10 mds scheduling essentials intro to pps …...09, 10, 88, [-] ** to | | payment model. resources:...

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MDS ESSENTIALS

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Introduction to PPS Scheduling and The Patient-Driven Payment Model (PDPM)


Faculty Disclosures

• I have no financial relationships to disclose• I have no conflicts of interests to disclose• I will not promote any commercial products or

services

All Planning Committee members, content reviewers, authors, and presenters have been evaluated for conflicts of interest and there are not any to disclose.


Educational Activity Completion and CE Disclosure

Requirements for Successful Completion• 1.25 contact hours will be awarded for this continuing nursing

education activity.• Criteria for successful completion includes attendance for at

least 80% of the entire event. Partial credit may not be awarded.

• Approval of this continuing education activity does not imply endorsement by AANAC or ANCC (American Nurses Credential Center) of any commercial products or services.

American Association of Post-Acute Care Nursing (AAPACN)* is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

*AAPACN d/b/a American Association of Nurse Assessment Coordination (AANAC)


ContentRAI User’s Manual Chapter 2• PPS Assessment

Scheduling

RAI User’s Manual Chapter 6• Medicare Skilled

Nursing Facility Prospective Payment System (SNF PPS)

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Understanding Medicare PPS Assessments


2.8 The SNF Medicare PPS Assessment Schedule

Skilled nursing facilities must assess the clinical condition of beneficiaries by completing the MDS assessment for each Medicare resident receiving Part A SNF-level care for reimbursement of SNF Prospective Payment System (PPS)

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Key concept:Required for

payment


6.2 Using the MDS in the Medicare Prospective Payment System

The MDS is used to calculate the Patient-Driven Payment Model (PDPM) classification necessary for payment• Made up of five case-mix adjusted component

and one non-case-mix component 1. Physical Therapy (PT)2. Occupational Therapy (OT)3. Speech Language Pathology (SLP)4. Nursing5. Non-therapy ancillary (NTA)

7Visit us at AANAC.org | Copyright © 2019

6.4 Relationship between the Assessment and the Claim

• SNF PPS establishes a schedule of PPS assessments– The 5-Day assessment is the only required PPS assessment

that is used to support PPS reimbursement – The Interim Payment Assessment (IPA) is an optional

assessment and may be used to reclassify the resident into a new PDPM classification

• If a resident’s status does not meet the criteria for Medicare Part A SNF Coverage, the provider cannot bill Medicare for any non-covered days

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Scheduled PPS Assessments


PDPM PPS Scheduling Medicare

MDS Assessment

Schedule Type

Assessment Reference Date (ARD)

Applicable Standard Medicare Payment

Days

Completion Transmission to QIES ASAP

5-Day scheduled

PPSDays 1-8

All covered Medicare

Part A days until the

Part A discharge (unless an

IPA is completed)

Must be completed

(item Z0500B) within 14 days after the ARD

(ARD + 14 calendar

days)

Within 14 days after

completion (item Z0500B) (completion + 14 calendar

days)

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ApplicationDay 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

Day 8 Day 9 Day 10 Day 11 Day 12 Day 13 Day 14


5-day ARD must be set within days 1-8

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The 5-Day is used for payment for the entire Medicare Part A stay, unless an IPA is completed


PDPM PPS Scheduling Medicare

MDS Assessment

Schedule Type

Assessment Reference

Date (ARD)

Applicable Standard Medicare

Payment Days


Interim Payment

Assessment (IPA)

Optional

ARD of the assessment

through Part A discharge (unless

another IPA is completed)

Must be completed

(item Z0500B) within 14 days after the ARD

(ARD + 14 calendar

days)

Within 14 days after completion

(item Z0500B) (completion + 14

calendar days)

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Interim Payment Assessment

• Optional assessment• Payment starts on ARD • Will pay for the remainder of the Medicare stay,

unless another IPA is completed

0 8


PDPM PPS Scheduling

Medicare MDS Assessment

Schedule Type

Assessment Reference Date (ARD)

Applicable Standard Medicare Payment

Days


Part A PPS Discharge

Assessment

PPS Discharge: Equal to the end date of the most recent Medicare stay (A2400) or discharge date

(A2000) if combined with OBRA Discharge

N/A

Must be completed (item

Z0500B) within 14 days after the end

date of most recent Medicare

stay (A2400C + 14 calendar days)

Within 14 days after completion

(item Z0500B) (completion + 14 calendar

days)

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PPS Part A Discharge Assessment

• Required for Medicare Part A only• Required when a resident’s Medicare Part A stay

ends, but the resident remains in the facility• Required if the End Date of Most Recent Medicare

Stay (A2400C) occurs on the day or one day before physical discharge from the facility– Both OBRA and PPS Part A discharge are required– May be combined

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Remains in facility

Application

Resident is on a Medicare Part A stay• All skilled services ended and last day of Medicare is day 23• Resident will remain in the facility • End Date of Most Recent Medicare Stay (A2400C) = Day 23• Part A PPS Discharge assessment required - ARD on day 23

Last Day of

Medicare

Part A PPS Discharge

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ApplicationDay 8 Day 9 Day 10 Day 11 Day 12 Day 13 Day 14

Resident is on a Medicare Part A stay• Discharges unplanned to the acute care on day 12 and does not

return within 3 days• End Date of most recent Medicare Stay (A2400C) = day of

discharge• Part A PPS Discharge required with ARD of day 12• OBRA DC return anticipated required with ARD of day 12

–Combine OBRA Discharge and PPS Part A Discharge on day 12

Discharge to acute

OBRA Discharge/Part A PPS Discharge


Payment Penalty

What happens when you’re out of compliance?

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Non-compliance6.8 Non-compliance with the SNF PPS

Assessment Schedule • To receive payment you must complete the

required SNF PPS scheduled assessments – An assessment that does not have an ARD within

the prescribed ARD window will be paid at the default rate for the number of days out of compliance

– Default rate = ZZZZZ


Late Assessment

• ARD is set after the defined ARD window –Default is applied to the number of days the

assessment was out of compliance –Once outside of the ARD window, the ARD

can be no earlier than the day the error was identified

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Application - Late AssessmentDay 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7


5-Day ARD window5-Day ARD window

5-day

• 5-Day is set on day 10• 2 days outside of prescribed ARD window• Bill 2 days at the default rate

• Count the number of days out of compliance including the ARD

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Missed Assessment

• SNF fails to set the ARD of a PPS assessment prior to the end of the last day of the ARD window, including grace days, and the resident is no longer a SNF PPS Part A resident – Facility is liable

• Cannot bill Medicare or any other payer– Some exceptions (RAI -53)

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Introduction to PDPM23


PT Component and

OT Component

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PT and OT Components• Primary clinical category

– Primary reason for the SNF PPS stay– May be different from reason for qualifying hospital stay– Methodology uses MDS item I0020B– Use ICD-10 Mapping file to determine clinical category

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html


PT and OT Components• In addition to coding the ICD-10-CM code at

I0020B, if the resident had a surgery related to the primary diagnosis during the preceding hospital stay, this also needs to be identified– May be needed to achieve one of the surgery-related

clinical categories (not required by all diagnoses)• Major Joint Replacement or Spinal Surgery• Non-Orthopedic Surgery• Orthopedic Surgery

• The surgical procedure category will be selected by checking the applicable MDS items J2100 –J5000

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PT and OT Components


PT and OT Components• ICD-10 Mapping file:• Some diagnoses will return a message under the

fourth column named: Resident Had a Major Procedure During the Prior

Inpatient Stay That Impacts the SNF Care Plan• Indicates that the resident may be eligible for more

than one surgical category– Based on coding of J2100-J5000– If column 4 is “n/a” then surgery code is not required and

the default clinical category code applies

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PT and OT ComponentsI0020B: S72.041K


Key Insight• I0020B does not contain

enough information to determine primary clinical category

• J2100-J5000 will determine if primary clinical category is Major Joint or Other Orthopedic

S72.041K

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How Is J2300-J5000 Used?I0020B: S72.041K

No surgical procedure during hospital stay


PT and OT ComponentsThe 10 PDPM default clinical categories collapse to 4 categories

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PT and OT Components• Primary Clinical Category

– PDPM clinical category collapses into one of the four PT and OT clinical categories

– Some diagnoses may achieve more than one surgical category• MDS items J2100- J5000 will determine

primary category

Major Joint Replacement or Spinal Surgery

Other Orthopedic

Non-Orthopedic Surgery

Medical Management

Not all surgery diagnoses require a surgery code at J2100-5000; see column 4 of ICD-10 Mapping

file for details

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PT and OT ComponentsPT and OT function score• 5-Day MDS

– Section GG Admission performance in column 1

– Three-day assessment window starting on the first day of the Medicare stay

• Interim Payment Assessment (IPA) – Section GG interim

performance in column 5– Three-day assessment window

ending on the ARD of the IPA

• Eating (GG0130A) • Oral hygiene (GG0130B)• Toileting hygiene (GG0130C) • Sit to lying (GG0170B) • Lying to sitting on side of bed

(GG0170C)• Sit to stand (GG0170D) • Chair/bed-to-chair transfer

(GG0170E)• Toilet transfer (GG0170F) • Walk 10 feet (GG0170I) – Used only to determine if resident

has ability to ambulate• Walk 50 feet with two turns

(GG0170J) • Walk 150 feet (GG0170K)

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PT and OT Components

• Convert the section GG performance score to the PDPM function score


PT and OT Components• Scoring for the PT and OT function score

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SLP Component


SLP Component

Methodology• Presence of an acute neurologic condition,

cognitive impairment, or SLP-related comorbidity– None, Any one, Any two, or All three

• Presence of a swallowing disorder or mechanically altered diet – Neither, Either, or Both

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SLP Component

• Presence of acute neurologic condition – Coded as primary

reason for SNF PPS Stay at I0020B

– Determined per CMS Clinical Category Mapping file


SLP Component • Impaired Cognition

– BIMS interview (Preferably the day of or the day before the ARD)• Cognitively intact with a BIMS score of 13–15• Mildly impaired with a score of 8–12• Moderately impaired with a score of 0–7

– If BIMS is incomplete or not attempted, then the Cognitive Performance Score (CPS) is used • B0100 (with GG0170B, C, D, E, and F) • B0700• C0700• C1000 Tool on next slide

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SLP Component

Handout


SLP Component

• In cases where neither the BIMS nor the staff assessment is completed, the resident will be considered “cognitively intact” for PDPM SLP case-mix classification purposes

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SLP Component • BIMS or CPS scores must be evaluated using

PDPM cognitive scoring methodology • Scoring of “mildly” to “severely” will trigger as

cognitively impaired for the SLP case-mix methodology

Cognitive Level BIMS Score CPS Score Cognitively intact 13–15 0Mildly impaired 8–12 1–2

Moderately impaired 0–7 3–4

Severely impaired - 5–6


SLP Component

• SLP-Related Comorbidities

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SLP Component • Swallowing Disorder

– Signs and symptoms of potential swallowing disorder

– 7-day look-back


SLP Component

• Mechanically altered diet – 7-day look-back period– Only uses column 2, “while a resident”

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SLP Component

• RAI User’s Manual definition of mechanically altered diet

A diet specifically prepared to alter the texture or consistency of food to facilitate oral intake. Examples include soft solids, puréed foods, ground meat, and thickened liquids. A mechanically altered diet should not automatically be considered a therapeutic diet

• Coding Tip– Enteral feeding formulas should not be coded as a

mechanically altered diet


SLP Component • Step 1: Determine

whether None, Any one, Any two, or All three conditions are present– Acute Neurologic at

I0020B– Impaired cognition

(BIMS or CPS)– Any SLP-related

comorbidities

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SLP Component

• Step 2: Determine if Neither, Either, or Both of the following conditions are present:– Swallowing problem coded

at K0100A–D – Mechanically altered diet

coded at K0510C2


Nursing Component

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Nursing Component

• Case-Mix Methodology – GG function score – Qualifying services, conditions, and resources – Indicators of depression– Restorative programs


Nursing Component

• GG Function Score– 5-Day

• Admission performance score (column 1) • Usual performance days 1-3 of Medicare stay • Before benefitting from treatment intervention

– Interim Payment Assessment (IPA)• Interim performance score (column 5) • ARD of IPA + 2 previous calendar days • Usual performance

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Nursing Component

GG Function Score for Nursing • Eating (GG0130A)• Toileting hygiene (GG0130C)• Sit to lying (GG0170B)• Lying to sitting on side of bed (GG0170C)• Sit to stand (GG0170D)• Chair/bed-to-chair transfer (GG0170E)• Toilet transfer (GG0170F)

Three fewer items than PT/OT

function score!


Nursing ComponentConvert the section GG score on the MDS to

the PDPM Function Score

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Nursing ComponentFunction Score on 5-Day


GG Item

Adm. Performance score

PDPM Function Score Conversion

Eating (GG0130A1) 06

Toileting hygiene (GG0130C1) 03

Sit to lying (GG0170B1) 03Lying to sitting on side of bed

(GG0170C1) 03Sit to stand (GG0170D1) 02

Chair/bed-to-chair transfer (GG0170E1) 02

Toilet transfer (GG0170F1) 03

4222112

EXAMPLE

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GG Item



Scoring Method

Function Score






Toilet transfer (GG0170F1) 03TOTAL Function Score

ANSWERS

4222112


GG Item



Scoring Method

Function Score






Toilet transfer (GG0170F1) 03TOTAL Function Score

ANSWERS

Ind. Score4222112

4Ind. Score 2Avg. 2 bed mobility

items

(2+2) / 2= 2 2

Avg. 3 transfer

items

(1+1+2) / 3 = 1.3 1.3

4 + 2 + 2 + 1.3 = 9.3 (round to nearest integer) 958


Nursing Component• Qualifying services, conditions, and

resources– Start at top of hierarchical groups and work

down • First PDPM nursing group the resident

qualifies for is assigned


Nursing ComponentCATEGORY: EXTENSIVE SERVICESStep 1: One of the following:

– Tracheostomy care while a resident (O0100E2)– Invasive Mechanical Ventilator while a resident

(O0100F2)– Isolation or quarantine for active infectious

disease while a resident (O0100M2)Step 2: GG function score

–Nursing function score 14 or less • If 15 or 16, skip to Clinically Complex

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Nursing Component


Nursing ComponentCATEGORY: Special Care HighStep 1: One of the following:

– Comatose and completely dependent or activity did not occur at admission (B0100 and GG0130A1, GG0130C1, GG0170B1, GG0170C1, GG0170D1, GG0170E1, and GG0170F1, all equal 01, 09, or 88)

– Septicemia (I2100) – Diabetes with both insulin injections for all 7 days and insulin

order changes on 2 or more days (I2900, N0350A and B)– Quadriplegia (I5100) with Nursing function score less than or

equal to 11– Fever (J1550A) and Pneumonia (I2000), Vomiting (J1550B),

Weight loss (K0300), OR Feeding tube (K0510B1 or K0510B2)– COPD (I6200) and shortness of breath while lying flat (J1100C)– Parenteral or IV feedings (K0510A1 or A2) – Respiratory therapy while a resident (O0400D2) for all 7 days

Continued…62


Nursing ComponentCATEGORY: Special Care HighStep 1 continued: Tube feeding classification requirements

– (1) K0710A3 is 51% or more of total calories OR– (2) K0710A3 is 26% to 50% of total calories and

K0710B3 is 501 cc or more per day fluid enteral intake in the last 7 days

Step 2: GG function score – Nursing function score 14 or less

• If 15 or 16, skip to Clinically Complex

Continued…63


Nursing ComponentCATEGORY: Special Care HighStep 3: Evaluate for depression

– Identified from the PHQ-9 or PHQ-9-OVThe resident qualifies as depressed if:

D0300 is greater than or equal to 10 but not 99

orD0600 is greater than or equal to 10

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Nursing Component

CATEGORY: Special Care HighStep 4: Select classification based on nursing function score and presence or absence of depression:


Nursing ComponentCATEGORY: Special Care LowStep 1: One of the following:

– Cerebral palsy (I4400) and Nursing function score is less than or equal to 11

– Multiple Sclerosis (I5200) and Nursing function score is less than or equal to 11

– Parkinson’s disease (I5300) and Nursing function score is less than or equal to 11

– Respiratory failure (I6300) and oxygen therapy while a resident (O0100C2)

– Feeding tube (K0510B1 or K0510B2)Continued…

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– Two or more Stage 2 pressure ulcers (M0300B1) with two or more selected skin treatments (M1200)

– Any Stage 3 or 4 pressure ulcer or unstageable due to slough/eschar (M0300C1, D1, F1) with two or more selected skin treatments (M1200)

– Two or more venous/arterial ulcers (M1030) with two or more selected skin treatments (M1200)

– 1 Stage 2 pressure ulcer (M0300B1) and 1 venous/arterial ulcer (M1030)with two or more selected skin treatments (M1200)

– Foot infection (M1040A), diabetic foot ulcer (M1040B), or other open lesion on foot (M1040C) with application of dressings to the feet (M1200I)

Continued…67Visit us at AANAC.org | Copyright © 2019


– Radiation treatment while a resident (O0100B2) – Dialysis treatment while a resident (O0100J2)

Feeding tube requirements: • (1) K0710A3 is 51% or more of total calories OR• (2) K0710A3 is 26% to 50% of total calories and K0710B3 is 501 cc or more

per day fluid enteral intake in the last 7 daysSelected skin treatments:• Pressure-relieving chair and/or bed* (M1200A, B)• Turning/repositioning (M1200C)• Nutrition or hydration intervention (M1200D)• Pressure ulcer care (M1200E) • Application of dressings (not to feet) (M1200G)• Application of ointments (not to feet) (M1200H)

*Count as one treatment even if both provided68

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Nursing ComponentCATEGORY: Special Care LowStep 2: GG function score

–Nursing function score 14 or less • If 15 or 16, skip to Clinically Complex

Step 3: Evaluate for depression– Identified from the PHQ-9 or PHQ-9-OV

• The resident qualifies as depressed if:– D0300 is greater than or equal to 10 but not 99 OR – D0600 is greater than or equal to 10

Continued…69


Nursing Component

CATEGORY: Special Care LowStep 4: Select classification based on nursing function score and presence or absence of depression:

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Nursing ComponentCATEGORY: Clinically ComplexStep 1: One of the following:

– Pneumonia (I2000) – Hemiplegia/hemiparesis (I4900) with Nursing Function

score less than or equal to 11– Open lesions (other than ulcers, rashes, and cuts)

(M1040D) with any selected skin treatment* or surgical wounds (M1040E)

– Burns (M1040F) – Chemotherapy while a resident (O0100A2) – Oxygen therapy while a resident (O0100C2) – IV medications while a resident (O0100H2) – Transfusions while a resident (O0100I2 ) *Selected Skin Treatments: M1200F Surgical wound care, M1200G Application of nonsurgical dressing (other than to feet), M1200H Application of ointments/medications (other than to feet)


Nursing ComponentCATEGORY: Clinically ComplexStep 2: Evaluate for depression

– Identified from the PHQ-9 or PHQ-9-OV• The resident qualifies as depressed if D0300 is greater

than or equal to 10 but not 99 OR D0600 is greater than or equal to 10

Step 4: Select classification based on nursing function score and presence or absence of depression:

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Nursing ComponentCATEGORY: Behavioral Symptoms and Cognitive Performance Step 1: PDPM nursing function score

– If nursing function score less than 11, skip to the Reduced Physical Function category

Step 2: BIMS interview – If the BIMS interview was not conducted (C0100 = 0), go to

step 3 (next slide)– If BIMS Summary score is 9 or less, the resident classifies for

the Behavioral Symptoms and Cognitive Performance category

– If the BIMS interview scored “99” or the summary score is blank or dashed, go to step 3


Nursing ComponentCATEGORY: Behavioral Symptoms and Cognitive Performance Step 3: Staff Assessment of Mental Status If the resident meets one of the three following conditions, he/she classifies in the Behavioral Symptoms and Cognitive Performance category 1. Coma (B0100 = 1) and completely dependent or activity did not occur at

admission (GG0130A1, GG0130C1, GG0170B1, GG0170C1, GG0170D1, GG0170E1, and GG0170F1 all equal 01, 09, or 88)

2. Severely impaired cognitive skills for daily decision making (C1000 = 3) 3. Two or more of the following impairment indicators are present:

– B0700 > 0 Usually, sometimes, or rarely/never understood– C0700 = 1 Short-term memory problem– C1000 > 0 Impaired cognitive skills for daily decision makingand– One or more of the following severe impairment indicators is present:– B0700 > = 2 Sometimes or rarely/never makes self understood– C1000 > = 2 Moderately or severely impaired cognitive skills for daily

decision making74


Nursing ComponentCATEGORY: Behavioral Symptoms and Cognitive Performance Step 4: BehaviorsIf the resident presents with one of the following behavioral symptoms, he/she classifies in the Behavioral Symptoms and Cognitive Performance category • Hallucinations (E0100A) • Delusions (E0100B) • Physical behavioral symptoms directed towards others (E0200A = 2 or

3) • Verbal behavioral symptoms directed towards others (E0200C = 2 or 3) • Other behavioral symptoms not directed towards others (E0200C = 2

or 3) • Rejection of care (E0800 = 2 or 3) • Wandering (E0900 = 2 or 3)


Nursing ComponentCATEGORY: Behavioral Symptoms and Cognitive Performance

Step 5: Restorative Count

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Nursing Component

CATEGORY: Behavioral Symptoms and Cognitive Performance

Step 6: PDPM classification Select the final PDPM classification by using the total PDPM nursing function score and the restorative nursing count


Nursing ComponentCATEGORY: Reduced Physical FunctionStep 1: Did not meet previous categories • Residents who do not meet the conditions of any of the

previous categories, including those who would meet the criteria for the Behavioral Symptoms and Cognitive Performance category but have a PDPM nursing function score less than 11, are placed in this category

Step 2: Restorative count

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Nursing ComponentCATEGORY: Reduced Physical FunctionStep 3: PDPM nursing classification – Select the PDPM classification using the nursing

function score and the restorative count


Nursing Component

• HIV/AIDS Add-On–Permanent adjustment in the PDPM case-

mix groups• Additional 18% of the nursing component• Active HIV/AIDS diagnosis

– ICD-10-CM code B20 on the Medicare claim

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Non-Therapy Ancillary (NTA) Component


NTA Component

• Case-Mix Methodology – Sum of points assigned to the presence of 50

different conditions or extensive services – Primarily uses MDS for classification, with one

exception • HIV/AIDS (ICD-10 B20) is only identified on the

Medicare claim• Assigned 8 points

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NTA Component

– Tracheostomy Care• O0100E2 (while a resident) • Assigned 1 point

– Isolation• O0100M2 (while a resident) • Assigned 1 point

– Radiation• O0100B2 (while a resident) • Assigned 1 point

– Suctioning• O0100D2 (while a resident) • Assigned 1 point

– IV Medication • O0100H2 (while a resident) • Assigned 5 points

– Ventilator or Respirator• O0100F2 (while a resident) • Assigned 4 points

– Transfusion • O0100I2 (while a resident) • Assigned 2 points

Section O: Special Treatments, Procedures, and Programs


NTA Component – Intermittent Catheterization

• H0100D• Assigned 1 point

– Ostomy• H0100C• Assigned 1 point

– Feeding Tube• K0510B2 (while a resident)• Assigned 1 point

– Parenteral IV Feeding• K0510A2• Assigned 7 or 3 points

– Diabetic Foot Ulcer• M1040B• Assigned 1 point

– Stage 4 Pressure Ulcer• M0300D1• Assigned 1 point

– Foot Infection or Other open lesion on the foot• M1040A or M1040C• Assigned 1 point

Section M: Skin Conditions Section H: Bladder and Bowel

Section K: Nutritional Status

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NTA Component

– Multiple Sclerosis • I5200• Assigned 2 points

– Malnutrition • I5600• Assigned 1 point

– Asthma, COPD, Chronic Lung Disease • I6200• Assigned 2 points

– Inflammatory Bowel Disease• I1300• Assigned 1 point

– Multi-Drug Resistant Organism (MDRO)• I1700• Assigned 1 point

– Wound Infection • I2500• Assigned 2 points

– Diabetes Mellitus • I2900• Assigned 2 points

Section I: Active Diagnoses (I0100-I7900)


NTA Component

– Endocarditis• Assigned 1 point

– Immune Disorders• Assigned 1 point

– End-Stage Liver Disease• Assigned 1 point

– Narcolepsy and Cataplexy • Assigned 1 point

– Cystic Fibrosis• Assigned 1 point

– Specified Hereditary Metabolic/Immune Disorders• Assigned 1 point

– Lung Transplant Status • Assigned 3 points

– Major Organ Transplant Status, Except Lung• Assigned 2 points

– Opportunistic Infections• Assigned 2 points

– Bone/Joint/Muscle Infections/Necrosis – except Aseptic Necrosis of Bone • Assigned 2 points

– Chronic Myeloid Leukemia• Assigned 2 points

Section I: Additional Active Diagnoses (I8000)

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NTA Component All remaining assigned 1 point

– Systemic Lupus Erythematosus, Other Connective Tissue Disorders, and Inflammatory Spondylopathies

– Diabetic Retinopathy (Except Proliferative)

– Severe Skin Burn or Condition – Intractable Epilepsy– Disorders of Immunity – Except Immune

Disorders – Cirrhosis of Liver – Respiratory Arrest– Pulmonary Fibrosis and Other Chronic

Lung Disorders

– Morbid Obesity – Psoriatic Arthropathy and

Systemic Sclerosis – Chronic Pancreatitis – Proliferative Diabetic Retinopathy

and Vitreous Hemorrhage – Complications of Specified

Implanted Device or Graft– Aseptic Necrosis of Bone – Cardio-Respiratory Failure and

Shock – Myelodysplastic Syndromes and

Myelofibrosis

Section I: Additional Active Diagnoses (I8000)

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PDPM Per Diem CalculationPT = $ case-mix adjusted rate

OT = $ case-mix adjusted rate

SLP = $ case-mix adjusted rate

Nursing = $ case-mix adjusted rate

NTA = $ case-mix adjusted rate

Non-Case-Mix = $ flat rate

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Variable Per Diem• Payment Model Research identified that certain costs

and services did not remain constant throughout the Medicare stay – High initial cost of non-therapy ancillaries – Tapering costs and services of PT and OT

Component Case-Mix Adjusted Variable Per Diem (VPD) Adjustment Schedule

Physical Therapy X X

Occupational Therapy X X

Speech-language pathology X

Nursing X

Non-therapy ancillary X X

Non-case-mix


Variable Per Diem Adjustment Schedule

• PT and OT Variable Per Diem Adjustment Factor:

90


Variable Per Diem Adjustment Schedule

• NTA Variable Per Diem Adjustment Factor


PDPM Variable Rate Adjustments

PT= $ case-mix adjusted rate





Non-Case Mix = $ flat rate

Days 1-3 NTA x 3

x 3

92

89 90

91 92

1/13/2020

24

MDS ESSENTIALS









Days 4-20No Adjustments









Days 21-100PT and OT decline by 2% every 7 days

2%

2%$

94



PT= $111.54

OT = $92.78

SLP = $15.06

Nursing = $230.72

NTA = $74.93

Non-Case Mix = $92.63

Example only



PT= $111.54

OT = $92.78

SLP = $15.06

Nursing = $230.72

NTA = $74.93 x 3 = $224.79


x 3

Days 1-3 NTA x 3

Per Diem Rate: $767.52

Example only96

93 94

95 96

1/13/2020

25

MDS ESSENTIALS


PDPM Variable Rate AdjustmentsPT= $111.54

OT = $92.78

SLP = $15.06

Nursing = $230.72

NTA = $74.93


Days 4-20 No Adjustment


Example only



PT= $111.54 x 0.98 = $109.31

OT = $92.78 x 0.98 = $90.92

SLP = $15.06

Nursing = $230.72

NTA = $74.93


Days 21-100 PT/OT declines 2% every 7 days

Days 21-27PT rate x 0.98OT rate x 0.98


Example only

98



PT= $111.54 x 0.96 = $107.08

OT = $92.78 x 0.96 = $89.07

SLP = $15.06

Nursing = $230.72

NTA = $74.93


Example only

Days 21-100 PT/OT declines 2% every 7 days

Days 28-34PT rate x 0.96OT rate x 0.96



Interrupted Stay PolicyCMS Definition of Interrupted Stay• CMS defines an “interrupted” SNF stay as one in

which a patient is discharged from Part A covered SNF care and subsequently readmitted to Part A covered SNF care in the same SNF (not a different SNF) during the interruption window

• Note that if a resident drops to a non-skilled level of care or otherwise leaves Part A SNF care, the patient is considered to have been discharged for the purposes of the interrupted stay policy, even if the patient remains in the facility

97 98

99 100

1/13/2020

26

MDS ESSENTIALS


Interrupted Stay Policy

CMS Definition of Interruption Window• The interruption window is a 3-day period that

begins on the first non-covered day following a Part A-covered SNF stay and ends at 11:59pm on the third consecutive non-covered day

• It should be noted that the first non-covered day may be different depending on if the patient leaves the facility or simply leaves Part A coverage


Interrupted Stay Policy

SNF Stay Returns within window for a continued Medicare stay

D/C

Interrupted Stay Window

Medicare Stay


Interrupted Stay

SNF Stay Returns within window for a continued Medicare stay

D/C


Medicare Stay

SNF StayDoes not return within window. This is a new

Medicare stayD/C


Medicare Stay Medicare Stay


See Handouts

Case-Mix Group Conversion to

HIPPS Characters

101 102

103 104

1/13/2020

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MDS ESSENTIALS


Assessment Indicator (AI) Crosswalk


PDPM – HIPPS Code

• Example:Character Payment Group CMG HIPPS

1st character PT and OT payment group TN N

2nd character SLP payment group SH H

3rd character Nursing payment group CBC2 N

4th character NTA payment group NC C

5th character Assessment indicator 5-Day 1



108

105 106

107 108

1/13/2020

28

MDS ESSENTIALS


Questions

Please submit questions to:The New to MDS Community

109

109

Copyright 2019, American Association of Post-Acute Care Nursing, d/b/a American Association of Nurse Assessment Coordination. All Rights Reserved. AANAC.org | Released Aug. 2019Copyright 2019, American Association of Post-Acute Care Nursing, d/b/a American Association of Nurse Assessment Coordination. All Rights Reserved. AANAC.org `

Patient-Driven Payment Model (PDPM): At-a-GlanceThe PDPM establishes a rate on the 5-day MDS for the entire stay by combining five different case-mix components (PT, OT, SLP, Nursing, and Non-Therapy Ancillary) with the non-case-mix component. The rate may be changed during the Medicare Part A stay by completing the optional Interim Payment Assessment (IPA).

Use the following at-a-glance tools to identify the case-mix group for each component and improve your understanding of the Patient-Driven Payment Model.

NOTE: This document is intended to aid members in their review of the Patient-Driven Payment Model. Resources: FY 2019 and FY 2020 SNF PPS Final Rulemaking, CMS Fact sheet: PDPM Patient Classification, and CMS draft PDPM Calculation Worksheet for SNFs. AANAC has made every attempt to ensure the accuracy and reliability of the information provided. AANAC does not accept any responsibility or liability for the accuracy, content, and completeness of the information.

PT Case-Mix

Group

OT Case-Mix

Group

SLP Case-Mix

Group

Nursing Case-Mix

Group

Non-Therapy Ancillary Case-Mix

Group

Non-Case-Mix Component

Resident’s Total Rate

1

Patient-Driven Payment Model: At-a-Glance

Copyright 2019, American Association of Post-Acute Care Nursing, d/b/a American Association of Nurse Assessment Coordination. All Rights Reserved. AANAC.org | Released Aug. 2019

PT Component and OT Component*

Scoring Response for Section GG Items Score

05, 06 Set-up assistance, independent 4

04Supervision or touching assistance

3

03 Partial/moderate assistance 2

02 Substantial/maximal assistance 1

01, 07, 09, 10, 88, [-]

Dependent, refused, not attempted, resident does not walk**

0

Section GG items (column 1 on the 5-day or column 5 on the IPA)

Score

GG0130A Self-care: Eating 0–4

GG0130B Self-care: Oral hygiene 0–4

GG0130C Self-care: Toileting hygiene 0–4

GG0170B Mobility: Sit to lying 0–4 (avg. of 2 bed

mobility items)

GG0170CMobility: Lying to sitting on side of bed

GG0170D Mobility: Sit to stand 0–4 (avg. of 3 transfer items)

GG0170EMobility: Chair/bed-to-chair transfer

GG0170F Mobility: Toilet transfer

GG0170JMobility: Walk 50 feet with 2 turns

0–4 (avg. of 2 walking items)GG0170K Mobility: Walk 150 feet

Major Joint Replacement or Spinal Surgery

6–9

10–23

24

0–5

6–9

10–23

24

0–5

6–9

10–23

24

0–5

6–9

10–23

24

0–5

Other Orthopedic

Medical Management

TA

TB

TC

TD

TE

TF

TG

TH

TI

TJ

TK

TL

TM

TN

TO

TP

Non-Orthopedic Surgery and Acute Neurologic

Clinical Category

PT and OT Case-Mix Group

GG Function Score


PT Component and OT Component: PT and OT components will always result in the same case-mix group; however, the PT and OT case-mix indices/payment levels differ.

If a resident is coded as not attempted (07, 09, 10, or 88) for GG0170I1 (Walk 10 feet), then walking items for GG0170J1 (Walk 50 feet with 2 turns) and GG0170K1 (Walk 150 feet) will be scored as zero points.

1.53

1.70

1.88

1.92

1.42

1.61

1.67

1.16

1.13

1.42

1.52

1.09

1.27

1.48

1.55

1.08

1.49

1.63

1.69

1.53

1.41

1.60

1.64

1.15

1.18

1.45

1.54

1.11

1.30

1.50

1.55

1.09

PT CMI

OT CMI

2



SLP Component


Neither

Either

Both

Any one

Neither

Either

Both

Any two

Neither

Either

Both

All three

Neither

Either

Both

SD

SE

SF

SG

SH

SI

SJ

SK

SL

SA

SB

SC

None

Presence of Acute Neurologic Condition, SLP-Related Comorbidity*, or Cognitive Impairment**

Presence of: Swallowing Disorder (K0100A–D) OR Mechanically Altered Diet (K0510C2)

SLP Case-Mix

Group

SLP-Related Comorbidities:Aphasia (I4300); CVA, TIA, or Stroke (I4500); Hemiplegia or Hemiparesis (I4900); TBI (I5500); Tracheostomy (O0100E2); Ventilator (O0100F2); Laryngeal Cancer, Apraxia, Dysphagia, ALS, Oral Cancers, Speech and Language Deficits (I8000)

Cognitive Impairment:The PDPM cognitive level is based on the Brief Interview for Mental Status (BIMS) or staff assessment. See the CMS PDPM Calculation worksheet in chapter 6 of the RAI User's Manual.

SLP CMI

1.46

2.34

2.98

2.04

2.86

3.53

2.99

3.70

4.21

0.68

1.82

2.67

3



Nursing Component* NOTE: This document is intended to aid members in their review of the Patient-Driven Payment Model. Resources: FY 2019 and FY 2020 SNF PPS Final Rulemaking, CMS Fact sheet: PDPM Patient Classification, and CMS draft PDPM Calculation Worksheet for SNFs. AANAC has made every attempt to ensure the accuracy and reliability of the information provided. AANAC does not accept any responsibility or liability for the accuracy, content, and completeness of the information.

RESIDENT

CLINICALLY COMPLEX YES

2 DEPRESSED0-5

6-1415-16

CDE2 CBC2

CA2

1 NOT DEPRESSED

0-56-14

15-16

CDE1 CBC1

CA1

YES

2 NURSING REHAB 2+

0-56-14

15-16

PDE2 PBC2

PA2

1 NURSING REHAB 0-1

0-56-14

15-16

PDE1 PBC1

PA1 REDUCED PHYSICAL FUNCTION

BEHAVIOR SX COGNITION

11-16 BAB2

11-16 BAB1YES

2 NURSING REHAB 2+

1 NURSING REHAB 0-1

SPECIAL CARE HIGH

0-56-14

HDE2 HBC2

0-56-14

HDE1 HBC1

YES2 DEPRESSED

1 NOT DEPRESSED

SPECIAL CARE LOW

0-56-14

LDE2 LBC2

0-56-14

LDE1 LBC1

YES2 DEPRESSED

1 NOT DEPRESSED

NO

NO

NO

NO

NO

EXTENSIVE SERVICES YES

ES3 ES2

ES1

3 TRACHEOSTOMY & VENTILATOR2 TRACHEOSTOMY OR VENTILATOR1 INFECTION ISOLATION

0-140-140-14

GG-based Function Score

Scoring Response for Section GG Items Score

05, 06 Set-up assistance, independent 4

04 Supervision or touching assistance 3

03 Partial/moderate assistance 2

02 Substantial/maximal assistance 1

01, 07, 09, 10, 88, [-]

Dependent, refused, not attempted 0

Section GG items (column 1 on the 5-day or column 5 on the IPA)

Score

GG0130A Self-care: Eating 0–4

GG0130C Self-care: Toileting hygiene 0–4

GG0170B Mobility: Sit to lying 0–4 (avg. of 2 bed mobility items) GG0170C

Mobility: Lying to sitting on side of bed

GG0170D1 Mobility: Sit to stand0–4

(avg. of 3 transfer items)

GG0170E1Mobility: Chair/bed-to-chair transfer

GG0170F1 Mobility: Toilet transfer

Nursing Component: See the CMS PDPM calculation worksheet in chapter 6 of the RAI User's Manual for inclusion criteria for each nursing classification.

Nursing CMI

4.063.072.93

2.402.241.991.86

2.081.721.731.43

1.871.551.091.621.340.94

1.04

0.99

1.571.220.711.471.130.66

4



Non-Therapy Ancillary (NTA) Component


** High level: K0710A2 = 3. 51% or more (while a resident)** Low level: K0710A2 = 2. 26–50% (while a resident) and

K0710B2 = 2. 501cc/day or more (while a resident)

Condition/Extensive Service Source Points

HIV/AIDS SNF Claim 8

Parenteral IV Feeding: Level High MDS Item K0510A2, K0710A2 7

Special Treatments/Programs: Intravenous Medication Post-admit Code MDS Item O0100H2 5

Special Treatments/Programs: Ventilator or Respirator Post-admit Code MDS Item O0100F2 4

Parenteral IV Feeding: Level LowMDS Item K0510A2, K0710A2, K0710B2

3

Lung Transplant Status MDS Item I8000 3

Special Treatments/Programs: Transfusion Post-admit Code MDS Item O0100I2 2

Major Organ Transplant Status, Except Lung MDS Item I8000 2

Active Diagnoses: Multiple Sclerosis Code MDS Item I5200 2

Opportunistic Infections MDS Item I8000 2

Active Diagnoses: Asthma COPD Chronic Lung Disease Code MDS Item I6200 2

Bone/Joint/Muscle Infections/Necrosis—Except Aseptic Necrosis of Bone MDS Item I8000 2

Chronic Myeloid Leukemia MDS Item I8000 2

Wound Infection Code MDS Item I2500 2

Active Diagnoses: Diabetes Mellitus (DM) Code MDS Item I2900 2

Endocarditis MDS Item I8000 1

Immune Disorders MDS Item I8000 1

End-Stage Liver Disease MDS Item I8000 1

Other Foot Skin Problems: Diabetic Foot Ulcer Code MDS Item M1040B 1

Narcolepsy and Cataplexy MDS Item I8000 1

Cystic Fibrosis MDS Item I8000 1

Special Treatments/Programs: Tracheostomy Care Post-admit Code MDS Item O0100E2 1

Active Diagnoses: Multi-Drug Resistant Organism (MDRO) Code MDS Item I1700 1

Special Treatments/Programs: Isolation Post-admit Code MDS Item O0100M2 1

Specified Hereditary Metabolic/Immune Disorders MDS Item I8000 1

Morbid Obesity MDS Item I8000 1

Special Treatments/Programs: Radiation Post-admit Code MDS Item O0100B2 1

Highest Stage of Unhealed Pressure Ulcer—Stage 4 MDS Item M0300D1 1

Psoriatic Arthropathy and Systemic Sclerosis MDS Item I8000 1

Chronic Pancreatitis MDS Item I8000 1

Proliferative Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1

Continued

5



Non-Therapy Ancillary (NTA) Component (Continued)


Condition/Extensive Service Source Points

Other Foot Skin Problems: Foot Infection Code, Other Open Lesion on Foot Code, Except Diabetic Foot Ulcer Code (M1040B)

MDS Item M1040A, M1040C

1

Complications of Specified Implanted Device or Graft MDS Item I8000 1

Bladder and Bowel Appliances: Intermittent Catheterization MDS Item H0100D 1

Inflammatory Bowel Disease MDS Item I1300 1

Aseptic Necrosis of Bone MDS Item I8000 1

Special Treatments/Programs: Suctioning Post-admit Code MDS Item O0100D2 1

Cardio-Respiratory Failure and Shock MDS Item I8000 1

Myelodysplastic Syndromes and Myelofibrosis MDS Item I8000 1

Systemic Lupus Erythematosus, Other Connective Tissue Disorders, and Inflammatory Spondylopathies

MDS Item I8000 1

Diabetic Retinopathy—Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage

MDS Item I8000 1

Nutritional Approaches While a Resident: Feeding Tube MDS Item K0510B2 1

Severe Skin Burn or Condition MDS Item I8000 1

Intractable Epilepsy MDS Item I8000 1

Active Diagnoses: Malnutrition Code MDS Item I5600 1

Disorders of Immunity—Except: RxCC97: Immune Disorders MDS Item I8000 1

Cirrhosis of Liver MDS Item I8000 1

Bladder and Bowel Appliances: Ostomy MDS Item H0100C 1

Respiratory Arrest MDS Item I8000 1

Pulmonary Fibrosis and Other Chronic Lung Disorders MDS Item I8000 1

NTA Score Range NTA Case-Mix Group

NTA CMI

12+ NA 3.24

9–11 NB 2.53

6–8 NC 1.84

3–5 ND 1.33

1–2 NE 0.96

0 NF 0.72

6

Resident Cognitive Level DeterminationSTEP A – SEVERELY IMPAIRED

MDS Item MDS Score Yes No

Option 1:Comatose (B0100) = 1 and all following Section GG items:

Self-Care ItemsEating (GG0130A1)Toileting hygiene (GG0130C1)

Mobility ItemsSit to lying (GG0170B1)

Lying to sitting on side of bed (GG0170C1)Sit to stand (GG0170D1)

Chair/bed-to-chairtransfer (GG0170E1)Toilet transfer (GG0170F1)

Option 2:Cognitive skills for daily decision making

B0100 = (1)andResident completely dependent or activity did not occur for ALL seven (7) Section GG items of the MDS

MDS coding equals one of the following:(01) Dependent(09) Not Applicable(88) Not attempted due to medical condition or safety concerns(10) Not attempted due to environmental limitations

C1000 = (3)

If “yes”to either option #1 or#2 stop here[Resident is considered severely cognitively impaired for PDPM]

If “no” to both option #1 and #2 proceed to Step B

STEP B1 – BASIC IMPAIRMENT COUNTMDS Item MDS Score Score

A. Cognitive Skills for Daily Decision Making (C1000) Score 1 point if MDS response to C1000 = 1 or 2

B. Makes Self Understood (B0700) Score 1 point if MDS response to B0700 = 1, 2, or 3

C. Short-term Memory OK (C0700) Score 1 point if MDS response to C0700 = 1

B1: Basic Impairment Count (Sum of A, B, and C scores)

STEP B2 – SEVERE IMPAIRMENT COUNTMDS Item MDS Score Score

D. Cognitive Skills for Daily Decision Making (C1000) Score 1 point if MDS response to C1000 = 2

E. Makes Self Understood (B0700) Score 1 point if MDS response to B0700 = 2 or 3

B2: Severe Impairement Count (sum of D and E scores)

PDPM Cognitive LevelSeverely Impaired If yes is answered to step 1 or 2 in Step A

Moderately Impaired If the Basic Impairment Count (B1) is 2 or 3 AND the Severe Impairment Count (B2) is 1 or 2.

Mildly Impaired If the Basic Impairment Count (B1) is 1, 2, or 3 and the Severe Impairment Count (B2) is “0”.

Cognitively Intact If both the basic (B1) and severe (B2) impairment count are “0”

Copyright 2019, American Association of Post-Acute Care Nursing, d/b/a American Association of Nurse Assessment Coordination. All Rights Reserved | AANAC.org

Disclaimer: AANAC has made every attempt to ensure the accuracy and reliability of the information provided. AANAC does not accept any responsibility or liability for the accuracy, content, and completeness of the information.Skilled Nursing Facilities are responsible to review and understand the the PDPM Classification Walkthrough. For more information: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/SNF_PDPM_Classification_Walkthrough_20181116.pdf Release Date: April 2019

7

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/SNF_PDPM_Classification_Walkthrough_20181116.pdf

PDPM Case-Mix Group Conversion to HIPPS Characters

PT/OT Payment Group

SLP Payment Group

Nursing Payment Group

NTA Payment Group HIPPS Character

TA SA ES3 NA A

TB SB ES2 NB B

TC SC ES1 NC C

TD SD HDE2 ND D

TE SE HDE1 NE E

TF SF HBC2 NF F

TG SG HBC1 G

TH SH LDE2 H

TI SI LDE1 I

TJ SJ LBC2 J

TK SK LBC1 K

TL SL CDE2 L

TM CDE1 M

TN CBC2 N

TO CA2 O

TP CBC1 P

CA1 Q

BAB2 R

BAB1 S

PDE2 T

PDE1 U

PBC2 V

PA2 W

PBC1 X

PA1 Y

Assessment Type HIPPS CharacterIPA 0

PPS 5-day 1

1st character PT and OT payment group

2nd character SLP payment group

3rd character Nursing payment group

4th character NTA payment group

5th character Assessment Indicator

Disclaimer: AANAC has made every attempt to ensure the accuracy and reliability of the information provided. AANAC does not accept any responsibility or liability for the accuracy, content, and completeness of the informationCopyright 2019, American Association of Post-Acute Care Nursing, d/b/a American Association of Nurse Assessment Coordination. All Rights Reserved | AANAC.org | Release Date: February 2019

10

10 mds scheduling essentials intro to pps …...09, 10, 88, [-] ** to | | payment model. resources:...

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