10 mds scheduling essentials intro to pps …...09, 10, 88, [-] ** to | | payment model. resources:...
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1/13/2020
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MDS ESSENTIALS
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Introduction to PPS Scheduling and The Patient-Driven Payment Model (PDPM)
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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.
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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)
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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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MDS ESSENTIALS
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Understanding Medicare PPS Assessments
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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
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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)
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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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MDS ESSENTIALS
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Scheduled PPS Assessments
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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
Day 15 Day 16 Day 17 Day 18 Day 19 Day 20 Day 21
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
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PDPM PPS Scheduling Medicare
MDS Assessment
Schedule Type
Assessment Reference
Date (ARD)
Applicable Standard Medicare
Payment Days
Completion Transmission to QIES ASAP
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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MDS ESSENTIALS
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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
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PDPM PPS Scheduling
Medicare MDS Assessment
Schedule Type
Assessment Reference Date (ARD)
Applicable Standard Medicare Payment
Days
Completion Transmission to QIES ASAP
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
1
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Day 15 Day 16 Day 17 Day 18 Day 19 Day 20 Day 21
Day 22 Day 23 Day 24 Day 25 Day 26 Day 27 Day 28
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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MDS ESSENTIALS
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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
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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
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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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MDS ESSENTIALS
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Application - Late AssessmentDay 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 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 Page 6-53)
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Introduction to PDPM23
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PT Component and
OT Component
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MDS ESSENTIALS
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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
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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
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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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MDS ESSENTIALS
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PT and OT ComponentsI0020B: S72.041K
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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
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PT and OT ComponentsThe 10 PDPM default clinical categories collapse to 4 categories
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MDS ESSENTIALS
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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
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PT and OT Components• Scoring for the PT and OT function score
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MDS ESSENTIALS
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SLP Component
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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
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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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MDS ESSENTIALS
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SLP Component
Handout
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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
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SLP Component
• SLP-Related Comorbidities
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MDS ESSENTIALS
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SLP Component • Swallowing Disorder
– Signs and symptoms of potential swallowing disorder
– 7-day look-back
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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
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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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MDS ESSENTIALS
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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
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Nursing Component
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Nursing Component
• Case-Mix Methodology – GG function score – Qualifying services, conditions, and resources – Indicators of depression– Restorative programs
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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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MDS ESSENTIALS
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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!
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Nursing ComponentConvert the section GG score on the MDS to
the PDPM Function Score
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Nursing ComponentFunction Score on 5-Day
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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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MDS ESSENTIALS
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GG Item
Adm. Performance score
PDPM Function Score Conversion
Scoring Method
Function Score
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) 03TOTAL Function Score
ANSWERS
4222112
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GG Item
Adm. Performance score
PDPM Function Score Conversion
Scoring Method
Function Score
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) 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
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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
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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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MDS ESSENTIALS
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Nursing Component
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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
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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
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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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MDS ESSENTIALS
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Nursing Component
CATEGORY: Special Care HighStep 4: Select classification based on nursing function score and presence or absence of depression:
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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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Nursing ComponentCATEGORY: Special Care LowStep 1: One of the following:
– 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
Nursing ComponentCATEGORY: Special Care LowStep 1: One of the following:
– 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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MDS ESSENTIALS
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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
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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)
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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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MDS ESSENTIALS
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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
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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
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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)
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Nursing ComponentCATEGORY: Behavioral Symptoms and Cognitive Performance
Step 5: Restorative Count
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MDS ESSENTIALS
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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
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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
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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
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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
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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)
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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
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Variable Per Diem Adjustment Schedule
• PT and OT Variable Per Diem Adjustment Factor:
90
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Variable Per Diem Adjustment Schedule
• NTA Variable Per Diem Adjustment Factor
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PDPM Variable Rate Adjustments
PT= $ 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
Days 1-3 NTA x 3
x 3
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PDPM Variable Rate Adjustments
PT= $ 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
Days 4-20No Adjustments
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PDPM Variable Rate Adjustments
PT= $ 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
Days 21-100PT and OT decline by 2% every 7 days
2%
2%$
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PDPM Variable Rate Adjustments
PT= $111.54
OT = $92.78
SLP = $15.06
Nursing = $230.72
NTA = $74.93
Non-Case Mix = $92.63
Example only
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PDPM Variable Rate Adjustments
PT= $111.54
OT = $92.78
SLP = $15.06
Nursing = $230.72
NTA = $74.93 x 3 = $224.79
Non-Case Mix = $92.63
x 3
Days 1-3 NTA x 3
Per Diem Rate: $767.52
Example only96
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PDPM Variable Rate AdjustmentsPT= $111.54
OT = $92.78
SLP = $15.06
Nursing = $230.72
NTA = $74.93
Non-Case Mix = $92.63
Days 4-20 No Adjustment
Per Diem Rate: $617.66
Example only
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PDPM Variable Rate Adjustments
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
Non-Case Mix = $92.63
Days 21-100 PT/OT declines 2% every 7 days
Days 21-27PT rate x 0.98OT rate x 0.98
Per Diem Rate: $613.57
Example only
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PDPM Variable Rate Adjustments
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
Non-Case Mix = $92.63
Example only
Days 21-100 PT/OT declines 2% every 7 days
Days 28-34PT rate x 0.96OT rate x 0.96
Per Diem Rate: $609.49
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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
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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
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Interrupted Stay Policy
SNF Stay Returns within window for a continued Medicare stay
D/C
Interrupted Stay Window
Medicare Stay
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Interrupted Stay
SNF Stay Returns within window for a continued Medicare stay
D/C
Interrupted Stay Window
Medicare Stay
SNF StayDoes not return within window. This is a new
Medicare stayD/C
Interrupted Stay Window
Medicare Stay Medicare Stay
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See Handouts
Case-Mix Group Conversion to
HIPPS Characters
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Assessment Indicator (AI) Crosswalk
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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
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Questions
Please submit questions to:The New to MDS Community
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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
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 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
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
SLP 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.
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
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
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
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
Non-Therapy Ancillary (NTA) 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.
** 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
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
Non-Therapy Ancillary (NTA) Component (Continued)
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.
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
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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
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