SNF Medicare Part A Training for Therapy Professionals · SNF Medicare Part A Training for Therapy...

Nov 2018

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Montero Therapy Services Copyright 2018 1

SNF Medicare Part A Training for Therapy Professionals

2018

Course Outline

What:

New Payment Model coming 10/1/19 for Medicare Part A in the SNF –Patient Driven Payment Model

1Why

Long-standing issues with RUG IV Payment System

2Details:

Key Features of the New Model

3Impact:

How will the new model impact SNF Therapists and MDS Coord?

4Prepare:

How can SNF Therapists and MDS Coordinators prepare

5Putting the Pieces Together:

Discussion and examples of program components

6


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Objectives

•Participants will identify key changes between the existing RUG-IV Model and the new PDPM Model

Identify

•Participants will gain an understanding of the new Proposed Patient Driven Payment ModelGain

•Participants will calculate a Function Score and Daily Payment Rate based on resident characteristics

Calculate

•Participants will be prepared to identify the new model’s impact on therapy and identify ways to prepare upcoming changes

Prepare

2018

New Payment Model for Medicare Part A SNF

• Major changes ahead based on SNF PPS Final Rule Released August 2018

• Advanced Notice of Proposed Rulemaking (ANPRM) was released in May 2017 identifying a change was coming to SNF Medicare Part A payment structure

• Replace existing case-mix classification methodology “Resource Utilization Groups, Version IV RUG-IV

• Originally thought to be RCS-1

• April 2018 the Proposed Rule was released confirming changes to come; Final Rule August 2018 made only few changes to Proposed Rule

• Patient-Driven Payment Model – PDPM

42018

https://www.regulations.gov/document?D=CMS-2017-0061-0002

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When Will the Changes Take Place?

October 1, 2019

Confirmed in August Final Rule

1 more Proposed and Final Rule before 10/1/19

2018

Why Is This Happening?

CMS has commented in the Final Rule for at least the last 5 years that there was significant concern regarding the therapy trends in the SNF

The % classifying into the Ultra-High therapy category has increased steadily (reaching >60% of total scores in 2017)

The % receiving just enough therapy to surpass the Ultra-High and Very-High therapy thresholds has also increased (some SNF’s achieved 100% of RU and RV RUGS with exact minutes of 720 and 500 respectively)


Nov 2018

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Medicare….On YOUR SIDE?

“We believe the increase in “thresholding” is a strong indication of service provision predicated on financial considerations rather than resident need.” “….Therefore, services which are not specifically tailored to meet the individualized needs and goals of the resident, based on the resident’s condition and the evaluation and judgment of the resident’s clinicians, may not meet [the] definition for covered SNF care, and we believe that internal provider rules should not seek to circumvent the Medicare statute, regulations and policies, or the professional judgment of clinicians.” 2015 SNF PPS FR


Why Is This Happening?

Years of recommendations and clear data from the OIG

and MedPAC to make a changes

CMS took a stand last May, gave fair warning of a new

payment system and allowed comments for an extended period of time. CMS considered all the

comments and concerns about RCS-1, took them into account and created a new

payment model

Multitude of CMS statements over the years

reiterating that therapy service provision should be

based on the resident’s individual needs


Nov 2018

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Just To Be Clear…..

• In the Proposed Rule, CMS is attempting to be crystal clear…

• “To make clear the purpose and intent of replacing the existing RUG-IV system, the model we are proposing in this rule is called the Patient-Driven Payment Model (PDPM).”

• Patient-Driven…..not Minute Driven…not Therapy Driven!

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Details: What Do We Know About PDPM?

A lot! The Final Rule spells out all details

https://www.federalregister.gov/documents/2018/08/08/2018-16570/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities

May be tweaked in the next Final Rule but key components won’t change

MDS Changes already in effect 10/1/18: Section I, GG, etc

Less than 1 year to prepare


https://www.federalregister.gov/documents/2018/08/08/2018-16570/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities

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Key Features of PDPM

Made of 6 independent components, each adding up to a final payment

PT OT SLP NursingNon Therapy

AncillaryNon-Case

Mix

Now based on multiple factors….each determining portion of payment

Not based on therapy volume or therapy minutes


A Review of PPS RUG-IV

Need understanding of RUG-IV to dispel myths of PDPM

Nursing vs Rehab RUG = Only 1 triumphs and sets payment

Case Mix Maximizes


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A Review of PPS RUG-IV


FY 2019 Urban

2018

Review of PPS RUG-IV


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Key Features of PDPM

Sets daily Medicare Part A payment rates on factors other than therapy days and minutes

Data from the MDS, starting with the ICD-10 code and category

that supports the SNF Part A stay, are used to classify a resident

Additional MDS data including function, cognition, swallowing

disorders and other clinical diagnoses also contribute to

classifications

Unlike the RUG-IV classification where each resident is only

classified into 1 RUG group based on the MDS, PDPM breaks apart

therapy and nursing to allow for a separate classification for each


6 Components


ALL COMPONENTS ADDED TOGETHER = DAILY RATE

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Nov 2018

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Component 1: Nursing

Nursing is finally “free” from therapy’s grip

66 RUGS to a total of 25 by combining existing groups

Same criteria for each RUG

The method for calculating the ADL score will also change and Section GG items will be added to the mix. Uses Eating, Transfers, Toileting Hygiene, Bed Mobility info.


Nursing


Extensive: Trach, Vent, Iso

Special Care High: COPD/Bed; IV; RT

Special Care Low: CP,MS,PD,Tube,Skin

Clinical: O2, Hemi, IV Meds, Pneumonia

Case Mix Group with in each category is determined by GG

Function Score, Depression,

Restorative Nursing Program….and….In general, more

Dependent = Higher CMI

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Nov 2018

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New Function Score – ADL Score Does Not Determine RUG

ADL Score

• Based on 4 Section G answers

• Determined last character in RUG• Bed Mobility• Transfers• Toileting• Eating

New Function Score

• Will be based on multiple MDS answers from GG on 5 day only• Nursing uses 4

• Eating• Toilet Hygiene• Bed Mob Average• Transfer Ave – Toilet, Bed

• PT/OT use 6• Above +• Oral Hygiene• Walking Average 50, 150


Function Score Points

Nursing

Independent or Set up =4

Supervision, Touching=3

Partial/Mod Assist=2

Substantial/Max Assist=1

Dependent; Refused; N/A=0

Points assigned to answers in Section GG determine score


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How GG was coded is transcribed into new ADL Score Calculation to determine Functional Score

2018

Component 2: Physical Therapy

PT case mix and payment will be determined by the ICD-

10 code category for SNF admission and the functional

score based on MDS questions in GG


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Physical Therapy

PT case mix and payment will be determined by the ICD-

10 code category for SNF admission and the functional

score based on MDS questions in GG


Case Mix Group with in each category is determined by GG

Function Score….and….

In general, more Independent =

Higher CMI

2018

Function Score Points

PT / OT

Independent or Set up =4

Supervision, Touching=3

Partial/Mod Assist=2

Substantial/Max Assist=1

Dependent; Refused; N/A=0

Points assigned to answers in Section GG determine score


Nov 2018

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Function Score for PT and OT


How GG was coded is transcribed into new ADL Score Calculation to determine Functional Score

2018

Function Score: 6 ?’s – Total Ranges 0-24


0 = Dependent 4 = Independent

Total 0 = More Dependent Function vs Total 24 = Independent Function

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Nov 2018

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Details: PT and OT Function Score

Replaces ADL Score of RUG-IV for determining case mix category

Function Score factors into case mix score for PT, OT and Nursing

Score derived from MDS questions Section GG

More Dependent does NOT always mean higher CMI


Physical Therapy

There are a total of 16 potential PT case mix groups as

shown here.


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Physical Therapy

There are a total of 16 potential PT case mix groups as

show here. Each group has a corresponding CMI


Component 3: Occupational Therapy

OT case mix and payment are determined exactly like PT, however, case mix scores and payment will differ for each category.


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Case Mix Difference Between PT and OT


Details: PT and OT Payment

Example: $100 per day case mix daily rate:

Day 1-20 = $100 per day

Day 21-27=$98 per day

Day 28-34= $96.04 per day

Day 35-41=$94.12 per

day

Day 42-48= $92.24

Day 49-55= $90.40

Decrease by 2% every 7 days after that

Day 1-20 pays in full

Daily payment for PT and OT will decrease over the course of 100 days

2018

Nov 2018

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Where Does “Clinical Category” Come From?


From 10 to 5

2018

5 Clinical Category “Pillars”


Nov 2018

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Clinical Category for PT and OT

ICD-10 Code

Section I = New Questions - I8000

Code for primary SNF stay reason

Need to match

Tables – next slide

2018

Link to Tables – ICD-10 Codes

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/PDPM_Clinical_Category_Mapping.zip

Search ICD-10 Codes mapped to each of the 5 pillars

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Component 4: Speech TherapySpeech case mix and payment is determined by the ICD-

10 code category for SNF admission, as well as factors

including swallowing disorders, mechanically altered diets,

speech co-morbidities and cognition (all from MDS

answers).


Speech Therapy

1- Acute Neuro Condition listed by ICD-10 (I8000A)2- SLP Related Co-Morbidity from list in Section I (ie: CVA, Aphasia, Hemi, SL Deficits)3- Cognitive Impairment determined by MDS questions (BIMS – Section C)


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Speech Therapy

1- Mechanically Altered Diet – Answer to MDS Question2- Swallowing Disorder – Answer to MDS Question (K0100 – Loss of liq; Holding; Coughing; Pain…)


Speech Therapy


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Speech Therapy

Daily Speech rate does NOT decrease over time

(like PT and OT)

Pays in full days 1-100


Minutes Don’t Matter ??

PT, OT and Speech categories/case-mix are not impacted by the presence or absence of an active therapy program

Pay is the same with therapy vs no therapy!Facilities are paid a daily rate for therapy services even if therapy is not active

Why? CMS expects the SNF to save payment for when therapy services are necessary

Still need Skilled Therapy at least 5 days per week for Medicare Part A coverage

2018

Nov 2018

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Component 5: Non-Therapy Ancillary

There is also a case mix category called “Non-Therapy

Ancillary” that will use MDS questions from Section I, K, M

and O to determine a case mix score. This payment is

tripled for the first 3 days of the stay to cover any costs

upfront. Drugs, Medical Supplies, Labs, etc


Non-Therapy Ancillary Example


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Non-Therapy Ancillary Category

Day 1 – 3 = Daily Rate x 3Day 4-100 = Daily Rate x 1


Component 6: Non-Case Mix Payment

Non-case mix component

Flat rate

Covers overhead costs such as room/board, laurdry, capital, dietary, etc.


Nov 2018

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Details: How Is Payment Derived?

Nursing PT OT SpeechNon-

Therapy Ancillary

Non-Case Mix Flat

Rate

Total Daily Rate




Therapy Ancillary

Non-Case Mix Flat

Rate

Total Daily Rate

• Payment will be derived from the 5 Day PPS MDS• Score used for duration of 100 days unless stay is interrupted OR resident status changes

warranting a new MDS (IPA)

• For Medicare Part A, significant decrease in the # of MDS’s required = Elimination of the Scheduled Assessments (14,30,60,90) AND the Unscheduled Assessments (SOT, COT, EOT…)

• Data collection of all therapy modes, days and minutes on the DC MDS – accountability!


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Therapy Ancillary

Non-Case Mix Flat

Rate

Total Daily Rate


If each category = $50 per day, the Total Daily Rate = $300 per day

2018

PDPM Payment

Breakdown


Nov 2018

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Sample Payment – Case Example



Therapy Ancillary

Non-Case Mix Flat

Rate

Total Daily Rate

=$351.52

2018

PDPM BreakdownSummary


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How Will PDPM Impact SNF Therapists and MDS Coordinators?

Therapy minutes are no longer driving RUG score

• Staffing

• Look up your SNF’s predicted change

Less MDS assessments, more resident monitoring

for daily changes

Increase in Group and Concurrent??? Limited to

25% of total minutes. 75% will need to be 1 on

1 therapy

Importance of accurate data on 5 day MDS –

Therapy can’t wait until Day 4 for Eval

Less weekend therapy? No holidays?

Outcomes….soon. GG will be tied to $$

2018

What is NOT CHANGING?

Chapter 8 of the Medicare Benefit Policy Manual: All SNF Med A Rule

Eligibility100 day benefit

period

Daily skilled careReasonable and

Necessary

Skilled Nursing 7 days/week; Skilled Therapy minimum

of 5 days/week

ADR’s


Nov 2018

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How Can Therapists and MDS Coordinators Prepare?

Review the Final RuleInsight into Medicare’s

thought process for Part A payment

Familiarize yourself with the MDS – Don’t rely on therapy

software!

The MDS tool is and will continue to be the central point for outcomes, Part A

reimbursement, Quality Measures, Star Ratings, State case mix and more

Know your ICD-10 codes!


How Can Therapists and MDS Coordinators Prepare?

SNF PPS Final Rule for Oct 1st 2019

https://www.federalregister.gov/documents/2018/08/08/2018-16570/medicare-program-prospective-payment-system-and-

consolidated-billing-for-skilled-nursing-facilities#h-60

Acumen Technical Report – SNF PPS Data for PDPM – April 2018

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

SNF PPS Payment Driven Payment Model CMS Webpage

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

ICD-10 Tables


Final Rule… may have minor changes as the date approaches


https://www.federalregister.gov/documents/2018/08/08/2018-16570/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities#h-60







Nov 2018

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Will SNF Therapy Change When Minutes Won’t Matter?

CMS used EXISTING provider data to revamp

the payment system

Looking at significant increase in $ if not an “Ultra Over-provider”

Reasonable and Necessary

Tough to argue someone needs “less”

vs more

Know your department set up

Contract vs in-house –Contract companies will need to restructure how

they are paid as % of RUG will no longer work


How: How Can Therapists and MDS Coordinators Prepare?

• Use the CMS Comparison Tool to look up your facility

• Sneak peek

• “If” PDPM in 2017

• Highest vs lowest

• PDPM Comparison Tool

• Know the MDS!


https://www.monterotherapyservices.com/wp-content/uploads/2018/04/PDPM-Provider-Comparison-2017.xlsx

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Summary

• Medicare A $$ in the system

• Redistributed based on practice patterns

• SNF’s paid “as if”

• Therapists value beyond “minute provider”

• Opportunity to shine as autonomous clinicians!

• Visit our PDPM Resource Page at:

• https://www.monterotherapyservices.com/pdpm


Can’t think of a question now? Email us at [email protected]. All our course purchases include Q&A on the material as needed.

Individual Members.. You can ask a question any time…Visit our JustAsk! Q&A Forum


https://www.monterotherapyservices.com/pdpm

mailto:[email protected]

http://www.monterotherapyservices.com/just-ask

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Disclaimer

• This information for this presentation was current at the time it was published. Source documents and links are provided. Due to the frequent change in Medicare policy, participants should verify policy change at the time of study.

• This presentation was prepared to provide general information on the subject material. Participants are encouraged to further review the specific statutes, regulations and other materials for a full understanding of how to utilize this information in practice.

• Montero Therapy Services is available for consulting on specific practice issues or concerns related to this or any other material.


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SNF Medicare Part A Training for Therapy Professionals · SNF Medicare Part A Training for Therapy...

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