MEDICARE PART A SNF PROSPECTIVE PAYMENT SYSTEM
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1 MEDICARE PART A SNF PROSPECTIVE PAYMENT SYSTEM MDS 3.0 Captured Services as Qualifiers for Medicare Part A RUG-IV Grouper REHABILITATION Base Rates Urban Unadjusted AWI = ADL END 10/1/2017 INDEX SPLITS RUG 9/30/2018 ULTRA HIGH Extensive Services qualifier RUX $ Tx. 720 mins. a week minimum 2-10 Extensive Services qualifier RUL $ disciplines: one 5+days, one 3+ days RUC $ RUB $ RUA $ VERY HIGH Extensive Services qualifier RVX $ Tx. 500 mins. a week minimum 2-10 Extensive Services qualifier RVL $ At least 1 discipline - 5 days RVC $ RVB $ RVA $ HIGH Extensive Services qualifier RHX $ Tx. 325 mins. a week minimum 2-10 Extensive Services qualifier RHL $ discipline, 5 days a week RHC $ RHB $ RHA $ MEDIUM Extensive Services qualifier RMX $ Tx. 150 mins. a week minimum 2-10 Extensive Services qualifier RML $ distinct days across 3 disciplines RMC $ RMB $ RMA $ LOW 2-16 Extensive Services qualifier RLX $ days Tx / 45 min/wk; >5 days; >1 activity RLB $ RLA $ EXTENSIVE SERVICES Tracheostomy care AND ventilator/respirator 2-16 Not Used ES3 $ Tracheostomy care OR ventilator/respirator 2-16 Not Used ES2 $ Isolation for active infectious disease 2-16 Not Used ES1 $ SPECIAL CARE HIGH Any of the following conditions: PHQ Depression HE2 $ Comatose; Septicemia; Diabetes w/ daily inj. & insulin order change HE1 $ on 2 or more days; Quadriplegia with ADL score 5; PHQ Depression HD2 $ Chronic obstructive pulmonary disease and shortness of breath HD1 $ when lying flat; Fever with pneumonia, Vomiting, Tube feed 6-10 PHQ Depression HC2 $ or Weight loss; Parenteral/IV feedings; 6-10 HC1 $ Respiratory therapy for 7 days 2-5 PHQ Depression HB2 $ Depression split qualifier: PHQ score HB1 $ Zimmet Healthcare Services Group, LLC
2 MEDICARE PART A SNF PROSPECTIVE PAYMENT SYSTEM MDS 3.0 Captured Services as Qualifiers for Medicare Part A RUG-IV Grouper SPECIAL CARE LOW Base Rates Urban Unadjusted AWI = ADL END 10/1/2017 INDEX SPLITS RUG 9/30/2018 Any of the following conditions: PHQ Depression LE2 $ Cerebral palsy, Multiple sclerosis, or Parkinson s disease with ADL LE1 $ score 5; Feeding tube (calories 51% or 26-50% & fluid 501cc); PHQ Depression LD2 $ or more Stage II or 1 or more III or IV pressure ulcer; 2 or more LD1 $ skin Tx w/ 2 or more ven/art ulcers; or 1 Stage 2 PU & 1 venous/arterial ulcer 6-10 PHQ Depression LC2 $ foot infection/diabetic foot ulcer/open lesions of foot with treatment; 6-10 LC1 $ Radiation therapy while a resident; Oxygen therapy w/ respiratory failure 2-5 PHQ Depression LB2 $ while a resident; Dialysis while a resident 2-5 LB1 $ CLINICALLY COMPLEX Extensive Services, Special Care High or Special Care Low qualifier PHQ Depression CE2 $ and ADL score of 0 or 1; OR CE1 $ Pneumonia; hemiplegia with ADL score 5; PHQ Depression CD2 $ Surgical wounds or open lesions with treatment; burns; CD1 $ Chemotherapy while a resident; 6-10 PHQ Depression CC2 $ IV medications while a resident; 6-10 CC1 $ Transfusions while a resident 2-5 PHQ Depression CB2 $ Oxygen therapy while a resident 2-5 CB1 $ Depression split qualifier: PHQ score PHQ Depression CA2 $ CA1 $ BEHAVIORS & COGNITIVE PERFORMANCE Cognitive impairment BIMS score 9 or CPS 3 OR 2-5 Nursing Rehabilitation BB2 $ Hallucinations or delusions OR Physical or verbal behavioral symptoms 2-5 BB1 $ toward others, Other behavioral symptoms, Rejection of care, or Wandering 0-1 Nursing Rehabilitation BA2 $ See Reduced Physical Function for restorative nursing services 0-1 BA1 $ PHYSICAL FUNCTION REDUCED No clinical variables used Nursing Rehabilitation PE2 $ PE1 $ Restorative nursing services: Nursing Rehabilitation PD2 $ or more restorative nursing on 6+ days/wk PD1 $ Urinary and/or bowel training program, 6-10 Nursing Rehabilitation PC2 $ Passive or Active ROM, amputation/prosthesis care training, 6-10 PC1 $ Splint or brace assistance, Dressing or grooming training, 2-5 Nursing Rehabilitation PB2 $ Eating or swallowing training, Transfer training, 2-5 PB1 $ Bed mobility and/or walking training, Communication training 0-1 Nursing Rehabilitation PA2 $ PA1 $ DEFAULT Resident is clinically eligibility but no valid MDS record; technical violations, etc. AAA $ NOTE: Rates are NOT net of sequestration. Zimmet Healthcare Services Group, LLC
3 RCS-I Impact Projections Resident Characteristics Winner Change Loser Change Length of SNF stay 1-15 days 15.9% 31+ days -2.5% Length of qualifying H stay 31+ days 4.6% 3 days -2.3% Cognitive impairment Severe 6.1% Moderate -1.8% HIV diagnosis No 0.2% Yes -40.0% IV meds during stay Yes 22.9% No -2.0% Wound infection With 17.9% Without -0.4% Therapy services 1 therapy only 37.3% Receiving 3 types -3.9% NTA cost $150+ / day 19.2% $10 - $50 / day -3.2% Tracheostomy Receiving 18.1% - - Most Common Therapy Level Change RU -9.1% RV 9.3% RH 24.4% RM 36.9% RL 49.3% Non-Rehabilitation 44.5% Provider Characteristics Winner Change Loser Change Facility size Under 50 beds 6.7% > 200 beds -0.7% Ownership status Non-profit 3.1% For-profit -1.1% Institution type Hospital-based 15.8% - - Ultra High % days 0-10% 28.4% 90% % Non-rehab % days 50-75% 45.6% 0-10% -2.2%
4 PT/OT Case-Mix Classification Groups Category Function Score Moderate/Severe Cognitive Imp. Case-Mix Group CMI Major Joint No TA 1.82 Replacement or Yes TB 1.59 Spinal Surgery 8-13 No TC Yes TD No TE Yes TF 1.36 Other Orthopedic No TG Yes TH No TI Yes TJ No TK Yes TL 1.14 Acute Neurologic No TM Yes TN No TO Yes TP No TQ Yes TR 1.17 Non-Orthopedic No TS 1.57 Surgery Yes TT No TU Yes TV No TW Yes TX 0.80 Medical No T Management Yes T No T Yes T No T Yes T6 0.82
5 SLP Case-Mix Classification Groups Category Variable 1 Variable 2 Case-Mix Group CMI Acute Neurologic Both Both SA 4.19 Both Either SB 3.71 Both Neither SC 3.37 Either Both SD 3.67 Either Either SE 3.12 Either Neither SF 2.54 Neither Both SG 2.97 Neither Either SH 2.06 Neither Neither SI 1.28 Non-Neurologic Both Both SJ 3.21 Both Either SK 2.96 Both Neither SL 2.63 Either Both SM 2.62 Either Either SN 2.22 Either Neither SO 1.70 Neither Both SP 1.91 Neither Either SQ 1.38 Neither Neither SR Presence of swallowing disorder or mechanically-altered diet 2. SLP related comorbidity or moderate to severe cognitive impairment SLP Related Comorbidities Aphasia Laryngeal Cancer CVA, TIA, or Stroke Apraxia Hemiplegia or Hemiparesis Dysphagia Traumatic Brain Injury ALS Tracheostomy (while Resident) Oral Cancers Ventilator (while Resident) Speech and Language Deficits
6 Nursing Case-Mix Classification Groups and CMI Weights GROUP RUG-IV RCS GROUP RUG-IV RCS ES CD ES CC ES CC HE CB HE CB HD CA HD CA HC BB HC BB HB BA HB BA LE PE LE PE LD PD LD PD LC PC LC PC LB PB LB PB CE PA CE PA CD
7 Non-Therapy Ancillary Scoring / Groups Condition / Service Source Tier Points HIV/AIDS SNF Claim Ultra-High 8 Parenteral/IV Feeding - High (> 50% of cal) MDS Item K0510A2 Very-High 7 Parenteral/IV Feeding - Low (25-50% of cal) MDS Item K0710A2, K0710B2 High 5 Average fluid intake by IV or tube feeding of at least 501cc per day IV Medication MDS Item O0100H2 High 5 Ventilator / Respirator MDS Item O0100F2 High 5 Transfusion MDS Item O0100I2 Medium 2 Kidney Transplant Status MDS Item I8000 Medium 2 Opportunistic Infections MDS Item I8000 Medium 2 Infection with multi-resistant organisms MDS Item I1700 Medium 2 Cystic Fibrosis MDS Item I8000 Medium 2 Multiple Sclerosis (MS) MDS Item I5200 Medium 2 Major Organ Transplant Status MDS Item I8000 Medium 2 Tracheostomy MDS Item O0100E2 Medium 2 Asthma, COPD, Chronic Lung Disease MDS Item I6200 Medium 2 Chemotherapy MDS Item O0100A2 Medium 2 Diabetes Mellitus (DM) MDS Item I2900 Medium 2 End-Stage Liver Disease MDS Item I8000 Low 1 Wound Infection (other than foot) MDS Item I2500 Low 1 Transplant MDS Item I8000 Low 1 Infection Isolation MDS Item O0100M2 Low 1 MRSA MDS Item I8000 Low 1 Radiation MDS Item O0100B2 Low 1 Diabetic Foot Ulcer MDS Item M1040B Low 1 Bone / Joint / Muscle Infections / Necrosis MDS Item I8000 Low 1 Highest Ulcer Stage is Stage 4 MDS Item M300D1 Low 1 Osteomyelitis and Endocarditis MDS Item I8000 Low 1 Suctioning MDS Item O0100D2 Low 1 DVT / Pulmonary Embolism MDS Item I8000 Low 1 NTA Case-Mix Classification Groups Range Group CMI 11+ NA NB NC ND NE NF 0.83
8 Variable Per Diem Adjustment & Base Rates PT / OT NTA Day Factor Day Factor Urban Component Base Rate PT / OT $ SLP $ Nursing $ NTA $ Non-Case Mix $ Rural Component Base Rate PT / OT $ SLP $ Nursing $ NTA $ Non-Case Mix $
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