3/5/2019

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Disclosure of Commercial Interests

I have commercial interests in the following organization(s): (or I consult for the following organizations)

HealthPRO/Heritage:

Senior Vice President of Clinical Strategies

HealthPRO/Heritage is a healthcare consulting and innovative rehabilitation company providing healthcare and payment reform consulting services, full service and management rehabilitation services in hospitals, SNFs, senior living and home health

I do not consult for any other companies other than HealthPRO/Heritage

Be on the Winning Side:A Strategic Approach to PDPM

PREPARE. EXECUTE. SUCCEED.

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Agenda

Prepare.• PDPM

Overview & Component Details

Execute.• EMR

Readiness• Expect

Evolution

Succeed.

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• PDPM• October 1, 2019 implementation• Payment driven by resident clinical

characteristics versus therapy minute delivery

Patient-Driven Payment Model

[SNF]

• PDGM• January 1, 2020 implementation• A shift to a calculated episodic payment,

eliminating therapy-driven bumps in payment

Patient-Driven Grouping Model [Home Health]

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Payment Reform is HERE!

Patient-Driven Payment Model (PDPM) • Clinical characteristic driven over therapy minutes• Some changes may occur in the April 2019 Proposed Rule• Base rates below illustrate the 6 components driving reimbursementor 44% of the base rate

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FINAL Rule for SNF FY 2019 Effective Oct 1, 2019

Today vs. TomorrowCurrent Case Mix Adjusted Payment

Case Mix Adjusted Payment

Case Mix Adjusted Payment

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Case Mix Component Overview Nursing •RUG-IV

•Section GG

*PT•Clinical Category/

Primary Reason for SNF Stay•Section GG

*OT•Clinical Category/

Primary Reasons for SNF Stay•Section GG

SLP

•Clinical Category/Primary Reason for SNF Stay

•SLP related comorbid conditions•Cognitive Status•Presence of Mechanically Altered Diet and/or Swallowing Disorder

*NTA•Comorbidities Present•Extensive Services Received

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*Indicates a variable per diem adjustment

Variable Per Diem Adjustment

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Day in Stay

PT and OT Adjustment Factor

1-20 1.0021-27 .9828-34 .9635-41 .9442-48 .9249-55 .9056-62 .8863-69 .8670-76 .8477-83 .8284-90 .8091-97 .7898-100 .76

Day in Stay

NTA Adjustment Factor

1-3 3.004-100 1.00

Day in Stay

PT and OT Adjustmen

t Factor

PTPer

Diem

OTPer Diem

1-20 1.00 $111.54 $92.7921-27 .98 $109.31 $90.9328-34 .96 $107.08 $89.0835-41 .94 $104.85 $87.2242-48 .92 $102.62 $85.3749-55 .90 $100.39 $83.5156-62 .88 $98.16 $81.6663-69 .86 $95.92 $79.8070-76 .84 $93.69 $77.9477-83 .82 $91.46 $76.0984-90 .80 $89.23 $74.2391-97 .78 $87.00 $72.3898-100 .76 $84.77 $70.52

Example PT & OT TC UrbanOT base rate $55.23 X TC CMI 1.68 = $92.79

PT base rate $59.33 X TC CMI 1.88 = $111.54

Clinical Categories – ICD-10 is Key

CMS states: It is the provider’s responsibility to ensure staff is properly trained in ICD-10 coding. CMS will not provide training.

CURRENTLYDiagnostic coding has no role in SNF reimbursement• Typically managed

through multiple nursing staff, untrained in nuances of accurate coding

• Coding largely completed later in the stay or even upon discharge

UNDER PDPMDiagnostic coding significantly impacts the initial reimbursement rate (less likely to change throughout stay, compared to current system, excluding significant change in condition). Precise, accurate coding is critical!

• ICD-10 coding must reflect main reason for SNF stay• Reimbursement is weighted to both primary code and

sequence of supporting codes• ICD-10 coding must be aligned among multiple disciplines

for proper billing• Coding must be accurately completed either pre-admission

or very early in the stay

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Strategy #1

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Questions Worth Asking

Have you assessed your community or organization’s readiness for PDPM?

Consider:

What is the key staff’s understanding of the changes coming?

Do they understand how their role is going to shift?

Are they aware of the financial impact to the community/organization?

PDPM Assessment Schedule

• Reduction in administrative burden• One scheduled assessment• IPA is OPTIONAL – ARD is when provider choses, note interrupted stay policy• No more COTs, EOTs, SOTs• OBRA requirements remain the SAME

Medicare MDS Type Assessment Reference Date Effective Payment

5-day Scheduled Assessment Days 1 – 8

All covered days until Part A discharge

(unless IPA is completed)

Interim Payment Assessment (IPA)

IPA ARD through Part A discharge (unless

another IPA is completed)

Discharge AssessmentEnd Date of the Most

Recent Medicare Stay (A2400C) or End Date

N/A

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The date the facility chooses to complete the IPA

relative to the triggering event that causes the facility to

choose to complete the IPA.

• Optional, known as IPA

• Will be it’s own item set with demographic and payment items only

• ARD will be when the SNF provider chooses

• Completed when a change in the first tier classifications

• Communication will be KEY!

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Interim Payment Assessment

• PT & OT: • Clinical Category

• Nursing: • RUG-IV

• NTA: • Conditions/Extensive

Services• SLP:

• Presence of Acute Neurologic Condition

• SLP-Related Comorbidity• or Cognitive Impairment

First Tier Classifications:

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New Item set for PDPM

IPA has its own item set

•Payment items •Demographic items•Attain a billing code under PDPM

Case Mix states: CMS has created an optional assessment -Medicaid payments are not adversely impacted when PDPM is implemented

•States will have the ability to determine the policy associated with this assessment to meet Medicaid payment needs

•The optional assessment will be in place from October 1, 2019 through September 30, 2020

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Interrupted Stay Policy

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Interrupted Stay Policy –QRP and VBP affected

“Interrupted SNF Stay” -patient is discharged from SNF care and

subsequently readmitted to the same SNF (not a different SNF)

within 3 days or less after the discharge (the “interruption window”)

Both the assessment schedule and the variable per diem payment schedule

continue from the point just prior to discharge

When the stay is not considered interrupted,

both the assessment schedule and the

variable per diem rate reset to Day 1-

considered a new stay

20 MDS items Driving

determining RUG rates today

168 MDS items driving PDPM payment on October 1st

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MDS Role is Changing

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Strategy #2

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Questions Worth Asking

With the MDS now impacting reimbursement, have you considered a pre-transmission

review?Consider:

Who will review the MDS prior to submission?

Which items should be reviewed for clinical accuracy?

How will this process compare to pre-admission?

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Nursing Category Distribution

Documentation & coordination

are KEY

Collaboration will elicit optimal coding

Process & systems for supportive

nursing documentation

are needed

Provided by AANAC 2018

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Nursing Classification GroupsSpecial Care High

PDPM Nursing Function Score of 15 or 16 = Resident falls to Clinically Complex

Depression End Split applies

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Nursing Functional Score Calculation1. Average Scores for Bed Mobility and Transfers

Average Bed MobilityAverage Transfers

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2. AND THEN Add Four Components TogetherEating (GG0130A1) • Toileting Hygiene (GG0130C1)

Average Bed Mobility • Average Transfers 

TransfersSit to Stand (GG0170D1)

Chair/Bed to Chair Transfer (GG0170E1)Toilet Transfer (GG0170F1)

Bed MobilitySit to Lying (GG0170B1)

Lying to Sitting at Side of Bed (GG0170C1)

Admission Performance

05, 06

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01, 07, 09, 88

Function Score

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IMPORTANTSection GG Scoring of 0-5 Most Optimal

Consider the strategy – timing of this assessment, most usual performance before any treatment has occurred.Average Function Score can only be supported, not determined, by HealthPRO® Heritage.

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Non Therapy Ancillary - NTA

NTA Calculation Example

21*Total Missed $ over national average LOS (FY 2017 28.86 days) = $1,850.31

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• N39.0 maps to acute infection

• Respiratory failure is 1 NTA pt.

• Dysphagia is an SLP related comorbid condition

• Liver disease unspecified is nothing, but End Stage liver disease and cirrhosis of the liver are NTA items

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Patient #1: Diagnosis

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Questions Worth Asking

Have you reviewed your clinical capabilities and facility assessment to see where you

have need for clinical education and competency?

Consider:

Does your community take high acuity residents based on extensive services, special care high etc. and on the NTA list?

What is your current pre-admission process look like today for referrals and admissions?

Strategy #3

Therapy Clinical Categories – Diagnosis is Key• Primary Diagnosis or Reason for Treatment in the SNF

• New Section I0020B• Select inpatient surgical procedure category in sub-item within item J2000 to augment

the patient’s PDPM clinical category*• Accurate, supportive documentation and ICD-10 coding required• Therapy, MDS, and billing must align• Coordination of interdisciplinary documentation

PT and OT Clinical Categories SLP Clinical CategoriesMajor Joint Replacement or Spinal Surgery Acute Neurological

Other Orthopedic Non NeurologicalNon Orthopedic Surgery or Acute Neurologic

Medical Management

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FINAL Elements Determine PT and OT Case Mix

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Clinical Capacity• Clinical diagnosis (reason for

treatment in SNF)• Section I0020B of MDS

Functional Score• Revised Section GG of MDS• Sums performance in 6

functional areas• More functional = higher score

**Group and Concurrent can be done up to 25%

PT and OT Functional Score Calculation1. Average Scores for Bed Mobility, Transfers, Walking

Average Bed MobilityAverage TransfersAverage Walking

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2. AND THEN Add Six Components TogetherEating (GG0130A1) • Oral Hygiene (GG0170B1) • Toileting Hygiene (GG0130C1)

Average Bed Mobility • Average Transfers • Average Walking

TransfersSit to Stand (GG0170D1)

Chair/Bed to Chair Transfer (GG0170E1)Toilet Transfer (GG0170F1)

Bed MobilitySit to Lying (GG0170B1)Lying to Sitting at Side of Bed (GG0170C1)

IMPORTANTThose providing supportive Section GG scoring based on therapy: Staff must code accurately and be CARE Tool Certified!

GG score of 10-23 is most optimal*not part of GG – replacing “Does the resident walk?” on the MDS starting 10.01.18

Average Function Score can only be supported, not determined, by HealthPRO® Heritage.

WalkingWalk 10 feet (GG0170I1)*

Walk 50 feet with 2 turns (GG0170J1)Walk 150 feet (GG0170K1)

Aphasia Tracheostomy Dysphagia

CVA, TIA, Stroke Ventilator ALS

Hemiplegia or Hemiparesis Laryngeal CA Oral CA

TBI Apraxia Speech/Language Deficits

Elements Determine SLP Case MixClinical Category• Reason for the SNF stay• Presence of Acute Neurologic

Condition?• I0020B on MDS

SLP Comorbidity• Additional ICD-10 codes listed in Section

I8000 on MDS• Specific mapping of ICD-10 codes

provided

Cognitive Impairment • Uses Cognitive Function Scale (CFS)

score• New scale that uses BIMS & CPS scales• Note higher impairment = higher CMI

Swallowing Disorder or Mech Altered Diet• Swallow uses K0100A-D of MDS• Diet uses K0510C2 of MDS

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Reporting Minutes

Added: Section O; 0425A1 – O0425C5

• Lookback period - Entire PPS stay • Report minutes by mode for each discipline • Warning Message: If the total amount of Group/Concurrent minutes, combined,

comprises more than 25% of the total amount of therapy for that discipline• Issued on the final validation report.

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PDPM Administrative Presumption

PDPM classifiers designated under the presumption:

• Nursing: Extensive Services, Special Care High, Special Care Low, and Clinically Complex nursing categories

• PT & OT groups TA, TB, TC, TD, TE, TF, TG, TJ, TK, TN, and TO • (TH, TI, TL, TM, TP not included – which contain GG

scores of 0-5 and 24)• SLP groups SC, SE, SF, SH, SI, SJ, SK, and SL

• (SA, SB, SD, SG not included – do not have MAD or Swallow disorder)

• NTA component’s uppermost (12+) comorbidity group

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EMR Readiness for PDPM

PREPARE. EXECUTE. SUCCEED.

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Point Click Care

• PDPM Comparison Tool• Standardized nursing assessment and skilled

daily UDA• PDPM analyzer• IPA Dashboard• Diagnosis Coding – rank, clinical category,

autopopulate into MDS

Team TSI

• PDPM to RUG rates comparison• Crosswalk ICD-10 to PDPM• ID Optimal ICD-10 diagnosis codes • “What If” MDS Scrubber• PDPM Navigator Tool • Discharge EOS and IPA Tracking Tools

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Is Your EMR Ready?

How will the skilled nursing assessment be standardized so as to guide best practices? How will ongoing supportive skilled nursing documentation be standardized?

To better understand potential needs/cost associated with each new admission, can we use a pre-admission calculator for admissions/clinical/marketing?

Can reports be available that capture “pre-admission versus submission” and shine a light on areas of opportunity to hone our teams’ approach/skills?

Can an IPA calculator be available to compute the impact that clinical changes might have on overall rate?

How will the system handle “return to provider” codes as the primary reason for the SNF stay under section I0020B?

Will there be patient, facility and corporate level reporting to determine potential opportunity: GG, NTA, Nursing, Diagnosis?

Will orders (e.g.: changes in DM medication, new IV antibiotics, daily oxygen) trigger alerts on the dashboard for IPAs, clinical meetings

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EMR Partnership in PDPM

Expect Evolution.

PREPARE. EXECUTE. SUCCEED.

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The New Clinical Meeting• After admission• ongoing

Section GG

Admission assessment and daily skilled UDA

MDS admission notes

Pre-transmission review

Revised Triple Check

Nursing Documentation

Therapy:• Group & concurrent 25%• Utilization of minutes may

decrease• Staff may shift or decrease • Therapy involvement in

documentation • Therapy involvement in

coding and collaboration on the MDS

• 10.01.19 transition of minutes

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The Evolution.

Strategies for Effective Treatment & Coding :

Critical assessment, labs and order changes within 24-72 hours after admission

Assess the whole patient to determine co-morbid factors affecting progress or discharge

Be specific in diagnosing in the medical record

Add diagnosis versus “probable” to the chart when able

Availability to assess new or developing conditions to ensure they are treated & captured

Ensure readmission mitigation practices are in place and effective

Effective IDT communication throughout the stay

Get information timely to coders/medical records to update diagnosis codes in PCC

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The Physician’s & Nurse Practitioner’s Role in PDPM

Replaces daily PPS meeting for Medicare residents

Clinical focus

Obtain clinical characteristics

Last 2-3 days after admission

Shifts to IPA/Clinical change focus

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The New Clinical Meeting

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Section GG Strategies• MDS, DON, Rehab and nursing managers review process to expand approaches

for communication and collaboration on this baseline reporting

• Review how this data will be used by your center to impress referring networks

• Assign areas to review at daily meeting– What areas will Rehab report– Nursing observations and documentation– New admissions and discharges

• Elicit information about baseline from caretakers– Nursing assistants– Activities– Social Services– Prepare these departments for the areas to observe

• MDS and Rehab reference the CARE Tool cross walk

• Most usual performance BEFORE the resident has benefitted from treatment

Early Education/Identify OpportunitiesPDPM overview education

CMS Provider Impact File review & discussionsProcess review – deep dive

Roadmap/work plan for success

IT Systems/Data Capability

EMR vendor meetingsCompliance & data collection

RehabilitationEvidence based practice

Group & concurrentEffective & efficient functional treatment

Nursing/Social Work/NP/MDSkilled services/documentation

Communication & collaboration Safe & effective discharge planning

Strategies to Leverage Success TODAY and in the FUTURE

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Kristy Yoskey, MOT, OTR/L, RAC-CT

OffersUnique perspective on what’s happening everywhere else

Visionary clinical strategies for a crazy world 

Focuses onDischarge navigation across the continuum 

Assuring “Win, Win, Win” outcomes 

Known forProactive communication, open collaboration,

honest (and often funny) dialogue“My purpose in life is to help organizations

be better, do better and continue to evolve.”

– Kristy’s #HigherCalling

kyoskey@healthpro-heritage.com

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