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1 www. Source Documents Sec7on GG & the PPS Discharge Judy Wilhide Brandt, RN, BA, RAC-MT, CPC, DNS-CT www. What is a PPS Discharge? (NPE) J1800 & J1900: Falls since entry or last OBRA/PPS MDS Part A PPS Discharge (NPE) GG DC Func7onal Status M0210, M0300, M0800 Current & Worsened Pressure Ulcers When is PPS DC Required? Part A stay ends & resident stays in SNF May (MUST) be combined with OBRA DC when Part A stay ends and resident physically discharges from SNF on or one day a_er last Part A day (A2400C) What is the purpose of the PPS DC? Falls w/major injury SNF-QRP Admit/DC Func7onal Ability & Goal Three QRP Quality Measures New/worsened Pressure Ulcer SNF-QRP NOT required when Part A stay ends in death (c) 1

2 Cri7cal Point OBRA Discharge (ND) Stand-Alone SNF PPS DC is more than Sec7on GG GG Discharge Fxl Status Falls Pressure Ulcers Falls Pressure Ulcers Cogni7ve Pacerns, Mood, Behaviors, Fxl Status, Bowel/Bladder, Diagnoses, Pain, Other Health Condi7ons, Swallowing/ Nutri7on, PU dimensions, Meds, Special Tx, Restraints, Discharge Plan RA or RNA & planned PPSDC/OBRA Discharge (ND) Unplanned OR To acute hospital OR Part A stay < 3 days PPS DC/OBRA Discharge (ND) Any except 03 GG Discharge Fxl Abili7es Falls Pressure Ulcers Falls Pressure Ulcers At least 3 days Cogni7ve Pacerns, Mood, Behaviors, Fxl Status, Bowel/Bladder, Diagnoses, Pain, Other Health Condi7ons, Swallowing/ Nutri7on, PU dimensions, Meds, Special Tx, Restraints, Discharge Plan Cogni7ve Pacerns, Mood, Behaviors, Fxl Status, Bowel/Bladder, Diagnoses, Pain, Other Health Condi7ons, Swallowing/ Nutri7on, PU dimensions, Meds, Special Tx, Restraints, Discharge Plan Unplanned OR To acute hospital OR Part A stay < 3 days PPS DC/OBRA Discharge (ND) First forced combina7on in MDS history What s going on here? Falls Pressure Ulcers Cogni7ve Pacerns, Mood, Behaviors, Fxl Status, Bowel/Bladder, Diagnoses, Pain, Other Health Condi7ons, Swallowing/ Nutri7on, PU dimensions, Meds, Special Tx, Restraints, Discharge Plan OBRA Discharge and PPS Discharge must be combined when both are due. A2400C = A2000 Discharge Date A2400C one day prior to A2000 Discharge Date PPS DC doesn t always have Discharge Fxl Abili7es Sec7on GG PPS DC always has items to calculate QRP Falls w/major injury and QRP new/worsened pressure ulcers Reminder: You just have to remember to do the stand-alone PPS Discharge! (c) 2

3 Qualifying QRP Stay If there is no PPS 5 Day or PPS DC Stay excluded from QRP calcula7on Special Situa7ons RAI Manual Ch 6, Sec7on 6.8 Stay < 8 days Use OBRA assessments to cover SNF days in certain pay source situa7ons No PPS Discharge If A2400 Medicare dates are correct, PPS DC is a forced combina7on with qualifying OBRA DC If A2400C is last covered day and resident remains in facility, must do stand-alone PPS DC. We can forget this one! Be careful! What s going on here? Skilled Nursing Facility Quality Repor7ng Program (SNF-QRP) Post Acute Care Quality Repor7ng System Overlap in services and expertise Significantly different costs No clear evidence regarding appropriateness of care or outcomes. SNF-QRP SNF IRF-QRP PAC-QRP HHA-QRP IRF Hip Fracture HHA LTCH-QRP LTCH PAC costs vary eightfold across the country, costs rising, comparative quality unknown SNF Require skilled therapy 5xW or skilled Nsg 7xW # of facilities: 15,000 Post Acute Settings IRF Therapy 15 hr wk (3 hr day) 2 disc MD 3xW # of facilities: 1166 HHA Be homebound Require intermittent skilled therapy or nsg # of facilities: 12,311 Standardization LTCH Stay > 25 days, rehab, resp ther, head trauma, pain mgt # of facilities: 420 Endgame Refine PAC rules Standardize items Reshape Payment & Reward System Stop RUG system Build payment system based on resident characteris7cs and outcomes Decision making Collect data Valid comparisons Analyze data Start PAC-QRP Begins Begin standardiza7on process for certain items on PAC assessment tools QRP measure data collec7on begins Big Picture (c) 3

4 Many QRP Measures: Adding, changing, re:ring - now and for several years MDS-based QRP measure collection method Falls w/major Injury MDS Fxl Status MDS Fall maj injury MDS New/Worsening Pressure ulcer All these started Oct 1, 2016 Claim Medicare Spending per Beneficiary Claim Poten7ally Preventable Unplanned Rehospitaliza7on Claim Successful Discharge PPS 5 Day Fxl Abili7es & Goal(s) Covariates for worsened PU Falls w/major Injury: Any OBRA or scheduled PPS or PPS DC in the Part A stay MDS Based Unique QRP Measures Claims Based Unique QRP Measures Discharge Fxl Abili7es Falls w/major Injury New/worsened PU PPS Discharge Special allowance in the law for discharge functional abilities Discharge Fxl Abili7es Falls w/major Injury New/worsened PU PPS Discharge SNF-QRP MDS-Based Measure Specifica7ons This is why DC GG is not on ALL PPS DC/OBRA DC combos! CMS shall not collect discharge func7onal abili7es on incomplete stays. That would not give valid, reliable, usable data to sa7sfy PAC-QRP goals. QRP Collec:on Method: Calculated for each qualifying stay Fall with Major Injury SNF-QRP New Sec7on GG Any OBRA/ Scheduled PPS New Assessment Initial 5 day Maj injury PPS 5 Day MDS Fxl Ability & Goal(s) Fall Major Injury Risk adjustments for New/Worsened Pressure Ulcers Fall Major Injury Part A PPS DC New/Worsened PU Falls w/major Injury DC Fxl Abili7es** on qualifying discharges 14 Day 30 Day SNF PPS Discharge Falls w/major injury includes a look-back scan of OBRA or scheduled PPS MDS for the Part A stay. The fall w/major injury could be on any assessment in the stay. (c) 4

5 Falls Major Injury SNF-QRP New/worsened Pressure Ulcers SNF-QRP Does not use M0800 for calcula3on! M0300 ONLY MAJOR INJURY Initial/5 Day Obtain covariates 14 Day 30 Day SNF Discharge Includes bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma. New/worsened pressure ulcer SNF-QRP On a PPS DC: New/worsened Pressure Ulcers - PPS DC: Number present Greater than number present on admission triggers Stage 2: M0200B1 Stage 3: M0200C1 > > Stage 2: M0200B2 Stage 3: M0200C2 M0300B1 > M0300B2 Stage 4: M0200D1 > Stage 4: M0200D2 Covariates reported on PPS 5 day Residents with admission & discharge func7onal assessment and care plan that addresses func7on PVD (I0900) 5 1 Bed Mobility > 2, limited (G0110A1) New Sec7on GG New Assessment 4 Low BMI: (weight * 703 / height 2 )K0200A & B New/ worse PU SNF-QRP 3 2 Diabetes (I2900) Bowel Con7nence > 2, frequently (H0400) PPS 5 Day MDS Fxl Ability & Goal(s) Part A PPS DC DC Fxl Abili7es** on qualifying discharges dashes in these items on PPS 5 day count towards 2% APU penalty (c) 5

6 Residents with admission & discharge func7onal assessment and care plan that addresses func7on Something to consider Two ways to get into the numerator: higher scores are beber Denominator = all qualifying SNF stays If no PPS 5 day OR no PPS DC the stay is excluded from QRP calcula7on Lookback for Sec7on M & J ends on ARD Lookback for GG ends on A2400C A2000 A2300 PPSDC/ OBRA DC combo Complete stay? Process Measure Incomplete stay? Admit fxl assessment & > 1 goal AND DC fxl assessment Admit fxl assessment & > 1 goal GG introduces the first 7me in MDS history that an item s lookback it not 7ed to the ARD. A2400C 2% Annual Payment Update (APU) Penalty MDS Based Data collec7on period for penal7es: Phase In Data Collected Penal@es Apply Oct, Nov, Dec 2016 FY 2018 CY 2017 FY 2019 CY 2018 FY 2020 And so forth 80% of all MDSs submiced must contain 100% of the data elements required to calculate the 3 MDS Based QRP measures. No dashes in ANY calculator fields Direct items Covariates SNF-QRP Calculator Fields: Func7onal Abili7es and Goals: Sec7on GG Admit and Discharge (unless incomplete) and at least one goal** on the PPS 5 day GG Falls with Major Injury: J1800 & J1900 on EVERY OBRA or scheduled PPS MDS in SNF stay New/worsened Pressure Ulcer: Covariate items on PPS 5 day AND On PPS DC: Sec7on M0300 items for Stage 2, 3 and 4 pressure ulcers (present and present on admission) **Special InstrucEons on Goals Column (c) 6

7 For all the goals you do not use, you must have dashes in the goal boxes in Column 2. Doesn t count toward 2% APU penalty. (GG-6) Dashes in Column 1 will count towards the 2% APU penalty Dashes in Column 2 will not count towards the 2% APU penalty Important Coding Tips See RAI Manual & QRP Q&A for complete coding instruc7ons. Really. Read it all. A2400C (Medicare end) is whichever occurs first: Date SNF benefit exhausts or Date of last day covered as recorded on NOMNC or Date payer source changes from Medicare A to another payer (regardless if the resident was moved to another bed or not) or Date resident was discharged from the facility. A2400 does not include stays billable to Medicare Advantage HMO plans. Always = A1600 entry date Coding Pressure Ulcers Present on If a resident who has a pressure ulcer that was present on admission (not acquired in the facility) is hospitalized and returns with that pressure ulcer at the same numerical stage, the pressure ulcer is still coded as present on admission because it was originally acquired outside the facility and has not changed in stage. Never dashes on ANY discharge Present on Present on : Admitted with unstageable due to slough/ eschar Initial MDS: Unstageable Present on Debrided: Stage 4 Next MDS Stage 4 Present on Acquired Stage 2 pressure ulcer in facility On next MDS: Stage 2 Not Present on DCRA to hospital with same Stage 2 Upon readmit from hospital, now Stage 3 Admitted with Stage 3 Initial MDS: Stage 3 Present on DCRA to hospital with same Stage 3 MDS after hospital same Stage 3 Present on Next MDS: Stage 3 Present on admission (c) 7

8 Present on : Present on Acquired Stage 2 pressure ulcer in facility On next MDS: Stage 2 Not Present on DCRA to hospital with same Stage 2 Upon readmit from hospital, same Stage 2 Stage 2 pressure ulcer Present on On next MDS: Unstageable to due slough/ eschar Not Present on M-19 Next MDS: Stage 2 Not Present on Sec7on GG: Big Picture Sec7on GG: Big Picture Determine usual performance during first 3 days of PPS stay Set at least one goal on PPS 5 day Determine usual performance during last 3 days of complete PPS stay. Self Care Eating Oral hygiene Toileting hygiene Sit to lying Lying to sitting on side of bed Sit to stand Chair/bed to chair transfer Toilet transfer Mobility Walking Walk 50 ft with 2 turns Walk 150 ft Wheelchair Wheel 50 ft with 2 turns Wheel 150 ft Self-Care and Mobility Rating Scale 06: Independent independent 05: Setup or clean-up assistance Helper assists only prior to or following the activity. 04: Supervision or touching assistance VERBAL CUES or TOUCHING/ STEADYING as resident completes activity. 03: Partial/moderate assistance Helper does LESS THAN HALF 02: Substantial/maximal assistance Helper does MORE THAN HALF 01: Dependent Helper does ALL of the effort. Or the assistance of 2 or more helpers required 04, 03, 02: Could be weight bearing or not Weight bearing not relevant! If activity was not attempted, code reason: Code 07, Resident refused Code 09, Not applicable: resident did not perform this activity prior to the current illness, exacerbation, or injury Code 88, Not attempted due to medical condition or safety concerns: activity was not attempted due to medical condition or safety concerns (c) 8

9 01: Dependent Walk 50 feet with two turns: Nurse: How much help does Mr. T need to walk 50 feet and make two turns once he is standing? Cer@fied nursing assistant: He walks about 50 feet with one of us holding onto the gait belt and another following closely with a wheelchair in case he needs to sit down. Coding: GG0170J. Walk 50 feet with two turns would be coded 01, Dependent. Ra@onale: Mr. T requires two helpers to complete this ac7vity. No3ce that one of the helpers did not touch the resident. GG-38 GG 0130 Self-Care Item Tips & Tricks Eating: Ability to use suitable utensils to bring food to the mouth and swallow food once the meal is presented on a table/tray. Includes modified food consistency. CMS Q&A document defines fingers as utensils. The manual does not define utensils. Oral hygiene: The ability to use suitable items to clean teeth. [Dentures (if applicable): The ability to remove and replace dentures from and to the mouth, and manage equipment for soaking and rinsing them.] Example on GG-9 suggests that brushing gums, in the absence of teeth or dentures, counts here. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after using the toilet, commode, bedpan or urinal. If managing an ostomy, include wiping the opening but not managing equipment. GG0170 Mobility Items - Tips & Tricks Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed. Use clinical judgment to determine what lying flat means (GG-25) Lying to sitting on side of bed: The ability to safely move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support. May have to lower bed or get a footstool. Back support could be person or object (GG-25) Walk 50 feet with two turns (GG0170J): Once standing, the ability to walk at least 50 feet and make two turns. Walk 150 feet (GG0170K): Once standing, the ability to walk at least 150 feet in a corridor or similar space. If they walk but not the en7re distance, or not with two turns: code 88 Turns are 90 at any point in the 50 walk (or wheel) Walk 150 feet: Mr. R has endurance limita7ons due to heart failure and has only walked about 30 feet during the 3-day assessment period. He has not walked 150 feet or more during the assessment period, including with the physical therapist who has been working with Mr. R. Coding: GG0170K. Walk 150 feet would be coded 88, Ac7vity not acempted due to medical or safety concerns. Ra@onale: The ac7vity was not acempted. (GG-32) (c) 9

10 Wheel 50 feet with two turns (GG0170R): Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. Indicate the type of wheelchair/scooter used (GG0170RR). 0.Manual 1.Motorized Wheel 150 feet (GG0170S): Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. Indicate the type of wheelchair/scooter used (GG0170SS). 0.Manual 1.Motorized assessment for wheelchair items should be coded for residents who used a wheelchair prior to admission or are an7cipated to use a wheelchair by discharge, even if the resident is an7cipated to ambulate during the stay or by discharge. (GG-34) Mobility Examples: Toilet transfer (GG0170F): The ability to safely get on and off a toilet or commode. Reminder: Toileting hygiene (GG0130C): The ability to maintain perineal hygiene, adjust clothes before and after using the toilet, commode, bedpan or urinal. If managing an ostomy, include wiping the opening but not managing equipment. Does the resident walk? Walking goal is/is not clinically indicated Discussion: Consider therapy evalua7on and goals when comple7ng this sec7on DC Goal can be: What if they don t meet their goal(s)? Higher Lower Same Required to code at least one goal. Can t use 07, 09, or 88. Skilled therapy plan of treatment cannot be for a lower goal. 1. No financial penalty 2. They will post it on the internet eventually (Medicare.gov) 3. While the first one is a process measure, they have outcomes measures in TEP as we speak. (may be done by now) 4. There is no mechanism in GG for plans of care that change over the course of care 5. Advocacy opportunity (c) 10

11 Assessment can be based on: Direct observa7on How do we document the GG assessments? Self-report Family reports Direct-care staff reports During 3 day lookback, documented in medical record USUAL PERFORMANCE If the func7onal status varies, record usual ability. Not the best and not the worst. -GG-3 For, code based on assessment of performance that occurs soon a_er the resident s admission. Must be within days 1 through 3 of the Medicare Part A stay. Should occur prior to the start of therapeu7c interven7on in order to capture the resident s true admission baseline status. -GG-4 For Discharge, code based on assessment of performance that occurs as close to the 7me of discharge as possible. Must be completed within last 3 calendar days of the resident s stay, which include day of discharge and the two days prior to the day of discharge. (GG-20) Must be completed in last 3 days of Part A stay. (GG-17) Ques7ons Can we do a single point in 7me assessment? Yes Does the assessment have to be done before therapy starts? No, but the assessor must discern usual status prior to therapeu7c interven7on, which is more than just therapy. How do you do that? If you don t do the assessment immediately upon arrival, ask the resident, family, staff, etc. Has your ability improved due to our assistance? Did you need more help with this when you first got here? Ques7ons What if they are asleep or doped up when I do the assessment? You may have to come back later What if CNAs say he was independent 12 7mes and mod assist 12 7mes, what s usual? I don t know, I didn t assess the resident, but this assessment is not about couneng things. It s using clinical judgment to make a determina7on. Are they somehow, someday going to use this against us? What if this doesn t match G or therapy documenta7on or? They may, but all I can do is follow the manual now. GG is never going to match G or therapy or CNA documenta7on. An7cipatory worrying has never helped anyhow. (c) 11

12 Ques7ons What if they come in on Friday night and I don t see them un7l Monday? Can I write a note then? Yes, but you couldn t use direct observa7on. You d have to rely on resident/family/direct-care staff report. Why not make this assessment part of the admission nursing assessment? Don t we need to know this stuff right away to care for them? Can therapy do this? Yes Mrs. M had fracture of right wrist and hip during a recent fall. She is right-handed. She is admitted at 6 pm on a Tuesday. She had surgery the day prior to admission. She has mild dementia. Day 1 Day 2 Very tired and weak, drank some juice, didn t want to eat anything that evening Weak during breakfast. Ate a few bites using her fork, drifted off to sleep, CNA few her about 75% of the meal. For lunch CNA fed about 25%, resident fed herself the rest. For evening meal she fed herself after set up 07: Resident refused! 02: Max assist! 03: Mod assist! 05: set up/clean up!! What if therapy is not in? Nursing has to do it. Day 3 CNA fed about half of breakfast, but by lunch she was more alert, feeling stronger and only needed supervision and cueing to eat using utensils. At the evening meal, she felt strong enough to go to the dining room. When eating with other residents, she fed herself using suitable utensils without cueing by staff. 02: Max assist! 04: Supervision/ touching! 06: independent! Non-Part A Considera7ons There is no item set for the PPS 5 day that does not include Sec7on GG: Func7onal Abili7es and Goals Coding A2400 forces PPSDC/OBRA DC Combina7on We follow the PPS schedule for everyone in case we need it later. Considera7ons: OBRA schedule must be submiced PPS schedule can t be submiced What about GG? Do it on the PPS 5 day that is not submiced. Do a stand-along NPE item set on last day of non-part A stay Submit an OBRA discharge (A2400A = no) It s three months later and now we must submit the PPS assessments because it was Part A all along. Modify the (if applicable) and add the 5 day Change A2400 to Yes with Dates Change A2400 to Yes (with Dates) for all PPS assessments prior to submiyng. Modify the OBRA discharge to add A0310H = yes with GG (if applicable) Use the GG informa7on you had on the NPE item set you completed and did not submit. OBRA Discharge and OBRA/PPS Discharge combina7on are both on the same ND item set We know for sure we will not be submiyng these PPS Assessments. Dash GG, don t do the NPE item set Won t macer at all (c) 12

13 Potentially Preventable 30-Day Post-Discharge Readmission Measure for SNFQRP Explanation of SNF-QRP Claims Based Measures in FY 2017 Calculates risk-adjusted poten7ally preventable and unplanned readmission (PPR) rate for each PAC provider using hospital claims. Poten7ally preventable condi7on categories: Inadequate management of chronic condi7ons; Inadequate management of infec7ons; and Inadequate management of other unplanned events. Accidents, injury Risk adjustment/exclusions very similar to the other two hospitalization measures for 5 star & QRP (All done by same 2 contractors: RTI and ABT) PPR condi7ons: Examples ICD codes will come from hospital claims Acute exacerba7on of CHF related condi7ons: hypertensive heart disease/chronic kidney disease Acute exacerba7on in COPD/respiratory condi7ons Diabe7c crisis HTN unmanaged Sep7cemia Celluli7s Impac7on Pressure ulcers Flu Pneumonia UTI C-diff Dehydra7on/electrolyte imbalance/acute renal failure Poten7ally Preventable 30-Day Post-Discharge Readmission Measure for SNFQRP No simple form numerator/denominator of observed PPR over predicted Numerator is risk-adjusted es3mate of the number of unplanned hospital readmissions that occurred within 30 days of PAC discharge. Risk-adjusted for pa7ent/resident characteris7cs Within PAC-stay readmission excluded: hospital to SNF to hospital Because they don t currently have a method to apply it to all PAC seyngs This is a primary difference between this one and the one in the Five Star system Data from calendar year 2013 data was used to develop the SNF PPR measure. Exclusions: < 18 DC AMA (from SNF DC disposi7on code on claim) Not con7nuously enrolled in Part A for 12 months prior to the SNF stay or 30 days a_er Prior hospitaliza7on for nonsurgical tx of cancer Exclusions: SNF stays with problema7c data (Jacked up claims data, upstream, in SNF, or downstream) Pts transferred to a federal hospital (DoD, VA, Prison, etc), or foreign hospital (Medicare claims data won t be complete) Discharge to Community- Post Acute Care SNF QRP - Definitions Successful Discharge: No unplanned hospitaliza7ons (Acute or LTCH) No death from any cause Within 31 days from SNF Discharge Community, defined as home/self-care, with/ without HHA, based on Pa7ent Discharge Status Codes 01, 06, 81, and 86 on the SNF Medicare claim. Risk adjustment/ exclusions similar to previous claims based measures (c) 13

14 Discharge to Community Post Acute Care SNF QRP - Definitions Exclusions unique to this measure DC to psych hospital (community may be inappropriate due to mental health) DC to law enforcement/court Medicare A benefits exhaust (DC des7na7on may be r/t exhaus7on) For SNF residents with mul7ple SNF stays during the one year window, each stay is eligible for inclusion in the measure. Data from CY 2013 were used to develop this measure. Medicare Spending per Beneficiary- Post-Acute Care SNF QRP (MSPB-PAC SNF) Designed to benchmark resource use of provider against expected spending as predicted through risk adjustment. Not a simple sum of costs Begins upon admission to SNF and ends a_er 30 day associated services period a_er SNF discharge. Certain services excluded as clinically unrelated to SNF care (ex: Dialysis, tx for preexis7ng cancers) Mirrors hospital MSPB measure that has been used in Hospital Value-Based Purchasing (VBP) Program since FY 2015 Medicare Spending per Beneficiary- Post-Acute Care SNF QRP (MSPB-PAC SNF) Payment standardized and risk-adjusted. Removes geographic payment differences, incen7ve payment adjustments, and other add-on payments that support broader Medicare program goals including indirect graduate medical educa7on (IME) and hospitals serving a dispropor7onate share of uninsured pa7ents (DSH) Risk adjusted for covariates including the clinical case mix categories, HCC indicators, age brackets, indicators for originally disabled, ESRD enrollment, and long-term care status, hospice status Drug Regimen Review Conducted with Follow-Up for Iden7fied Issues SNF QRP MDS Based Begin collec7on Oct 2018 Ques7ons/Discussion (c) 14