Transcript
Page 1: LeadingAge New York Financial Professionals 2017

1ZIMMET HEALTHCARE SERVICES GROUP, LLC, 2017

ZIMMET HEALTHCARE 2017

LeadingAge New York

Financial Professionals 2017

Medicare PPS Payment System Reform:

Introduction to Resident Classification System - I

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Problem with Current PPS

• Mispriced therapy – especially at Ultra High level

• Incentive to “treat to the minutes”

• Does not recognize comorbidities

• Non-therapy ancillary costs poorly accounted for

• Flawed nursing time studies

• ADL inconsistencies & inversions

• Not conducive to accurate benchmarking

• Minimizes relevance of the Medicare claim as analytics tool

The result is a hyper-active audit environment predicated

almost exclusively on “Necessity” of therapy services

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Audit Initiatives

HHS Medicare FFS 2016 Improper Payments Report

• 2015 improper payment rate = 12.09% ($43.3B)

• 2016 improper payment rate = 11.08% ($41.1B)

• 2016 “Improper” SNF payments = $2.8B

• Insufficient documentation and coding errors

• Up 60% from 2014’s improper payment rate• https://www.cms.gov/Research-Statistics-Data-and-Systems/

Concentration remains on Rehab Ultra High (RU)

CMS orders auditing by Supplemental MR Contractor (April 2017)

WPS MAC starts pre-pay review of RU (April 2017)

ZPICs extrapolating therapy denial % for $ million+ recoupments

SNFs routinely being held accountable for actions of their contractors

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Recent Therapy Settlements

• Genesis: $52M DOJ settlement for therapy overbilling (2016)

• Kindred: $125M settlement for unnecessary SNF therapy (2016)

• Extendicare: $32M for medically unreasonable and unnecessary

therapy services (plus $6M to 8 state Medicaid programs) (2015)

• Manor Care: Whistleblower suit re: unnecessary therapy ongoing

• Life Care Centers: $145M for unwarranted therapy (2016)

• DOJ: “Life Care carefully tracked the minutes of therapy provided

to each patient and number of days in therapy…”

• Regional operators also targeted: Ohio: $19.5M (2017);

Boston: $2.5M (2016); Missouri: $8.4M (2017)

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ZHSG Audit / Investigations

• Midwest Region: OIG shows up a MDSC house and asks questions about R&N, keeping patients on at specific therapy levels

• Mid-Atlantic Region: Medium size multi-state chain under ZPIC scrutiny for one facility, but quickly expands to dozens (all therapy related)

• Northeast Region: OIG investigating marketing and operating issues of a national contract therapy company – asks SNF for all marketing material used by the company

• Southern Region: Medium size, one-state “in-house” chain under ZPIC for whistleblower relating to excessive therapy (even though their RUGs were below average)

• Southwest Region: OIG penalizes single provider for productivity and RUG level mandates

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• IMPACT Act mandated MedPAC to outline a unified payment system

that would replace the four current post-acute care Medicare

payment systems (SNF, HHA, IRF, LTCH)

• Objective is to base payment on patient characteristics rather than setting or

amount of therapy furnished (significant redistribution of PAC dollars)

• IMPACT Timeline: Propose system by 2023, then implement

• MedPAC demonstrated that the system is highly feasible & accurate;

recommends implementation in 2021 with 3-year optional phase-in

• See June 2017 MedPAC Report to Congress, chapter 1 for details

RCS is NOT the Unified Post-Acute Payment System

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About RCS-I

• Advanced Notice of Proposed Rulemaking (5/4/17; CMS-1686)

• Public comment period extended from June 26 to August 25, 2017

• Based on extensive research and TEPs (revisions are likely)

• Target date is October 1, 2018

• Likelihood of implementation?

• Budget Neutrality assumed (Parity adjustments)

• No mention of “phase-in”

• Improvement over RUGs?

• Shift from Volume to Patient Characteristics as $ driver

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• No change in Medicare “clinical” or “technical” eligibility requirements

• “Focus on reducing administrative burden for providers”

• MDS remains basis for rate setting, but the 5-day locks the composite score

for the entire benefit period (assuming no discharges or sig. changes)

• Current assessment schedule is eliminated, including COTOs

• Sets up benchmarking mechanism from admission – discharge

• Recognizes disproportionate costs during first days of stay

• Frequency / Amount of therapy does not impact reimbursement

• Therapy is “just another component of the care plan” –

Nursing acuities and Diagnosis coding drive revenue

About RCS-I

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RCS Structure

• RUG-IV contains 3 rate components:

• Therapy, Nursing (including NTAs) and Overhead

• Blended into one of 66 distinct per diem rates

• RCS includes 5 distinct, variable rate components:

• PT/OT (30 categories)

• SLP (18 categories)

• Nursing (43 RUGs)

• Non-Therapy Ancillaries (6 levels)

• Overhead / Non-Case Mix Adjusted (1 rate)

Per Diem RUG

O

N T

1 of 30

1 of 18

1 of 61 of 43

1

Composite

How many possible combinations???

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Take Components One at a Time

Each component has its own

grouping process using

different variables and

scoring methodologies

PT/OT• 30 categories

SLP• 18 categories

Nrsng• 43 RUGs

NTA• 6 groups

OH• 1 CBSA

RCS Score

RCS: Where Do We Start?

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Why is the Patient Here?

• 10 “Clinical Categories” capture the “range of general resident

types” found in SNFs

• MDS Section I8000: ICD-10 code

• “Primary reason for SNF stay”

•DRG “Mapping”

Major Joint Rep. or Spinal

Surgery

Non-Surgical Orthopedic/

Musculoskeletal

Orthopedic Surgery (Except

Major Joint)

Acute Infections

Medical Management

Cancer Pulmonary Cardiovascular & Coagulations

Acute Neurologic

Non-Orthopedic

Surgery

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The 10 categories are collapsed into 5 for PT/OT

Medical Management

Other Orthopedic

Major Joint Rep. or Spinal

Surgery

Acute Neurologic

Non-Orthopedic

Surgery

2 for SLP

Acute Neurologic

Non-Neurologic

Orthopedic Surgery (Except

Major Joint)

Acute Infections

Pulmonary

Cardiovascular & Coagulations

Major Joint Rep. or Spinal

Surgery

Non-Surgical Orthopedic/

Musculoskeletal

CancerAcute Neurologic

Non-Orthopedic

Surgery

Medical Management

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Major Joint Rep. or Spinal Surgery

Other Orthopedic

Medical Management

Non-Orthopedic Surgery

AcuteNeurologic

14 – 18

8 – 13

0 – 7

Intact or Mildly Impaired

Moderately or Severely Impaired

Physical / Occupational Component Calculation

Clinical Category (5)

FunctionalScore (3)

CognitiveImpairment (2)

MDS Section

Clinical: I8000 Primary reason for SNF stay (ICD-10)

Functional: GTrans, Eating, Toileting: Self Perf only

Cognitive: CCognitive Function Scale

All patients score in one PT/OT group no matter if they receive therapy (or how much)

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PT/OT Functional Score

• RCS PT/OT scoring differs from RUG-IV ADL system

• Transfers, Eating and Toileting Self-Performance scores only

• Each ADL scored on a 0 – 6 scale; (v. 4 in RUG-IV)

• 0 – 18 point range

• Higher point totals increase reimbursement but are not linearly correlated with functional performance changes

• “Points assigned to each response mirror the inverse U-shape of the dependence-cost curve for the transfer and toileting items and the monotonic decrease in costs associated with increasing dependence on the eating item.”

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RCS: PT/OT Functional Score v. RUG-IV: Self-Performance Scale

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PT/OT Cognitive Function

• New cognitive measure: Cognitive Function Scale (CFS)

• Combines Brief Interview for Mental Status (BIMS) and Cognitive Performance Score (CPS) into one scale

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PT/OT Case-Mix Classification Groups

See handout for complete listing of case-mix groups

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Speech Language Pathology Component Calculation

Clinical Category (2)

Swallowing

Disorder or

Mechanically-

Altered Diet (3)

SLP Related

Comorbidity or

Mod. to Severe

Cog Imp (3)

MDS Section

Clinical: I8000 Sw Dis: K0100Z MA Diet: K0510C2 Comorb: Misc.Cognitive: C (CFS)

All patients score in one SLP group no matter if they receive therapy (or how much)

AcuteNeurologic

Non-Neurologic

Either

Neither

Both

Either

Neither

Both

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SLP Related Comorbidities

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SLP Case-Mix Classification Groups

See handout for complete listing of case-mix groups

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Nursing Case-Mix Classification

• 43 “nursing RUGs”

• RUG-IV Reimbursement drivers, ADL scoring & splits and hierarchy remain intact

• Minus Rehab RUGs

• Reweighted indices

• 19% HIV/AIDS rate enhancement only applies to this component

• Triggered by ICD-10 code B20 on the UB-04

See handout for complete listing of case-mix groups and comparison of RUG-IV to RCS CMI weights

ZIMMET HEALTHCARE 2017

NTA Group Classification

• Non-Therapy Ancillaries

• Based on the number of services and conditions: • When did it occur?

• Crosswalk considered for conditions & services where the source is indicated as MDS item I8000 to the ICD-10-CM codes

See handout for complete listing of NTA service / condition drivers and related Points

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RCS Rate Composite Calculation

• 5-day MDS (ARD 1 – 8) establishes Composite for the entire

benefit period with limited exceptions

• Significant Change / Readmissions

• Each component has a “Base Rate” adjusted by CBSA

• Multiply each Base Rate by respective CMI weight

• “Variable Per Diem Adjustment Factors”

• PT/OT and NTA components decrease as the benefit period

progresses (see handout for detail on Base Rates & VPDA)

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Significant Change Assessments / Readmissions

• SCSA would change the resident’s RCS-I classification but NOT

reset Variable per diem adjustment schedule

• Interrupted Stay Policy:

• Resident discharged from SNF and returns to same SNF within 3

calendar days: Stay is treated as a “continuation” for purposes of RCS

classification and VPDA

• Resident readmitted to the same SNF more than 3 calendar days after

discharge, or in any case where resident is readmitted to a different

SNF: Resident receives a new 5-day; RCS and VPDA are reset to Day 1

• PPS Discharge Assessment required (CMS to add items to track

therapy minutes over the course of a resident’s stay)

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• No therapy “levels” to audit – cannot be “excessive”

• “Rationing” therapy (too little?)

• Nursing RUG drivers and “end splits”• “Lock & Drop” patterns

• ADL scoring

• NTA drivers • Medical necessity, method of administration, supporting documentation

• Justification for Significant Change assessments

• Technical Eligibility (OIG: 3-day stay within 30 days of SNF admit)

• DRG – ICD-10 assignment (“Mapping”)

Possible RCS Audit Scope

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DRG – ICD-10

DRG Mapping

• 757 active MS-DRGs in 2017

• Medicare Severity – Diagnosis Related Group:

• The system of clinically classifying a Medicare patient’s hospital stay into groups in order to set payment

• Diagnoses drive variable RCS components

• Link to MDS: ICD-10 Coding

• Section I8000: Primary reason for SNF stay

• Secondary & Tertiary codes

ZIMMET HEALTHCARE 2017

RCS Operations Implications

• Admissions decisions• Profitability profiles change

• Target length of stay

• Billing and corrections; time limitations?

• Financial modeling / revenue projections

• Revenue allocations

• Impact on managed care contracts / rates

• Hospital-based resurgence?

• Assessment burden – MDS staffing & qualifications • No margin for error on 5-day

• We need “New Analytics”

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Therapy Implications

• No treatment minimums, but ANPRM specifies limits of 25% each for Concurrent and Group of whatever formal therapy is provided

• No RUG / COTO management

• Department staffing requirements and ratios• Therapists, Assistants, Techs

• Development of therapy-centric programs under the direction of licensed staff (Activities, Restorative Nursing)

• Alternative modalities (Acupuncture, Therapeutic Massage, Chiropractic)

• Outsource v. In-House management considerations:• “Pricing” therapy component: no direct link to reimbursement may

incentivize over/under-utilization depending on contract structure

• Reconciling Dx to need, inverse ADL / Cognitive revenue issues

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RCS Reimbursement Implications

• Facility-specific revenue transition analysis: • Budget neutral redistribution creates “Winners & Losers”

• Comparison to RUG-IV transition projections

• Changes in Provider behavior

• Parity adjustment

• Relative values among rate components

• Realizable value of non-therapy payment drivers• Reimbursement-sensitivity & documentation requirements

• Diagnosis mapping & coding

• Understanding NET revenue impact of ADL coding

• Timing of NTA drivers

Page 17: LeadingAge New York Financial Professionals 2017

ADL 10/1/2017

INDEX RUG 9/30/2018

REHABILITATION

ULTRA HIGH 11 - 16 Extensive Services qualifier RUX $812.97

Tx. 720 mins. a week minimum 2 - 10 Extensive Services qualifier RUL $795.25

2-3 disciplines: one 5+days, one 3+ days 11 - 16 RUC $616.32

6 - 10 RUB $616.32

0 - 5 RUA $515.34

VERY HIGH 11 - 16 Extensive Services qualifier RVX $723.61

Tx. 500 mins. a week minimum 2 - 10 Extensive Services qualifier RVL $649.20

At least 1 discipline - 5 days 11 - 16 RVC $528.73

6 - 10 RVB $457.87

0 - 5 RVA $456.10

HIGH 11 - 16 Extensive Services qualifier RHX $655.60

Tx. 325 mins. a week minimum 2 - 10 Extensive Services qualifier RHL $584.73

1 discipline, 5 days a week 11 - 16 RHC $460.72

6 - 10 RHB $414.66

0 - 5 RHA $365.06

MEDIUM 11 - 16 Extensive Services qualifier RMX $601.40

Tx. 150 mins. a week minimum 2 - 10 Extensive Services qualifier RML $551.79

5 distinct days across 3 disciplines 11 - 16 RMC $404.75

6 - 10 RMB $379.95

0 - 5 RMA $312.62

LOW 2 - 16 Extensive Services qualifier RLX $528.16

3 + days Tx / 45 min/wk; >5 days; >1 activity 11 - 16 RLB $393.52

0 - 10 RLA $253.56

EXTENSIVE SERVICES

Tracheostomy care AND ventilator/respirator 2 - 16 Not Used ES3 $742.23

Tracheostomy care OR ventilator/respirator 2 - 16 Not Used ES2 $581.02

Isolation for active infectious disease 2 - 16 Not Used ES1 $519.01

SPECIAL CARE HIGH

Any of the following conditions: 15 - 16 PHQ Depression HE2 $501.30

Comatose; Septicemia; Diabetes w/ daily inj. & insulin order change 15 - 16 HE1 $416.26

on 2 or more days; Quadriplegia with ADL score ≥ 5; 11 - 14 PHQ Depression HD2 $469.41

Chronic obstructive pulmonary disease and shortness of breath 11 - 14 HD1 $391.46

when lying flat; Fever with pneumonia, Vomiting, Tube feed 6 - 10 PHQ Depression HC2 $442.83

or Weight loss; Parenteral/IV feedings; 6 - 10 HC1 $370.20

Respiratory therapy for 7 days 2 - 5 PHQ Depression HB2 $437.52

Depression split qualifier: PHQ score ≥ 10 2 - 5 HB1 $366.65

MEDICARE PART A SNF PROSPECTIVE PAYMENT SYSTEMMDS 3.0 Captured Services as Qualifiers for Medicare Part A RUG-IV Grouper

Base Rates Urban END

Unadjusted AWI = 1.0000 SPLITS

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Page 18: LeadingAge New York Financial Professionals 2017

ADL 10/1/2017

INDEX RUG 9/30/2018

MEDICARE PART A SNF PROSPECTIVE PAYMENT SYSTEMMDS 3.0 Captured Services as Qualifiers for Medicare Part A RUG-IV Grouper

Base Rates Urban END

Unadjusted AWI = 1.0000 SPLITS

SPECIAL CARE LOW

Any of the following conditions: 15 - 16 PHQ Depression LE2 $455.23

Cerebral palsy, Multiple sclerosis, or Parkinson’s disease with ADL 15 - 16 LE1 $380.83

score ≥ 5; Feeding tube (calories ≥ 51% or 26-50% & fluid ≥ 501cc); 11 - 14 PHQ Depression LD2 $437.52

2 or more Stage II or 1 or more III or IV pressure ulcer; 2 or more 11 - 14 LD1 $366.65

skin Tx w/ 2 or more ven/art ulcers; or 1 Stage 2 PU & 1 venous/arterial ulcer 6 - 10 PHQ Depression LC2 $384.37

foot infection/diabetic foot ulcer/open lesions of foot with treatment; 6 - 10 LC1 $324.14

Radiation therapy while a resident; Oxygen therapy w/ respiratory failure 2 - 5 PHQ Depression LB2 $364.88

while a resident; Dialysis while a resident 2 - 5 LB1 $309.96

CLINICALLY COMPLEX

Extensive Services, Special Care High or Special Care Low qualifier 15 - 16 PHQ Depression CE2 $405.63

and ADL score of 0 or 1; OR 15 - 16 CE1 $373.74

Pneumonia; hemiplegia with ADL score ≥ 5; 11 - 14 PHQ Depression CD2 $384.37

Surgical wounds or open lesions with treatment; burns; 11 - 14 CD1 $352.48

Chemotherapy while a resident; 6 - 10 PHQ Depression CC2 $336.54

IV medications while a resident; 6 - 10 CC1 $311.73

Transfusions while a resident 2 - 5 PHQ Depression CB2 $311.73

Oxygen therapy while a resident 2 - 5 CB1 $288.70

Depression split qualifier: PHQ score ≥ 10 0 - 1 PHQ Depression CA2 $263.90

0 - 1 CA1 $246.18

BEHAVIORS & COGNITIVE PERFORMANCE

Cognitive impairment BIMS score ≤ 9 or CPS ≥ 3 OR 2 - 5 Nursing Rehabilitation BB2 $279.85

Hallucinations or delusions OR Physical or verbal behavioral symptoms 2 - 5 BB1 $267.44

toward others, Other behavioral symptoms, Rejection of care, or Wandering 0 - 1 Nursing Rehabilitation BA2 $232.01

See Reduced Physical Function for restorative nursing services 0 - 1 BA1 $221.38

PHYSICAL FUNCTION REDUCED

No clinical variables used 15 - 16 Nursing Rehabilitation PE2 $373.74

15 - 16 PE1 $356.02

Restorative nursing services: 11 - 14 Nursing Rehabilitation PD2 $352.48

2 or more restorative nursing on 6+ days/wk 11 - 14 PD1 $334.76

Urinary and/or bowel training program, 6 - 10 Nursing Rehabilitation PC2 $302.88

Passive or Active ROM, amputation/prosthesis care training, 6 - 10 PC1 $288.70

Splint or brace assistance, Dressing or grooming training, 2 - 5 Nursing Rehabilitation PB2 $256.81

Eating or swallowing training, Transfer training, 2 - 5 PB1 $246.18

Bed mobility and/or walking training, Communication training 0 - 1 Nursing Rehabilitation PA2 $212.52

0 - 1 PA1 $203.67

DEFAULT Resident is clinically eligibility but no valid MDS record; technical violations, etc. AAA $203.67

NOTE: Rates are NOT net of sequestration.

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Page 19: LeadingAge New York Financial Professionals 2017

RCS-I Impact Projections

from Advance Notice of Proposed Rulemaking: CMS-1686-ANPRM

Winner Change Loser Change

Resident Characteristics

Length of SNF stay 1 - 15 days 15.9% 31+ days   -2.5%

Length of qualifying H stay 31+ days   4.6% 3 days   -2.3%

Cognitive impairment Severe   6.1% Moderate   -1.8%

HIV diagnosis No   0.2% Yes -40.0%

IV meds during stay Yes 22.9% No   -2.0%

Wound infection With 17.9% Without   -0.4%

Therapy services 1 therapy only 37.3% Receiving 3 types   -3.9%

NTA cost $150+ / day 19.2% $10 - $50 / day   -3.2%

Tracheostomy Receiving 18.1% - -

Change

Most Common Therapy Level

RU -9.1%

RV 9.3%

RH 24.4%

RM 36.9%

RL 49.3%

Non-Rehabilitation 44.5%

Winner Change Loser Change

Provider Characteristics

Facility size Under 50 beds   6.7% > 200 beds   -0.7%

Ownership status Non-profit   3.1% For-profit   -1.1%

Institution type Hospital-based 15.8% - -

Ultra High % days 0 - 10% 28.4% 90% +   -9.9%

Non-rehab % days 50 - 75% 45.6% 0 - 10%   -2.2%

Compiled by Zimmet Healthcare

Page 20: LeadingAge New York Financial Professionals 2017

Medicare Part A: Resident Classification System (RCS-I) Component Detail

from Advance Notice of Proposed Rulemaking: CMS-1686-ANPRM

PT/OT Case-Mix Classification Groups

Category Function Score

Moderate/Severe

Cognitive Imp.

Case-Mix

Group CMI

Major Joint 14 - 18 No TA 1.82

Replacement or 14 - 18 Yes TB 1.59

Spinal Surgery 8 - 13 No TC 1.73

  8 - 13 Yes TD 1.45

  0 - 7 No TE 1.68

  0 - 7 Yes TF 1.36

Other Orthopedic 14 - 18 No TG 1.70

  14 - 18 Yes TH 1.55

  8 - 13 No TI 1.58

  8 - 13 Yes TJ 1.39

  0 - 7 No TK 1.38

  0 - 7 Yes TL 1.14

Acute Neurologic 14 - 18 No TM 1.61

  14 - 18 Yes TN 1.48

  8 - 13 No TO 1.52

  8 - 13 Yes TP 1.36

  0 - 7 No TQ 1.47

  0 - 7 Yes TR 1.17

Non-Orthopedic 14 - 18 No TS 1.57

Surgery 14 - 18 Yes TT 1.43

  8 - 13 No TU 1.38

  8 - 13 Yes TV 1.17

  0 - 7 No TW 1.11

  0 - 7 Yes TX 0.80

Medical 14 - 18 No T1 1.55

Management  14 - 18 Yes T2 1.39

  8 - 13 No T3 1.36

  8 - 13 Yes T4 1.17

  0 - 7 No T5 1.10

  0 - 7 Yes T6 0.82

Compiled by Zimmet Healthcare

Page 21: LeadingAge New York Financial Professionals 2017

Medicare Part A: Resident Classification System (RCS-I) Component Detail

from Advance Notice of Proposed Rulemaking: CMS-1686-ANPRM

SLP Case-Mix Classification Groups

Category Variable 1 Variable 2

Case-Mix

Group CMI

Acute Neurologic Both Both SA 4.19

  Both Either SB 3.71

  Both Neither SC 3.37

  Either Both SD 3.67

  Either Either SE 3.12

  Either Neither SF 2.54

  Neither Both SG 2.97

  Neither Either SH 2.06

  Neither Neither SI 1.28

Non-Neurologic Both Both SJ 3.21

  Both Either SK 2.96

  Both Neither SL 2.63

  Either Both SM 2.62

  Either Either SN 2.22

  Either Neither SO 1.70

  Neither Both SP 1.91

  Neither Either SQ 1.38

  Neither Neither SR 0.61

1. Presence of swallowing disorder or mechanically-altered diet

2. SLP related comorbidity or moderate to severe cognitive impairment

Aphasia Laryngeal Cancer

CVA, TIA, or Stroke Apraxia

Hemiplegia or Hemiparesis Dysphagia

Traumatic Brain Injury ALS

Tracheostomy (while Resident) Oral Cancers

Ventilator (while Resident) Speech and Language Deficits

SLP Related Comorbidities

Compiled by Zimmet Healthcare

Page 22: LeadingAge New York Financial Professionals 2017

Medicare Part A: Resident Classification System (RCS-I) Component Detail

from Advance Notice of Proposed Rulemaking: CMS-1686-ANPRM

Nursing Case-Mix Classification Groups and CMI Weights

GROUP RUG-IV RCS GROUP RUG-IV RCS

ES3 3.58 3.84 CD1 1.38 1.51

ES2 2.67 2.90 CC2 1.29 1.49

ES1 2.32 2.77 CC1 1.15 1.30

HE2 2.22 2.27 CB2 1.15 1.37

HE1 1.74 2.02 CB1 1.02 1.19

HD2 2.04 2.08 CA2 0.88 1.03

HD1 1.60 1.86 CA1 0.78 0.89

HC2 1.89 2.06 BB2 0.97 1.05

HC1 1.48 1.84 BB1 0.90 0.97

HB2 1.86 1.88 BA2 0.70 0.74

HB1 1.46 1.67 BA1 0.64 0.68

LE2 1.96 1.88 PE2 1.50 1.60

LE1 1.54 1.68 PE1 1.40 1.47

LD2 1.86 1.84 PD2 1.38 1.48

LD1 1.46 1.64 PD1 1.28 1.36

LC2 1.56 1.55 PC2 1.10 1.23

LC1 1.22 1.39 PC1 1.02 1.13

LB2 1.45 1.48 PB2 0.84 0.98

LB1 1.14 1.32 PB1 0.78 0.90

CE2 1.68 1.84 PA2 0.59 0.68

CE1 1.50 1.60 PA1 0.54 0.63

CD2 1.56 1.74

Compiled by Zimmet Healthcare

Page 23: LeadingAge New York Financial Professionals 2017

Medicare Part A: Resident Classification System (RCS-I) Component Detail

from Advance Notice of Proposed Rulemaking: CMS-1686-ANPRM

Non-Therapy Ancillary Scoring / Groups

Source Tier Points

HIV/AIDS SNF Claim Ultra-High 8

Parenteral/IV Feeding - High (> 50% of cal) MDS Item K0510A2 Very-High 7

Parenteral/IV Feeding - Low (25-50% of cal) MDS Item K0710A2, K0710B2 High 5

Average fluid intake by IV or tube feeding of at least 501cc per day

IV Medication MDS Item O0100H2 High 5

Ventilator / Respirator MDS Item O0100F2 High 5

Transfusion MDS Item O0100I2 Medium 2

Kidney Transplant Status MDS Item I8000 Medium 2

Opportunistic Infections MDS Item I8000 Medium 2

Infection with multi-resistant organisms MDS Item I1700 Medium 2

Cystic Fibrosis MDS Item I8000 Medium 2

Multiple Sclerosis (MS) MDS Item I5200 Medium 2

Major Organ Transplant Status MDS Item I8000 Medium 2

Tracheostomy MDS Item O0100E2 Medium 2

Asthma, COPD, Chronic Lung Disease MDS Item I6200 Medium 2

Chemotherapy MDS Item O0100A2 Medium 2

Diabetes Mellitus (DM) MDS Item I2900 Medium 2

End-Stage Liver Disease MDS Item I8000 Low 1

Wound Infection (other than foot) MDS Item I2500 Low 1

Transplant MDS Item I8000 Low 1

Infection Isolation MDS Item O0100M2 Low 1

MRSA MDS Item I8000 Low 1

Radiation MDS Item O0100B2 Low 1

Diabetic Foot Ulcer MDS Item M1040B Low 1

Bone / Joint / Muscle Infections / Necrosis MDS Item I8000 Low 1

Highest Ulcer Stage is Stage 4 MDS Item M300D1 Low 1

Osteomyelitis and Endocarditis MDS Item I8000 Low 1

Suctioning MDS Item O0100D2 Low 1

DVT / Pulmonary Embolism MDS Item I8000 Low 1

Range Group CMI

11+ NA 3.33

8 - 10 NB 2.59

6 - 7 NC 2.02

3 - 5 ND 1.52

1 - 2 NE 1.16

0 NF 0.83

NTA Case-Mix Classification Groups

Condition / Service

Compiled by Zimmet Healthcare

Page 24: LeadingAge New York Financial Professionals 2017

Medicare Part A: Resident Classification System (RCS-I) Component Detail

from Advance Notice of Proposed Rulemaking: CMS-1686-ANPRM

Variable Per Diem Adjustment & Base Rates

Day Factor Day Factor

1 - 14 1.00 1 - 3 3.00

15 - 17 0.99 4 - 100 1.00

18 - 20 0.98

21 - 23 0.97

24 - 26 0.96

27 - 29 0.95

30 - 32 0.94

33 - 35 0.93 Component Base Rate

36 - 38 0.92 PT / OT $126.76

39 - 41 0.91 SLP $24.14

42 - 44 0.90 Nursing $100.91

45 - 47 0.89 NTA $76.12

48 - 50 0.88 Non-Case Mix $90.35

51 - 53 0.87

54 - 56 0.86

57 - 59 0.85 Component Base Rate

60 - 62 0.84 PT / OT $141.47

63 - 65 0.83 SLP $31.06

66 - 68 0.82 Nursing $96.40

69 - 71 0.81 NTA $72.72

72 - 74 0.80 Non-Case Mix $92.02

75 - 77 0.79

78 - 80 0.78

81 - 83 0.77

84 - 86 0.76

87 - 89 0.75

90 - 92 0.74

93 - 95 0.73

96 - 98 0.72

99 - 100 0.71

PT / OT NTA

Urban

Rural

Compiled by Zimmet Healthcare


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