LLP Preparing for the Patient Driven Payment Model · 2019-08-21 · ©2018 CliftonLarsonAllen LLP...

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Preparing for the Patient‐Driven Payment ModelSeptember 6, 2019

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Disclaimers

The information contained herein is general in nature and is not intended, and should not be construed, as legal, accounting, or tax advice or opinion provided by CliftonLarsonAllen LLP to the user. The user also is cautioned that this material may not be applicable to, or suitable for, the user’s specific circumstances or needs, and may require consideration of non‐tax and other tax factors if any action is to be contemplated. The user should contact his or her CliftonLarsonAllen LLP or other tax professional prior to taking any action based upon this information. CliftonLarsonAllen LLP assumes no obligation to inform the user of any changes in tax laws or other factors that could affect the information contained herein.

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About CLA

• A professional services firm with three distinct business lines– Wealth Advisory– Outsourcing– Audit, Tax, and Consulting

• More than 6,400 employees• Offices coast to coast• Serving 8,300+ health care organizations Investment advisory services are offered through CliftonLarsonAllen Wealth Advisors, LLC.

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Learning Objectives

At the end of this session, you will be able to:• Understand how PDPM links payment to residents’

conditions and care needs, rather than volume of services provided

• Explore the expansion of case‐mix based payment components and how MDS assessment data will be used for payment purposes

• Explore the changes to the MDS assessment process, ICD‐10 coding, and billing

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PDPM Prospective Payment System

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Why PDPM?“The PDPM would be a significant shift in how SNFs are paid and, we believe, a very positive one. It reflects our belief that we should not be paying providers in ways that drive overuse of services. Instead, we should pay providers based on the patients they treat, while assessing quality fairly.”

Secretary Alex M. Azar, Secretary of Health and Human Services, AHCA/NCAL Congressional Briefing. June 4, 2018.

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What is PDPM?• PDPM removes the use of therapy minutes to assess

residents for a reimbursement level.• PDPM is based on clinical and diagnosis information rather

than amount of service needed.• Creates a separate payment component for non‐therapy

ancillary (NTA) services, using resident characteristics to predict utilization.

• Enhances payment accuracy based on clinical aspects of care.

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What is PDPM (con’t)?

• PDPM consists of five case mix adjusted payment components– Physical Therapy (PT)– Occupational Therapy (OT)– Speech Language Pathology (SLP)– Nursing– Non‐Therapy Ancillary (NTA)

• A non‐case mix component for services that don’t vary based on resident characteristics

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PDPM Replaces RUG‐IV SNF Payment Model on October 1, 2019

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Components of PDPM

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Macro Financial Considerations

•Behavior changes

Budget neutral

•8,101 of 13,769 providers analyzed by CMS are expected to gain

More winners than losers

• Varying provider perspectives

Therapy cost and utilization

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PDPM Base Rates vs RUGs Base Rates

RUG‐IV

Source: https://https://www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/SNFPPS/Spotlight.html

Urban - $423.49/Rural - $438.50

Urban - $428.85/Rural - $444.61

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Big Change ‐ Variable Payments

Constant payments do not accurately reflect medical needs and resources used.

Two aspects of variable payment:

•PT/OT rate•After 20 days, PT/OT portion of rate declines by 2 percent every 7 days

•Non‐Therapy Ancillary (NTA) rate•After 3 days, NTA portion of rate declines by 67 percent until discharge

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Leading Practices in Preparing for PDPM

Understanding financial

implications

Recognizing the financial

drivers

Training and coordination

Therapy contract

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Understanding Financial Implications and Recognizing the Financial Drivers

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Financial Modeling

Exploration of top five RUG levels

Revenue modeling‐provider example

Sensitivity Analysis• Therapy CMI• Comorbidity• Length of Stay

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Exploration of Top Five RUG levels

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PDPM vs RUG Rate ‐ Very High

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PDPM vs RUG Rate ‐ Very High

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PDPM vs RUG Rate ‐ Ultra High

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PDPM vs RUG Rate ‐ Ultra High

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Revenue Modeling – Provider Example

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Revenue Modeling – Provider Example

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Sensitivity Analysis

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SLP Therapy CMI Impact

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SLP Therapy CMI Impact

$17.97/day increase

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Impact of Co‐Morbidity Selection

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Impact of Co‐Morbidity Selection

Potential Increase of $38.01 in NTA component

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Billing Changes

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How to Bill Starting 10/1/19

• Any Skilled Part A in‐house resident MUSThave a PDPM HIPPS code in order to bill for services on or after 10/1/19

• Each Skilled resident with need an IPA beginning 10/1/19. The ARD cannot be later than 10/7/19

• The IPA will determine the PDA classification and payment starting 10/1/19 throughout the skilled benefit period.

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Current RUG IV Sample UB‐04 Bill

R Rehab AssessmentU Ultra High Rehab (720+ Minutes received)B ADL Category 10 Assessment Period (5 day covers days 1‐14)

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New PDPM Sample UB‐04 Bill

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New SNF PDPM HIPPS (Billing) Codes Format• The HIPPS codes are derived from each of the five case mix components in this specific order

HIPPS Component

Case Mix GroupNumber of Case Mix Groups

1st PT/OT 16 (A ‐ P)2nd SLP 12 (A ‐ L)3rd Nursing 25 (A ‐ Y)4th NTA (Non Therapy Ancillary) 6 (A ‐ F)5th Assessment Indicator for a 5 day assessment 2 (1 or 0)

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HIPPS Codes: PT/OT

• PT/OT uses T for Therapy

• 16 codes A thru P

Case Mix Group

HIPPS Code

TA ATB BTC CTD DTE ETF FTG GTH HTI ITJ JTK KTL LTM MTN NTO OTP P

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HIPPS Codes: SLP (Speech Language Pathology)

• SLP uses S for Therapy

• 12 codes A thru L

Case Mix Group

Hipps Code

SA ASB BSC CSD DSE ESF FSG GSH HSI ISJ JSK KSL L

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HIPPS Codes: Nursing

• Nursing uses multiple case mix codes to describe the type of nursing service performed

• 25 codes A thru Y

Case Mix

Hipps Code

ES3 AES2 BES1 CHDE2 DHDE1 EHBC2 FHBC1 GLDE2 HLDE1 ILBC2 JLBC1 KCDE2 LCDE1 MCBC2 NCA2 OCBC1 PCA1 QBAB2 RBAB1 SPDE2 TPDE1 UPBC2 VPA2 WPBC1 XPA1 Y

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HIPPS Codes: NTA (Non Therapy Ancillaries)

• NTA uses N

• 6 codes A thru F

Case Mix Group

Hipps Code

NA ANB BNC CND DNE ENF F

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PDPM Case‐Mix Adjusted Federal Rate & Associated Indexes –URBAN

Based on Federal Register Proposed FY 2020 Rates

Proposed FY 2020 rates

PDPM Group

PT CMI

PT Rate

OT CMI

OT Rate

SLP CMI

SLP Rate

Nursing CMG

Nursing CMI

Nursing Rate

NTA CMI

NTA Rate

A 1.53 93.57$ 1.49 84.83$ 0.68 15.52$ ES3 4.06 432.96$ 3.24 260.66$ B 1.70 103.97$ 1.63 92.80$ 1.82 41.55$ ES2 3.07 327.38$ 2.53 203.54$ C 1.88 114.98$ 1.63 92.80$ 2.67 60.96$ ES1 2.93 312.46$ 1.84 148.03$ D 1.92 117.43$ 1.53 87.10$ 1.46 33.33$ HDE2 2.40 255.94$ 1.33 107.00$ E 1.42 86.85$ 1.41 80.27$ 2.34 53.42$ HDE1 1.99 212.21$ 0.96 77.23$ F 1.61 98.47$ 1.60 91.09$ 2.98 68.03$ HBC2 2.24 238.87$ 0.72 57.92$ G 1.67 102.14$ 1.64 93.37$ 2.04 46.57$ HBC1 1.86 198.35$ ‐ ‐$ H 1.16 70.95$ 1.15 65.47$ 2.86 65.29$ LDE2 2.08 221.81$ ‐ ‐$ I 1.13 69.11$ 1.18 67.18$ 3.53 80.59$ LDE1 1.73 184.49$ ‐ ‐$ J 1.42 86.85$ 1.45 82.55$ 2.99 68.26$ LBC2 1.72 183.42$ ‐ ‐$ K 1.52 92.96$ 1.54 87.67$ 3.70 84.47$ LBC1 1.43 152.50$ ‐ ‐$ L 1.06 64.83$ 1.11 63.19$ 4.21 96.11$ CDE2 1.87 199.42$ ‐ ‐$ M 1.27 77.67$ 1.30 74.01$ ‐$ CDE1 1.62 172.76$ ‐ ‐$ N 1.48 90.52$ 1.50 85.40$ ‐$ CBC2 1.55 165.29$ ‐ ‐$ O 1.55 94.80$ 1.55 88.24$ ‐$ CA2 1.09 116.24$ ‐ ‐$ P 1.08 66.05$ 1.09 62.05$ ‐$ CBC1 1.34 142.90$ ‐ ‐$ Q ‐ ‐$ ‐$ ‐$ CA1 0.94 100.24$ ‐ ‐$ R ‐ ‐$ ‐$ ‐$ BAB2 1.04 110.91$ ‐ ‐$ S ‐ ‐$ ‐$ ‐$ BAB1 0.99 105.57$ ‐ ‐$ T ‐ ‐$ ‐$ ‐$ PDE2 1.57 167.42$ ‐ ‐$ U ‐ ‐$ ‐$ ‐$ PDE1 1.47 156.76$ ‐ ‐$ V ‐ ‐$ ‐$ ‐$ PBC2 1.22 130.10$ ‐ ‐$ W ‐ ‐$ ‐$ ‐$ PA2 0.71 75.71$ ‐ ‐$ X ‐ ‐$ ‐$ ‐$ PBC1 1.13 120.50$ ‐ ‐$ Y ‐ ‐$ ‐$ ‐$ PA1 0.66 70.38$ ‐ ‐$

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New System: PDPM HIPPS Code for BillingSample EHMA1

Casemix Group

Clinical CategorySection GG Function

ScoreHIPPS Code

PT/OT TE Other Orthopedic 0‐5 E

SLP SH

Presence of Acute Neurologic Condition, SLP‐related comorbidity, or cognitive

impairment. Any 2

Mechanically Altered Diet or swallowing discorder. Either

Nursing CDE1

Classification Group: Clinically Complex. Clinical Conditions: Conditions requiring complex medical care. E.g. Pneumonia,

surgical wounds, burns. Depression: No

0‐5 M

NTA NA NTA Score Range: 12+ N/A A

Assessment 1 = 5 Day 0 = IPA

1 N/A 1

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Estimated PDPM Rate Calculations –Sample 1 EHMA1

PDPM Group

HIPPS Code CMI

VPD FY 2020 Per Diem

Estimated Adjusted

Per Diem RateDays1‐20 PT TE E 1.42 1.00 61.16$ 86.85$ 1‐20 OT TE E 1.41 1.00 56.93$ 80.27$ 1‐20 SLP SH H 2.86 ‐ 22.83$ 65.29$ 1‐20 Nsg CDE1 M 1.62 ‐ 106.64$ 172.76$ 1‐3 NTA NA A 3.25 3.00 80.45$ 784.39$

1,189.56$ Per Day for days 1 ‐ 3

PDPM Group

HIPPS Code

CMI VPD FY 2020 Per Diem

Estimated Adjusted

Per Diem RateDays1‐20 PT TE E 1.42 1.00 61.16$ 86.85$ 1‐20 OT TE E 1.41 1.00 56.93$ 80.27$ 1‐20 SLP SH H 2.86 ‐ 22.83$ 65.29$ 1‐20 Nsg CDE1 M 1.62 ‐ 106.64$ 172.76$ 4‐20 NTA NA A 3.25 1.00 80.45$ 261.46$

666.63$ Per Day for Days 4 ‐ 20

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New System: PDPM HIPPS Code for Billing Sample LCVD1

Casemix Group

Clinical CategorySection GG Function

ScoreHIPPS Code

PT/OT TL Medical Management 24 L

SLP SC

Presence of Acute Neurologic Condition, SLP‐related comorbidity, or cognitive

impairment. None

Mechanically Altered Diet or swallowing

discorder. Both

Nursing PBC2

Classification Group: Reduced Physical Function

Clinical Conditions: Assistance with daily Living and General supervision

Depression: N/A

6 ‐ 14 V

NTA ND NTA Score Range: 3‐5 N/A D

Assessment 1 = 5 Day 0 = IPA

1 N/A 1

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Estimated PDPM Rate Calculations –Sample 2 LCVD1

PDPM Group

HIPPS Code

Estimated Adjusted

Per Diem RateDays1‐20 PT TL L 1.09 1.00 61.16$ 66.66$ 1‐20 OT TL L 1.11 1.00 56.93$ 63.19$ 1‐20 SLP SC C 2.67 ‐ 22.83$ 60.96$ 1‐20 Nsg PBC2 V 1.21 ‐ 106.64$ 129.03$ 1‐3 NTA ND D 1.34 3.00 80.45$ 323.41$

643.26$ Per Day for days 1 ‐ 3

PDPM Group

HIPPS Code

Adjusted Per Diem Rate

Days1‐20 PT TL L 1.09 1.00 61.16$ 66.66$ 1‐20 OT TL L 1.11 1.00 56.93$ 63.19$ 1‐20 SLP SC C 2.67 ‐ 22.83$ 60.96$ 1‐20 Nsg PBC2 V 1.21 ‐ 106.64$ 129.03$ 4 ‐ 20 NTA ND D 1.34 1.00 80.45$ 107.80$

427.65$ Per Day for Days 4 ‐ 20

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MDS and ICD‐10 coding implications on PDPM calculation

Clinical Considerations and Component Rate Calculations

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Calculation of PDPM payment• Similar to RUGs, PDPM takes components

from the MDS and diagnoses to determine payment

• A main difference is how therapy payment is determined

• The MDS assessment and ICD‐10 CM coding accuracy are critical to success

• The nursing component has remained mostly the same along with the non‐case mix adjusted component.

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Clinical Considerations Overview

Therapy• PT/OT• Speech

ICD‐10• Primary•Mapping

Nursing• NTA• Coding

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PDPM Flowchart – PT+OT

PT and OT are classified into the same category but each component is assigned a different case mix adjustment factor

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Clinical Categories for PT & OT

PT & OT Clinical CategoriesMajor Joint Replacement or Spinal SurgeryNon‐Orthopedic Surgery & Acute Neurologic

Other OthopedicMedical Management

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ADL Changes Under PDPM

• No longer based on 4 late loss ADLs• Based on Functional Abilities and Goals,

Section GG of MDS Assessment– 2 main categories: self‐care and mobility

• PT/OT will utilize 3 self care and 6 mobility questions

• Nursing utilizes 4 questions• SLP does not utilize ADLs

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Function Score for PDPM

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Section GG

• 3 day evaluation– First 3 Medicare days– IPA requirement

• Usual performance– IDT decision

• Education

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Section GG Functional Score• ADL functional score calculated using the following ADL items

– Eating– Bed mobility (average of 2 scores)– Oral hygiene– Transfer (average of 3 scores)– Toileting– Walking (average of 2 scores)

• Based on a scale from 0‐24 combined– 0‐4 points (from entries on section GG of MDS) for each

ADL group above based on relative costliness associated with each response

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Sample Section GG Questions

Source: https://www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/SNFPPS/Downloads/MDS_Manual_Ch_6_PDPM_508.pdf

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PDPM Flowchart ‐ SLP

Acute Neurologic, Cognitively Impaired,

or SLP Related Comorbidity

Mechanically Altered Diet or Swallowing

Disorder

Neither

Either

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SLP Comorbidities

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Cognitive Impairment

• Assessed using either Brief Interview for Mental Status (BIMS) or Cognitive Performance Scale (CPS)

• Accurate assessment of cognition will be imperative in category placement.

• Rehab teams should familiarize themselves with the scoring for accurate category placement

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Nursing• Nursing component would maintain existing case‐mix groups but

will be based on a function score from ADL items on Section GG of the MDS (0‐16 combined score)– Self‐care: Eating– Self‐care: Toileting hygiene– Bed Mobility: Sit to lying– Bed Mobility: Lying to sitting on side of bed– Transfer: Sit to stand– Transfer: Chair/bed‐to chair transfer– Transfer: Toilet transfer

• The nursing component will still be determined by a type of index maximization system.

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Non‐Therapy Ancillary (NTA)

• Classification based on comorbidities/extensive services provided –point scale developed for each comorbidity creating 6 classifications as noted below

Source: https://https://www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/SNFPPS/Downloads/PDPM_Technical_Report_508.pdf

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MDS Example of I8000 Section

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PDPM – NTA Comorbidities and Points

Source: https://https://www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/SNFPPS/Downloads/PDPM_Technical_Report_508.pdf

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MDS Resident’s Primary Medical Condition

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MDS New Section J questions about surgery

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MDS Assessments Required in PDPM

• 5 day assessment• PPS Discharge (does not impact payment but

is required when a PPS stay ends)• Interim Payment Assessment (IPA)

– Optional assessment– Draft available now on CMS site– Will reset payment but not the variable portion

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PDPM Assessment schedule

ASSESSMENT ARD PAYMENT

5 DAY MDS DAYS 1‐8 SETS PAYMENT FOR ENTIRE MEDICARE PART A STAY UNLESS AN IPA IS DONE

INTERIM PAYMENT ASSESSMENT (IPA)

CHOSEN BY THE PROVIDER PAYMENT BEGINS ON THE ARD

PPS DISCHARGE LAST DAY OF MEDICARE PART A STAY

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5 Day MDS

• Day 1‐8 of Medicare Part A stay• Sets payment for entire stay unless…

– Discharged – Interim Payment Assessment

• ARD driver– Nursing– Rehab

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Interim Payment Assessment (IPA)

• Section GG items will be derived from a new column which will capture the self performance of the patient

• The look‐back for this new column will be the three‐day window leading up to and including the ARD of the IPA (ARD and the two calendar days prior to the ARD)

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Interim GG assessment

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Discharge Therapy Collection Items (New)• New items in Section O• Using a look‐back of the entire PPS stay,

providers report, by each discipline and mode, amount of therapy (in minutes) received by the patient.

• If the total amount of group/concurrent minutes, combined, comprises more than 25%, a warning message is issued on the final validation report

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Concurrent and Group Therapy Limits

• Under RUG‐IV, no more than 25% of therapy services can be group, while there is no limit on concurrent.

• Under PDPM, we use a combined limit both concurrent and group can be no more than 25% of the total therapy received for each therapy discipline.

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Transition to PDPM on 10/1/19

• All providers will be required to complete an IPA with an ARD no later than 10/7/19 for all SNF Part A patients.

• NO transition period between RUGs and PDPM with both systems running simultaneously

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MDS Interrupted Stay Policy

• If a patient is discharged and returns to same SNF in 3 or fewer days, stay is considered same stay.– Variable per diem continues from time of

discharge

• If patient is charged and readmitted more than 3 days, considered new stay– Variable rate is reset to day 1

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Overview of Important of ICD‐10 Items

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Coding Basics

• The ICD‐10‐CM for the Primary Diagnosis is the key determinant of payment

• The Primary Diagnosis is likely to be different from the reason for the hospital stay

• ICD‐10‐CM information is also used to assign a patient to a clinical category for the therapy service component

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Importance of ICD‐10 under PDPM

• PDPM will utilize patient’s ICD‐10 diagnosis to categorize a patient into one of ten clinical categories

• Diagnosis code is the diagnosis that is the primary reason for the Part A SNF staff

• Must map to SNF PDPM Clinical Category Mapping

• Specificity will be key under PDPM

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Significant Change in Practice

• Primary skilled diagnosis has not played such a major role in the past.

• Current MDS directions for entering diagnoses in I8000 indicate to only include an “additional active diagnosis” in I8000 – Specificity of that active diagnosis will now be impactful

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Best Practices

• Determine who is currently responsible for ICD‐10 coding.

• What additional training is needed?• What steps will you implement to verify the correct ICD‐10 code is determined and communicated to all members of the interdisciplinary team.

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Best Practices (Continued)

• Engagement of Acute Care, Care Managers both within the organization and outside of the organization. Know your referral sources. – Provide checklist of information required for

• Provide information/education to Medical Director and Providers– Provide them with resources that are brief and

concise.79

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Review Records/Determine diagnosis

Entire medical record necessary from hospital.• Hospital discharge summary• Physician H & P• Specialist consults/notes• Medication lists• Dietary notes• PT/OT notes• Social workers notes (if involved)

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Finding Diagnosis (es)Reason for admission usually on Discharge Summary but may need to review other documents in the chart to clarify diagnosis and for other conditions that would apply during stay.• Check for major surgical procedures occurring during

impatient hospitalization in last 30 days and documented by physician. Determine if surgical intervention related to reason for SNF stay.

• Checking medication list can point to specific conditions, but physician/provider still needs to document diagnosis for it to be coded.

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Finding Diagnosis (es)• Are documented by physicians (MD) Physician Assistant

(PA), Clinical Nurse Specialist (CNS), Advanced Nurse Practitioner (ANP).– Would not be RN, LPN,CMA, PT/OT

‐Nursing diagnosis NOT applicable to code (ex. alteration in skin integrity). Only code diagnosis confirmed and documented by physician/provider.

• Reviewing nurse’s notes, therapy notes, lab reports, etc., may help in researching patients medical conditions, but do not code symptoms that may be listed (EX; Low HGb doesn’t = Anemia, have to check for physician documentation)

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Query/Communicate with Provider• Establish a method to query physician for specificity if need

to clarify the diagnosis. • Do not guess or assume what could be diagnosis is no other

information available in the record. ‐Obvious connections can be made without asking providerex: if provider forgets to list Rt or LT hip on discharge summary can use the operative note to confirm which side joint replacement performed

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Medicare Triple Check Considerations

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The New SNF Medicare PDPM Triple Check – Billing Issues

• Compliance minded organizations have a triple check process designed to internally audit claims prior to submission may decrease your facility’s chance of being audited. The system can eliminate errors that are usually responsible for inaccurate claims submission including the following:

• Technical errors – inaccurate modifiers, incorrect ARD• Process errors – Data entry errors• Documentation errors – inconsistencies between documentation and MDS

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Triple Check Areas of Focus

• Beneficiary Data – Name (as it appears in HETS system), Medicare #, Payment source, etc.

• Facility Identifiers – NPI, PTAN, TID

• UB‐04 and MDS Data – Type of Bill and Date(s) of Service, SNF Certs/Recerts are accurate and signed timely, etc.

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Triple Check Q&A Questions

• Admitted Sept. 15 and remains a patient on Medicare Part A through October 15 How many Medicare days were used? 31 Does the resident get a new 100 days on October 1st?

• Was there an “Interrupted Stay” Resident discharged – returns within 3 days or less to same (or another SNF)

No new 5 day assessment required – Assessment schedule AND the VPD continue from prior stay!

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Clinical Readiness

• MDS still drives the process• Documentation accuracy and timeliness

critical• ICD‐10 coding more important than ever• Data collection from Medicare day 1 through

the 5 day ARD (no later than day 8) is key to successful payment foundation

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Clinical Readiness continued

• Evaluate nursing RUGS • Evaluate MDS accuracy• Educate entire IDT

– PDPM– GG– ICD‐10

• Restorative

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Operational Readiness

• What changes have you made• What changes do you plan to make• Who will be a part of the team to make the change seamless

• Reliability and validity of your delivery of care and practice patterns

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CLAconnect.com

Thank you! Deb Freeland, CPAPrincipal317‐569‐6230deb.freeland@CLAconnect.com

LLP Preparing for the Patient Driven Payment Model · 2019-08-21 · ©2018 CliftonLarsonAllen LLP...

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