the final rule – an in-depth overview - bkd

9/11/2018

1

MEDICARE UPDATE

The Final Rule –An In-Depth Overview

SEPTEMBER 12 , 2018

TO RECEIVE CPE CREDIT• Individuals

Participate in entire webinar

Answer polls when they are provided

• Groups Group leader is the person who registered & logged on to the webinar

Answer polls when they are provided

Complete group attendance form

Group leader sign bottom of form

Submit group attendance form to [email protected] within 24 hours of webinar

• If all eligibility requirements are met, each participant will be emailed their

CPE certificate within 15 business days of webinar

9/11/2018

2

Presenters

Joanne Jones, [email protected]

Camille Lockhart, [email protected]

Chris Murphy, [email protected]

Medicare Update

PDPMSNF QRP

SNF VBP

Market Basket

9/11/2018

3

Final Rule

Link to BKD Rates

https://www.bkd.com/services/snf-rate-calculatorsVBP/QRP

2.4% Market Basket

Value-Based Purchasing

VBPRequired by 2014 Protecting Access to Medicare Act

2% with hold to fund program

Medicare payment incentive based on performance (30-day hospital readmissions)

Potential rate increase based on performance

9/11/2018

4

VBP Incentive Multiplier

Quality Reporting Program

• Penalty if less than 80% of quality reporting data is submitted

• 2% reduction in the market basket rate

• Claims-based measures

• Assessment-based measures

9/11/2018

5

QRP-Overview of Reports

Review & Correct Report

QM Reports

Provider Preview Report

QRP Measures New FY 2020

Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury

Drug Regimen Review Conducted with Follow-Up for Identified Issues – PAC SNF QRP

Application of IRF Functional Outcome Measure: Change in Self-Care for Medical Rehabilitation Patients (NQF #2633)

Application of IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients (NQF #2634)

Application of IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients (NQF #2635)

Application of IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients (NQF #2636)

9/11/2018

6

From RUG-IV to PDPM

Payment Drives Culture

Chris Murphy, CPA

*Spoiler Alert*

• ICD-10 coding: from compliance issue to payment driver

• Rehab minutes: from payment driver to expense

• ADL to functional scoring, capturing patient conditions – The songremains the same

• The rise of patient-centered care

9/11/2018

7

PDPM Key Changes

PDPM Functional Score

Patient Characteristics

ICD-10 Reason for Skilled Care

MDS Schedule

Patient-Driven Payment Model

PT OT SLP

Nursing Nontherapy Ancillaries

Noncase Mix

9/11/2018

8

PT PT Base Rate PT CMI PT Adjustment Factor

OT OT Base Rate OT CMI OT Adjustment Factor

SLP SLP Base Rate SLP CMI

Nursing Nursing Base Rate Nursing CMI

NTA NTA Base Rate NTA CMI NTA Adjustment Factor

Noncase Mix Noncase Mix Base Rate

PDPM Case Mix Adjusted Payment

PDPM Components – PT – OT – SLP

• Identification of a Clinical Category

• Primary reason for SNF stay

• Not necessary the reason for hospitalization

• Determined by ICD-10 code on five-day PPS MDS

• Listed in MDS Section I 8000 A

• Surgical procedure done in the hospital may change category

• Will be list of surgical procedures to indicate by in Section J

9/11/2018

9

PDPM 10 Clinical Categories

Major Joint Replacement or Spinal Surgery

Cancer

Nonsurgical Orthopedic/Musculoskeletal

Pulmonary

Orthopedic Surgery Except Joint Replacement or Spinal Surgery

Cardiovascular & Coagulations

Acute Infections Acute Neurologic

Medical Management Nonorthopedic Surgery

PT/OT 10 Clinical Categories Collapsed to Four

• Major Joint Replacement/Spinal Surgery

• Nonorthopedic Surgery & Acute Neurological

• Other Orthopedic

• Nonsurgical orthopedic/musculoskeletal

• Orthopedic surgery/spinal surgery

• Medical Management

• Acute infections

• Cancer

• Pulmonary

• Cardiovascular & coagulations

• Medical management

9/11/2018

10

PT/OT Function Score

• MDS Section GG – Functional Abilities & Goals

• Assessed during first three days of admission

• Documents “usual performance”

• 10 ADL ActivitiesEating Average Bed Mobility (2)

Oral Hygiene Average Transfer (3)

Toilet Hygiene Average Walking (2)

PT/OT Function Score Calculation

Admission Performance Section GG Code Function Score

Independent or Setup 05, 06 4

Supervision or Touching Assistance 04 3

Partial/Moderate Assistance 03 2

Substantial/Maximal Assistance 02 1

Dependent, Refused, N/A or Cannot Walk

Any Code for Not Attempted

01, 07, 09, 10, 11, 88 0

PT/OT Function Score can range from zero to 24

9/11/2018

11

PDPM PT/OT Case Mix Classification Groups

Clinical Category Section GG Function Score

PT/OT Case Mix Group PT Case Mix Index OT Case Mix Index


0-5 TA 1.53 1.49


6-9 TB 1.69 1.63


10-23 TC 1.88 1.68


24 TD 1.92 1.53

Other Orthopedic 0-5 TE 1.42 1.41

Other Orthopedic 6-9 TF 1.61 1.59

Other Orthopedic 10-23 TG 1.67 1.64

Other Orthopedic 24 TH 1.16 1.15

PDPM PT/OT Case Mix Classification Groups

Clinical Category Section GG Function Score

PT/OT Case Mix Group

PT Case Mix Index

OT Case Mix Index

Medical Management 0-5 TI 1.13 1.17

Medical Management 6-9 TJ 1.42 1.44

Medical Management 10-23 TK 1.52 1.54

Medical Management 24 TL 1.09 1.11

Nonorthopedic Surgery/ Acute Neurologic

0-5 TM 1.27 1.30


6-9 TN 1.48 1.49


10-23 TO 1.55 1.55


24 TP 1.08 1.09

9/11/2018

12

Variable Per Diem Adjustment Factor – PT & OT

Medicare Payment Days Adjustment Factor

1-20 1.00

21-27 0.98

28-34 0.96

35-41 0.94

42-48 0.92

49-55 0.90

56-62 0.88

63-69 0.86

70-76 0.84

77-83 0.82

84-90 0.80

91-97 0.78

98-100 0.76

SLP Component

• Presence of Three Conditions

• Acute neurological clinical classification

• Co-morbidity

• Driven by MDS sections I & O

• Cognitive impairment

• BIMS ≤ 12

• At least moderate impairment

9/11/2018

13

SLP Co-Morbidities

Section I Section I ICD-10 Codes Section O

Aphasia Laryngeal Cancer Tracheostomy Care While a Resident

CVA, TIA or Stroke Apraxia Ventilator or Respirator While a Resident

Hemiplegia or Hemiparesis Dysphagia

Traumatic Brain Syndrome ALS

Oral Cancers

Speech & Language Deficits

SLP Component

• Presence of

• Mechanically Altered Diet (Section K)

• Swallowing Disorder (Section K)

9/11/2018

14

PDPM SLP Case Mix Classification Groups

Presence of Acute Neurologic Condition, SLP-Related Comorbidity or cognitive

Altered Diet or Swallowing Disorder

SLP Case Mix Group

SLP Case-Mix Index

None Neither SA 0.68None Either SB 1.82None Both SC 2.66Any one Neither SD 1.46Any one Either SE 2.33Any one Both SF 2.97Any two Neither SG 2.04Any two Either SH 2.85Any two Both SI 3.51

All three Neither SJ 2.98

All three Either SK 3.69

All three Both SL 4.19

Nursing Component

• Same RUG IV Major Categories

• Extensive Services

• Special Care High

• Special Care Low

• Clinically Complex

• Behavior Symptoms & Cognitive Impairment

• Reduced Physical Function

9/11/2018

15

Nursing Functional Score

• MDS Section GG – Functional Abilities & Goals

• Assessed during first three days of admission

• Documents “usual performance”

• Functional score ranges from zero to 16

Eating Average Bed Mobility

Toilet Hygiene Average Transfer

Nursing RUG Function Score CMI

ES3 0-14 4.04

ES2 0-14 3.06

ES1 0-14 2.91

HDE2 0-5 2.39

HDE1 0-5 1.99

HBC2 6-14 2.23

NBC1 6-14 1.85

LDE2 0-5 2.07

LDE1 0-5 1.72

LBC2 6-14 1.71

LBC1 6-14 1.43

CDE2 0-5 1.86

CDE1 0-5 1.62

Nursing RUG Function Score CMI

CBC2 6-14 1.54

CA2 15-16 1.08

CBC1 6-14 1.34

CA1 15-16 0.94

BAB2 11-16 1.04

BAB1 11-16 0.99

PDE2 0-5 1.57

PDE1 0-5 1.47

PBC2 6-14 1.21

PA2 15-16 0.70

PBC1 6-14 1.13

PA1 15-16 0.66

9/11/2018

16

Nursing Component

• Important to Note

• Determination of the nursing RUG is based on the RUG hierarchy, not CMI maximization

• Nursing component will be increased by 18% for residents with HIV/AIDS

• B20 must be on SNF claim

NTA Component

• Calculated based on points assigned for 50 MDS items including diagnosis or extensive services

• Many of the diagnoses will be based on ICD-10 codes

9/11/2018

17

Diagnosis/Service Or ICD-10 Points

HIV/AIDS SNF Claim 8

Parenteral IV (high level) 7

IV Medication (post-admission) 5

Ventilator (post-admission) 4

Parenteral IV Feeding (low level) 3

Lung Transplant Status ICD-10 3

Transfusion (post-admission) 2

Major Organ Transplant Status Except Lung

ICD-10 2

Multiple Sclerosis ICD-10 2

Opportunistic Infections ICD-10 2

Asthma, COPD, Chronic Lung Disease 2

Bone/Joint/Muscle Infections/Necrosis Except Aseptic Necrosis of Bone

ICD-10 2

Chronic Myeloid Leukemia ICD-10 2

Wound Infection 2

Diabetes Mellitus 2


Endocarditis ICD-10 1

Immune Disorders ICD-10 1

End-Stage Liver Disease ICD-10 1

Diabetic Foot Ulcer 1

Narcolepsy & Cataplexy ICD-10 1

Cystic Fibrosis ICD-10 1

Tracheostomy (post-admission) 1

MDRO Code 1

Isolation (post-admission) 1

Hereditary Metabolic/Immune Disorders ICD-10 1

Morbid Obesity ICD-10 1

Radiation (post-admission) 1

Stage 4 Pressure Ulcer 1

Chronic Pancreatitis ICD-10 1

Proliferative Diabetic Retinopathy & Vitreous Hemorrhage

ICD-10 1


Other Foot Problems/Infection 1

Complications of Specific ImplantedDevice or Graft

ICD-10 1

Intermittent Bladder Catheterization 1

Inflammatory Bowel Disease ICD-10 1

Aseptic Necrosis of Bone ICD-10 1

Suctioning (post-admission) 1

Cardiorespiratory Failure & Shock ICD-10 1

Myelodysplastic Syndromes & Myelofibrosis

ICD-10 1

ALS, Other Connective Tissue Disorders ICD-10 1

Diabetic Retinopathy ICD-10 1

Feeding Tube 1

Severe Skin Burn or Condition ICD-10 1


Intractable Epilepsy ICD-10 1

Malnutrition 1

Disorders of Immunity ICD-10 1

Cirrhosis of Liver ICD-10 1

Ostomy 1

Respiratory Arrest ICD-10 1

Pulmonary Fibrosis & Other Chronic Lung Disorders

ICD-10 1

9/11/2018

18

NTA Case Mix Classification Groups

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 3.25

9-11 NB 2.53

6-8 NC 1.85

3-5 ND 1.34

1-2 NE 0.96

0 NF 0.72

Variable Per Diem Adjustment Factor – NTA

Medicare Payment Days Adjustment Factor

1-3 3.0

4-100 1.0

9/11/2018

19

Assessment Changes

Admission (Five-Day)

• ARD – Days 1–8• Covers entire stay

unless IPA completed

Interim Payment Assessment (IPA)

• ARD can be no later than 14 days after change in first tier classification

• Pays from ARD until discharge except if another IPA is completed

PPS Discharge Assessment

• ARD equals end date of the most recent stay

• Not used for payment purposes

• Section O therapy days/minutes

Three-Day Interruption Window

If readmitted within three days,

pick up where they left off

If readmitted after three days, MDS

cycle restarts

If admitted from another SNF, MDS cycle

restarts

9/11/2018

20

PDPM Impact on OBRA Assessments

• No changes to OBRA requirements

• Admission/quarterly/annual/significant change

• Monitor any changes to state Medicaid case mix

• Use of Medicare PPS MDS for case mix determination

Preparation for PDPM Today

• ICD-10 Diagnoses Coding

• Goal

• Accurate documentation of diagnosis that will impact PDPM

• Steps

• Assess current process

• Assess staff competencies

• Start including ICD-10 codes on current MDS

9/11/2018

21

Preparation for PDPM Today

• MDS Section GG Coding

• Goal

• Change focus from compliance to accuracy

• Steps

• Assess process

• Provide education for staff on PDPM impact

• Start coding as if payment depended on it

Preparation for PDPM Tomorrow

• Therapy Service Model• Goal

• Identification of appropriate therapy provision within the PDPM modelto achieve resident goals/outcomes

• Steps• Assess data & identify best practices

• Develop “care paths” for rehab services

• Open discussion with contract therapy providers

9/11/2018

22


• Therapy – Nursing Communication

• Goal

• Develop an effective team approach to achieve resident goals & outcomes without negatively affecting medical necessity for skilled therapy services

• Steps

• Assess current communication system between nursing & therapy

• Evaluate current nursing restorative program

• Identify education needs for nursing staff


• Length of Stay Management• Goal

• Develop the goals for length of stay management under PDPM

• Steps• Assess length of stay data on current population by diagnosis/clinical

condition

• Evaluate impact on PDPM payment

• Establish goals for LOS management

9/11/2018

23

Final Thoughts – Making the Transition

• Develop systems, knowledge & habits on ICD-10 now

• Learn & implement strategies to improve ADL/functionalscoring

• Revitalize & elevate restorative nursing programs

9/11/2018

24

CONTINUING PROFESSIONAL EDUCATION (CPE) CREDIT

BKD, LLP is registered with the National Association of State Boards of Accountancy (NASBA) as a sponsor of continuing professional education on the National Registry of CPE Sponsors. State boards of accountancy have final authority on the acceptance of individual courses for CPE credit. Complaints regarding registered sponsors may be submitted to the National Registry of CPE Sponsors through its website: www.nasbaregistry.org

The information contained in these slides is presented by professionals for your information only & is not to be considered as legal advice. Applying specific information to your situation requires careful consideration of facts & circumstances. Consult your BKD advisor or legal counsel before acting on any matters covered.

CPE CREDIT

• CPE credit may be awarded upon verification of participant attendance

• For questions, concerns or comments regarding CPE credit, please email the BKD Learning & Development Department at [email protected]

9/11/2018

25

BKD Thoughtware®

• Webinars & articles – Many CPE-eligible

• Recent articles

• Compassionate Care Series

• Deciphering the Final Rule

• Upcoming webinars

• 9/7 – QRP

• 9/12 – Final Rule

bkd.com/hc | @BKDHC

Camille Lockhart | [email protected]

Chris Murphy | [email protected]

Joanne Jones | [email protected]