pdpm effective oct 1, 2019 (fy20) · ortho/musculoskeletal ortho surgery not major joint...

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Patient Driven Payment SystemPDPM

OverviewEffective Oct 1, 2019 (FY20)

Nov 2018

Judy Wilhide Brandt, RN, BA, CPC, QCP, RAC-MT, DNS-CT

909-800-9124

[email protected]

JudyWilhide.com

And you shall rise and show respect to the aged

Twitter: @WilhideMDSFacebook: /WilhideConsulting

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Objectives:

• Review the six components of the Patient Driven Payment System

• Discuss role of diagnosis coding and in the PT, OT, SLP, NTA components of a PDPM payment category

• Explain the variable per diem adjustment schedule• Review the PPS MDS schedule

• Examine additions to the Part A PPS Discharge and limitations on modes of therapy

• Explain the Interim Payment Assessment and it’s role in adjusting payment

• Review the differences between the PT/OT function score and the Nursing function score

• Explain how a function score is calculated• Review the ‘interrupted stay policy’

• Discuss changes to the nursing component categories

• Explain how presumption of coverage will work

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www.judywilhide.com/resources

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Patient Driven Payment System (PDPM)

Goals:• Remove therapy minutes as a determinant of

payment and create a new therapy payment model in which payment is linked to differences in clinical characteristics• Create a separate payment component for non-

therapy ancillary (NTA) services, using resident characteristics to predict utilization of these services.• Will begin Oct 1, 2019

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Overview

Six components in daily rate, all taken from PPS 5 day MDS. Each separate component will be assigned a daily rate based on that component’s case mix index (CMI), all added together for that resident’s daily rate.

$50

$50

$50

$50

$50

$50

= $300

NTA = non-therapy ancillaries

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Non-Case Mix

Nursing

NTA

PT

ST

OT


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Non-Case Mix

Nursing

NTA

PT

ST

OT

Full component rate for days 1 – 20, then both PT and OT each decrease 2% every 7 days

Full component rate for days 1-3, then 70% decrease for days 4 - 100

No variable per diem adjustment for ST, Nursing, Non-Case Mix

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Non-Case Mix

Nursing

NTA

PT

ST

OT ADL score is “end-split.” Now called “Function score”

• PT and OT use a function score derived from 10 ADL activities assessed in Section GG of a PPS 5 day MDS

• Nursing uses a function score derived from 7 ADL activities assessed in Section GG of a PPS 5 day MDS

Section GG Function Score Data Elements:

Eating GG0130A1 Eating

Oral Hygiene

GG0130B1 Oral Hygiene

Toileting Hygiene

GG0130C1 Toileting Hygiene

Average Bed Mobility

GG0170B1 Sit to Lying

GG0170C1 Lying to Sitting on Side of Bed

Average Transfer

GG0170D1 Sit to Stand

GG0170E1 Chair/Bed-to-Chair

GG0170F1 Toilet Transfer

Average Walking

GG0170J1 Walk 50 Feet with Two Turns

GG0170K1 Walk 150 Feet

Start of PPS Stay Section GG on PPS 5 day MDS

PT and OT componentsNursing component

Eating GG0130A1 Eating

Toileting Hygiene





Average Transfer




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For PT and OT Component: Section GG Responses Function Score

Independent or Set-up (05,06) 4Supervision or touching assistance (04) 3Partial/moderate assistance (03) 2Substantial/maximal assistance (02) 1Dependent, refused, N/A, or cannot walk (01,07,09,10, 88 or “could not walk 10 feet” (GG0170H = any code for “not attempted” 07,07,11,88), missing value

0

Function Score Range 0 - 24

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10

Category - ItemsAdmission

PerformanceInterim Score

W/averages (round to nearest whole number)

Eating G0130A1 Eating 06 set-up 4 4Oral Hygiene GG0130B1 Oral Hygiene 06 set-up 4 4Toileting Hygiene GG0130C1 Toileting Hygiene 02 max assist 1 1Bed Mobility GG0170B1 Sit to Lying 03 mod assist 2

2Bed Mobility GG0170C1 Lying/sit 03 mod assist 2Transfer GG0170D1 Sit to Stand 03 mod assist 2 1.66

Round to 2Transfer GG0170E1 Chair/Bed-to-Chair 03 mod assist 2Transfer GG0170F1 Toilet Transfer 02 max assist 1Walking GG0170J1 Walk 50 ft w/2 Turns 01 dependent 0 0Walking GG0170K1 Walk 150 Feet 01 dependent 0

Function Score: NA 13

When averaging bed mobility, transfer and walking, round to nearest whole number.

Six final elements for PT/OT Function Score

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Category - ItemsAdmission

PerformanceInterim Score

W/averages (round to

nearest whole number)

Eating GG0130A1 Eating 06 set-up 4 4

Toileting Hygiene GG0130C1 Toileting Hygiene

02 max assist 1 1

Bed Mobility GG0170B1 Sit to Lying03 mod assist 2

2Bed Mobility GG0170C1 Lying to Sitting on Side of Bed

03 mod assist 2

Transfer GG0170D1 Sit to Stand 03 mod assist 2

1.66 Round to 2

Transfer GG0170E1 Chair/Bed-to-Chair

03 mod assist 2

Transfer GG0170F1 Toilet Transfer 02 max assist 1Function

Score: NA 9

When averaging bed mobility and transfers, round to nearest whole number.

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Nursing Function score: 4 final elements

• Every resident is classified into every component, every time, based on PPS 5 day MDS.

• Even if no PT or OT or SLP received, each resident’s rate is determined using the CMI achieved for each separate component.

• Each major component is further subdivided into groups, each with a unique CMI.

• The computation for PT and for OT are identical, but the resident will get a separate CMI for PT and for OT, every time.

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Background - Clinical Categories:

• Based on analysis of primary reason for SNF care ten clinical categories were created:

1. Acute Infections2. Acute Neurologic3. Cancer 4. Cardiovascular and Coagulation 5. Major Joint Replacement or Spinal Surgery6. Medical Management7. Non-Surgical Orthopedic/Musculoskeletal8. Pulmonary 9. Non-Orthopedic Surgery10. Orthopedic Surgery (Except Major Joint Replacement or Spinal Surgery)

• Used Medical Severity – Diagnostic Related Group (MS-DRG) from the prior inpatient stay to define the primary reason for SNF care and assign residents to clinical categories

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•Acute infections•Medical Management•Cancer•Pulmonary•Cardiovascular & Coagulation

•Non-surgical orthopedic/musculoskeletal•Ortho Surg (not Maj Joint Repl/Spinal Surgery)

Maj Joint Repl/Spinal Surgery

Non-ortho surgery and Acute neurologic

Other Orthopedic

Medical Management

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• 10 Categories collapsed into 4 for PT and OT, because cost of care is commensurate

• Acute Neurologic is split out and used as a factor to generate the ST component rate

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15

17%

14%

9%60%

Percentage of SNF stays in PDPM Research

Acute neuro/non-ortho surgOther ortho

Maj JointRepl/Spinal Surg

Rounded to nearest whole number

Medical Management

Determine “Primary Diagnosis Clinical Category” using only the ICD-10 code listed first I8000A. Some primary diagnosis clinical categories may change if there is a surgical procedure done in hospital

If there was a surgical procedure during inpt stay that relates to primary reason for Part A SNF stay, there will be

checkboxes in J2000 to assign appropriate category

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Maj Joint Repl/Spinal Surgery


Other Orthopedic

Medical Management

PT and OT component

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CMS is developing sub-items for item J2000, which will allow providers to report the patient’s procedural information in a way that uses a checkbox mechanism, and this procedural information will be used in concert with the patient’s diagnosis information to classify the patient into a clinical category.

Primary Diagnosis Clinical Category

Example:

S72002S Fracture of unspecified part of neck of left femur, sequela = Other orthopedic categoryS72022S with ORIF = Other orthopedic categoryS72022S with hip replacement = Major joint replacement category

TA 1.53TB 1.69TC 1.88TD 1.92

Major Joint ReplacementTE 1.42TF 1.61TG 1.67TH 1.16

Other Ortho

Other Ortho = non-surgical ortho/musculoskeletal and ortho surgery not major joint repl or spinal surery

More dependent function score

Clinical Category Mapping

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

Huge spreadsheet with all the ICD-10CM codes and assignments on CMS website

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Return to Provider: Not deemed appropriate to enter as the primary reason for SNF care. Such codes either lack certainty and specificity required to properly categorize a resident under PDPM or the underlying condition cannot be the main reason of care in SNFs. When a code is returned to a provider, the provider is to select an appropriate ICD-10-CM diagnosis code from the SNF PDPM Clinical Category Mapping available at CMS’ website.

TM

TNTO

TP

0-5

6-910-23

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TE

TFTG

TH

Major Joint Replacement or Spinal Surgery

Other Ortho

Medical Mgt


0-5

6-910-23

TA

TBTC

TD

0-5

6-9

10-23

24

24

24 possible PT groups

Function Score: Lower number is more dependent

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TI

TJTK

TL

0-5

6-910-23

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PT and OT

Note: categories are identical for PT and OT but

they are separate components with

separate CMIs

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Maj. Joint Repl or Spinal SurgeryM97-periprothetic fracture around internal prosthetic hip & knee joint (other joints under “other ortho”)S12- fracture of neck bones

S22- fracture of ribs, sternum or thoracic spine

S32- fracture of lumbar spine and pelvis

S34.0-concussion and edema of lumbar and sacral spinal cord

S34.101D or S Unspec injury to L1

T84-Broken hip & knee prosthesis

Z47.1 Aftercare following joint replacement surgery

Example diagnoses

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Other Ortho

Ortho Surg that is not Maj Joint Repl or Spinal Surgery

Non-surg

ortho/M usculoskeletal

Ortho Surgery Not Major Joint Repl/Spinal

M96.6- bone fx after insertion of implant, prothesis or plate

M97-Periprothetic fracture around internal prosthetic joint: all others not hip and knee

Fracture, crushing, traumatic amputation of any bones not mentioned so far

Mechanical complications of implanted devices (fixation devices, plates, etc) for anything other than hip and knee)

Complications of reattachment of body parts

Stump issues: Neuromas, dehiscence

Encounter to remove any device the MD put in and it didn’t go well

Encounter for other orthopedic aftercare

Example diagnoses

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PT a

nd O

TOther Ortho

Ortho Surg that is not Maj Joint Repl or

Spinal Surgery

Non-surg ortho/Musculoskeletal

Clinical Category

Mixed bag of other ortho conditions such as: subluxation, avulsion, dislocation, stenosis, some other fractures that often don’t require surgery, compression fractures, benign bone/cartilage/etc tumors

Some non-surg ortho will bump to a surgery category if the surgical procedure checkbox applies in J2000

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PT a

nd O

T

Medical Mgt

Acute Infections

CV and Coagulations

Pulmonary

Cancer

Medical Management

Ch 1: Certain infectious & parasitic diseases, and some infections coded in other chapters: ex: Cellulitis, flu, appendicitis, staph arthritis, etc.

Ch 3: diseases of blood and blood forming organs & certain disorders involving immune mechanismCh 9: Diseases of the circulatory systemCh 10: Diseases of the respirator system, and some lung issues from other chapters, ex: traumatic pneumothorax

Ch 2: Neoplasms

TI 1.13TJ 1.42TK 1.52

TL 1.09

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(see next slide)

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Medical Management Other: examples - thyroiditis, benign tumors, diabetes, protein-calorie malnutrition, psych, eye, ear, unspecified and other CV disease, postthrombotic syndrome, bronchitis, Chrohn’s disease, liver failure, unspecified, pressure ulcers, chronic ulcers, non-pressure, Stress/pathologic fractures (may bump up to surgical category with surgical procedure in J2000), kidney disease, puncture wounds, lacerations

Sub-category “medical management” under “Medical Management” Category

PT a

nd O

T

Non Ortho surgery & Acute Neurologic

Most any surgery for anything not ortho: GI, GU, trauma, burn, graft, flap,

Acute neuro examples. Encephalitis, meningitis, hemiplegia, quadriplegia, brain hemorrhage, effects of stroke and other cerebral events, some skull fractures, nerve injuries, head injuries, spinal cord injuries(without surgery), nervous system issues

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Recap

Clinical Category Function ScorePT & OT Case

M ix Group PT CM I

M ajor Joint Replacement or Spinal Surgery 0-5 TA 1.53

M ajor Joint Replacement or Spinal Surgery 6-9 TB 1.69

M ajor Joint Replacement or Spinal Surgery 10-23 TC 1.88

M ajor Joint Replacement or Spinal Surgery 24 TD 1.92

Other Orthopedic 0-5 TE 1.42

Other Orthopedic 6-9 TF 1.61

Other Orthopedic 10-23 TG 1.67

Other Orthopedic 24 TH 1.16

M edical M anagement 0-5 TI 1.13

M edical M anagement 6-9 TJ 1.42

M edical M anagement 10-23 TK 1.52

M edical M anagement 24 TL 1.09

Non-Orthopedic Surgery and Acute Neurologic 0-5 TM 1.27

Non-Orthopedic Surgery and Acute Neurologic 6-9 TN 1.48

Non-Orthopedic Surgery and Acute Neurologic 10-23 TO 1.55

Non-Orthopedic Surgery and Acute Neurologic 24 TP 1.08

OT CM I

1.491.631.681.531.411.591.641.151.171.441.541.111.301.491.551.09

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SLP Component: Building BlocksStep 1: Services Count (Tier 1 Category)One point for each:

Acute Neurologic

Comorbidity

Cognitive Impairment

S

Swallowing disorder:Any in K0100

Mechanically Altered diet

Step 2: (Tier 2) Neither, either, or both?

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SLP Component

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MDS Item DescriptionI4300 AphasiaI4500 CVA, TIA, or StrokeI4900 Hemiplegia or HemiparesisI5500 Traumatic Brain InjuryI8000 Laryngeal CancerI8000 ApraxiaI8000 DysphagiaI8000 ALSI8000 Oral CancersI8000 Speech and Language DeficitsO0100E2 Tracheostomy Care While a ResidentO0100F2 Ventilator or Respirator While a Resident

SLP related co-morbidities

Cognitive Impairment:

BIMS < 12ORAt least mild impairment:• Cognitive skills for daily decision

making: modified independence or worse

• Makes self understood: usually or worse

• Memory Problem

Acute Neurologic: Same as PT and OT, based on diagnosis code in I8000A

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0.68

1.82

2.66

1.46

2.33

2.97

2.04

2.85

3.51

2.98

3.69

4.19

0neither SAeither SBboth SC

1neither SDeither SEboth SF

2neither SGeither SHboth SI

3neither SJeither SKboth SL

0. None of the 3 conditions1. Acute Neurologic2. Comorbidity3. Cognitive Impairment

1. Mechanically altered diet2. Swallowing Disorder

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SLP Categories

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NTA Component

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Non-case-mix component addresses consistent costs that are incurred for all residents, such as room and board and various capital related expenses.

Non-therapy ancillaries50 separate items on the MDS assigned a points value, many diagnosis codes in I8000

Condition/Extensive Service MDS Item Points

HIV/AIDS SNF Claim ICD-10 B20 8

Parenteral IV Feeding: Level High (51% calories) (not peg tube) K0510A2 K0710A2 7Special Treatments/Programs: Intravenous Medication Post-admit Code

O0100H2 5

Special Treatments/Programs: Ventilator Post-admit Code O0100F2 4Parenteral IV feeding: Level Low (26% calories/501cc fluid) (not peg tube)

K0510A2 K0710A2 K0710B2 3

Lung Transplant Status I8000 3Special Treatments/Programs: Transfusion Post-admit Code O0100I2 2Major Organ Transplant Status, Except Lung I8000 2Active Diagnoses: Multiple Sclerosis Code I5200 2Opportunistic Infections I8000 2Active Diagnoses: Asthma COPD Chronic Lung Disease Code I6200 2Bone/Joint/Muscle Infections/Necrosis - Except: Aseptic Necrosis of Bone I8000 2

Chronic Myeloid Leukemia I8000 2Wound Infection Code I2500 2Active Diagnoses: Diabetes Mellitus (DM) Code I2900 2Endocarditis I8000 1Immune Disorders I8000 1End-Stage Liver Disease I8000 1Other Foot Skin Problems: Diabetic Foot Ulcer Code M1040B 1

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Narcolepsy and Cataplexy I8000 1Cystic Fibrosis I8000 1Special Treatments/Programs: Tracheostomy Post-admit Code O0100E2 1Active Diagnoses: Multi-Drug Resistant Organism (MDRO) Code I1700 1Special Treatments/Programs: Isolation Post-admit Code O0100M2 1Specified Hereditary Metabolic/Immune Disorders I8000 1Morbid Obesity I8000 1Special Treatments/Programs: Radiation Post-admit Code O0100B2 1Highest Stage of Unhealed Pressure Ulcer - Stage 4 M0300X1 1Psoriatic Arthropathy and Systemic Sclerosis I8000 1Chronic Pancreatitis I8000 1Proliferative Diabetic Retinopathy and Vitreous Hemorrhage I8000 1Other Foot Skin Problems: Foot Infection Code, Other Open Lesion on Foot Code, Except Diabetic Foot Ulcer Code

M1040A M1040B M1040C

1

Complications of Specified Implanted Device or Graft I8000 1Bladder and Bowel Appliances: Intermittent catheterization H0100D 1Inflammatory Bowel Disease I8000 1Aseptic Necrosis of Bone I8000 1Special Treatments/Programs: Suctioning Post-admit Code O0100D2 1


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Cardio-Respiratory Failure and Shock I8000 1Myelodysplastic Syndromes and Myelofibrosis I8000 1Systemic Lupus Erythematosus, Other Connective Tissue Disorders, and Inflammatory Spondylopathies I8000 1

Diabetic Retinopathy - Except : Proliferative Diabetic Retinopathy and Vitreous Hemorrhage I8000 1

Nutritional Approaches While a Resident: Feeding Tube (peg tube) K0510B2 1Severe Skin Burn or Condition I8000 1Intractable Epilepsy I8000 1Active Diagnoses: Malnutrition Code I5600 1Disorders of Immunity - Except : RxCC97: Immune Disorders I8000 1Cirrhosis of Liver I8000 1Bladder and Bowel Appliances: Ostomy H0100C 1Respiratory Arrest I8000 1Pulmonary Fibrosis and Other Chronic Lung Disorders I8000 1


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NTA Comorbidity Score

NTA Case Mix Group CMI

12+ NA 3.259-11 NB 2.536-8 NC 1.853-5 ND 1.341-2 NE 0.960 NF 0.72

NTA CMI

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Nursing Component

Same major categories as RUG IV 66

Extensive Services

Special Care High

Special Care Low

Clinically Complex

Behavior Symptoms and Cognitive Impairment

Reduced Physical Function Eating GG0130A1 Eating

Toileting Hygiene





Average Transfer




Function ScoreInstead of ADL Score

0 – 16Lower score = more dependentUses hierarchy, not CMI

18% increase in payment for nursing component for residents with HIV/AIDS (B20 on SNF claim)

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Nursing Component

Same Nursing categories as RUG IV 66,except Function score, resulting in 24 nursing categories.

PDPM Nursing RUG Function Score CMI

ES3 0-14 4.04ES2 0-14 3.06ES1 0-14 2.91HDE2 0-5 2.39HDE1 0-5 1.99HBC2 6-14 2.23HBC1 6-14 1.85LDE2 0-5 2.07LDE1 0-5 1.72LBC2 6-14 1.71LBC1 6-14 1.43CDE2 0-5 1.86CDE1 0-5 1.62CBC2 6-14 1.54CA2 15-16 1.08CBC1 6-14 1.34CA1 15-16 0.94BAB2 11-16 1.04BAB1 11-16 0.99PDE2 0-5 1.57PDE1 0-5 1.47PBC2 6-14 1.21PA2 15-16 0.70PBC1 6-14 1.13PA1 15-16 0.66

Uses hierarchy, not CMI

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Illustrative Base Rates:

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Example:

Component Group CMI Amount Comments

PT TC 1.88 111.54 Maj Joint Replacement, PT/OT Function Score: 10

OT TC 1.68 92.79 Maj Joint Replacement, PT/OT Function Score: 10

SLP SA 0.68 15.06 Nothing to score higher

Nursing HBC2 2.23 230.72 Septicemia, depression, nursing function score 7

NTA 1 0.96 74.93 Chronic pancreatitis

Non-Case Mix

NA NA 92.63 (Urban rate)

Total per diem

617.67 Subject to variable per diem adjustment for PT, OT and NTA

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Interim Payment Assessment (IPA): NP item set

• Optional assessment: Facilities will be able to determine when IPAs will be completed for their patients to address potential changes is clinical status and what criteria should be used to decide when an IPA would be necessary.

• “We will seek additional stakeholder input on this issue of criteria for completion.”

• An IPA will not stop or change the variable per diem adjustment.• The ARD for the IPA will be the date the facility chooses to complete

the assessment relative to the triggering event that causes a facility to choose to complete the IPA. Payment based on the IPA will begin the same day as the ARD.

• The IPA will not be susceptible to assessment penalties, given the optional nature of the assessment.

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Therapy Delivery

• There will be a combined 25 percent limit on concurrent therapy and group therapy for each discipline of therapy provided.

• For example, if a resident received 800 minutes of physical therapy, no more than 200 minutes of this therapy could be provided on a concurrent or group basis.• Group and concurrent therapy should not be utilized to

satisfy therapist or resident schedules, and all group and concurrent therapy should be well documented in a specific way to demonstrate why they are the most appropriate mode for the resident and reasonable and necessary for his or her individual condition.

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Therapy Delivery• Therapy delivery items will be added to Part

A PPS Discharge Assessment for each discipline:• Start and End dates• Total individual, concurrent, group minutes• Total days

• If concurrent/group limits exceeded, non-fatal warning on validation report• Could be used to deny payment for those stays

upon medical review

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Interrupted Stay Policy• If resident is discharged from a SNF and returns to the same SNF

by midnight at the end of the third day of the interruption window, the resident’s stay will be a continuation of the previous stay for purposes of both resident classification and the variable per diem adjustment schedule. • If absence exceeds 3-day interruption window, readmission will

be treated as a new stay, in which the resident would receive a new 5-day assessment upon admission and the variable per diem adjustment schedule would reset to Day 1.• If resident readmits to a different SNF, it’s a new stay with new

5-day and variable per diem adjustment schedule

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Interrupted stay policy changes nothing about OBRA and PPS Discharges (or OBRA MDS schedule)

• You can be required to do an OBRA/PPS Discharge for what may be classified as an “interrupted stay” upon return.

• CMS will revise codes for SNF-QRP so that a hospital admission and return to SNF in “interrupted stay” does not trigger a new stay for SNF-QRP

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Questions/Discussion

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pdpm effective oct 1, 2019 (fy20) · ortho/musculoskeletal ortho surgery not major joint...

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