medicare prospective payment system update “how to do more with less from cms” presented by...

MEDICARE PROSPECTIVE MEDICARE PROSPECTIVE PAYMENT SYSTEM PAYMENT SYSTEM

UPDATEUPDATE““How to do more with less from How to do more with less from

CMS”CMS”Presented by Sheila Gunter, CEOPresented by Sheila Gunter, CEO

VNA of Cordele, Inc.VNA of Cordele, Inc.

Current SystemCurrent System

Effective 10/1/2000Effective 10/1/2000 80 Different Payment Scenarios80 Different Payment Scenarios HHRG’s and HIPPSHHRG’s and HIPPS OASIS DrivenOASIS Driven

Clinical DomainClinical Domain Functional DomainFunctional Domain Service UtilizationService Utilization

Revised SystemRevised System Effective 1/1/2008Effective 1/1/2008 153 Different Payment Scenarios153 Different Payment Scenarios HHRGs and HIPPSHHRGs and HIPPS

Four equation modelFour equation model Early Episodes (1Early Episodes (1stst and 2 and 2ndnd) with fewer than 14 therapy ) with fewer than 14 therapy

visitsvisits Early Episodes (1Early Episodes (1stst & 2 & 2ndnd) with 14+ therapy visits) with 14+ therapy visits Later Episodes (3Later Episodes (3rdrd +) with fewer than 14 therapy visits +) with fewer than 14 therapy visits Later Episodes (3Later Episodes (3rdrd+) with 14+ therapy visits+) with 14+ therapy visits

OASIS DrivenOASIS Driven ClinicalClinical FunctionalFunctional Service UtilizationService Utilization

PPS Base RatesPPS Base Rates

2007 rate - $2,339.002007 rate - $2,339.00 New ratesNew rates

Episodes beginning in 2007 and ending Episodes beginning in 2007 and ending in 2008 - $2,355.96in 2008 - $2,355.96

Episodes beginning in 2008 - $2,300.60Episodes beginning in 2008 - $2,300.60

Case Mix Creep Case Mix Creep AdjustmentAdjustment

Rationale: CMS estimates increases Rationale: CMS estimates increases in PPS payments are due to agencies in PPS payments are due to agencies scoring practices which in affect, scoring practices which in affect, result in higher case mix weights. result in higher case mix weights. Therefore, CMS has instituted a Therefore, CMS has instituted a “case mix creep” adjustment “case mix creep” adjustment reducing the PPS case mix reducing the PPS case mix adjustments by 2.75% in 2008, 2009 adjustments by 2.75% in 2008, 2009 and 2010 and 2.71% in 2011. and 2010 and 2.71% in 2011.

HHRG’S AND HIPPS’SHHRG’S AND HIPPS’S

FORGET EVERYTHING YOU FORGET EVERYTHING YOU THOUGHT YOU KNEW ABOUT THOUGHT YOU KNEW ABOUT HHRG AND HIPPS CODES HHRG AND HIPPS CODES BECAUSE NOTHING IS AS IT WAS.BECAUSE NOTHING IS AS IT WAS.

Episodes and EquationsEpisodes and Equations EpisodesEpisodes

MO110 – new OASIS itemMO110 – new OASIS item Early = 1Early = 1stst and 2 and 2ndnd adjacent episode adjacent episode

(Equation 1 and/or 3)(Equation 1 and/or 3) Late = 3Late = 3rdrd or more adjacent episode or more adjacent episode

(Equation 2 and/or 4)(Equation 2 and/or 4) Adjacent episodeAdjacent episode

An episode is considered as adjacent as long An episode is considered as adjacent as long as there is not more than a break in service as there is not more than a break in service (admission/recertification through discharge) (admission/recertification through discharge) of more than 60 days.of more than 60 days.

Episodes and Equations Episodes and Equations cont’dcont’d

Equation 1 = 1Equation 1 = 1stst and 2 and 2ndnd episode and episode and 0-13 therapy visits0-13 therapy visits

Equation 2 = 1Equation 2 = 1stst and 2 and 2ndnd episode and episode and 14+ therapy visits14+ therapy visits

Equation 3 = 3Equation 3 = 3rdrd or more episodes or more episodes and 0-13 therapy visitsand 0-13 therapy visits

Equation 4 = 3Equation 4 = 3rdrd or more episodes or more episodes and 14+ therapy visitsand 14+ therapy visits

Clinical DomainClinical Domain Diagnosis – MO230/240/246 Diagnosis – MO230/240/246

(Eliminated Payment Diagnoses - MO245(Eliminated Payment Diagnoses - MO245 Therapies – MO250 Therapies – MO250 Vision – MO390Vision – MO390 Pain – MO420Pain – MO420 Pressure Ulcers – MO450 & MO460Pressure Ulcers – MO450 & MO460 Stasis Ulcers – MO476Stasis Ulcers – MO476 Surgical Wounds – MO488Surgical Wounds – MO488 Dyspnea – MO490Dyspnea – MO490 Urinary Incontinence – MO530Urinary Incontinence – MO530 Bowel Incontinence – MO540Bowel Incontinence – MO540 Ostomy – MO550Ostomy – MO550 Injectable drugs – MO800 (new)Injectable drugs – MO800 (new)

Clinical Diagnoses Clinical Diagnoses ExpandedExpanded

BlindnessBlindness Blood disordersBlood disorders CancerCancer DiabetesDiabetes Gait abnormalityGait abnormality Gastrointestinal disordersGastrointestinal disorders Heart diseaseHeart disease HypertensionHypertension Neuro – brain, peripheral & strokeNeuro – brain, peripheral & stroke

Clinical Diagnoses Clinical Diagnoses ExpandedExpanded (cont’d) (cont’d)

Multiple SclerosisMultiple Sclerosis Ortho – leg & other disordersOrtho – leg & other disorders Psych – affected and other psychosesPsych – affected and other psychoses Psych – degenerative & other organic Psych – degenerative & other organic

psychiatric disorderspsychiatric disorders PulmonaryPulmonary Skin – traumatic wounds, burns & post-opSkin – traumatic wounds, burns & post-op Skin – ulcers & otherSkin – ulcers & other

Diagnosis FactorDiagnosis Factor In 2008, PPS payments will be based In 2008, PPS payments will be based

on a broad spectrum of diagnoses, on a broad spectrum of diagnoses, not just the primary diagnosis. not just the primary diagnosis.

Record all patient’s diagnoses.Record all patient’s diagnoses. Payments will be tied to both Payments will be tied to both

diagnosis and clinical conditions, i.e. diagnosis and clinical conditions, i.e. OASIS data, and both must be OASIS data, and both must be present in combination in order to present in combination in order to generate payment under the Clinical generate payment under the Clinical Domain.Domain.

Clinical and diagnosis payment Clinical and diagnosis payment combinationscombinations Clinical and diagnosis payment combinationsClinical and diagnosis payment combinations : : Primary diagnosis or other diagnosis = Dysphagia Primary diagnosis or other diagnosis = Dysphagia andand Primary or other Primary or other

diagnosis = Neuro 3 – Strokediagnosis = Neuro 3 – Stroke Primary diagnosis or other diagnosis = Dysphagia Primary diagnosis or other diagnosis = Dysphagia andand M0250 = 3 (Enteral) M0250 = 3 (Enteral) Primary diagnosis or other diagnosis = Gastrointestinal disorders Primary diagnosis or other diagnosis = Gastrointestinal disorders andand

M0550 = 1 or 2M0550 = 1 or 2 Primary diagnosis or other diagnosis = Gastrointestinal disorders Primary diagnosis or other diagnosis = Gastrointestinal disorders andand

Primary or other diagnosis = Neuro 1 or Neuro 2 or Neuro 3 or Neuro 4Primary or other diagnosis = Neuro 1 or Neuro 2 or Neuro 3 or Neuro 4 Primary or other diagnosis = Heart Disease Primary or other diagnosis = Heart Disease andand M0250 = 1 or 2 M0250 = 1 or 2 Primary or other diagnosis = Neuro 1 - Brain disorders Primary or other diagnosis = Neuro 1 - Brain disorders andand M0530 = 1 or 2 M0530 = 1 or 2 Primary or other diagnosis = Neuro 1 - Brain disorders Primary or other diagnosis = Neuro 1 - Brain disorders andand at least one of at least one of

the following M0690 = 2 or more the following M0690 = 2 or more oror M0700 = 3 or more M0700 = 3 or more Primary or other diagnosis = Neuro 1 Primary or other diagnosis = Neuro 1 oror Neuro 2 Neuro 2 andand M0680 = 2 or more M0680 = 2 or more Primary or other diagnosis = Neuro 3 Primary or other diagnosis = Neuro 3 andand at least one of the following at least one of the following

M0690 = 1 M0690 = 1 oror M0680 = 2 or more M0680 = 2 or more Primary or other diagnosis = Neuro 3 Primary or other diagnosis = Neuro 3 andand at least one of the following at least one of the following

M0690 = 2 or more M0690 = 2 or more oror M0700 = 3 or more M0700 = 3 or more Primary or other diagnosis = Neuro 4 Primary or other diagnosis = Neuro 4 andand at least one of the following at least one of the following

M0670 = 2 or more M0670 = 2 or more oror M0680 = 2 or more M0680 = 2 or more Primary or other diagnosis = Neuro 4 Primary or other diagnosis = Neuro 4 andand at least one of the following at least one of the following

M0690 = 2 or more M0690 = 2 or more oror M0700 = 3 or more M0700 = 3 or more Primary or other diagnosis = Ortho 1 Primary or other diagnosis = Ortho 1 andand M0460 = 1, 2, 3, or 4 M0460 = 1, 2, 3, or 4 Primary or other diagnosis = Ortho 1 Primary or other diagnosis = Ortho 1 oror Ortho 2 Ortho 2 andand M0250 = 1 or 2 M0250 = 1 or 2 Primary or other diagnosis = Pulmonary disordersPrimary or other diagnosis = Pulmonary disorders Primary or other diagnosis = Pulmonary disorders Primary or other diagnosis = Pulmonary disorders andand M0700 = 1 or more M0700 = 1 or more Primary or other diagnosis = Skin 1 Primary or other diagnosis = Skin 1 oror Skin 2 Skin 2 andand M0250 = 1 or 2 M0250 = 1 or 2

Functional DomainFunctional Domain

Components unchangedComponents unchanged Dressing – MO650 or MO660Dressing – MO650 or MO660 Bathing – MO670Bathing – MO670 Toileting – MO680Toileting – MO680 Transferring – MO690Transferring – MO690 Ambulation – MO700Ambulation – MO700

Service Utilization Service Utilization DomainDomain

Therapy Utilization OnlyTherapy Utilization Only Three Thresholds – 6, 14 & 20 visitsThree Thresholds – 6, 14 & 20 visits Graduated payment increasesGraduated payment increases Four equations applied to episodes andFour equations applied to episodes and numbers of therapy visits anticipatednumbers of therapy visits anticipated

MO825 based on 10 therapy visit MO825 based on 10 therapy visit threshold threshold ELIMINATEDELIMINATED

MO826 based on number of predicted MO826 based on number of predicted therapy visits indicatedtherapy visits indicated

Four Equation Four Equation MethodologyMethodology

Equations 1 and 3 Service DomainEquations 1 and 3 Service Domain First and second episodes 0-13 First and second episodes 0-13

therapy visitstherapy visits

S2 – 6 visitsS2 – 6 visits

S3 – 7 to 9 visitsS3 – 7 to 9 visits

S4 – 10 visitsS4 – 10 visits

S5 – 11 to 13 visitsS5 – 11 to 13 visits

Four Equation Methodology Four Equation Methodology (cont’d)(cont’d)

Equations 2 and 4 Service DomainEquations 2 and 4 Service Domain Third or more episodes 14 to 19 therapy Third or more episodes 14 to 19 therapy

visitsvisits S1 – 14 to 15 visitsS1 – 14 to 15 visits S2 – 16 to 17 visitsS2 – 16 to 17 visits S3 – 18 to 19 visitsS3 – 18 to 19 visits

All Episodes 20+ therapy visitsAll Episodes 20+ therapy visits

S1 – 20+ visitsS1 – 20+ visits

Case Mix ScoringCase Mix ScoringDimensionDimension 11stst & 2 & 2ndnd Episodes Episodes 33rdrd + Episodes + Episodes All All

EpisodesEpisodes

0-13 0-13

TherapyTherapy

VisitsVisits

14-19 14-19

Therapy Therapy VisitsVisits

0-13 0-13

Therapy Therapy

VisitsVisits

14-19 14-19

Therapy Therapy

VisitsVisits

20 + 20 + Therapy Therapy

VisitsVisits

EquationEquation 11 22 33 44 (2 or 4)(2 or 4)

ClinicalClinical

(sum of(sum of

points)points)

C1C1 0 to 40 to 4 0 to 40 to 4 0 to 20 to 2 0 to 40 to 4 0 to 40 to 4

C2C2 5 to 95 to 9 5 to 125 to 12 3 to 43 to 4 5 to 125 to 12 5 to 125 to 12

C3C3 10+10+ 13+13+ 5+5+ 13+13+ 13+13+

FunctionaFunctionall

(sum of (sum of points) points)

F1F1 0 to 30 to 3 0 to 50 to 5 0 to 80 to 8 0 to 80 to 8 0 to 50 to 5

F2F2 4 to 54 to 5 6 to 86 to 8 9 to 139 to 13 9 to 139 to 13 6 to 86 to 8

F3F3 6+6+ 9+9+ 14+14+ 14+14+ 9+9+

ServiceService

UtilizationUtilization

(number (number ofof

therapytherapy

visits)visits)

S1S1 0 to 50 to 5 14 to 1514 to 15 0 to 50 to 5 14 to 1514 to 15 20+20+

S2S2 66 16 to 1716 to 17 66 16 to 1716 to 17

S3S3 7 to 97 to 9 18 to 1918 to 19 7 to 97 to 9 18 to 1918 to 19

S4S4 1010 1010

S5S5 11 to 1311 to 13 11 to 1311 to 13

Clinical Scoring Domain ImpactClinical Scoring Domain Impact

Equation 1Equation 1

(1(1st st & 2& 2ndnd Episodes)Episodes)

0 – 130 – 13

TherapyTherapy

$1,322.9$1,322.922

Base=C1Base=C1


(1(1stst & 2 & 2ndnd Episodes)Episodes)

14 – 1914 – 19

TherapyTherapy

$3,659.3$3,659.311

Base=C1Base=C1


(3(3rdrd or more or more Episodes)Episodes)

0 – 130 – 13

TherapyTherapy

$1,485.47$1,485.47

Base=C1Base=C1



14 – 1914 – 19

TherapyTherapy

$3,979.88$3,979.88

Base=C1Base=C1

EpisodesEpisodes

(All (All Episodes)Episodes)

20+20+

TherapyTherapy

$5,788.1$5,788.199

Base=C1Base=C1Base +Base +

C2 C2 $342.36$342.36

C3 C3 $722.64$722.64

Base +Base +

C2 C2 $569.40$569.40

C3 C3 $1,227.33$1,227.33

Base +Base +

C2 $131.91C2 $131.91

C3 $648.40C3 $648.40

Base +Base +

C2 $623.43C2 $623.43

C3 C3 $1,350.61$1,350.61

Base +Base +

C2 $485.17C2 $485.17

C3 C3 $1,212,35$1,212,35

Ex: C2 =Ex: C2 =

$1,665.28 $1,665.28 Ex: C3 =Ex: C3 =

$4,886.64 $4,886.64 Ex: C2 =Ex: C2 =

$1,617.38 $1,617.38 Ex: C3 =Ex: C3 =

$5,330.49$5,330.49Ex: C2 =Ex: C2 =

$6,273.36 $6,273.36

Functional Scoring Domain ImpactFunctional Scoring Domain Impact


(1(1st st & 2& 2ndnd Episodes)Episodes)

0 – 130 – 13

TherapyTherapy

$1,322.9$1,322.922

Base = Base = C1FIC1FI


(1(1stst & 2 & 2ndnd Episodes)Episodes)

14 – 1914 – 19

TherapyTherapy

$3,659.3$3,659.311



(3(3rdrd or or more more

Episodes)Episodes)

0 – 130 – 13

TherapyTherapy

$1,485.4$1,485.477




Episodes)Episodes)

14 – 1914 – 19

TherapyTherapy

$3,979.8$3,979.888


EpisodesEpisodes


20+20+

TherapyTherapy

$5,788.1$5,788.199


Base +Base +F2 F2

$201.15$201.15

F3 F3 $391.18$391.18

Base +Base +F2 F2

$264.04$264.04

F3 F3 $429.54$429.54

Base +Base +F2 F2

$304.00$304.00

F3 F3 $592.10$592.10

Base +Base +F2 F2

$297.18$297.18

F3 F3 $681.32$681.32

Base +Base +F2 F2

$430.23$430.23

F3 F3 $916.53$916.53

Ex: C1F2 Ex: C1F2 ==

$1,524.07$1,524.07


$4,088.85$4,088.85


$1,789.47$1,789.47


$4,661.20$4,661.20


$6,218.42$6,218.42

Service Domain Scoring ImpactService Domain Scoring Impact


(1(1stst& 2& 2ndnd Episodes)Episodes)

0 – 130 – 13

TherapyTherapy

$1,322.92$1,322.92Base = Base = C1F1S1C1F1S1


(1(1stst % 2 % 2ndnd Episodes)Episodes)

14 – 1914 – 19

TherapyTherapy

$3,659.31$3,659.31Base = Base = C1F1S1C1F1S1



0 – 130 – 13

TherapyTherapy

$1,485.47$1,485.47Base = Base = C1F1S1C1F1S1



Episodes)Episodes)

14 – 1914 – 19

TherapyTherapy

$3,979.8$3,979.888

Base = Base = C1F1S1C1F1S1

EpisodesEpisodes


20+20+

TherapyTherapy

$5,788.19$5,788.19Base = Base = C1F1S1C1F1S1

Base +Base +S2 $608.45S2 $608.45

S3$1083.40S3$1083.40

S4$1,570.3S4$1,570.388

S5 S5 $1,970.41$1,970.41

Base +Base +S2 $353.49S2 $353.49

S3 $644.75S3 $644.75

Base +Base +S2 $794.16S2 $794.16

S3 S3 $1,253.67$1,253.67

S4 S4 $1,755.87$1,755.87

S5 S5 $2,152.49$2,152.49

Base +Base +S2 $263.13S2 $263.13

S3 $617.98S3 $617.98

Base +Base +

C(2 or 3) C(2 or 3) ++

F (2 or 3)F (2 or 3)

EXAMPLES SERVICE DOMAIN EXAMPLES SERVICE DOMAIN IMPACTIMPACT


(1(1stst& 2& 2ndnd Episodes)Episodes)

0 – 130 – 13

TherapyTherapy


(1(1stst % 2 % 2ndnd Episodes)Episodes)

14 – 1914 – 19

TherapyTherapy



Episodes)Episodes)

0 – 130 – 13

TherapyTherapy



Episodes)Episodes)

14 – 1914 – 19

TherapyTherapy

EpisodesEpisodes


20+20+

TherapyTherapy

C2F2S1 C2F2S1 ==

$1,866.4$1,866.433

C3F3S2 C3F3S2 ==

$5,669.6$5,669.677

C2F2S3 C2F2S3 ==

$3,175.0$3,175.055

C1F3S2 C1F3S2 ==

$4,924.3$4,924.333

C3F3S1 C3F3S1 ==

$7,917.0$7,917.077

C1F3S5 C1F3S5 ==

$3,684.5$3,684.511

C2F2S3 C2F2S3 ==

$5,137.5$5,137.500

C3F3S4 C3F3S4 = =

$4,481.8$4,481.844

C1F1S3 C1F1S3 ==

$4,597.8$4,597.866

C1F2S1 C1F2S1 ==

$6,218.4$6,218.422

This is what is going through your mind at This is what is going through your mind at this point in the presentation.this point in the presentation.

““You have got to be kidding me!!!!!”You have got to be kidding me!!!!!”

“What!!!!!! You mean you are actually serious!!!!!!”

This is what is going through my mind at This is what is going through my mind at this point in the presentation.this point in the presentation.

“I’m too old to run away and join the circus so we have to make this work!”

““How to do more with less How to do more with less from CMS”from CMS” Be preparedBe prepared

Educate, educate, educateEducate, educate, educate PPS revisionsPPS revisions Assessment skillsAssessment skills OASIS data itemsOASIS data items

Analyze current case mixAnalyze current case mix Run calculations to gauge impact of PPS Run calculations to gauge impact of PPS

revisionsrevisions Design and implement financial Design and implement financial

strategies to assure financial viabilitystrategies to assure financial viability Analyze business practicesAnalyze business practices

Documentation systemDocumentation system Medical supplies ordering/distributionMedical supplies ordering/distribution Timeliness factorsTimeliness factors

Work as a teamWork as a teamExecutive ManagementExecutive ManagementSupervisory StaffSupervisory StaffNursesNursesTherapistsTherapistsAidesAidesMedical Records CoordinatorMedical Records CoordinatorMIS DepartmentMIS DepartmentBilling DepartmentBilling Department

• • Assure accuracyAssure accuracyOASIS assessmentsOASIS assessmentsDiagnosis codingDiagnosis codingBillingBilling

Work smartWork smart Organize your caseload to saveOrganize your caseload to save

travel time and expensetravel time and expense

Achieve the best outcomeAchieve the best outcome

by care planning andby care planning and

co-ordinationco-ordination

Employ technology to Employ technology to

save time and expensesave time and expense

••TelehealthTelehealth

••Telephone VisitsTelephone Visits

Work with the “Three E’s” in mindWork with the “Three E’s” in mind

• • EffectiveEffective Be effective in all you do because yourBe effective in all you do because your

patients are counting on you.patients are counting on you.

EfficientEfficient Be efficient in all you do because yourBe efficient in all you do because your

employer (VNA) is counting on you.employer (VNA) is counting on you.

EnthusiasticEnthusiastic Be enthusiastic in all you do because yourBe enthusiastic in all you do because your

co-workers are counting on you.co-workers are counting on you.

Q&A’sQ&A’s

In conclusion…….In conclusion…….Always remember a code is just a series of numbers and Always remember a code is just a series of numbers and letters,letters,But a patient is a person whom we try to make better.But a patient is a person whom we try to make better.An equation is just another mathematical term we employ,An equation is just another mathematical term we employ,But a patient is a person and into their life we bring some joy.But a patient is a person and into their life we bring some joy.A payment mode is just a method for CMS to dispense money,A payment mode is just a method for CMS to dispense money,But a patient is a person whose day we can make sunny.But a patient is a person whose day we can make sunny.

So never lose sight of that person for whom we give service So never lose sight of that person for whom we give service and care.and care.Provide for their needs and do for them what is right and what Provide for their needs and do for them what is right and what is fair.is fair.For a patient is a person and their care is our sacred trust;For a patient is a person and their care is our sacred trust;Their needs are individual and providing them is a must.Their needs are individual and providing them is a must.It’s because of our patients that we will continue to survive.It’s because of our patients that we will continue to survive.So, we’ll all pull together and for knowledge we’ll strive.So, we’ll all pull together and for knowledge we’ll strive.We’ll learn to do more with less and be prudent and smart,We’ll learn to do more with less and be prudent and smart,Because a patient is a person who has first place in our heart.Because a patient is a person who has first place in our heart.

sbgsbg

medicare prospective payment system update “how to do more with less from cms” presented by...

Documents