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TRANSCRIPT
#1‐Is Your Triple Check PDPM Ready? Examining the Financial Risks of Aberrant
Claims
Stacy Baker & Shelly Maffia
Tuesday 11/19/2019
1 PM ‐ 2:30 PM
KBN # 5‐0002‐12‐19‐559
KAHCF – 2019 Fall Conference
www.proactivemedicalreview.com 2019
Is Your Triple Check PDPM Ready?
Examining Financial Risks of Aberrant Claims
Presented by:
Shelly Maffia, Director of Regulatory Services
Stacy Baker, Director of Audit Services
Objectives
1. Review best practices for internal audit of PDPM claims prior to
submission to decrease potential billing errors and promote accurate
reimbursement
2. Identify key roles of the interdisciplinary team in completion of a
collaborative triple check process of items/data elements impacting
PDPM reimbursement
3. Review key data collection, billing and monitoring processes important to
PDPM reimbursement accuracy including but not limited to
understanding the updated HIPPS codes and validating UB-04 accuracy
prior to submission.
2
PDPM COMPLIANCE
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Medical Review & Data Monitoring
“Given the more holistic style of care emphasized under
PDPM, program integrity and data monitoring efforts will
also be more comprehensive and broad. For program
integrity, we expect provider risk will be more easily
mitigated to the extent that reviews focus on more clearly
defined aspects of payment, such as documentation
supporting patient diagnoses and assessment
coding.”
Source: CMS Quality Reporting Program Provider Training August 14, 2019, Slide 66 4
Medical Review & Data Monitoring
• CMS will be monitoring therapy
provision under PDPM, as compared
to RUG - IV, at the national, regional,
state, and facility level.
• Significant changes under PDPM, as
compared to RUG - IV, in volume or
treatment delivery may trigger
program reviews and potential policy
changes.
5
Documentation Compliance Risks
• PDPM does not change documentation requirements, but strengthens the importance of documenting all aspects of a patient’s/resident's care, consistent with PDPM’s focus on a more holistic care model.
• Given the increased relevance of a greater set of data elements supporting payment under PDPM, providers should ensure that there is strong documentation and support for the care associated with each PDPM component.
Source: CMS Quality Reporting Program Provider Training August 14, 2019 (slide
77)
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PDPM Risk Areas
Active Dx / Section I Clinical
Conditions
HIV/AIDS Diagnosis
Surgery in Hospital
Comprehensive Resident Care
Plans
Accurate Functional Measures
MDS Interview Process
(BIMS/PHQ9)
Mechanically Altered Diet
Swallow Disorder
Therapy Intensity
Group / Concurrent
Therapy
IPA Determination
Interrupted Stay
7
Medicare Benefit Policy Manual
Chapter 8
Medicare Claims Processing Manual
Chapter 6
Resident Assessment Instrument 3.0 User’s
Manual
Final Rule /
Federal Register
Billing Compliance
8
PDPM BILLING
9
RUG-IV & PDPM: SNF services must be skilled service, required on a daily
basis, and be reasonable and necessary for the treatment of a
patient’s/resident's particular illness or injury, based on the individual’s
particular medical needs, and accepted standards of medical practice. Source: CMS Quality Reporting Program Provider Training August 14, 2019
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Skilled Level of Care Criteria
All Existing Criteria for Eligibility and Access Remain
• Must require daily skilled service
• Qualifying hospital stay requirement
• Supportive Documentation
Skilled Nursing Services
• Observation & Assessment
• Management & Evaluation
of a Care Plan
• Teaching & Training
• Direct Skilled Nursing Care
10
Certification Timeframes
Certification • Admission
Initial Recertification
• No later than day 14 (May be combined with admission cert)
Subsequent Recertifications
• Every 30 days
11
Certifications & Interrupted Stay Policy
12
• Tied to SNF
Admission
• Cert schedule
does not change
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Administrative Level of Care Presumption
Nursing Groups
Extensive Services Special Care High Special Care Low Clinically Complex
PT and OT Groups
TA TB TC TD TE TF TG TJ TK TN TO
SLP Groups
SC SE SF SH SI SJ SK SL
NTA Group
Uppermost 12+ Comorbidity Group
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PDPM Payment for Patients with AIDS
• PDPM rate components were specifically designed to account
accurately and appropriately for the increased cost of AIDS-related
care
• PDPM addresses costs for this subpopulation in two ways:
• Highest point value (8 points) of any condition or service for under NTA
component
• 18% add-on to the PDPM Nursing component
• AIDS diagnosis continues to be identified through the SNF’s
entry of ICD-10-CM Code B20 on the SNF claim
14
5-character HIPPS code
• Character 1: PT/OT Payment Group
• Character 2: SLP Payment Group
• Character 3: Nursing Payment Group
• Character 4: NTA Payment Group
• Character 5: Assessment Indicator
15
Health Insurance Prospective Payment System (HIPPS) Rate Codes
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UB04 Claim Example
16
HIPPS Code – Character 1
17
HIPPS Code – Character 2
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HIPPS Code –
Character 3
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HIPPS Code- Character 4
20
HIPPS Code – Character 5
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5 Character HIPPS Code Example (NHNC1)
Character Component HIPPS Code Explanation
1 PT/OT
Payment
N – (TN) Non-Orthopedic Surgery & Acute Neurologic. Function Score 6-9. Documentation must
validate primary reason for SNF stay ICD-10 code appropriate and was a condition treated during
the hospital stay. Function score must be supported within the documentation as usual
performance during first 3 days of admission.
2 SLP Payment H – (SH) Documentation must support two of the following: Acute Neurologic Condition, SLP-
related Comorbidity, or Cognitive Impairment. Must also validate supporting documentation for
either swallow impairment or a mechanically altered diet.
3 Nursing
Payment
N – (CBC2) Documentation must support nursing category Clinically Complex which might include
Pneumonia, hemiplegia/hemiparesis with NFS <=11, open lesions with treatment or surgical
wounds, burns, receiving chemotherapy or oxygen therapy while a resident, or IV medications or
transfusions. PHQ9 score of >10 and the nursing function score for 6-14 must also be validated as
usual performance.
4 NTA Payment C – (NC) Documentation must support presence of certain comorbidities or use of certain
extensive services which total NTA score range 6-8.
5 AI 1 – (5 day) Documentation must support appropriate setting of ARD and documentation to support
coding items on the 5 day assessment.
PDPM Default Billing
• Default HIPPS Code: ZZZZZ
• Default rate refers to lowest possible per diem rate
• Equivalent to billing:
• PT – TP (1.08)
• OT – TP (1.09)
• SLP – SA (0.68)
• Nursing – PA1 (0.66)
• NTA - NF (0.72)
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TRIPLE CHECK PROCESS
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Ensuring Claim Accuracy: Triple Check
• Internal Claims Audit
• Pre-bill claims
• Medicare Part A Claims and other
payers designated by the facility
• IDT representatives
• Routine review
25
Why is Triple Check Important?
• Promotes Compliance
• CMS guidance and regulations
• Payment Accuracy Initiatives
• Reduce denied, rejected, adjusted claims
• Reduce potential for medical review
• Prevent submission of false claims
• Appropriate report of facility data
• Accurate billing for services provided
26
Triple Check Team
27
Business Office
MDS Department
Rehab Department
Clinical
DNS/ADNS
Administrator
/ Executive Director
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Triple Check Process
Routine Meeting Time
Come Prepared
Efficiency
Checklist / Audit Form
Validate Accuracy
Identify Errors & Need for Follow-up
Ongoing Communication
28
Medical Record Review
1. UB-04 (draft claims)
2. ICD-10 Diagnosis List
3. MDS Assessment(s)
4. Medical Record
• Hospital documentation
• SNF Certification / Recertification
• Physician Documentation
• Nursing Documentation
• Therapy Documentation
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Sample Triple Check Form
© Proactive 2019
30
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EXAMINING THE FINANCIAL RISKS OF
ABERRANT CLAIMS
31
Common Claims Errors • Billing for service prior to verifying HIPPS code
• Inaccurate primary SNF condition identified as
extension of acute stay
• Proof of Active Condition(s)
• ICD10 codes not included in MDS Section I as
secondary conditions
• Conditions coded without active treatment supported (ie.
SLP comorbidity)
• Documentation to support swallow impairment, modified
diet
• Documentation to effective support function score
• Proof of sufficient of physician oversight
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Section GG Function Score:
RAI Documentation Guidance
• CMS anticipates that an interdisciplinary team of
qualified clinicians is involved in assessing the
resident during the three-day assessment period
(GG-10)
• Documentation in the medical record is used to support
assessment coding of Section GG. Data entered should be
consistent with the clinical assessment documentation in the
resident’s medical record (GG-14)
LTC RAI MDS 3.0 User’s Manual V1.17 October 2019 Retrieved from: https://www.cms.gov/Medicare/Quality-Initiatives-
Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html
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34
Supporting Documentation Impact: OT/PT Function Score
Clinical
Category
Function
Score
PT-OT
CMG
PT
CMI PT Rate
OT
CMI OT Rate
Daily
Rate
Impact
LOS 20
Day
Impact
Major Joint
Replacement or
Spinal Surgery
0-5 TA 1.53 $92.95 1.49 $84.26
-$32.57 -$711.40
10-23 TC 1.88 $114.21 1.69 $95.57
Other
Orthopedic
0-5 TE 1.42 $86.27 1.41 $79.74 -$28.18 -$563.60
10-23 TG 1.67 $101.45 1.64 $92.74
Medical
Management
0-5 TI 1.13 $68.65 1.18 $66.73 -$44.05 -$881.00
10-23 TK 1.52 $92.34 1.54 $87.09
Non-Orthopedic
Surgery and
Acute
Neurologic
0-5 TM 1.27 $77.15 1.30 $73.52
-$31.14 -$622.80
10-23 TO 1.55 $94.16 1.55 $87.65
Supporting Documentation Impact: Nursing Function Score
Nursing Classification Function
Score
Nursing
CMG
Nursing
CMI
Nursing
Rate
Daily Rate
Impact
LOS 20 Day
Impact
Special Care High
0-5 HDE1 1.99 $210.78
-$13.77 -$275.40
6-14 HBC1 1.86 $197.01
Special Care Low
0-5 LDE1 1.73 $183.24
-$31.77 -$635.40
6-14 LBC1 1.43 $151.47
Clinically Complex
0-5 CDE1 1.62 $171.59
-$72.03 -$1,440.60
15-16 CA1 0.94 $99.56
Reduced Physical
Function
0-5 PDE1 1.47 $155.70 -$85.79 -$1,715.80
15-16 PA1 0.66 $69.91 35
Supporting Active Conditions
Therapy plans, MDS assessments and the UB-04 must include
relevant diagnosis codes to describe the medical condition(s) and
symptoms that have prompted SNF services.
• SNF stay = extension of hospitalization
• Physician approved active conditions
• Consider systems for maintaining
active diagnosis list
• Rehab diagnosis codes included
• Sec I of MDS: active conditions
• Under PDPM, dx codes & supporting
documentation directly Impact payment
36
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SNF Primary
Diagnosis
Clinical
Category PT Rate OT Rate SLP Rate NTA Rate Nursing Rate
Total
Unadjusted Rate
Spinal stenosis,
lumbar region (M48.062)
Non-Surgical
Orthopedic $102.14 $93.37 $15.52 $107.00 $120.50 $534.01
Spinal stenosis,
lumbar region
(M48.062)
Non-Surgical
Orthopedic $102.14 $93.37 $15.52 $57.92 $120.50 $484.93
• BIMS Score = 14; Regular diet; No SLP
related comorbidities
• GG Function Score –PT/OT=16;
Nursing=9
• NTA Score = 3
NTA
points
Supporting Documentation NTA: Active Diagnosis
37
© Proactive 2019
Claim review:
NTA points
reduced to 0
SNF Primary
Diagnosis
Clinical
Category PT Rate OT Rate SLP Rate NTA Rate
Nursing
Rate
Total
Unadjusted
Rate
Sepsis, unspecified
organism (A41.9)
Acute Infections $92.96 $87.67 $65.29 $107.00 $120.50 $480.88
Sepsis, unspecified
organism (A41.9) Acute Infections $92.96 $87.67 $53.42 $107.00 $70.38 $469.01
• BIMS Score = 10, Mech Soft diet, SLP
related comorbidity CVA
• GG Function Score: OT/PT=20;
Nursing=16
• NTA Score = 5
CVA
38
© Proactive 2019
Supporting Documentation SLP Comorbidity:
Active Diagnosis
Claim review:
unable to
validate active
CVA condition
SNF Primary
Diagnosis Clinical
Category PT Rate OT Rate SLP Rate NTA Rate
Nursing
Rate
Total
Unadjusted
Rate
OA of Rt hip
(M16.11) Non-
surgical
ortho
$94.79 $95.64 $33.33 $107.80 $164.22 $495.78
Aftercare
following joint
replacement
surgery (Z47.1)
Major Joint
replace-
ment
$114.98 $88.24 $33.33 $107.80 $164.22 $508.57
• Diagnosis: Osteoarthritis of right hip. In
hospital underwent Right hip replacement
and is coming to SNF for skilled PT/OT.
• BIMS Score = 12; Regular diet; No SLP
related comorbidities
• PT/OT GG Function Score -12
• NTA Score = 4
+ Dx
39
© Proactive 2019
Triple Check review:
team identifies
inappropriate SNF Dx
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SNF Primary
Diagnosis
Clinical
Category PT Rate OT Rate SLP Rate NTA Rate Nursing Rate
Total
Unadjusted Rate
Parkinson’s
Disease (G20)
Acute
Neurologic
$90.51 $85.40 $53.42 $103.49 $184.49 $517.31
Parkinson’s
Disease (G20)
Acute
Neurologic
$90.51 $85.40 $68.03 $103.49 $184.49 $531.92
• BIMS Score = 13; Mech Diet; No
Swallow Impairment, No SLP
comorbidities
• GG Function Score: OT/PT=7;
Nursing=3
• NTA Score = 4
+
Swallow
Disorder
40
© Proactive 2019
Triple Check review:
team identifies
documentation to support
swallow impairment
4
1
MITIGATE Compliance Risks
41
• Provider Behavior Changes
– Pathways/Protocols & trending of therapy intensity & mode
– MDS coding & supportive documentation audits
– Outcomes monitoring
• Negligence/Professional Liability
– Competencies established NTAs & higher acuity care
– Compliance work plan updates
• Targeted Medical Reviews
– Coding and Documentation Training
– Triple Check processes
– Formal auditing and monitoring
– Coaching and system updates in response to audit findings
Auditing & Monitoring
• ICD-10 Coding
• MDS accuracy
• Interview processes
• New reimbursement items
• PDPM relevant coding &
supportive documentation
• Care plans
• Overuse IPA / Interrupted Stay
• Clinical meeting processes
• Standards of care/Clinical
competency
• Therapy (modes and intensity)
• Skilled documentation
42
FY 2019 Final Rule (pg.
39198)
“the information reported to CMS
must be accurate. Inaccuracies
in the data reported to CMS, or a
failure to document the basis for
such data, will necessitate (the
same types of) administrative
actions”
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4
3
Risk Mitigation
Triple
Check
QA Audits
Documentation Clinical Need Drives Care
Contact Information: [email protected]
Questions
PDPM
Billing
Accuracy
Proactive partners with providers for
regulatory compliance, training, and medical review solutions.
©2019 Proactive Medical Review & Consultants, LLC, may be used with permission by current affiliates.
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1. Proactive Medical Review Triple Check Toolkit https://www.proactivemedicalreview.com/shop
2. Medicare Benefit Policy Manual Ch. 8 https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c08.pdf
3. Medicare Claims Processing Manual Ch. 6 https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c06.pdf
4. Medicare Claims Processing Manual Ch. 6 (Transmittal PDPM Update 10/8/19): https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4409CP.pdf
5. Center for Medicare and Medicaid Services. (2019). MDS 3.0 RAI Manual. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html
6. SNF PPS FY2019 Final Rule https://www.govinfo.gov/content/pkg/FR-2018-08-08/pdf/2018-16570.pdf
7. SNF PPS FY2020 Final Rule: https://www.federalregister.gov/documents/2019/08/07/2019-16485/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities
8. Centers for Medicare and Medicaid Services. (2019). Patient Driven Payment Model. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html
9. SNF QRP Provider Training Day 2, part 2 (August 14, 2019). Retrieved from: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Training.html
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References and Resources
Patient Driven Payment Model (PDPM) HIPPS Coding Crosswalk
May be used by permission only. Proactive Medical Review, LLC www.proactivemedicalreview.com
PT/OT Component HIPPS Guide (1st Character) Clinical Category Function Score PT-OT Case-mix Group HIPPS Character
Major Joint Replacement or Spinal Surgery
0-5 TA A 6-9 TB B
10-23 TC C 24 TD D
Other Orthopedic
0-5 TE E
6-9 TF F
10-23 TG G
24 TH H
Medical Management
0-5 TI I
6-9 TJ J
10-23 TK K
24 TL L
Non-Orthopedic Surgery and Acute Neurologic
0-5 TM M 6-9 TN N
10-23 TO O 24 TP P
SLP Component HIPPS Guide (2nd Character) Acute Neurologic Condition, SLP-related Comorbidity, or
Cognitive Impairment
Mechanically Altered Diet or Swallowing Disorder SLP Case-mix Group HIPPS Character
None Neither SA A None Either SB B None Both SC C
Any one Neither SD D Any one Either SE E Any one Both SF F Any two Neither SG G Any two Either SH H Any two Both SI I All three Neither SJ J All three Either SK K All three Both SL L
NTA Component HIPPS Guide (4th Character) Comorbidities / Conditions NTA Score Range NTA Case Mix Group HIPPS Character
See additional reference for Comorbidities Included in
NTA Comorbidity Score and Assigned Points
12+ NA A 9-11 NB B 6-8 NC C 3-5 ND D 1-2 NE E 0 NF F
Assessment Indicator Guide (5th Character) Assessment Type HIPPS Character
IPA 0 PPS – 5 Day 1
OBRA Assessment (not coded as a PPS Assessment) 6
Patient Driven Payment Model (PDPM) HIPPS Coding Crosswalk
May be used by permission only. Proactive Medical Review, LLC www.proactivemedicalreview.com
Nursing Component HIPPS Guide (3rd Character) Extensive Services Conditions /
Services Function
Score Nursing
Classification HIPPS
Character • Tracheostomy care• Ventilator / Respirator• Isolation or quarantine
0-14 ES3 A
0-14 ES2 B
0-14 ES1 C
Special Care High PHQ-9 Score Function Score
Nursing Classification
HIPPS Character
• Comatose and completelydependent or activity did notoccur
• Septicemia• Diabetes with both of the
following: 1) Insulin injectionsfor all 7 days; 2) Insulin order changes on 2 or more days
• Quadriplegia with NFS Score<=11
• COPD and SOB when lying flat • Fever with one of the following:
Pneumonia; Vomiting; Weight loss; Feeding tube withrequirements¹
• Parenteral/IV feedings• Respiratory Therapy for all 7 days
10 or greater 0-5 HDE2 D
Less than 10 0-5 HDE1 E
10 or greater 6-14 HBC2 F
Less than 10 6-14 HBC1 G
Special Care Low PHQ-9 Score Function Score
Nursing Classification
HIPPS Character
• Cerebral palsy with NFS <=11• Multiple sclerosis with NFS
<=11 • Parkinson’s disease with NFS
<=11 • Respiratory failure and oxygen
therapy (while a resident)• Feeding tube with
requirements¹• Two or more stage 2 pressure
ulcers with two or moreselected skin treatments²
• Any stage 3 or 4 pressure ulcer with two or more selected skintreatments²
• One stage 2 pressure ulcer and one venous/arterial ulcer withtwo or more selected skin treatments²
• Foot infection or diabetic footulcer or other open lesion of footwith application of dressings tothe feet
• Radiation treatment (while a resident)
• Dialysis treatment (while a resident)
10 or greater 0-5 LDE2 H
Less than 10 0-5 LDE1 I
10 or greater 6-14 LBC2 J
Less than 10 6-14 LBC1 K
Clinically Complex PHQ-9 Score Function Score
Nursing Classification
HIPPS Character
• Pneumonia• Hemiplegia/hemiparesis with NFS <=11• Open lesions (other than ulcers, rashes, and cuts) with any selected skin
treatment³ or surgical wounds• Burns• Any of the following while a resident: Chemotherapy; Oxygen therapy;• IV medications; Transfusions
10 or greater 0-5 CDE2 L Less than 10 0-5 CDE1 M 10 or greater 6-14 CBC2 N 10 or greater 15-16 CA2 O Less than 10 6-14 CBC1 P Less than 10 15-16 CA1 Q
Behavioral Cognitive Symptoms Restorative Programs
Function Score
Nursing Classification
HIPPS Character
• BIMS Summary Score <=9 OR CPS >=3• Hallucinations• Delusions• Any of the following 4 or more days: Physical behavioral symptoms
directed toward others; Verbal behavioral symptoms directed toward others; Other behavioral symptoms not directed toward others; Rejectionof care; Wandering
2 or more 11-16 BAB2 R
0 or 1 11-16 BAB1 S
Reduced Physical Function Restorative Programs
Function Score
Nursing Classification
HIPPS Character
• Behavioral Symptoms and Cognitive Performance with NFS <11• Residents who do not meet the conditions in any of the previous
categories • Restorative Nursing Services administered for 6 or more days
2 or more 0-5 PDE2 T 0 or 1 0-5 PDE1 U
2 or more 6-14 PBC2 V 2 or more 15-16 PA2 W
0 or 1 6-14 PBC1 X 0 or 1 15-16 PA1 Y
Patient Driven Payment Model (PDPM) HIPPS Coding Crosswalk
May be used by permission only. Proactive Medical Review, LLC www.proactivemedicalreview.com
HIPPS Code Worksheet
Resident: HICN: Admit Date: Last Covered Day: Primary Payor: Secondary Payor: 5 Character HIPPS Code:
Interdisciplinary Team Members:
Character Place
PDPM Component
HIPPS Character
Case Mix Group Reason(s) for Case Mix Group Qualification
Example: Character 1 PT/OT Payment N TN Non-ortho surgery; GG score = 7
Character 1 PT/OT
Payment
Character 2 SLP
Payment
Character 3 Nursing
Payment
Character 4 NTA
Payment
Character 5 Assessment
Indicator � 5-day � IPA
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