slp services in a pdpm world€¦ · slp presence of acute neurological condition, slp -related...
TRANSCRIPT
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SLP Services in a PDPM World
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Agenda
• Truth or Myth
• PDPM Overview
• SLP and the MDS
• Key Focus Areas
• Next Steps
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Truth or Myth
SLP services alone cannot “skill” a patient.
FALSE.
• No Medicare regulations that indicate that SLP services are insufficient in order to “skill” the patient. Coverage for SNF Part A is met when all the coverage guidelines are met.
• Care in an SNF is covered under Medicare Part A if the following four factors are met: the
patient requires skilled nursing services or skilled rehabilitation services (i.e., services that must be performed by or under the supervision of professional or technical personnel); are
ordered by a physician and the services are rendered for a condition which the patient
received inpatient hospital services or for a condition that arose while receiving care in an SNF; the patient requires these skilled services daily; and as a practical matter, considering
economy and efficiency, the daily skilled services can be provided only on an inpatient basis
in an SNF; and§ the services delivered are reasonable and necessary for the treatment of a patient’s illness or injury (i.e., they are consistent with the nature and severity of the
individual’s illness or injury, the individual’s medical needs, and accepted standards of
medical practice). The services must also be reasonable in terms of duration and quantity.
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Under PDPM, I will no longer be able to use the common dysphagia ICD codes such as R13.11 (Dysphagia, oral phase) and R13.12 (Dysphagia, oropharyngeal phase) as these codes are listed as
“Return to Provider” on the Clinical Categories Mapping. False.
• The Clinical Categories Mapping only applies to the ICD code in I0020B which is the primary medical condition that best describes the primary reason for the Medicare Part A stay. It
would not be common that dysphagia is the “primary” reason why the patient is in an SNF.
Truth or Myth
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ICD coding of therapy medical diagnoses and treatment diagnoses have increased relevance under PDPM, and, therefore, must accurately reflect the focus of the SLP treatment and the
cause of the decline.
True.
• As there are more fields on the MDS that impact reimbursement, that means that there will be more areas within the documentation that will be looked at to justify the coding in the
MDS. For example, the ICDs captured in I8000 help to identify the presence of an SLP-related
comorbidity and if we are treating that comorbidity, the related ICD should be included on our POC. If we are treating a patient with a swallowing disorder identified in Section K of the
MDS, we should have a dysphagia ICD on our POC.
Truth or Myth
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Under PDPM, SLP will be limited primarily to patients with neurological conditions since the ICD mappings for the PDPM SLP Component mostly relate to apraxia, dysphasia and dysphagia
following cerebral hemorrhages or stroke.
False.
• While it’s true that the conditions that support the SLP component in the areas of apraxia, dysphagia and speech/language deficits use the ICD codes linking these deficits to cerebral
hemorrhages or stroke, we must still treat the patients as we do today as the patients won’t
change under PDPM - providing the medically necessary services required to regain lost function based on the individual clinical needs of the patient. In addition, if the patient is
reported as having a swallowing disorder in Section K of the MDS and SLP is treating the
patient for dysphagia, a dysphagia ICD code must be used on the SLP POC to support our services. The most accurate dysphagia ICD code that reflects the patient’s condition must be
used, regardless of whether or not it is on the ICD “list” for the SLP Component.
Truth or Myth
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If a patient is on SLP caseload for dysphagia intervention and K0510C is checked on the MDS to indicate that the patient is on a mechanically altered diet, I have to explain in my SLP
documentation why the patient requires a mechanically altered diet.True.
• When a patient during the current SNF stay is being placed on a mechanically altered diet, the SLP documentation must support and explain why the altered diet is necessary. If a
patient comes to SLP already on a mechanically altered diet, the SLP must explain the historical events and condition that led to the need for previously being placed on a mechanically altered diet.
Truth or Myth
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Problems with RUG Payment System:
• Current RUG-IV payment system is driven primarily by number of therapy minutes
• Does not yield significant correlation to outcomes
• Does not fully consider the wide range of clinical characteristics that influence the relative
resource use of SNF residents
Recommendations:
• CMS contracted Acumen in 2012 to identify and evaluate possible reimbursement model alternatives
• Remove therapy minutes as a determinant of payment and create a separate payment
component for Non-Therapy Ancillary services
Results:
• Created revised payment method called Patient-Driven Payment Model (PDPM)
• PDPM will replace RUGS-IV effective Oct. 1, 2019
Assessing the Rug model
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PDPM is a new model that derives payment based on resident characteristics
There will be five different case-mix components that will help determine payment:
• Physical Therapy
• Occupational Therapy
• Speech-Language Pathology
• Nursing
• Non-Therapy Ancillary (NTA)
Non-Case-Mix component
CMS will institute a ‘variable rate adjustment’ for PT, OT and NTA
• PT/OT rates reduced by 2% every 7 days after day 21
• NTA will be 3X higher for first 3 days and then drop to 100% and remain flat
Patient Driven Payment Model (PDPM)
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• Minutes of Therapy drive reimbursement
• Two care components (Therapy, Nursing)
• Extensive reporting / documentation
• Payments tied to Patient Condition
• Five care components (PT, OT, SLP, Nursing, NTA)
• Reduced administrative burden
Comparing RUG-IV to PDPM
RUG-IV vs PDPM
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Base Rates are Multiplied by Case-Mix Indexes (CMIs)
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PDPM Patient Classification
• Patient classifications are used for each of the components (PT, OT, SLP, NTA and Nursing)
• Breakdown of criteria for classification
Component Criteria
PT Clinical Category, Functional Score
OT Clinical Category, Functional Score
SLP Presence of Acute Neurological Condition, SLP-related Comorbidity or Cognitive Impairment, Mechanically altered Diet, Swallowing Disorder
NTA NTA Comorbidity Score
Nursing Same as RUG-IV
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SLP has three elements:
• Clinical Category for stay – Acute Neurologic or Non-Neurologic
• Presence of Swallowing Disorder and Mechanically Altered Diet
• Cognitive status and/or presence of a SLP-related comorbidity (12 Dx groups)Additionally, PDPM transitions from section G of MDS under RUG-IV to GG to account for both
early- and late-loss ADL areas
PDPM Case Mix - ST
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SLP has twelve comorbidities groups under PDPM
• SLP comorbidity flag combines conditions and services
• Only the presence of only one of the following is required for patient to qualify:
SLP Comorbidities
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• Acumen study identified variations of utilization across the different modalities
of PT, OT and NTA
• To compensate for the cost in relationship
to the utilization days, a per diem adjustment factor was added as seen here
• PT/OT factor reduces gradually over
time as is seen in these modalities
• NTA has a sharp decrease after day 3, then remains constant over time.
Note the first 3 days are a factor of
3.0, reflective of the load at the beginning of the stay
PDPM Variable Per Diem Rate Adjustment
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PDPM Assessment Schedule
• MDS 3.0 will still be the basis for assessments under PDPM
• Schedule is altered as follows:
• IPA/OSA (see upcoming slide)
• OBRA-related assessments not impacted by PDPM
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Interim Payment Assessment (IPA) is OPTIONAL
• Used to report a change in the patient’s PDPM classification
• ARD: Determined by the provider
• Changes payment beginning on the ARD until the end of the Part A stay or until another IPA
is completed
Optional State Assessment (OSA)
• Solely to report on Medicaid-covered stays, per requirements set forth by their state
• Allows providers in states using RUG-III or RUG-IV models as the basis for Medicaid payment
to do so until September 30, 2020, at which point CMS support for legacy payment models
will end
IPA / OSA
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A Look into the MDS
• Section A: Basic Identification Information• Section B: Hearing, Speech and Vision
• Section C: Cognitive Patterns• Section D: Mood• Section E: Behavior
• Section G: Functional Status• Section GG: Functional Ability and Goals• Section H: Bladder and Bowel
• Section I: Active Diagnoses• Section J: Health Conditions and Pain• Section K: Swallowing/Nutritional Status
• Section L: Oral/Dental Status• Section M: Skin Conditions• Section N: Medications
• Section O: Special Treatments, Procedures and Programs• Section P: Restraints and Alarms
• Section Q: Participation in Assessment and Goal Setting
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B0700 Makes Self UnderstoodSteps for Assessment:1. Assess using the resident’s preferred
language or method of communication
2. Interact with the resident. Be sure he or she can hear you or have access to his or her preferred method for communication. If the resident seems unable to communicate, offer alternatives such as writing, pointing, sign language or using cue cards
3. Observe his or her interactions with others in different settings and circumstances
4. Consult with the primary nurse assistants (over all shifts) and the resident’s family and speech-language pathologist
Coding Instructions• Code 0, understood: if the resident
expresses requests and ideas clearly
• Code 1, usually understood: if the resident has difficulty communicating some words or finishing thoughts but is able if prompted or given time. He or she may have delayed responses or may require some prompting to make self understood
• Code 2, sometimes understood: if the resident has limited ability but is able to express concrete requests regarding at least basic needs (e.g., food, drink, sleep, toilet)
• Code 3, rarely or never understood: if, at best, the resident’s understanding is limited to staff interpretation of highly individual, resident-specific sounds or body language (e.g., indicated presence of pain or need to toilet)
Section B: Hearing, Speech and Vision
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B0800 Ability to Understand OthersSteps for Assessment 1. Assess in the resident’s preferred language or
preferred method of communication2. If the resident uses a hearing aid, hearing device
or other communications enhancement device, the resident should use that device during the evaluation of the resident’s understanding of person-to-person communication
3. Interact with the resident and observe his or her understanding of others’ communication
4. Consult with direct care staff over all shifts, if possible, the resident’s family, and speech-language pathologist (if involved in care)
5. Review the medical record for indications of how well the resident understands others
Coding Instructions • Code 0, understands: if the resident clearly
comprehends the message(s) and demonstrates comprehension by words or actions/behaviors
• Code 1, usually understands: if the resident misses some part or intent of the message but comprehends most of it. The resident may have periodic difficulties integrating information but generally demonstrates comprehension by responding in words or actions
• Code 2, sometimes understands: if the resident demonstrates frequent difficulties integrating information and responds adequately only to simple and direct questions or instructions. When staff rephrase or simplify the message(s) and/or use gestures, the resident’s comprehension is enhanced
• Code 3, rarely/never understands: if the resident demonstrates very limited ability to understand communication. Or, if staff have difficulty determining whether or not the resident comprehends messages, based on verbal and nonverbal responses. Or, the resident can hear sounds but does not understand messages
Section B: Hearing, Speech and Vision
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Section B
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Section C: Cognitive Patterns
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Section C: Cognitive Patterns
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Section C: Cognitive Patterns
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How Does it Relate to PDPM?
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Section I: Active Diagnosis
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SLP Comorbidities
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Intent:
• The items in this section are intended to assess the many conditions that could affect the resident’s ability to maintain adequate nutrition and hydration. This section covers swallowing disorders, height and weight, weight loss and nutritional approaches. The
assessor should collaborate with the dietitian and dietary staff to ensure that items in this section have been assessed and calculated accurately.
Section K: Swallowing and Nutrition
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Section K: Swallowing and Nutrition
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Section K: Swallowing and Nutrition
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Patient Drive Groupings Model
• Moving from volume to value
• Eliminates therapy thresholds from reimbursement
• 30-day unit of payment
• Patient characteristics for payment groupings
• Variable LUPA thresholds
• Budget neutral
• To begin on or after 1/1/2020
PDGM
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PDGM
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Institutional
• Acute or post-acute stay occurred in the 14 days prior to the start of the 30-day period of care
Community
• No acute- or post-acute stay in the preceding 14 days prior to the start of the 30-day period
of care
Episode Timing
Early
• First 30-day period
Late
• All subsequent 30-day periods
Admission Source
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• Musculoskeletal Rehab
• Neuro Rehab
• Wounds
• Complex Nursing
• Behavioral Health
Medication Management, Teaching and Assessment (MMTA) • MMTA – Surgical Aftercare• MMTA – Cardiac• MMTA – Endocrine• MMTA – GI/GU
• MMTA – Infectious Disease• MMTA – Respiratory• MMTA - Other
Clinical Groups
Determined by the primary Dx for the HH episode:
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Keys to Finding Success in PDPM/PDGM
1. Understand your role in the MDS
2. Ensure cognitive and swallowing status of each admission
3. Know the speech comorbidities
4. Make sure to understand your full scope of practice
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QUESTIONS?
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