putting onTaking off Footwear

NA NA

PDPM WORKSHOP

GG0130A Eating

bull Admission Performance Coding = 06 Independent

bull Rationale Mr L was able to open containers cut meat amp eat without assistance on admission

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to remain independent with eating on discharge

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

53

MDS Sample ndash Section I (Active Diagnoses)

PDPM WORKSHOP

54

Section I ndash Continued

PDPM WORKSHOP

Section GG

PDPM WORKSHOP

Functional Scoring under PDPM

bull ldquoReversedrdquo scoring between RUG vs PDPMbull RUG-IV Section G with a higher score means increased dependence

bull PDPM Section GG with a higher score means increased independence

bullPayment Differences related to Function between RUG vs PDPMbull RUG-IV payments increase with dependence within a given RUG

bull PDPM has no consistent relationship between increased dependence amp increased payments (differs for Therapy amp Nursing)

bull For the PT amp OT component payment for three clinical categories is lower for the most amp least dependent patients (who are less likely to require high amounts of therapy) amp higher for those in between (who are more likely to require high amounts of therapy)

56

PDPM WORKSHOP

Nursing Component

bullPDPM uses the same basic structure as RUG-IV except for the following changes o Function score based on Section GG of the MDS 30

o Collapsed functional nursing groups from 43 to 25

57

PDPM WORKSHOP

58

Section GG0130 -Self Care

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

59

Section GG0170 -Mobility

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

60

PDPM WORKSHOP

Why Does This Matter

bull Therapy amp nursing use different languagebull Therapy ratings may not accurately reflect the residents

ldquousual performancerdquo because residents may act differently in therapy than they do on the unit

61

PDPM WORKSHOP

Usual Performance RAI Manual page GG-9

bull A residentrsquos functional status can be impacted by the environment or situations encountered at the facilitybull Observing the residentrsquos interactions with others in different

locations amp circumstances is important for a comprehensive understanding of the residentrsquos functional statusbull If the residentrsquos functional status varies record the

residentrsquos usual ability to perform each activity bull Do not record the residentrsquos best performance amp do not

record the residentrsquos worst performance but rather record the residentrsquos usual performance

62

PDPM WORKSHOP

Patient Case Study

bull Mr L lives with his wife in a one-level home which is accessed by 3 steps bull Prior to a recent fall Mr L was independent with self-care

activities including bathing dressing toileting amp eating bull He was able to ambulate about the house without problem with

the use of a cane bullWhen ascending amp descending the external steps of the house

Mr L would hold onto rails to ensure his balance bull Mr L prepares his own daily medications amp takes turns with his

wife to ensure the bills are paid amp grocery shopping is done

63

PDPM WORKSHOP

OT Evaluation

64

EATING

Receiving a no added salt regular consistency diet Independent opening containers amp cutting up meat once the tray is set before him Discharge goal is to remain independent with eating

ORAL HYGIENE

Edentulous wears full dentures Able to remove dentures to soak clean amp replace in mouth once needed items are set up Once activity is complete staff put away items It is anticipated he will not require assistance of any type with oral hygiene by discharge

TOILETING HYGIENE

Uses toilet to void amp have bowel movements Once standing before toilet requires steadying assistance from one helper as he pulls down his pants amp underwear After elimination requires staff to wipe amp clean Contact guard assistance is needed to stand amp readjust clothing Expected that he will perform perineal hygiene amp management of clothing with supervision Per clinical staff documentation required substantialmax assistance with toileting hygiene on 7 of the 9 observed shifts in the first 3 days of his stay Interview with staff indicate that he required staff to wipe amp clean him assist him to stand amp to pull up his pants amp underwear after elimination

PDPM WORKSHOP

PT Evaluation

65

ROLL LEFT amp RIGHT

Requires therapist to position pillow between legs to prevent adduction of the affected extremity amp then to assist him to roll side to side in bed Therapist provided more than half of the effort Therapy goal states it is expected that he will be independent with bed mobility including being able to roll left amp right at discharge

SIT TO LYING

Requires assistance of 1 therapist to support trunk amp lift both legs back into bed Did contribute a small amount of effort as he used his right arm to lower himself to a supine position Therapy goal is for him to be independent with this activity by discharge

LYLYING TO SITTINGON SIDE OF BED

Able to bring his left leg off the bed amp assist with pushing up with right arm Required assist to bring right leg off the side of the bed amp needed to be fully supported to come to a sitting position Helper provided more than half the effort Therapy goal is for Mr L to be independent with this activity by discharge

PDPM WORKSHOP

Case Study Scoring

bull Use handouts to complete taskbull Please work in groups at your tablebull Items to code on Admission5-PPS Assessmento GG0130 Self Care Items (just 3 areas covered)

o GG0170 Mobility Items (just 3 areas covered)

o Discharge goals for one Self Care amp Mobility Item

PDPM WORKSHOP

Admission5-Day PPS AssessmentGG0130 Self-Care

PDPM WORKSHOP

GG0130 Self-Care

68

ITEM 1 ADMISSION PERFORMANCE

2 DISCHARGE GOAL

GG0130A Eating 06 Independent 06 Independent

GG0130B Oral Hygiene 05 Setup or Clean-up Assistance

06 Independent

GG0130C Toileting Hygiene 02 SubstantialMaximal Assistance

04 Supervision or Touching Assistance

GG0130E ShowerBath Self NA NA

GG0130F Upper Body Dressing NA NA

GG0130G Lower Body Dressing NA NA

GG0130H Putting onTaking off Footwear

NA NA

PDPM WORKSHOP

GG0130A Eating

bull Admission Performance Coding = 06 Independent

bull Rationale Mr L was able to open containers cut meat amp eat without assistance on admission

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to remain independent with eating on discharge

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

54

Section I ndash Continued

PDPM WORKSHOP

Section GG

PDPM WORKSHOP

Functional Scoring under PDPM

bull ldquoReversedrdquo scoring between RUG vs PDPMbull RUG-IV Section G with a higher score means increased dependence

bull PDPM Section GG with a higher score means increased independence

bullPayment Differences related to Function between RUG vs PDPMbull RUG-IV payments increase with dependence within a given RUG

bull PDPM has no consistent relationship between increased dependence amp increased payments (differs for Therapy amp Nursing)

bull For the PT amp OT component payment for three clinical categories is lower for the most amp least dependent patients (who are less likely to require high amounts of therapy) amp higher for those in between (who are more likely to require high amounts of therapy)

56

PDPM WORKSHOP

Nursing Component

bullPDPM uses the same basic structure as RUG-IV except for the following changes o Function score based on Section GG of the MDS 30

o Collapsed functional nursing groups from 43 to 25

57

PDPM WORKSHOP

58

Section GG0130 -Self Care

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

59

Section GG0170 -Mobility

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

60

PDPM WORKSHOP

Why Does This Matter

bull Therapy amp nursing use different languagebull Therapy ratings may not accurately reflect the residents

ldquousual performancerdquo because residents may act differently in therapy than they do on the unit

61

PDPM WORKSHOP

Usual Performance RAI Manual page GG-9

bull A residentrsquos functional status can be impacted by the environment or situations encountered at the facilitybull Observing the residentrsquos interactions with others in different

locations amp circumstances is important for a comprehensive understanding of the residentrsquos functional statusbull If the residentrsquos functional status varies record the

residentrsquos usual ability to perform each activity bull Do not record the residentrsquos best performance amp do not

record the residentrsquos worst performance but rather record the residentrsquos usual performance

62

PDPM WORKSHOP

Patient Case Study

bull Mr L lives with his wife in a one-level home which is accessed by 3 steps bull Prior to a recent fall Mr L was independent with self-care

activities including bathing dressing toileting amp eating bull He was able to ambulate about the house without problem with

the use of a cane bullWhen ascending amp descending the external steps of the house

Mr L would hold onto rails to ensure his balance bull Mr L prepares his own daily medications amp takes turns with his

wife to ensure the bills are paid amp grocery shopping is done

63

PDPM WORKSHOP

OT Evaluation

64

EATING

Receiving a no added salt regular consistency diet Independent opening containers amp cutting up meat once the tray is set before him Discharge goal is to remain independent with eating

ORAL HYGIENE

Edentulous wears full dentures Able to remove dentures to soak clean amp replace in mouth once needed items are set up Once activity is complete staff put away items It is anticipated he will not require assistance of any type with oral hygiene by discharge

TOILETING HYGIENE

Uses toilet to void amp have bowel movements Once standing before toilet requires steadying assistance from one helper as he pulls down his pants amp underwear After elimination requires staff to wipe amp clean Contact guard assistance is needed to stand amp readjust clothing Expected that he will perform perineal hygiene amp management of clothing with supervision Per clinical staff documentation required substantialmax assistance with toileting hygiene on 7 of the 9 observed shifts in the first 3 days of his stay Interview with staff indicate that he required staff to wipe amp clean him assist him to stand amp to pull up his pants amp underwear after elimination

PDPM WORKSHOP

PT Evaluation

65

ROLL LEFT amp RIGHT

Requires therapist to position pillow between legs to prevent adduction of the affected extremity amp then to assist him to roll side to side in bed Therapist provided more than half of the effort Therapy goal states it is expected that he will be independent with bed mobility including being able to roll left amp right at discharge

SIT TO LYING

Requires assistance of 1 therapist to support trunk amp lift both legs back into bed Did contribute a small amount of effort as he used his right arm to lower himself to a supine position Therapy goal is for him to be independent with this activity by discharge

LYLYING TO SITTINGON SIDE OF BED

Able to bring his left leg off the bed amp assist with pushing up with right arm Required assist to bring right leg off the side of the bed amp needed to be fully supported to come to a sitting position Helper provided more than half the effort Therapy goal is for Mr L to be independent with this activity by discharge

PDPM WORKSHOP

Case Study Scoring

bull Use handouts to complete taskbull Please work in groups at your tablebull Items to code on Admission5-PPS Assessmento GG0130 Self Care Items (just 3 areas covered)

o GG0170 Mobility Items (just 3 areas covered)

o Discharge goals for one Self Care amp Mobility Item

PDPM WORKSHOP

Admission5-Day PPS AssessmentGG0130 Self-Care

PDPM WORKSHOP

GG0130 Self-Care

68

ITEM 1 ADMISSION PERFORMANCE

2 DISCHARGE GOAL

GG0130A Eating 06 Independent 06 Independent

GG0130B Oral Hygiene 05 Setup or Clean-up Assistance

06 Independent

GG0130C Toileting Hygiene 02 SubstantialMaximal Assistance

04 Supervision or Touching Assistance

GG0130E ShowerBath Self NA NA

GG0130F Upper Body Dressing NA NA

GG0130G Lower Body Dressing NA NA

GG0130H Putting onTaking off Footwear

NA NA

PDPM WORKSHOP

GG0130A Eating

bull Admission Performance Coding = 06 Independent

bull Rationale Mr L was able to open containers cut meat amp eat without assistance on admission

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to remain independent with eating on discharge

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Section GG

PDPM WORKSHOP

Functional Scoring under PDPM

bull ldquoReversedrdquo scoring between RUG vs PDPMbull RUG-IV Section G with a higher score means increased dependence

bull PDPM Section GG with a higher score means increased independence

bullPayment Differences related to Function between RUG vs PDPMbull RUG-IV payments increase with dependence within a given RUG

bull PDPM has no consistent relationship between increased dependence amp increased payments (differs for Therapy amp Nursing)

bull For the PT amp OT component payment for three clinical categories is lower for the most amp least dependent patients (who are less likely to require high amounts of therapy) amp higher for those in between (who are more likely to require high amounts of therapy)

56

PDPM WORKSHOP

Nursing Component

bullPDPM uses the same basic structure as RUG-IV except for the following changes o Function score based on Section GG of the MDS 30

o Collapsed functional nursing groups from 43 to 25

57

PDPM WORKSHOP

58

Section GG0130 -Self Care

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

59

Section GG0170 -Mobility

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

60

PDPM WORKSHOP

Why Does This Matter

bull Therapy amp nursing use different languagebull Therapy ratings may not accurately reflect the residents

ldquousual performancerdquo because residents may act differently in therapy than they do on the unit

61

PDPM WORKSHOP

Usual Performance RAI Manual page GG-9

bull A residentrsquos functional status can be impacted by the environment or situations encountered at the facilitybull Observing the residentrsquos interactions with others in different

locations amp circumstances is important for a comprehensive understanding of the residentrsquos functional statusbull If the residentrsquos functional status varies record the

residentrsquos usual ability to perform each activity bull Do not record the residentrsquos best performance amp do not

record the residentrsquos worst performance but rather record the residentrsquos usual performance

62

PDPM WORKSHOP

Patient Case Study

bull Mr L lives with his wife in a one-level home which is accessed by 3 steps bull Prior to a recent fall Mr L was independent with self-care

activities including bathing dressing toileting amp eating bull He was able to ambulate about the house without problem with

the use of a cane bullWhen ascending amp descending the external steps of the house

Mr L would hold onto rails to ensure his balance bull Mr L prepares his own daily medications amp takes turns with his

wife to ensure the bills are paid amp grocery shopping is done

63

PDPM WORKSHOP

OT Evaluation

64

EATING

Receiving a no added salt regular consistency diet Independent opening containers amp cutting up meat once the tray is set before him Discharge goal is to remain independent with eating

ORAL HYGIENE

Edentulous wears full dentures Able to remove dentures to soak clean amp replace in mouth once needed items are set up Once activity is complete staff put away items It is anticipated he will not require assistance of any type with oral hygiene by discharge

TOILETING HYGIENE

Uses toilet to void amp have bowel movements Once standing before toilet requires steadying assistance from one helper as he pulls down his pants amp underwear After elimination requires staff to wipe amp clean Contact guard assistance is needed to stand amp readjust clothing Expected that he will perform perineal hygiene amp management of clothing with supervision Per clinical staff documentation required substantialmax assistance with toileting hygiene on 7 of the 9 observed shifts in the first 3 days of his stay Interview with staff indicate that he required staff to wipe amp clean him assist him to stand amp to pull up his pants amp underwear after elimination

PDPM WORKSHOP

PT Evaluation

65

ROLL LEFT amp RIGHT

Requires therapist to position pillow between legs to prevent adduction of the affected extremity amp then to assist him to roll side to side in bed Therapist provided more than half of the effort Therapy goal states it is expected that he will be independent with bed mobility including being able to roll left amp right at discharge

SIT TO LYING

Requires assistance of 1 therapist to support trunk amp lift both legs back into bed Did contribute a small amount of effort as he used his right arm to lower himself to a supine position Therapy goal is for him to be independent with this activity by discharge

LYLYING TO SITTINGON SIDE OF BED

Able to bring his left leg off the bed amp assist with pushing up with right arm Required assist to bring right leg off the side of the bed amp needed to be fully supported to come to a sitting position Helper provided more than half the effort Therapy goal is for Mr L to be independent with this activity by discharge

PDPM WORKSHOP

Case Study Scoring

bull Use handouts to complete taskbull Please work in groups at your tablebull Items to code on Admission5-PPS Assessmento GG0130 Self Care Items (just 3 areas covered)

o GG0170 Mobility Items (just 3 areas covered)

o Discharge goals for one Self Care amp Mobility Item

PDPM WORKSHOP

Admission5-Day PPS AssessmentGG0130 Self-Care

PDPM WORKSHOP

GG0130 Self-Care

68

ITEM 1 ADMISSION PERFORMANCE

2 DISCHARGE GOAL

GG0130A Eating 06 Independent 06 Independent

GG0130B Oral Hygiene 05 Setup or Clean-up Assistance

06 Independent

GG0130C Toileting Hygiene 02 SubstantialMaximal Assistance

04 Supervision or Touching Assistance

GG0130E ShowerBath Self NA NA

GG0130F Upper Body Dressing NA NA

GG0130G Lower Body Dressing NA NA

GG0130H Putting onTaking off Footwear

NA NA

PDPM WORKSHOP

GG0130A Eating

bull Admission Performance Coding = 06 Independent

bull Rationale Mr L was able to open containers cut meat amp eat without assistance on admission

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to remain independent with eating on discharge

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Functional Scoring under PDPM

bull ldquoReversedrdquo scoring between RUG vs PDPMbull RUG-IV Section G with a higher score means increased dependence

bull PDPM Section GG with a higher score means increased independence

bullPayment Differences related to Function between RUG vs PDPMbull RUG-IV payments increase with dependence within a given RUG

bull PDPM has no consistent relationship between increased dependence amp increased payments (differs for Therapy amp Nursing)

bull For the PT amp OT component payment for three clinical categories is lower for the most amp least dependent patients (who are less likely to require high amounts of therapy) amp higher for those in between (who are more likely to require high amounts of therapy)

56

PDPM WORKSHOP

Nursing Component

bullPDPM uses the same basic structure as RUG-IV except for the following changes o Function score based on Section GG of the MDS 30

o Collapsed functional nursing groups from 43 to 25

57

PDPM WORKSHOP

58

Section GG0130 -Self Care

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

59

Section GG0170 -Mobility

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

60

PDPM WORKSHOP

Why Does This Matter

bull Therapy amp nursing use different languagebull Therapy ratings may not accurately reflect the residents

ldquousual performancerdquo because residents may act differently in therapy than they do on the unit

61

PDPM WORKSHOP

Usual Performance RAI Manual page GG-9

bull A residentrsquos functional status can be impacted by the environment or situations encountered at the facilitybull Observing the residentrsquos interactions with others in different

locations amp circumstances is important for a comprehensive understanding of the residentrsquos functional statusbull If the residentrsquos functional status varies record the

residentrsquos usual ability to perform each activity bull Do not record the residentrsquos best performance amp do not

record the residentrsquos worst performance but rather record the residentrsquos usual performance

62

PDPM WORKSHOP

Patient Case Study

bull Mr L lives with his wife in a one-level home which is accessed by 3 steps bull Prior to a recent fall Mr L was independent with self-care

activities including bathing dressing toileting amp eating bull He was able to ambulate about the house without problem with

the use of a cane bullWhen ascending amp descending the external steps of the house

Mr L would hold onto rails to ensure his balance bull Mr L prepares his own daily medications amp takes turns with his

wife to ensure the bills are paid amp grocery shopping is done

63

PDPM WORKSHOP

OT Evaluation

64

EATING

Receiving a no added salt regular consistency diet Independent opening containers amp cutting up meat once the tray is set before him Discharge goal is to remain independent with eating

ORAL HYGIENE

Edentulous wears full dentures Able to remove dentures to soak clean amp replace in mouth once needed items are set up Once activity is complete staff put away items It is anticipated he will not require assistance of any type with oral hygiene by discharge

TOILETING HYGIENE

Uses toilet to void amp have bowel movements Once standing before toilet requires steadying assistance from one helper as he pulls down his pants amp underwear After elimination requires staff to wipe amp clean Contact guard assistance is needed to stand amp readjust clothing Expected that he will perform perineal hygiene amp management of clothing with supervision Per clinical staff documentation required substantialmax assistance with toileting hygiene on 7 of the 9 observed shifts in the first 3 days of his stay Interview with staff indicate that he required staff to wipe amp clean him assist him to stand amp to pull up his pants amp underwear after elimination

PDPM WORKSHOP

PT Evaluation

65

ROLL LEFT amp RIGHT

Requires therapist to position pillow between legs to prevent adduction of the affected extremity amp then to assist him to roll side to side in bed Therapist provided more than half of the effort Therapy goal states it is expected that he will be independent with bed mobility including being able to roll left amp right at discharge

SIT TO LYING

Requires assistance of 1 therapist to support trunk amp lift both legs back into bed Did contribute a small amount of effort as he used his right arm to lower himself to a supine position Therapy goal is for him to be independent with this activity by discharge

LYLYING TO SITTINGON SIDE OF BED

Able to bring his left leg off the bed amp assist with pushing up with right arm Required assist to bring right leg off the side of the bed amp needed to be fully supported to come to a sitting position Helper provided more than half the effort Therapy goal is for Mr L to be independent with this activity by discharge

PDPM WORKSHOP

Case Study Scoring

bull Use handouts to complete taskbull Please work in groups at your tablebull Items to code on Admission5-PPS Assessmento GG0130 Self Care Items (just 3 areas covered)

o GG0170 Mobility Items (just 3 areas covered)

o Discharge goals for one Self Care amp Mobility Item

PDPM WORKSHOP

Admission5-Day PPS AssessmentGG0130 Self-Care

PDPM WORKSHOP

GG0130 Self-Care

68

ITEM 1 ADMISSION PERFORMANCE

2 DISCHARGE GOAL

GG0130A Eating 06 Independent 06 Independent

GG0130B Oral Hygiene 05 Setup or Clean-up Assistance

06 Independent

GG0130C Toileting Hygiene 02 SubstantialMaximal Assistance

04 Supervision or Touching Assistance

GG0130E ShowerBath Self NA NA

GG0130F Upper Body Dressing NA NA

GG0130G Lower Body Dressing NA NA

GG0130H Putting onTaking off Footwear

NA NA

PDPM WORKSHOP

GG0130A Eating

bull Admission Performance Coding = 06 Independent

bull Rationale Mr L was able to open containers cut meat amp eat without assistance on admission

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to remain independent with eating on discharge

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Nursing Component

bullPDPM uses the same basic structure as RUG-IV except for the following changes o Function score based on Section GG of the MDS 30

o Collapsed functional nursing groups from 43 to 25

57

PDPM WORKSHOP

58

Section GG0130 -Self Care

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

59

Section GG0170 -Mobility

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

60

PDPM WORKSHOP

Why Does This Matter

bull Therapy amp nursing use different languagebull Therapy ratings may not accurately reflect the residents

ldquousual performancerdquo because residents may act differently in therapy than they do on the unit

61

PDPM WORKSHOP

Usual Performance RAI Manual page GG-9

bull A residentrsquos functional status can be impacted by the environment or situations encountered at the facilitybull Observing the residentrsquos interactions with others in different

locations amp circumstances is important for a comprehensive understanding of the residentrsquos functional statusbull If the residentrsquos functional status varies record the

residentrsquos usual ability to perform each activity bull Do not record the residentrsquos best performance amp do not

record the residentrsquos worst performance but rather record the residentrsquos usual performance

62

PDPM WORKSHOP

Patient Case Study

bull Mr L lives with his wife in a one-level home which is accessed by 3 steps bull Prior to a recent fall Mr L was independent with self-care

activities including bathing dressing toileting amp eating bull He was able to ambulate about the house without problem with

the use of a cane bullWhen ascending amp descending the external steps of the house

Mr L would hold onto rails to ensure his balance bull Mr L prepares his own daily medications amp takes turns with his

wife to ensure the bills are paid amp grocery shopping is done

63

PDPM WORKSHOP

OT Evaluation

64

EATING

Receiving a no added salt regular consistency diet Independent opening containers amp cutting up meat once the tray is set before him Discharge goal is to remain independent with eating

ORAL HYGIENE

Edentulous wears full dentures Able to remove dentures to soak clean amp replace in mouth once needed items are set up Once activity is complete staff put away items It is anticipated he will not require assistance of any type with oral hygiene by discharge

TOILETING HYGIENE

Uses toilet to void amp have bowel movements Once standing before toilet requires steadying assistance from one helper as he pulls down his pants amp underwear After elimination requires staff to wipe amp clean Contact guard assistance is needed to stand amp readjust clothing Expected that he will perform perineal hygiene amp management of clothing with supervision Per clinical staff documentation required substantialmax assistance with toileting hygiene on 7 of the 9 observed shifts in the first 3 days of his stay Interview with staff indicate that he required staff to wipe amp clean him assist him to stand amp to pull up his pants amp underwear after elimination

PDPM WORKSHOP

PT Evaluation

65

ROLL LEFT amp RIGHT

Requires therapist to position pillow between legs to prevent adduction of the affected extremity amp then to assist him to roll side to side in bed Therapist provided more than half of the effort Therapy goal states it is expected that he will be independent with bed mobility including being able to roll left amp right at discharge

SIT TO LYING

Requires assistance of 1 therapist to support trunk amp lift both legs back into bed Did contribute a small amount of effort as he used his right arm to lower himself to a supine position Therapy goal is for him to be independent with this activity by discharge

LYLYING TO SITTINGON SIDE OF BED

Able to bring his left leg off the bed amp assist with pushing up with right arm Required assist to bring right leg off the side of the bed amp needed to be fully supported to come to a sitting position Helper provided more than half the effort Therapy goal is for Mr L to be independent with this activity by discharge

PDPM WORKSHOP

Case Study Scoring

bull Use handouts to complete taskbull Please work in groups at your tablebull Items to code on Admission5-PPS Assessmento GG0130 Self Care Items (just 3 areas covered)

o GG0170 Mobility Items (just 3 areas covered)

o Discharge goals for one Self Care amp Mobility Item

PDPM WORKSHOP

Admission5-Day PPS AssessmentGG0130 Self-Care

PDPM WORKSHOP

GG0130 Self-Care

68

ITEM 1 ADMISSION PERFORMANCE

2 DISCHARGE GOAL

GG0130A Eating 06 Independent 06 Independent

GG0130B Oral Hygiene 05 Setup or Clean-up Assistance

06 Independent

GG0130C Toileting Hygiene 02 SubstantialMaximal Assistance

04 Supervision or Touching Assistance

GG0130E ShowerBath Self NA NA

GG0130F Upper Body Dressing NA NA

GG0130G Lower Body Dressing NA NA

GG0130H Putting onTaking off Footwear

NA NA

PDPM WORKSHOP

GG0130A Eating

bull Admission Performance Coding = 06 Independent

bull Rationale Mr L was able to open containers cut meat amp eat without assistance on admission

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to remain independent with eating on discharge

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

58

Section GG0130 -Self Care

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

59

Section GG0170 -Mobility

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

60

PDPM WORKSHOP

Why Does This Matter

bull Therapy amp nursing use different languagebull Therapy ratings may not accurately reflect the residents

ldquousual performancerdquo because residents may act differently in therapy than they do on the unit

61

PDPM WORKSHOP

Usual Performance RAI Manual page GG-9

bull A residentrsquos functional status can be impacted by the environment or situations encountered at the facilitybull Observing the residentrsquos interactions with others in different

locations amp circumstances is important for a comprehensive understanding of the residentrsquos functional statusbull If the residentrsquos functional status varies record the

residentrsquos usual ability to perform each activity bull Do not record the residentrsquos best performance amp do not

record the residentrsquos worst performance but rather record the residentrsquos usual performance

62

PDPM WORKSHOP

Patient Case Study

bull Mr L lives with his wife in a one-level home which is accessed by 3 steps bull Prior to a recent fall Mr L was independent with self-care

activities including bathing dressing toileting amp eating bull He was able to ambulate about the house without problem with

the use of a cane bullWhen ascending amp descending the external steps of the house

Mr L would hold onto rails to ensure his balance bull Mr L prepares his own daily medications amp takes turns with his

wife to ensure the bills are paid amp grocery shopping is done

63

PDPM WORKSHOP

OT Evaluation

64

EATING

Receiving a no added salt regular consistency diet Independent opening containers amp cutting up meat once the tray is set before him Discharge goal is to remain independent with eating

ORAL HYGIENE

Edentulous wears full dentures Able to remove dentures to soak clean amp replace in mouth once needed items are set up Once activity is complete staff put away items It is anticipated he will not require assistance of any type with oral hygiene by discharge

TOILETING HYGIENE

Uses toilet to void amp have bowel movements Once standing before toilet requires steadying assistance from one helper as he pulls down his pants amp underwear After elimination requires staff to wipe amp clean Contact guard assistance is needed to stand amp readjust clothing Expected that he will perform perineal hygiene amp management of clothing with supervision Per clinical staff documentation required substantialmax assistance with toileting hygiene on 7 of the 9 observed shifts in the first 3 days of his stay Interview with staff indicate that he required staff to wipe amp clean him assist him to stand amp to pull up his pants amp underwear after elimination

PDPM WORKSHOP

PT Evaluation

65

ROLL LEFT amp RIGHT

Requires therapist to position pillow between legs to prevent adduction of the affected extremity amp then to assist him to roll side to side in bed Therapist provided more than half of the effort Therapy goal states it is expected that he will be independent with bed mobility including being able to roll left amp right at discharge

SIT TO LYING

Requires assistance of 1 therapist to support trunk amp lift both legs back into bed Did contribute a small amount of effort as he used his right arm to lower himself to a supine position Therapy goal is for him to be independent with this activity by discharge

LYLYING TO SITTINGON SIDE OF BED

Able to bring his left leg off the bed amp assist with pushing up with right arm Required assist to bring right leg off the side of the bed amp needed to be fully supported to come to a sitting position Helper provided more than half the effort Therapy goal is for Mr L to be independent with this activity by discharge

PDPM WORKSHOP

Case Study Scoring

bull Use handouts to complete taskbull Please work in groups at your tablebull Items to code on Admission5-PPS Assessmento GG0130 Self Care Items (just 3 areas covered)

o GG0170 Mobility Items (just 3 areas covered)

o Discharge goals for one Self Care amp Mobility Item

PDPM WORKSHOP

Admission5-Day PPS AssessmentGG0130 Self-Care

PDPM WORKSHOP

GG0130 Self-Care

68

ITEM 1 ADMISSION PERFORMANCE

2 DISCHARGE GOAL

GG0130A Eating 06 Independent 06 Independent

GG0130B Oral Hygiene 05 Setup or Clean-up Assistance

06 Independent

GG0130C Toileting Hygiene 02 SubstantialMaximal Assistance

04 Supervision or Touching Assistance

GG0130E ShowerBath Self NA NA

GG0130F Upper Body Dressing NA NA

GG0130G Lower Body Dressing NA NA

GG0130H Putting onTaking off Footwear

NA NA

PDPM WORKSHOP

GG0130A Eating

bull Admission Performance Coding = 06 Independent

bull Rationale Mr L was able to open containers cut meat amp eat without assistance on admission

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to remain independent with eating on discharge

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

59

Section GG0170 -Mobility

(not all currently planned to be used for functional CMI calculation)

PDPM WORKSHOP

60

PDPM WORKSHOP

Why Does This Matter

bull Therapy amp nursing use different languagebull Therapy ratings may not accurately reflect the residents

ldquousual performancerdquo because residents may act differently in therapy than they do on the unit

61

PDPM WORKSHOP

Usual Performance RAI Manual page GG-9

bull A residentrsquos functional status can be impacted by the environment or situations encountered at the facilitybull Observing the residentrsquos interactions with others in different

locations amp circumstances is important for a comprehensive understanding of the residentrsquos functional statusbull If the residentrsquos functional status varies record the

residentrsquos usual ability to perform each activity bull Do not record the residentrsquos best performance amp do not

record the residentrsquos worst performance but rather record the residentrsquos usual performance

62

PDPM WORKSHOP

Patient Case Study

bull Mr L lives with his wife in a one-level home which is accessed by 3 steps bull Prior to a recent fall Mr L was independent with self-care

activities including bathing dressing toileting amp eating bull He was able to ambulate about the house without problem with

the use of a cane bullWhen ascending amp descending the external steps of the house

Mr L would hold onto rails to ensure his balance bull Mr L prepares his own daily medications amp takes turns with his

wife to ensure the bills are paid amp grocery shopping is done

63

PDPM WORKSHOP

OT Evaluation

64

EATING

Receiving a no added salt regular consistency diet Independent opening containers amp cutting up meat once the tray is set before him Discharge goal is to remain independent with eating

ORAL HYGIENE

Edentulous wears full dentures Able to remove dentures to soak clean amp replace in mouth once needed items are set up Once activity is complete staff put away items It is anticipated he will not require assistance of any type with oral hygiene by discharge

TOILETING HYGIENE

Uses toilet to void amp have bowel movements Once standing before toilet requires steadying assistance from one helper as he pulls down his pants amp underwear After elimination requires staff to wipe amp clean Contact guard assistance is needed to stand amp readjust clothing Expected that he will perform perineal hygiene amp management of clothing with supervision Per clinical staff documentation required substantialmax assistance with toileting hygiene on 7 of the 9 observed shifts in the first 3 days of his stay Interview with staff indicate that he required staff to wipe amp clean him assist him to stand amp to pull up his pants amp underwear after elimination

PDPM WORKSHOP

PT Evaluation

65

ROLL LEFT amp RIGHT

Requires therapist to position pillow between legs to prevent adduction of the affected extremity amp then to assist him to roll side to side in bed Therapist provided more than half of the effort Therapy goal states it is expected that he will be independent with bed mobility including being able to roll left amp right at discharge

SIT TO LYING

Requires assistance of 1 therapist to support trunk amp lift both legs back into bed Did contribute a small amount of effort as he used his right arm to lower himself to a supine position Therapy goal is for him to be independent with this activity by discharge

LYLYING TO SITTINGON SIDE OF BED

Able to bring his left leg off the bed amp assist with pushing up with right arm Required assist to bring right leg off the side of the bed amp needed to be fully supported to come to a sitting position Helper provided more than half the effort Therapy goal is for Mr L to be independent with this activity by discharge

PDPM WORKSHOP

Case Study Scoring

bull Use handouts to complete taskbull Please work in groups at your tablebull Items to code on Admission5-PPS Assessmento GG0130 Self Care Items (just 3 areas covered)

o GG0170 Mobility Items (just 3 areas covered)

o Discharge goals for one Self Care amp Mobility Item

PDPM WORKSHOP

Admission5-Day PPS AssessmentGG0130 Self-Care

PDPM WORKSHOP

GG0130 Self-Care

68

ITEM 1 ADMISSION PERFORMANCE

2 DISCHARGE GOAL

GG0130A Eating 06 Independent 06 Independent

GG0130B Oral Hygiene 05 Setup or Clean-up Assistance

06 Independent

GG0130C Toileting Hygiene 02 SubstantialMaximal Assistance

04 Supervision or Touching Assistance

GG0130E ShowerBath Self NA NA

GG0130F Upper Body Dressing NA NA

GG0130G Lower Body Dressing NA NA

GG0130H Putting onTaking off Footwear

NA NA

PDPM WORKSHOP

GG0130A Eating

bull Admission Performance Coding = 06 Independent

bull Rationale Mr L was able to open containers cut meat amp eat without assistance on admission

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to remain independent with eating on discharge

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

60

PDPM WORKSHOP

Why Does This Matter

bull Therapy amp nursing use different languagebull Therapy ratings may not accurately reflect the residents

ldquousual performancerdquo because residents may act differently in therapy than they do on the unit

61

PDPM WORKSHOP

Usual Performance RAI Manual page GG-9

bull A residentrsquos functional status can be impacted by the environment or situations encountered at the facilitybull Observing the residentrsquos interactions with others in different

locations amp circumstances is important for a comprehensive understanding of the residentrsquos functional statusbull If the residentrsquos functional status varies record the

residentrsquos usual ability to perform each activity bull Do not record the residentrsquos best performance amp do not

record the residentrsquos worst performance but rather record the residentrsquos usual performance

62

PDPM WORKSHOP

Patient Case Study

bull Mr L lives with his wife in a one-level home which is accessed by 3 steps bull Prior to a recent fall Mr L was independent with self-care

activities including bathing dressing toileting amp eating bull He was able to ambulate about the house without problem with

the use of a cane bullWhen ascending amp descending the external steps of the house

Mr L would hold onto rails to ensure his balance bull Mr L prepares his own daily medications amp takes turns with his

wife to ensure the bills are paid amp grocery shopping is done

63

PDPM WORKSHOP

OT Evaluation

64

EATING

Receiving a no added salt regular consistency diet Independent opening containers amp cutting up meat once the tray is set before him Discharge goal is to remain independent with eating

ORAL HYGIENE

Edentulous wears full dentures Able to remove dentures to soak clean amp replace in mouth once needed items are set up Once activity is complete staff put away items It is anticipated he will not require assistance of any type with oral hygiene by discharge

TOILETING HYGIENE

Uses toilet to void amp have bowel movements Once standing before toilet requires steadying assistance from one helper as he pulls down his pants amp underwear After elimination requires staff to wipe amp clean Contact guard assistance is needed to stand amp readjust clothing Expected that he will perform perineal hygiene amp management of clothing with supervision Per clinical staff documentation required substantialmax assistance with toileting hygiene on 7 of the 9 observed shifts in the first 3 days of his stay Interview with staff indicate that he required staff to wipe amp clean him assist him to stand amp to pull up his pants amp underwear after elimination

PDPM WORKSHOP

PT Evaluation

65

ROLL LEFT amp RIGHT

Requires therapist to position pillow between legs to prevent adduction of the affected extremity amp then to assist him to roll side to side in bed Therapist provided more than half of the effort Therapy goal states it is expected that he will be independent with bed mobility including being able to roll left amp right at discharge

SIT TO LYING

Requires assistance of 1 therapist to support trunk amp lift both legs back into bed Did contribute a small amount of effort as he used his right arm to lower himself to a supine position Therapy goal is for him to be independent with this activity by discharge

LYLYING TO SITTINGON SIDE OF BED

Able to bring his left leg off the bed amp assist with pushing up with right arm Required assist to bring right leg off the side of the bed amp needed to be fully supported to come to a sitting position Helper provided more than half the effort Therapy goal is for Mr L to be independent with this activity by discharge

PDPM WORKSHOP

Case Study Scoring

bull Use handouts to complete taskbull Please work in groups at your tablebull Items to code on Admission5-PPS Assessmento GG0130 Self Care Items (just 3 areas covered)

o GG0170 Mobility Items (just 3 areas covered)

o Discharge goals for one Self Care amp Mobility Item

PDPM WORKSHOP

Admission5-Day PPS AssessmentGG0130 Self-Care

PDPM WORKSHOP

GG0130 Self-Care

68

ITEM 1 ADMISSION PERFORMANCE

2 DISCHARGE GOAL

GG0130A Eating 06 Independent 06 Independent

GG0130B Oral Hygiene 05 Setup or Clean-up Assistance

06 Independent

GG0130C Toileting Hygiene 02 SubstantialMaximal Assistance

04 Supervision or Touching Assistance

GG0130E ShowerBath Self NA NA

GG0130F Upper Body Dressing NA NA

GG0130G Lower Body Dressing NA NA

GG0130H Putting onTaking off Footwear

NA NA

PDPM WORKSHOP

GG0130A Eating

bull Admission Performance Coding = 06 Independent

bull Rationale Mr L was able to open containers cut meat amp eat without assistance on admission

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to remain independent with eating on discharge

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Why Does This Matter

bull Therapy amp nursing use different languagebull Therapy ratings may not accurately reflect the residents

ldquousual performancerdquo because residents may act differently in therapy than they do on the unit

61

PDPM WORKSHOP

Usual Performance RAI Manual page GG-9

bull A residentrsquos functional status can be impacted by the environment or situations encountered at the facilitybull Observing the residentrsquos interactions with others in different

locations amp circumstances is important for a comprehensive understanding of the residentrsquos functional statusbull If the residentrsquos functional status varies record the

residentrsquos usual ability to perform each activity bull Do not record the residentrsquos best performance amp do not

record the residentrsquos worst performance but rather record the residentrsquos usual performance

62

PDPM WORKSHOP

Patient Case Study

bull Mr L lives with his wife in a one-level home which is accessed by 3 steps bull Prior to a recent fall Mr L was independent with self-care

activities including bathing dressing toileting amp eating bull He was able to ambulate about the house without problem with

the use of a cane bullWhen ascending amp descending the external steps of the house

Mr L would hold onto rails to ensure his balance bull Mr L prepares his own daily medications amp takes turns with his

wife to ensure the bills are paid amp grocery shopping is done

63

PDPM WORKSHOP

OT Evaluation

64

EATING

Receiving a no added salt regular consistency diet Independent opening containers amp cutting up meat once the tray is set before him Discharge goal is to remain independent with eating

ORAL HYGIENE

Edentulous wears full dentures Able to remove dentures to soak clean amp replace in mouth once needed items are set up Once activity is complete staff put away items It is anticipated he will not require assistance of any type with oral hygiene by discharge

TOILETING HYGIENE

Uses toilet to void amp have bowel movements Once standing before toilet requires steadying assistance from one helper as he pulls down his pants amp underwear After elimination requires staff to wipe amp clean Contact guard assistance is needed to stand amp readjust clothing Expected that he will perform perineal hygiene amp management of clothing with supervision Per clinical staff documentation required substantialmax assistance with toileting hygiene on 7 of the 9 observed shifts in the first 3 days of his stay Interview with staff indicate that he required staff to wipe amp clean him assist him to stand amp to pull up his pants amp underwear after elimination

PDPM WORKSHOP

PT Evaluation

65

ROLL LEFT amp RIGHT

Requires therapist to position pillow between legs to prevent adduction of the affected extremity amp then to assist him to roll side to side in bed Therapist provided more than half of the effort Therapy goal states it is expected that he will be independent with bed mobility including being able to roll left amp right at discharge

SIT TO LYING

Requires assistance of 1 therapist to support trunk amp lift both legs back into bed Did contribute a small amount of effort as he used his right arm to lower himself to a supine position Therapy goal is for him to be independent with this activity by discharge

LYLYING TO SITTINGON SIDE OF BED

Able to bring his left leg off the bed amp assist with pushing up with right arm Required assist to bring right leg off the side of the bed amp needed to be fully supported to come to a sitting position Helper provided more than half the effort Therapy goal is for Mr L to be independent with this activity by discharge

PDPM WORKSHOP

Case Study Scoring

bull Use handouts to complete taskbull Please work in groups at your tablebull Items to code on Admission5-PPS Assessmento GG0130 Self Care Items (just 3 areas covered)

o GG0170 Mobility Items (just 3 areas covered)

o Discharge goals for one Self Care amp Mobility Item

PDPM WORKSHOP

Admission5-Day PPS AssessmentGG0130 Self-Care

PDPM WORKSHOP

GG0130 Self-Care

68

ITEM 1 ADMISSION PERFORMANCE

2 DISCHARGE GOAL

GG0130A Eating 06 Independent 06 Independent

GG0130B Oral Hygiene 05 Setup or Clean-up Assistance

06 Independent

GG0130C Toileting Hygiene 02 SubstantialMaximal Assistance

04 Supervision or Touching Assistance

GG0130E ShowerBath Self NA NA

GG0130F Upper Body Dressing NA NA

GG0130G Lower Body Dressing NA NA

GG0130H Putting onTaking off Footwear

NA NA

PDPM WORKSHOP

GG0130A Eating

bull Admission Performance Coding = 06 Independent

bull Rationale Mr L was able to open containers cut meat amp eat without assistance on admission

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to remain independent with eating on discharge

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Usual Performance RAI Manual page GG-9

bull A residentrsquos functional status can be impacted by the environment or situations encountered at the facilitybull Observing the residentrsquos interactions with others in different

locations amp circumstances is important for a comprehensive understanding of the residentrsquos functional statusbull If the residentrsquos functional status varies record the

residentrsquos usual ability to perform each activity bull Do not record the residentrsquos best performance amp do not

record the residentrsquos worst performance but rather record the residentrsquos usual performance

62

PDPM WORKSHOP

Patient Case Study

bull Mr L lives with his wife in a one-level home which is accessed by 3 steps bull Prior to a recent fall Mr L was independent with self-care

activities including bathing dressing toileting amp eating bull He was able to ambulate about the house without problem with

the use of a cane bullWhen ascending amp descending the external steps of the house

Mr L would hold onto rails to ensure his balance bull Mr L prepares his own daily medications amp takes turns with his

wife to ensure the bills are paid amp grocery shopping is done

63

PDPM WORKSHOP

OT Evaluation

64

EATING

Receiving a no added salt regular consistency diet Independent opening containers amp cutting up meat once the tray is set before him Discharge goal is to remain independent with eating

ORAL HYGIENE

Edentulous wears full dentures Able to remove dentures to soak clean amp replace in mouth once needed items are set up Once activity is complete staff put away items It is anticipated he will not require assistance of any type with oral hygiene by discharge

TOILETING HYGIENE

Uses toilet to void amp have bowel movements Once standing before toilet requires steadying assistance from one helper as he pulls down his pants amp underwear After elimination requires staff to wipe amp clean Contact guard assistance is needed to stand amp readjust clothing Expected that he will perform perineal hygiene amp management of clothing with supervision Per clinical staff documentation required substantialmax assistance with toileting hygiene on 7 of the 9 observed shifts in the first 3 days of his stay Interview with staff indicate that he required staff to wipe amp clean him assist him to stand amp to pull up his pants amp underwear after elimination

PDPM WORKSHOP

PT Evaluation

65

ROLL LEFT amp RIGHT

Requires therapist to position pillow between legs to prevent adduction of the affected extremity amp then to assist him to roll side to side in bed Therapist provided more than half of the effort Therapy goal states it is expected that he will be independent with bed mobility including being able to roll left amp right at discharge

SIT TO LYING

Requires assistance of 1 therapist to support trunk amp lift both legs back into bed Did contribute a small amount of effort as he used his right arm to lower himself to a supine position Therapy goal is for him to be independent with this activity by discharge

LYLYING TO SITTINGON SIDE OF BED

Able to bring his left leg off the bed amp assist with pushing up with right arm Required assist to bring right leg off the side of the bed amp needed to be fully supported to come to a sitting position Helper provided more than half the effort Therapy goal is for Mr L to be independent with this activity by discharge

PDPM WORKSHOP

Case Study Scoring

bull Use handouts to complete taskbull Please work in groups at your tablebull Items to code on Admission5-PPS Assessmento GG0130 Self Care Items (just 3 areas covered)

o GG0170 Mobility Items (just 3 areas covered)

o Discharge goals for one Self Care amp Mobility Item

PDPM WORKSHOP

Admission5-Day PPS AssessmentGG0130 Self-Care

PDPM WORKSHOP

GG0130 Self-Care

68

ITEM 1 ADMISSION PERFORMANCE

2 DISCHARGE GOAL

GG0130A Eating 06 Independent 06 Independent

GG0130B Oral Hygiene 05 Setup or Clean-up Assistance

06 Independent

GG0130C Toileting Hygiene 02 SubstantialMaximal Assistance

04 Supervision or Touching Assistance

GG0130E ShowerBath Self NA NA

GG0130F Upper Body Dressing NA NA

GG0130G Lower Body Dressing NA NA

GG0130H Putting onTaking off Footwear

NA NA

PDPM WORKSHOP

GG0130A Eating

bull Admission Performance Coding = 06 Independent

bull Rationale Mr L was able to open containers cut meat amp eat without assistance on admission

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to remain independent with eating on discharge

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Patient Case Study

bull Mr L lives with his wife in a one-level home which is accessed by 3 steps bull Prior to a recent fall Mr L was independent with self-care

activities including bathing dressing toileting amp eating bull He was able to ambulate about the house without problem with

the use of a cane bullWhen ascending amp descending the external steps of the house

Mr L would hold onto rails to ensure his balance bull Mr L prepares his own daily medications amp takes turns with his

wife to ensure the bills are paid amp grocery shopping is done

63

PDPM WORKSHOP

OT Evaluation

64

EATING

Receiving a no added salt regular consistency diet Independent opening containers amp cutting up meat once the tray is set before him Discharge goal is to remain independent with eating

ORAL HYGIENE

Edentulous wears full dentures Able to remove dentures to soak clean amp replace in mouth once needed items are set up Once activity is complete staff put away items It is anticipated he will not require assistance of any type with oral hygiene by discharge

TOILETING HYGIENE

Uses toilet to void amp have bowel movements Once standing before toilet requires steadying assistance from one helper as he pulls down his pants amp underwear After elimination requires staff to wipe amp clean Contact guard assistance is needed to stand amp readjust clothing Expected that he will perform perineal hygiene amp management of clothing with supervision Per clinical staff documentation required substantialmax assistance with toileting hygiene on 7 of the 9 observed shifts in the first 3 days of his stay Interview with staff indicate that he required staff to wipe amp clean him assist him to stand amp to pull up his pants amp underwear after elimination

PDPM WORKSHOP

PT Evaluation

65

ROLL LEFT amp RIGHT

Requires therapist to position pillow between legs to prevent adduction of the affected extremity amp then to assist him to roll side to side in bed Therapist provided more than half of the effort Therapy goal states it is expected that he will be independent with bed mobility including being able to roll left amp right at discharge

SIT TO LYING

Requires assistance of 1 therapist to support trunk amp lift both legs back into bed Did contribute a small amount of effort as he used his right arm to lower himself to a supine position Therapy goal is for him to be independent with this activity by discharge

LYLYING TO SITTINGON SIDE OF BED

Able to bring his left leg off the bed amp assist with pushing up with right arm Required assist to bring right leg off the side of the bed amp needed to be fully supported to come to a sitting position Helper provided more than half the effort Therapy goal is for Mr L to be independent with this activity by discharge

PDPM WORKSHOP

Case Study Scoring

bull Use handouts to complete taskbull Please work in groups at your tablebull Items to code on Admission5-PPS Assessmento GG0130 Self Care Items (just 3 areas covered)

o GG0170 Mobility Items (just 3 areas covered)

o Discharge goals for one Self Care amp Mobility Item

PDPM WORKSHOP

Admission5-Day PPS AssessmentGG0130 Self-Care

PDPM WORKSHOP

GG0130 Self-Care

68

ITEM 1 ADMISSION PERFORMANCE

2 DISCHARGE GOAL

GG0130A Eating 06 Independent 06 Independent

GG0130B Oral Hygiene 05 Setup or Clean-up Assistance

06 Independent

GG0130C Toileting Hygiene 02 SubstantialMaximal Assistance

04 Supervision or Touching Assistance

GG0130E ShowerBath Self NA NA

GG0130F Upper Body Dressing NA NA

GG0130G Lower Body Dressing NA NA

GG0130H Putting onTaking off Footwear

NA NA

PDPM WORKSHOP

GG0130A Eating

bull Admission Performance Coding = 06 Independent

bull Rationale Mr L was able to open containers cut meat amp eat without assistance on admission

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to remain independent with eating on discharge

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

OT Evaluation

64

EATING

Receiving a no added salt regular consistency diet Independent opening containers amp cutting up meat once the tray is set before him Discharge goal is to remain independent with eating

ORAL HYGIENE

Edentulous wears full dentures Able to remove dentures to soak clean amp replace in mouth once needed items are set up Once activity is complete staff put away items It is anticipated he will not require assistance of any type with oral hygiene by discharge

TOILETING HYGIENE

Uses toilet to void amp have bowel movements Once standing before toilet requires steadying assistance from one helper as he pulls down his pants amp underwear After elimination requires staff to wipe amp clean Contact guard assistance is needed to stand amp readjust clothing Expected that he will perform perineal hygiene amp management of clothing with supervision Per clinical staff documentation required substantialmax assistance with toileting hygiene on 7 of the 9 observed shifts in the first 3 days of his stay Interview with staff indicate that he required staff to wipe amp clean him assist him to stand amp to pull up his pants amp underwear after elimination

PDPM WORKSHOP

PT Evaluation

65

ROLL LEFT amp RIGHT

Requires therapist to position pillow between legs to prevent adduction of the affected extremity amp then to assist him to roll side to side in bed Therapist provided more than half of the effort Therapy goal states it is expected that he will be independent with bed mobility including being able to roll left amp right at discharge

SIT TO LYING

Requires assistance of 1 therapist to support trunk amp lift both legs back into bed Did contribute a small amount of effort as he used his right arm to lower himself to a supine position Therapy goal is for him to be independent with this activity by discharge

LYLYING TO SITTINGON SIDE OF BED

Able to bring his left leg off the bed amp assist with pushing up with right arm Required assist to bring right leg off the side of the bed amp needed to be fully supported to come to a sitting position Helper provided more than half the effort Therapy goal is for Mr L to be independent with this activity by discharge

PDPM WORKSHOP

Case Study Scoring

bull Use handouts to complete taskbull Please work in groups at your tablebull Items to code on Admission5-PPS Assessmento GG0130 Self Care Items (just 3 areas covered)

o GG0170 Mobility Items (just 3 areas covered)

o Discharge goals for one Self Care amp Mobility Item

PDPM WORKSHOP

Admission5-Day PPS AssessmentGG0130 Self-Care

PDPM WORKSHOP

GG0130 Self-Care

68

ITEM 1 ADMISSION PERFORMANCE

2 DISCHARGE GOAL

GG0130A Eating 06 Independent 06 Independent

GG0130B Oral Hygiene 05 Setup or Clean-up Assistance

06 Independent

GG0130C Toileting Hygiene 02 SubstantialMaximal Assistance

04 Supervision or Touching Assistance

GG0130E ShowerBath Self NA NA

GG0130F Upper Body Dressing NA NA

GG0130G Lower Body Dressing NA NA

GG0130H Putting onTaking off Footwear

NA NA

PDPM WORKSHOP

GG0130A Eating

bull Admission Performance Coding = 06 Independent

bull Rationale Mr L was able to open containers cut meat amp eat without assistance on admission

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to remain independent with eating on discharge

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

PT Evaluation

65

ROLL LEFT amp RIGHT

Requires therapist to position pillow between legs to prevent adduction of the affected extremity amp then to assist him to roll side to side in bed Therapist provided more than half of the effort Therapy goal states it is expected that he will be independent with bed mobility including being able to roll left amp right at discharge

SIT TO LYING

Requires assistance of 1 therapist to support trunk amp lift both legs back into bed Did contribute a small amount of effort as he used his right arm to lower himself to a supine position Therapy goal is for him to be independent with this activity by discharge

LYLYING TO SITTINGON SIDE OF BED

Able to bring his left leg off the bed amp assist with pushing up with right arm Required assist to bring right leg off the side of the bed amp needed to be fully supported to come to a sitting position Helper provided more than half the effort Therapy goal is for Mr L to be independent with this activity by discharge

PDPM WORKSHOP

Case Study Scoring

bull Use handouts to complete taskbull Please work in groups at your tablebull Items to code on Admission5-PPS Assessmento GG0130 Self Care Items (just 3 areas covered)

o GG0170 Mobility Items (just 3 areas covered)

o Discharge goals for one Self Care amp Mobility Item

PDPM WORKSHOP

Admission5-Day PPS AssessmentGG0130 Self-Care

PDPM WORKSHOP

GG0130 Self-Care

68

ITEM 1 ADMISSION PERFORMANCE

2 DISCHARGE GOAL

GG0130A Eating 06 Independent 06 Independent

GG0130B Oral Hygiene 05 Setup or Clean-up Assistance

06 Independent

GG0130C Toileting Hygiene 02 SubstantialMaximal Assistance

04 Supervision or Touching Assistance

GG0130E ShowerBath Self NA NA

GG0130F Upper Body Dressing NA NA

GG0130G Lower Body Dressing NA NA

GG0130H Putting onTaking off Footwear

NA NA

PDPM WORKSHOP

GG0130A Eating

bull Admission Performance Coding = 06 Independent

bull Rationale Mr L was able to open containers cut meat amp eat without assistance on admission

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to remain independent with eating on discharge

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Case Study Scoring

bull Use handouts to complete taskbull Please work in groups at your tablebull Items to code on Admission5-PPS Assessmento GG0130 Self Care Items (just 3 areas covered)

o GG0170 Mobility Items (just 3 areas covered)

o Discharge goals for one Self Care amp Mobility Item

PDPM WORKSHOP

Admission5-Day PPS AssessmentGG0130 Self-Care

PDPM WORKSHOP

GG0130 Self-Care

68

ITEM 1 ADMISSION PERFORMANCE

2 DISCHARGE GOAL

GG0130A Eating 06 Independent 06 Independent

GG0130B Oral Hygiene 05 Setup or Clean-up Assistance

06 Independent

GG0130C Toileting Hygiene 02 SubstantialMaximal Assistance

04 Supervision or Touching Assistance

GG0130E ShowerBath Self NA NA

GG0130F Upper Body Dressing NA NA

GG0130G Lower Body Dressing NA NA

GG0130H Putting onTaking off Footwear

NA NA

PDPM WORKSHOP

GG0130A Eating

bull Admission Performance Coding = 06 Independent

bull Rationale Mr L was able to open containers cut meat amp eat without assistance on admission

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to remain independent with eating on discharge

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Admission5-Day PPS AssessmentGG0130 Self-Care

PDPM WORKSHOP

GG0130 Self-Care

68

ITEM 1 ADMISSION PERFORMANCE

2 DISCHARGE GOAL

GG0130A Eating 06 Independent 06 Independent

GG0130B Oral Hygiene 05 Setup or Clean-up Assistance

06 Independent

GG0130C Toileting Hygiene 02 SubstantialMaximal Assistance

04 Supervision or Touching Assistance

GG0130E ShowerBath Self NA NA

GG0130F Upper Body Dressing NA NA

GG0130G Lower Body Dressing NA NA

GG0130H Putting onTaking off Footwear

NA NA

PDPM WORKSHOP

GG0130A Eating

bull Admission Performance Coding = 06 Independent

bull Rationale Mr L was able to open containers cut meat amp eat without assistance on admission

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to remain independent with eating on discharge

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

GG0130 Self-Care

68

ITEM 1 ADMISSION PERFORMANCE

2 DISCHARGE GOAL

GG0130A Eating 06 Independent 06 Independent

GG0130B Oral Hygiene 05 Setup or Clean-up Assistance

06 Independent

GG0130C Toileting Hygiene 02 SubstantialMaximal Assistance

04 Supervision or Touching Assistance

GG0130E ShowerBath Self NA NA

GG0130F Upper Body Dressing NA NA

GG0130G Lower Body Dressing NA NA

GG0130H Putting onTaking off Footwear

NA NA

PDPM WORKSHOP

GG0130A Eating

bull Admission Performance Coding = 06 Independent

bull Rationale Mr L was able to open containers cut meat amp eat without assistance on admission

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to remain independent with eating on discharge

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

GG0130A Eating

bull Admission Performance Coding = 06 Independent

bull Rationale Mr L was able to open containers cut meat amp eat without assistance on admission

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to remain independent with eating on discharge

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

GG0130B Oral Hygiene

bull Admission Performance Coding = 05 Set up or touching assistance

bull Rationale Mr L was able to perform his own oraldenture care once items were brought to him to use

bull Discharge Goal = 06 Independent

bull Rationale Mr L is expected to be independent with oraldenture care on discharge

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

GG0130C Toileting Hygiene

bull Admission Performance Coding = 02 Substantialmaximal assistance

bull Rationale Mr L baseline performance would be substantialmaximal assistance as he performed better in therapy then he did for direct care staff on the first 3 days of his stay

bull Discharge Goal = 04 Supervision or touching assistance

bull Rationale Mr L is expected to require only supervision with toileting hygiene on discharge

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Admission5-Day PPS Assessment

GG0170 Mobility

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

GG0170 Mobility

73

ITEM 1 ADMISSION PERFORMANCE 2 DISCHARGE GOAL

GG0170A Rolling Left amp Right 02 SubstantialMaximal Assistance

06 Independent

GG0170B Sit to Lying 02 SubstantialMaximal Assistance

06 Independent

GG0170C Lying to Sitting on Side of Bed

02 SubstantialMaximal Assistance

06 Independent

GG0170D Sit to Stand NA NA

GG0170E ChairBed-to-Chair Transfer

NA NA

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

GG0170A Roll Left amp Right

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff provided more than half of the effort by placing a pillow between his legs amp assisting him to roll side to side in bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility on discharge

74

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

GG0170B Sit to Lying

75

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Staff had to lift both legs into bed amp support his trunk to lie down He provided only a small amount of effort by using his right arm to help lower himself

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of sitting to lying on the bed with discharge

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

GG0170C Lying to Sitting on Side of Bed

bullAdmission Performance Coding = 02 Substantialmaximal assistance

bullRationale Mr L was able to bring his left leg off the bed amp assist with pushing up with his right arm Staff had to bring his right leg off the bed amp fully support him as he came to a sitting position on the side of the bed

bullDischarge Goal = 06 Independent

bullRationale Mr L is expected to independent with bed mobility including the task of lying to sitting on the side bed at discharge

76

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Models for Success ndash Clinical

bullThe PDPM payment reform relies heavily on many items from the MDSbull Primary diagnosis (new MDS item I0020B) bull RecentPast surgical procedures (new MDS item J2100-J5000)bull Function Scoresbull Cognitionbull DepressionMoodbull Speech Co-morbiditiesbull Swallowing difficultiesmodified dietsbull Special conditions and services (NTA Component)

77

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Models for Success ndash Clinical

bullMDS Sections Utilized by PDPM bull Section B ndash Hearing Speech and Visionbull Section C ndash Cognitive Patternsbull Section H ndash Bladder and Bowelbull Section I ndash Active Diagnosesbull Section GG ndash Functional Abilitybull Section J ndash Health Conditionsbull Section K ndash SwallowingNutritional Statusbull Section M ndash Skin Conditionsbull Section O ndash Special Treatments

78

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

PDPMREIMBURSEMENT OVERVIEW

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Payment Methodology

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Payment Methodology Rate Components

Per-Diem Base Rates Case-Mix Index Base Rate Range

Urban Rural Low High Low High

Nursing $10592 $10120 066 406 $ 6991 $43004

NTA $ 7991 $ 7634 072 324 $ 5754 $25891

PT $ 6075 $ 6925 108 192 $ 6561 $11664

OT $ 5655 $ 6360 109 169 $ 6164 $ 9557

SLP $ 2268 $ 2857 068 421 $ 1542 $ 9548

Non-Case Mix $ 9484 $ 9659 na na $ 9484 $ 9659

Urban Rates

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 153 149 3026-9 170 163 333 031 182410-23 188 169 357 024 1433 24 192 153 345 (012) (662)

0-5 142 141 2836-9 161 160 321 039 228510-23 167 164 331 009 53424 116 115 231 (100) (5869)

Maj

or Jo

int

Repl

acem

ent o

r Sp

inal

Sur

gery

Oth

er

Ort

hope

dic

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Payment Methodology PTOT CMI

UrbanFunctional

Score PT CMI OT CMI Total CMICMI

ImpactRate

Impact0-5 113 118 2316-9 142 145 287 056 328910-23 152 154 306 019 111624 109 111 220 (086) (5044)

0-5 127 130 2576-9 148 150 298 041 240710-23 155 155 310 012 70824 108 109 217 (093) (5457)

Med

ical

Man

agem

ent

Non

-Ort

ho

Surg

ery

amp

Acut

e

Neu

rolo

gic

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Variable Payment PT amp OTPayment Days Adjustment Factor

1-20 100

21-27 098

28-34 096

35-41 094

42-48 092

49-55 090

56-62 088

63-69 086

70-76 084

77-83 082

84-90 080

91-97 078

98-100 076

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Payment Methodology SLP CMI

Case Mix Index Urban Base Rate

SLP Case Mix IndexMechanically Altered

DietSwallowing DisorderMechanically Altered

DietSwallowing Disorder

Acute Neuro Condition SLP-Related Comorbidity

Cognitive Impairment Neither Either Both Neither Either BothNone 068 182 267 $ 1552 $ 4155 $ 6096 One 146 234 298 $ 3333 $ 5342 $ 6803 Two 204 286 353 $ 4657 $ 6529 $ 8059 Three 299 370 421 $ 6826 $ 8447 $ 9611

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Payment Methodology Nursing Nursing RUG Function Score CMI

CBC2 6-14 155

CA2 15-16 109

CBC1 6-14 134

CA1 15-16 094

BAB2 11-16 104

BAB1 11-16 099

PDE2 0-5 157

PDE1 0-5 147

PBC2 6-14 122

PA2 15-16 071

PBC1 6-14 113

PA1 15-16 066

Nursing RUG Function Score CMI

ES3 0-14 406

ES2 0-14 307

ES1 0-14 293

HDE2 0-5 240

HDE1 0-5 199

HBC2 6-14 224

NBC1 6-14 186

LDE2 0-5 208

LDE1 0-5 173

LBC2 6-14 172

LBC1 6-14 143

CDE2 0-5 187

CDE1 0-5 162

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Payment Methodology NTA CMI

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 324

9-11 NB 253

6-8 NC 184

3-5 ND 133

1-2 NE 096

0 NF 072

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

VARIABLE PAYMENT NTA

Medicare Payment Days Adjustment Factor

1-3 30

4-100 10

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

WORKSHEET

bullPAYMENT CALCULATIONS UNDER PDPM

89

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Final Payment Example

Example 2 Final Total Labor Weighted 709

Labor Weighted Wage Index

(St Louis 09389)Non Labor (291 Non Labor + Wage Adjusted

PT 11193 7936 7451 3257 10708

OT 9366 6640 6235 2725 8960SLP 1542 1093 1026 449 1475NURSING 23726 16822 15794 6904 22698NTA 7671 5439 5106 2232 7339NON-CASE MIX 9484 6724 6313 2760 9073TOTAL 62981 44654 41925 18328 60253

90

Step 2 Wage Adjusted

Step 3 VBP Adjusted Step 4 Sequestration Adjusted

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

PDPMMDSBilling Changes

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Assessment Changes

Admission (Five-Day) ldquoinitial patient

assessmentrdquo

bull ARD ndash Days 1ndash8bull Covers entire stay unless

IPA completed

Interim Payment Assessment (IPA)

bull ARD can be no later than 14 days after change in first tier classification

bull Pays from ARD until discharge except if another IPA is completed

bull Does not change the variable payment schedule

PPS Discharge Assessment

bull ARD equals end date of the most recent stay

bull Not used for payment purposes

bull Section O therapy daysminutes

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

PDPM Impact on OBRA Assessments

bullNo changes to OBRA requirementsoAdmissionquarterlyannualsignificant change

bull Optional state assessmentoUsed for states needing to calculate a RUG III or RUG IV

oCoding requirements vary by state

o Initially CMS would only support through 930 at this time CMS has clarified that there is no definitive timeline for retiring the OSA amp CMS will continue to consult with states on this

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

PDPM Default

RAI Manual Section 68 (no changes to date)

Default PDPM RUG ZZZZZ

EARLYLATE DEFAULT FOR DAYS OUT OF COMPLIANCE

MISSED PROVIDER LIABILITY

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

PDPM Default

bullCMS has clarified that default days take place prior to the 5 day HIPPS code for purposes of variable payment

bullDefault Payment Under PDPM

bull PT= TPbull OT= TPbull SLP= SAbull Nursing= PA1bull NTA= NF

95

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

PDPM HIPPS Coding

1 bullPTOT PAYMENT GROUP

2 bullSLP PAYMENT GROUP

3 bullNURSING PAYMENT GROUP

4 bullNTA PAYMENT GROUP

5 bullASSESSMENT INDICATOR

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Assessment Indicators

HIPPS CHARACTER ASSESSMENT TYPE

0 IPA

1 PPS 5 DAY

6 OBRA

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

HIPPS Code CrosswalkNursing Group HIPPS Character Nursing Payment HIPPS

ES3 A CBC2 N

ES2 B CA2 O

ES1 C CBC1 P

HDE2 D CA1 Q

HDE1 E BAB2 R

HBC2 F BAB1 S

HBC1 G PDE2 T

LDE2 H PDE1 U

LDE1 I PBC2 V

LBC2 J PA2 W

LBC1 K PBC1 X

CDE2 L PA1 Y

CDE1 M

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

HIPPS CODE CROSSWALKPTOT SLP NTA HIPPS

TA SA NA A

TB SB NB B

TC SC NC C

TD SD ND D

TE SE NE E

TF SF NF F

TG SG G

TH SH H

TI SI I

TJ SJ J

TK SK K

TL SL L

TM M

TN N

TO O

TP P

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

WORKSHEET

bullHIPPS CODE CHANGES

100

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Three-Day Interruption Window

Readmission within 3 days (by midnight

of day 3) is considered a

continuation versus a new stay

Readmission after 3 days is considered a new stay New MDS amp variable payment

resets

Admission from another SNF is

considered a new stay regardless of

the timeframe

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Three-Day Interruption Window

bullldquoThe count starts the calendar day of discharge and including the 2 immediately following calendar days ending at midnightrdquo

bullBilling Criteria Similar to LOA (See IRF Billing Manual)oOccurrence span code 74 with fromthrough dates of leave

oValue Code 81 for number of non covered days

oRevenue code 0180 for non covered revenue

102

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP103

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

WORKSHEET

bull3 DAY INTERRUPTION WINDOW

104

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

RUG IVPDPM Transition

bullRUG IV billing ends 93019oMust have RUG with an ARD prior to 10119 to bill

bullPDPM begins 10119oTo establish PDPM payment a one time IPA with an ARD no later than

10719 needs completed for the transition

o10119 will be day 1 under the PDPM variable payment regardless of what day of the stay the resident is in

o If an IPA is has an ARD after 10719 it will be considered late and the default penalty for days out of compliance will apply

105

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Donrsquot Let This Be YouStrategies for Success

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Strategies for Success

bullDiagnosis CodingoRemember the impact on SLP amp NTAoWhat is your plan for educating physicianphysician extendersbullMDS Changes- Start coding nowoGG- who will be coding this in your FacilitybullContract Revisions- vendorspayersbullTriple Checkother meetingsbullSoftware ChangesbullTraining

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Therapy Service Model

bullAssess data amp identify best practicesbullDevelop ldquocare pathsrdquo for specific patient conditionsbullDiscuss with contract therapy likely contract revisionsbullGoals Optimal patient outcomes compliance proper incentivesbull Potential Pricing Options

bull Percent of PDPM

bull Time Based

bull Risk Based

bull Hybrid

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

PDPM Implementation Timeline

109

Should Be Complete In Process Planning to Complete

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 20-Feb

Organization amp Education

Select amp establish implementation

team

Guided self-education amp high-level gap analysis

Formal education -strategy ICD-10 MDSSection GG

information gathering processes

Formal education -billing processes

triple-check cutover

PDPM

Impl

emen

ted

Follow-Up Training from Compliance amp

Documentation Review

Business Processes

Discuss UpgradeUpdate

Plans for Software

Review Skilled Nursing Payer Contracts to Address RUG-based Payments or Other

Issues

Final Billing amp Clinical Software

Updates In Place + Training

Clinical Services Begin ICD-10 Coding Section GG amp MDS completion as if PDPM

Capture data on Section GG at

beginning amp end of stay to tell your

story about qualityIdentify high-frequency patient

characteristics for care maps using improved ICD-10 information

Develop care maps for high-frequency

patient characteristics

Re-evaluate service delivery model

Ancillary Services

Contact Ancillary Service Providers re

Planned Changes

Evaluate Ancillary Service Contracts and Models

Revised Ancillary Contracts in Place

Monitoring Performance amp

Compliance

Compute Baseline PDPM Rates

Compute training-impacted PDPM

rates

Clinical Documentation

Review - Compliance amp Opportunity

BKD Project

BKD Can Assist

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Questions

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Tools to Help You Succeed

bullRate Calculatorbull httpswwwbkdcomservicessnf-rate-calculators

bull Subscribe to BKD Thoughtwarebull Articles

bull Videos

bull Webinar Ask The Advisors The Final Rule amp PDPMbull 9112019 200 Register at the link below

bull httpswwwbkdcomwebinar201909ask-advisors-final-rule-pdpm

PDPM WORKSHOP

Tools to Help You Succeed

bullContact informationbull Brian Hickman bhickmanbkdcom

bull Julie Bilyeu jbilyeubkdcom

bull Sherri Robbins slrobbinsbkdcom

bull 4178658701

PDPM WORKSHOP

Thank You

• Slide Number 1
• Slide Number 2
• PDPMOverview
• Overview
• Overview
• RUG IV VS PDPM
• PDPMComponents amp Characteristics
• 5 CLINICAL PAYMENT DRIVERS
• PDPM Patient Classification
• PDPM Clinical Category
• Clinical Categories Collapsed to 4 for PT amp OT
• PDPM CASE MIX PTOT
• SLP Comorbidities
• PDPM Case Mix SLP
• SLP Component
• MDS Section K
• Nursing Component
• Nursing Functional Score
• Nursing CMI
• Nursing Component
• NTA amp Comorbidity Coding
• NTA Component
• Slide Number 23
• Slide Number 24
• Slide Number 25
• Slide Number 26
• Slide Number 27
• WORKSHEET
• NTA Scenarios
• NTA Scenarios
• NTA Scenarios
• NTA Scenarios
• NTA Payment Scenario
• ICD-10 Coding
• ICD-10 Fundamentals
• PDPM Clinical Category
• Clinical Category
• 10 Steps to Correct Coding
• 10 Steps to Correct Coding
• Example
• Aspiration Pneumonia
• Aspiration Pneumonia
• Aspiration Pneumonia
• Aspiration Pneumonia
• Aspiration Pneumonia
• Aspiration Pneumonia
• Aspiration Pneumonia
• Aspiration Pneumonia
• Which ICD-10 Codes Map to a PDPM Clinical Category
• Slide Number 50
• Section J ndash Past Surgical Categories
• Section J ndash Past Surgical Categories
• MDS Sample ndash Section I (Active Diagnoses)
• Section I ndash Continued
• Section GG
• Functional Scoring under PDPM
• Nursing Component
• Slide Number 58
• Slide Number 59
• Slide Number 60
• Why Does This Matter
• Usual Performance RAI Manual page GG-9
• Patient Case Study
• OT Evaluation
• PT Evaluation
• Case Study Scoring
• Slide Number 67
• GG0130 Self-Care
• GG0130A Eating
• GG0130B Oral Hygiene
• GG0130C Toileting Hygiene
• Slide Number 72
• GG0170 Mobility
• GG0170A Roll Left amp Right
• GG0170B Sit to Lying
• GG0170C Lying to Sitting on Side of Bed
• Models for Success ndash Clinical
• Models for Success ndash Clinical
• PDPMREIMBURSEMENT OVERVIEW
• Payment Methodology
• Payment Methodology Rate Components
• Payment Methodology PTOT CMI
• Payment Methodology PTOT CMI
• Variable Payment PT amp OT
• Payment Methodology SLP CMI
• Payment Methodology Nursing
• Payment Methodology NTA CMI
• VARIABLE PAYMENT NTA
• WORKSHEET
• Final Payment Example
• PDPMMDSBilling Changes
• Assessment Changes
• PDPM Impact on OBRA Assessments
• PDPM Default
• PDPM Default
• PDPM HIPPS Coding
• Assessment Indicators
• HIPPS Code Crosswalk
• HIPPS CODE CROSSWALK
• WORKSHEET
• Three-Day Interruption Window
• Three-Day Interruption Window
• Slide Number 103
• WORKSHEET
• RUG IVPDPM Transition
• Donrsquot Let This Be YouStrategies for Success
• Strategies for Success
• Therapy Service Model
• PDPM Implementation Timeline
• Slide Number 110
• Tools to Help You Succeed
• Tools to Help You Succeed
• Slide Number 113