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Prepare Your Skilled Nursing Facility for Patient-Driven Payment Model (PDPM)

Tracey Jenkins, MHI, RHIADoris Perry, RHIT

Objectives

Explain what PDPM is on a high level Describe how ICD-10-CM coding impacts

PDPM Describe the impact of documentation

improvement on PDPM Explain the importance of Minimum Data

Set (MDS) Section GG

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What is PDPM?

New reimbursement model for Medicare Replaces Resource Utilization Groups

(RUGs) IV Removes emphasis on therapy Promotes value-based care

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Patient Classification

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Clinical Categories (10)

• Acute Infections • Medical Management

• Acute Neurologic • Non-Orthopedic Surgery

• Cancer • Non-Surgical Orthopedic/Musculoskeletal

• Cardiovascular/Coagulation • Orthopedic Surgery – (except major joint) replacement

• Major Joint Replacement or Spinal Surgery

• Pulmonary

PDPM Components

PT OT ST Nursing Non-Therapy Ancillary (NTA) Non-Case-Mix Variable per diem adjustment

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PT/OT Functional score from MDS Section GG◦ Sum of 10 items◦ Some items are averaged together◦ Ex. GG0170B1 Mobility: Sit to lying 0-4

GG0170C1 Mobility: Lying to sitting on side of bed 0-4Average of these 2 items

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General Categories PT/OT Categories

Acute infections

Medical management

Cancer

Cardiovascular & coagulations

Medical management

Pulmonary

Major joint replacement/spinal surgery

Major joint replacement/spinal surgery

Acute neurologic Non-ortho surgery & acute neurologicNon-ortho surgery

Non-surgery

Other orthoOrtho/musculoskeletal

Ortho surgery (except major joint replacement)

7MLN Call: SNF PPS: Patient Driven Payment Model, 2018

Speech

Presence of Acute Neurologic condition

ST-related comorbidity Cognitive impairment

Mechanically altered diet

Swallowing disorder Comorbidities:◦ CVA/TIA with hemiplegia/hemiparesis

◦ Tracheostomy; ventilatorLaryngeal cancer; apraxia; dysphagia; ALS; oral cancers; speech & language deficits

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Nursing

Same characteristics as RUGs IV Function score based on MDS Section

GG (instead of Section G from RUGs IV) Collapsed functional groups◦ From 43 to 25

Some functional scores are averaged together

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Non-Therapy Ancillary

Patient comorbidities Take into account conditions/extensive

services that increase cost of care Tiered ranking related to cost of

comorbidities Ex. parenteral IV feeding, IV med, vent,

lung transplant status, COPD, wound infection, DM, morbid obesity, isolation, MDRO, malnutrition, etc.

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Basic Payment Calculation

PT Base Rate PT CMI VPD PT TOTAL

OT Base Rate OT CMI VPD OTTOTAL

ST Base Rate ST CMI ST TOTAL

NTA Base Rate NTA CMI VPD NTA TOTAL

NURSING Base Rate Nursing CMI Nursing TOTAL

NON-CASE-MIX

Base Rate TOTAL:

11MLN Call: SNF PPS: Patient Driven Payment Model, 2018

Basics of PDPM

Diagnoses will drive reimbursement◦ Principal diagnosis ◦ Secondary diagnoses◦ Major surgery in last 100 days

Reduces number of MDS Assessments to 3:◦ 5 Day Assessment◦ Interim Payment Assessment (IPA) – NOT

required◦ Discharge Assessment (comprehensive)

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Basics of PDPM cont. Concurrent & Group Therapy Limits Interrupted Stay Policy Non-linear relationship to payment◦ Increasing Activities of daily living (ADL) dependence ≠ higher payment◦ Least & most ADL dependence = lower need for

therapy Revised Health Insurance Prospective Payment System

(HIPPS)◦ Default code: ZZZZZ◦ Complete IPA Assessment with assessment reference

date (ARD) no later than 10/17/2019

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ICD-10-CM Coding & PDPM

Principal diagnosis determines PDPM category

Secondary diagnoses may increase reimbursement◦ NTA comorbidities Ranking of diagnoses

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ICD-10-CM Coding & PDPM

Who is coding?◦ Greater need for credentialed HIM in SNF

setting◦ Hone your coding skills

AHIMA Practice Brief: ICD-10-CM Coding Guidance for LTC Facilities◦ Being revised by LTPAC Practice Council

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ICD-10-CM Resources

Official ICD-10-CM Coding Guidelines Coding Clinic Current coding book

PCC Screen Shot

Google Screen Shot

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Google Screen Shot cont.

Code Book

Matrix Screen Shot

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Google Screen Shot

Google Screen Shot cont.

Google Screen Shot cont.

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Google Screen Shot cont.

Google Screen Shot cont.

Code Book

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Coding Scenario #1

No clear primary diagnosis:Patient was admitted to hospital with possible pneumonia, hypertension, diabetes mellitus Type 2, and generalized weakness. The chest x-ray was clear so antibiotics were discontinued in the hospital.

Coding Scenario #2 SepsisThis patient is admitted to the nursing facility for PT/OT following hospitalization for sepsis due to an infected hip prosthesis inserted 2 months ago. Resident was found to have VRE that will require antibiotic therapy for 6 weeks. The patient also has BPH with urinary obstruction, situational depression with agitation, hypertension, atrial fibrillation.

Coding Scenario #3

CVAThis nursing home resident is admitted following a hospital stay for an acute cerebral infarction with left hemiplegia, dysphasia, and facial droop. The resident also has GERD, rheumatoid arthritis, early onset Alzheimer’s disease with dementia and aggressive behavior.

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Coding Scenario #4

CHF Exacerbation:This 81-year old female is admitted to the nursing facility due to CHF exacerbation and atrial fibrillation. The History & Physical from the hospital states “diastolic heart failure” but several consults state “systolic heart failure”.

ICD-10-CM Coding & PDPM cont.

MD documentation Hospital records/transferring facility

records Queries◦ 5 days

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Sample QueryDear Dr. __________________

Date: __________________

Query: Do you agree with the _____________ report specifying ___________________.

Please document your response below and please provide clarification in a progress note.

Yes ____

No ____

Other ____

Clinically Undetermined _____

Signature: __________________ Date: ___________

Rationale: This yes/no query involves confirming a diagnosis that is already present as an interpretation of a diagnostic report in the health record or to resolve conflicting practitioner documentation.

33AHIMA, Guidelines for Achieving a Compliant Query Practice, 2016

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Clinical Documentation Improvement (CDI) & PDPM MD NP/PA Nursing Therapy CNA/Restorative

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Example of Poor Documentation

Hip Fx:

VS: 118/68, 16 T97.8. Alert, cooperative. Assist with ADLs. Attended PT in AM. Complained of hip pain, APAP given. Ate 100% of breakfast & lunch. Attended activities in PM.

Example of Better DocumentationHip Fx:

Vs: 118/68, 16,84,T97.8. Attended PT in AM. In afternoon was noted transferring self from bed to chair without device, with full weight bearing (PWB in orders). Reviewed transfer techniques and weight bearing status with resident, with understanding. Rt. Hip incision intact, in alignment, no edema. c/o LE pain (2 on 10 scale), Tylenol 650 mg po given with good relief. Continue to monitor transfer skills and reinforce PWB, monitor hip for pain notify MD if FWB transfers continue. Restorative transfer training continues BID.

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How do we tackle CDI in the SNF setting?

Historically the focus has been primarily on nursing documentation

SNF/NF CDI Tip Sheets (AHIMA)◦ Will be revised by LTPAC Practice Council

AHIMA LTC Health Information Practice & Documentation Guidelines

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MDS Section GG

Section G vs. Section GG Who should complete Section GG?◦ MDS/Nursing/Restorative◦ Therapy

MDS vs. Therapy Definitions ADLs/OT

MDS Independent: the resident completes the activity by

themselves, with or without an assistive device, with no assistance from a helper.

Set-up or clean-up assist: helper sets up or cleans up but resident completes the activity.

Supervision or touching assist: helper provides verbal cues and/or touching/steadying and/or contact guard assist as resident completes activity.

Partial/moderate assist: helper does less than ½ the effort. Helper lifts, hold, or supports trunk or limbs but provides less than ½ the effort.

Substantial/maximal assist: helper does more than ½ the effort. Helper lifts or holds trunk or limbs and provides more than ½ the effort.

Dependent: helper does all of the effort for the activity. Resident does none of the effort to complete the activity OR assist of 2 or more helpers is needed for the resident to complete the activity.

Therapy Complete independence: patient is able to

complete the activity by themself. Modified independence: patient completes activity

without a helper but with an assistive device. Supervision: helper provides cueing, set-up,

coaxing but does not touch the patient. Minimal assist: patient participation is 75% or

more; helper touches the patient to assist the patient to complete the activity..

Moderate assist: patient participation is 50% to 74%; helper must do more than touching to assist patient to complete activity.

Maximal assist: patient participation is 25% to 49%;

Dependent: patient is unable to participate to complete the activity.

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MDS vs. Therapy DefinitionsMobility/PT

MDS Independent: resident completes the activity by

themselves without assist from a helper. Set-op/clean-up assist: helper sets up or cleans

up; resident completes the activity. Supervision: helper provides verbal cues and/or

touching/steadying and/or contact guard assist as resident completes activity.

Partial/moderate assist: helper does less than ½ the effort; helper lifts/holds/supports trunk or limbs.

Substantial/maximal assist: helper does more than ½ the effort; helper lifts or holds trunk or limbs.

Dependent: helper does all of the effort; resident does none of the effort to complete the activity OR the assist of 2 or more helpers is needed for the resident to complete the activity.

Therapy Independent: all tasks performed without

modification, assistive devices or aids and within reasonable time.

Modified independent: one or more of the following are true about the activity – requires assistive device; takes more than reasonable time; there are safety/risk concerns.

Standby assist: requires no more than standby, cueing or coaxing without physical contact or helper sets up needed items or applies orthoses.

Contact guard assist: patient requires contact to maintain balance or dynamic stability.

Minimal assist: patient requires no more than touching and expends 75% or more of the effort; assist is needed to lift one limb.

Moderate assist: requires more help than touching or expends 51%-75% of the effort; assist needed to lift 2 limbs.

Maximal assist: patient expends 25%-50% of the effort.

Dependent: patient expends less than 25% of the effort; 2 or more helpers provide assistance.

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References/Resources: Combs RN MSN CCS CCDS CDIP, T. (2016). Guidelines for Achieving a Compliant Query

Practice. Retrieved June 5, 2019, from AHIMA: http://bok.ahima.org/PB/QueryCompliance#.XPfn2xZKjIV

Craycraft RN BSN NHA, S. (2018). SNF PPS FY 2019 Final Rule. Healthcare Information Network. Liverpool: HIN.

Keiter RN RAC-CT DNS-CT, M. a. (2018, July 23). PDPM - 6 Keys You Need to Know. Cumberland, MD, United States of America.

Keiter RN RAC-CT DNS-CT, M. a. (2018, July 23). PDPM - The Significance of ICD-10 Coding. Cumberland, MD, United States of America: Gravity Healthcare Consulting.

MLN Call: SNF PPS: Patient Driven Payment Model. (2018, December 11). Retrieved February 19, 2019, from CMS.gov: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/MLN_CalL_PDPM_Presentation_508.pdf

Patient Driven Payment Model. (2019). Retrieved April 8, 2019, from CMS.gov: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html

CMS. (2019). CMS.gov. Retrieved June 23, 2019, from MDS 3.0 RAI Manual: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html

Schmidt, A., & Kenney, A. (2019). Chapter 9: Diseases of the Circulatory System. In A. Schmidt, & A. Kenney, ICD-10-CM Expert for Hospitals (p. 646). Optum 360.

ICD10Data. (2019). Retrieved August 12, 2019, from ICD10Data: https://www.icd10data.com/ICD10CM/Codes/I00-I99/I10-I16/I11-/I11.0

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