Resource Utilization Group - IV (RUG-IV) SNF Consolidated Billing for Clinicians & Intro to Resident Classification System 1 (RCS-1)

Transcription

1 Judy Wilhide Brandt, RN, BA, RAC-MT, QCP, CPC, DNS-CT Resource Utilization Group - IV (RUG-IV) SNF Consolidated Billing for Clinicians & Intro to Resident Classification System 1 (RCS-1) January 2018 NC & VA Purpose: PPS rates expected to cover all operating and capital costs that efficient facilities would be expected to incur in furnishing most SNF services. Certain high-cost, low-probability services paid separately. JudyWilhide.com 2 JudyWilhide.com (c) 1

2 Daily rate includes: Routine Costs - Regular room, dietary, nursing services, minor medical supplies, medical social services, psychiatric social services, and the use of certain facilities and equipment for which a separate charge is not made. Ancillary costs - Costs for specialized services, such as therapy, drugs, and laboratory services, that are directly identifiable to individual patients. Capital-related costs - Costs of land, building, equipment, and the interest incurred in financing the acquisition of such items. JudyWilhide.com 3 Daily Rates Adjusted For: JudyWilhide.com 4 JudyWilhide.com (c) 2

3 Resident Acuity: Determined by classification into a specific Resource Utilization Group (RUG). Groups similar residents needing similar levels of care. Done by the use of a clinical assessment tool, the Minimum Data Set (MDS). Required periodically according to an established schedule for purposes of Medicare payment. JudyWilhide.com 5 Nursing + NTA RUG Rate Comprised of: Therapy Non Case Mix JudyWilhide.com 6 JudyWilhide.com (c) 3

4 Urban/Rural Adjustment: Base payment rates are computed separately for urban and rural areas Updated annually based on the projected increase in the SNF market basket index. FY18 Nursing Therapy Therapy Non- Case Mix Non-Case Mix Urban Rural JudyWilhide.com 7 FY 18 Urban example RUG Nursing Component Therapy Component Non-Case Mix Therapy Comp Non-Case Mix Comp. Total RUC $ $ $90.47 $ HE2 $ $17.59 $90.47 $ JudyWilhide.com 8 JudyWilhide.com (c) 4

5 Labor Cost Adjustment: Next, daily payments to SNFs are divided into labor and non-labor costs. Labor Cost (roughly 70%) example: Category Total Rate Labor Portion Non-Labor Portion RUB JudyWilhide.com 9 $ Santa Cruz, CA Hospital Wage Index Adjustment example RUC $ Travis City, TX $ Ohio Cty, WV JudyWilhide.com 10 JudyWilhide.com (c) 5

6 RUG: Resource Utilization Group-IV Classification system based on resources used to provide care. Eight Categories. 66 groups Refer to RUG-IV Diagram JudyWilhide.com 11 Hierarchy Rehabilitation + Extensive Services Rehabilitation Extensive Services Special Care High Special Care Low Clinically Complex Impaired Cognition & Behavior Reduced Physical Functioning Refer to RUG-IV Grouper JudyWilhide.com 12 JudyWilhide.com (c) 6

7 Index Maximization First, determine all of the RUG-IV groups for which the resident qualifies. Then from the qualifying groups, choose the RUG-IV group that has the highest case mix index. The highest case mix index is associated with the highest payment rate. Refer to CMI handout JudyWilhide.com 13 Index Maximization Hierarchy HE2 RVB HD2 RMC RVB RMC HE2 HD2 JudyWilhide.com 14 JudyWilhide.com (c) 7

8 Urban/Rural Hierarchy Difference: 31 Categories Urban RHB HE1 RMB LE1 Rural HE1 RHB LE1 RMB JudyWilhide.com 15 Bed Mobility Toilet Use Late Loss ADLs Transfer Eating Refer to ADL Algorithm JudyWilhide.com 16 JudyWilhide.com (c) 8

9 2 Columns: Self-Performance/Staff Support: JudyWilhide.com 17 ADL Score Computation: Bed Mobility, Transfers, Toileting Column 1: Column 2: Score: -,0,1,7,8 Any number 0 2 Any number 1 3 -,0,1, ,0,1,2 3 3 or JudyWilhide.com 18 JudyWilhide.com (c) 9

10 ADL Score Computation: Eating Column 1: Column 2: Score: -,0,1,2,7,8 -,0,1,8 0 -,0,1,2,7,8 2 or or 4 -,0 or or or 3 4 JudyWilhide.com 19 ADL Index Example ADL Column 1: Column 2: Score: Bed Mobility Transfer Toileting Eating Total: 5 JudyWilhide.com 20 JudyWilhide.com (c) 10

11 ADL Index Example ADL Column 1: Column 2: Score: Bed Mobility Transfer Toileting Eating Total: 6 JudyWilhide.com 21 FY18 Urban unadjusted rates RU A B/C $96.62/day 17.6%é RUA = RUB = One resident in one month: x 30 = residents in one month: x 30 = 86, residents in a year: 86, x 12 = 1,043, JudyWilhide.com 22 JudyWilhide.com (c) 11

12 Rehabilitation + Extensive Services Rehabilitation Special Care High Extensive Services Special Care Low Clinically Complex Behavioral Symptoms & Cognitive Performance Reduced Physical Functioning JudyWilhide.com 23 A. Speech-Language Pathology and Audiology Services B. Occupational Therapy C. Physical Therapy O0400. Therapies JudyWilhide.com 24 JudyWilhide.com (c) 12

13 Therapy Days: Number of days in 7 day look back or since most recent entry/reentry in which at least 15 minutes of specific therapy was delivered. Therapy Start Date: Date of initial evaluation of most recent regimen of therapy Therapy End Date: Last date, since most recent entry/reentry, resident received treatment minutes for each discipline. If discipline is on-going, enter dashes. JudyWilhide.com 25 Reimbursable Therapy Minutes Initial Evaluation minutes do not count But initial evaluation is the start date for the discipline Re-evaluations do count May treat either: Individually (100% RTM) Co-treatment: One resident, two therapists from different disciplines treating at the same time: Each discipline counts all time as individual minutes. Reason for co-treatment must be well documented. Concurrently: One therapist and only two residents (50% RTM) Group: (25% RTM not to exceed 25% of total) One therapist for exactly 4 residents, doing the same or similar activities JudyWilhide.com 26 JudyWilhide.com (c) 13

14 Reimbursable Therapy Minutes Includes only therapies that were provided after admission to the SNF stay Must do new re-evaluations every time resident requires discharge assessment and reentry tracking If a resident returns from a hospital stay, an initial evaluation must be performed after each entry to the facility, and only those therapies that occurred since admission/reentry to the facility and after the initial evaluation shall be counted. JudyWilhide.com 27 Reimbursable Therapy Minutes The therapist s time spent on documentation or on initial evaluation is not included. The therapist s time spent on subsequent reevaluations, conducted as part of the treatment process, should be counted. Family education when the resident is present is counted and must be documented in the resident s record. JudyWilhide.com 28 JudyWilhide.com (c) 14

15 Ultra High + Ext Very High + Ext High + Ext Medium + Ext Low + Ext Rehabilitation + Extensive Services RUL RHL 2-10 RVL RML RUX RVX RHX RMX RLX JudyWilhide.com 29 While a resident Extensive Services ADL > 2: Trach AND Vent ES3 Trach OR Vent ES2 Isolation for Active Infectious Disease ES1 JudyWilhide.com 30 JudyWilhide.com (c) 15

16 Rehab RTM Calendar Days/Disciplines ADL Ultra calendar days of 1 discipline AND 3 calendar days of a 2d discipline. Very calendar days of 1 discipline High calendar days of 1 discipline Medium *5 calendar days, but not one discipline for 5 calendar days, may be any combination of disciplines C = B = 6-10 A = 1-5 Low >=45 *3 calendar days, no requirement for any minimum number of disciplines + 2 qualifying restorative programs B = A = 0-10 JudyWilhide.com 31 Nursing Restorative: >=2 on 6 days in lookback Urinary and/or bowel training program* Passive and/or active ROM* Splint and/or brace assistance Bed Mobility and/or walking training* Transfer Training Dressing and/or Grooming Training Eating and/or Swallowing Training Amputation/Prosthesis Care Training Communication Training *Count as 1 for RUG purposes. JudyWilhide.com 32 JudyWilhide.com (c) 16

17 Section O0100: Trach, Vent, Isolation while a resident May code treatments, programs and procedures that the resident performed themselves independently or after set-up by facility staff. Do not code services that were provided solely in conjunction with a surgical procedure or diagnostic procedure, such as IV medications or ventilators. Surgical procedures include routine pre- and post-operative procedures. JudyWilhide.com 33 Section O0100: Trach, Vent, Isolation while a resident O0100E, Tracheostomy care: Code cleansing of the tracheostomy and/or cannula in this item. This item may be coded if the resident performs his/her own tracheostomy care. O0100F, Ventilator or respirator: Code any type of electrically or pneumatically powered closed-system mechanical ventilator support devices that ensure adequate ventilation in the resident who is, or who may become, unable to support his or her own respiration in this item. JudyWilhide.com 34 JudyWilhide.com (c) 17

18 O0100 M: Isolation O-4 Code only when the resident requires transmission-based precautions and single room isolation (alone in a separate room) because of active infection (i.e., symptomatic and/or have a positive test and are in the contagious stage) with highly transmissible or epidemiologically significant pathogens that have been acquired by physical contact or airborne or droplet transmission. Do not code this item if the resident only has a history of infectious disease (e.g., s/p MRSA or s/p C-Diff - no active symptoms). Do not code this item if the precautions are standard precautions, because these types of precautions apply to everyone. Standard precautions include hand hygiene compliance, glove use, and additionally may include masks, eye protection, and gowns. Examples of when the isolation criterion would not apply include urinary tract infections, encapsulated pneumonia, and wound infections. JudyWilhide.com 35 Code for single room isolation only when all of the following conditions are met: 1. The resident has active infection with highly transmissible or epidemiologically significant pathogens that have been acquired by physical contact or airborne or droplet transmission. 2. Precautions are over and above standard precautions. That is, transmissionbased precautions (contact, droplet, and/or airborne) must be in effect. 3. The resident is in a room alone because of active infection and cannot have a roommate. This means that the resident must be in the room alone and not cohorted with a roommate regardless of whether the roommate has a similar active infection that requires isolation. 4. The resident must remain in his/her room. This requires that all services be brought to the resident (e.g. rehabilitation, activities, dining, etc.). JudyWilhide.com 36 JudyWilhide.com (c) 18

19 Isolation: Effect on Medicare RUGS Isolation is an Extensive Service Rehab + Extensive Services End in L or X Ex: RUL RHX ES1 = RUC = $ RUX = $ $187.97/day * 30 days = $5, JudyWilhide.com 37 Ultra High Very High High Medium Low 0-5 RUA 0-5 RVA 0-5 RHA 0-5 RMA Rehabilitation 6-10 RUB RUC RVB RVC RHB RHC RMB RMC RLA RLB JudyWilhide.com 38 JudyWilhide.com (c) 19

20 Rehabilitation + Extensive Services Rehabilitation Extensive Services Special Care High Special Care Low Clinically Complex Behavioral Symptoms & Cognitive Performance Reduced Physical Functioning JudyWilhide.com 39 Special Care High ADL Signs of Depression HE1 HE2 ADL Signs of Depression HD1 HD2 ADL 6-10 Signs of Depression HC1 HC2 ADL 2-5 Signs of Depression HB1 HB2 JudyWilhide.com 40 JudyWilhide.com (c) 20

21 Special Care High: ADL >= 2 Depression End Split: >= 10 PHQ9/OV Comatose & ADL 4/8 IV Fluid Septicemia Respiratory Therapy 7 days Diabetes w/daily Insulin inj & Insulin Rx changes on > 2 days Quadriplegia & ADL > 5 COPD & SOB lying flat Fever & 1: Pneumonia Weight Loss Qualifying Feeding Tube all 7 days: >=51% calories 26-50% calories & 501cc fluid JudyWilhide.com 41 Special Care High Coding Tips Diagnoses, Section I: Diabetes Septicemia COPD Quadraplegia pneumonia Two Step Process: 1. Identify Diagnoses: MD/NPP Documented in 60 day lookback 2. Determine Diagnosis Status: Active/Inactive in 7 day lookback JudyWilhide.com 42 JudyWilhide.com (c) 21

22 Indicators of Active Diagnosis: Specific Documentation of Active Diagnosis in medical record by MD/NPP Recent onset or acute exacerbation indicated by a positive study, test, or procedure, hospitalization for acute S/S, and/or recent changes in therapy. Symptoms and abnormal signs indicating ongoing or decompensated disease. Must be specifically attributable to a disease Ongoing therapy w/meds or other interventions to manage a condition that requires monitoring for therapeutic efficacy or to monitor potential adverse effects. JudyWilhide.com 43 COPD & SOB Lying Flat: Critical Crosscheck: If I6200 checked, is J1100C checked? Also code this as present if the resident avoids lying flat because of shortness of breath. JudyWilhide.com 44 JudyWilhide.com (c) 22

23 Respiratory Therapy Definition: Services that are provided by a qualified professional (respiratory therapists, respiratory nurse). Respiratory therapy services are for the assessment, treatment, and monitoring of patients with deficiencies or abnormalities of pulmonary function. Respiratory therapy services include coughing, deep breathing, nebulizer treatments, assessing breath sounds and mechanical ventilation, etc., which must be provided by a respiratory therapist or trained respiratory nurse. A respiratory nurse must be proficient in the modalities listed above either through formal nursing or specific training and may deliver these modalities as allowed under the state Nurse Practice Act and under applicable state laws. Appendix A Glossary Respiratory therapy only minutes that the respiratory therapist or respiratory nurse spends with the resident shall be recorded on the MDS. This time includes resident evaluation/assessment, treatment administration and monitoring, and setup and removal of treatment equipment. Time that a resident selfadministers a nebulizer treatment without supervision of the respiratory therapist or respiratory nurse is not included in the minutes recorded on the MDS. Do not include administration of metered-dose and/or dry powder inhalers in respiratory minutes. Ch 3, O-19 JudyWilhide.com 45 (Fever and ) IV Fluid Section K: 7 day lookback Either count JudyWilhide.com 46 JudyWilhide.com (c) 23

24 (Fever and ) Qualifying Tube Feeding Must have either: 26-50% AND 501cc OR 51% JudyWilhide.com 47 Rehabilitation + Extensive Services Rehabilitation Extensive Services Special Care High Special Care Low Clinically Complex Behavioral Symptoms & Cognitive Performance Reduced Physical Functioning JudyWilhide.com 48 JudyWilhide.com (c) 24

25 Special Care Low ADL Signs of Depression LE1 LE2 ADL Signs of Depression LD1 LD2 ADL 6-10 Signs of Depression LC1 LC2 ADL 2-5 Signs of Depression LB1 LB2 JudyWilhide.com 49 Special Care Low: ADL >=2 Depression End Split 10 PHQ9/OV Cerebral Palsy & ADL > 5. Multiple Sclerosis & ADL > 5. Parkinson s Disease & ADL > 5. Qualifying Tube Feeding (entire 7 days) Foot Infection, Diabetic foot ulcer, or open lesions on foot w/ dressings to feet. Radiation therapy while resident. Respiratory Failure and Oxygen therapy while resident. Dialysis while resident. JudyWilhide.com 50 JudyWilhide.com (c) 25

26 Special Care Low: ADL >=2 Depression End Split 10 PHQ9/OV >=2 St II PU & >=2 skin treatments >=1 St III, IV, or unstageable slough/eschar PU & >=2 skin treatments >=2 venous/arterial ulcers & >=2 skin treatments 1 St II PU & 1 venous/arterial ulcer & >=2 skin treatments. JudyWilhide.com 51 Qualifying Skin Treatments Pressure relieving chair and/or bed * Turning/repositioning Nutrition or hydration intervention Ulcer care Application of dressings (not to feet) Application of ointments (not to feet) JudyWilhide.com 52 JudyWilhide.com (c) 26

27 Rehabilitation + Extensive Services Rehabilitation Extensive Services Special Care High Special Care Low Clinically Complex Behavioral Symptoms & Cognitive Performance Reduced Physical Functioning JudyWilhide.com 53 Clinically Complex ADL Signs of Depression CE1 CE2 ADL Signs of Depression CD1 CD2 ADL 6-10 Signs of Depression CC1 CC2 ADL 2-5 Signs of Depression CB1 CB2 ADL 0-1 Signs of Depression CA1 CA2 JudyWilhide.com 54 JudyWilhide.com (c) 27

28 Clinically Complex: Any ADL Score Depression End Split 10 PHQ9/OV Extensive Services, Special Care High or Low with an ADL score of <2 Pneumonia Hemiplegia and ADL score > 5 Surgical wounds or open lesions w/treatment Burns Chemotherapy while resident Oxygen therapy while resident IV Medications while resident Transfusions while resident JudyWilhide.com 55 Rehabilitation + Extensive Services Rehabilitation Extensive Services Special Care High Special Care Low Clinically Complex Reduced Physical Functioning Behavioral Symptoms & Cognitive Performance JudyWilhide.com 56 JudyWilhide.com (c) 28

29 Behavioral Symptoms & Cognitive Performance ADL Restorative BB1 BB2 ADL Restorative BA1 BA2 JudyWilhide.com 57 Any 1 of the following: Behavioral Symptoms & Cognitive Performance ADL <=5 Restorative Nursing End Split BIMS Score < 9 or CPS > 3 Physical or verbal behavioral symptoms directed to others* Other behavioral symptoms not directed to others* Rejection of Care* Wandering* Hallucinations Delusions *>=4 days JudyWilhide.com 58 JudyWilhide.com (c) 29

30 Rehabilitation + Extensive Services Rehabilitation Extensive Services Special Care High Special Care Low Clinically Complex Behavior Symptoms & Cognitive Performance Reduced Physical Functioning JudyWilhide.com 59 Reduced Physical Function ADL Restorative PE1 PE2 ADL Restorative PD1 PD2 ADL Restorative PC1 PC2 ADL Restorative PB1 PB2 ADL Restorative PA1 PA2 JudyWilhide.com 60 JudyWilhide.com (c) 30

31 SNF PPS Consolidated Billing Bundled Unbundled JudyWilhide.com 61 Process SNF completes PPS MDS HIPPS used to bill MAC SNF or outside supplier may have provided care/service Outside suppliers receive payment from the SNF JudyWilhide.com 62 JudyWilhide.com (c) 31

32 SNF Responsibilities Inform beneficiaries of CB requirements upon admission Notify all outside suppliers/vendors: Resident is in a SNF stay Provider must bill the SNF and not Medicare for included services. Ensure applicable standards for service are met. JudyWilhide.com 63 Examples of Included Goods & Services Nursing Services Rehab Services DME Pharmacy Laboratory Tests Enteral/parenteral feeding X-Rays PET Scans Ultrasounds Supplies Room & Board Splints, braces JudyWilhide.com 64 JudyWilhide.com (c) 32

33 MDS RUC10 $ * 14 = $ If item is EXCLUDED, the payment for that item DOES NOT come from your $ The supplier of the item billed Medicare directly. If item is INCLUDED, the payment for that item DOES come from your $ The supplier of the item billed Medicare directly. JudyWilhide.com 65 Room & Board Semiprivate unless medically indicated. May collect payment for private room if requested by resident, who, at the time of the request was informed what the charge would be. Charges to the beneficiary for admission or readmission are not allowable, but When temporarily leaving a SNF, a resident can choose to make bed-hold payments to the SNF. Must inform residents in advance of their option to make bedhold payments, as well as the amount of the facility s charge. Facility cannot simply deem a resident to have opted to make such payments and then automatically bill for them upon the resident s departure from the facility. JudyWilhide.com 66 JudyWilhide.com (c) 33

34 Excluded Medicare covers service but SNF does not have to pay Example: MRI at Hospital Outpatient Clinic. JudyWilhide.com 67 Not Covered Medicare never covers service so SNF does not have to pay Example: Wheelchair Van JudyWilhide.com 68 JudyWilhide.com (c) 34

35 Excluded Professional Services: Physician Physician Assistant Nurse Practitioner Clinical Nurse Specialist Nurse Anesthetist Clinical Psychologist Podiatrist Dentist JudyWilhide.com 69 Technical/Professional Component Example (Rates for illustration only) 73070: $ X ray elbow, 2 views TC: $ : $9.30 SNF not responsible for Professional Component: -26 JudyWilhide.com 70 JudyWilhide.com (c) 35

36 Included: Incident to Services Supplies/procedures used during physician visit Ex: drugs, gauze, oxygen, labs. JudyWilhide.com 71 LOA over Midnight During SNF Stay If resident out over midnight, SNF is not responsible for charges incurred during the absence. JudyWilhide.com 72 JudyWilhide.com (c) 36

37 Major Categories for SNF Consolidated Billing: JudyWilhide.com 73 Major Category I: Must be delivered at a hospital outpatient clinic CT scan Cardiac catheterization MRI Radiation therapies Certain angiography, lymphatic & venous procedures Certain outpatient surgeries and related procedures Medically necessary ambulance service when related to an excluded Category I service Major disaster-related ambulance transportation Emergency services JudyWilhide.com 74 JudyWilhide.com (c) 37

38 Major Category II End Stage Renal Disease Hospice If provided in the SNF, ESRD services are not excluded. To be excluded, services must be provided in a renal dialysis facility. JudyWilhide.com 75 Hospice Resident can access both Medicare Hospice and SNF benefit as long as the reason for the SNF stay is in no way related to the terminal condition. Example from CMS Web-based training: Res. w/terminal GI cancer falls & breaks leg at home. After qualifying hospital stay, goes to SNF for rehab. Instances of such cases may be rare. Broken leg can t be r/t bone mets, sedation for terminal condition, etc. Furthermore, the beneficiary must be able to tolerate rehab and rehab must be R&N. JudyWilhide.com 76 JudyWilhide.com (c) 38

39 Major Category III: Certain Types Excluded, by HCPCS, when given outside SNF chemotherapy & administration radioisotopes & administration Customized prosthetic devices Not ALL are excluded. Must check current CMS update file JudyWilhide.com 77 Major Category IV Preventive/Screening Services: Mammography Screening Pneumonia, flu and Hepatitis B vaccine Screening Pap Smear and Pelvic Exams Colorectal Screening Services Prostate Cancer Screening Glaucoma Screening Diabetic Screening Cardiovascular Screening JudyWilhide.com 78 JudyWilhide.com (c) 39

40 Major Category V PT ST OT INCLUDED: Even if received outside the SNF. Examples: Wound clinic MBS JudyWilhide.com 79 Ambulance Transportation Must be medically necessary. If covered by Medicare, SNF must recognize when the service is INCLUDED or EXCLUDED Cat I: Excluded Dialysis: Excluded MD office visit: Included JudyWilhide.com 80 JudyWilhide.com (c) 40

41 RUG Reform: Resident Classification System 1 (RCS-1) Medicare Trust Fund Report 2017 In 2016, Medicare A income exceeded expenditures by $5.4 billion. The Trustees project modest surpluses to continue in 2017 through 2022, with a return to deficits thereafter until the trust fund becomes depleted in Consideration of further reforms should occur in the near future. The sooner solutions are enacted, the more flexible and gradual they can be. Moreover, the early introduction of reforms increases the time available for affected individuals and organizations including health care providers, beneficiaries, and taxpayers to adjust their expectations and behavior. The Trustees recommend that Congress and the executive branch work closely together with a sense of urgency to address the depletion of the Part A trust fund and the projected growth in Part A and Parts B and D expenditures. 82 JudyWilhide.com (c) 41

42 SNF RUG Reform: RCS-1 Advance notice of proposed rulemaking (ANPRM) announced 5/4/17. CMS seeking comments on replacing the SNF PPS' existing case-mix classification model, the Resource Utilization Groups, Version 4 (RUG-IV), with a new model, the Resident Classification System, Version I (RCS-I) This model is based on resident characteristics, not days/minutes of therapy delivered 83 SNF RUG Reform: Problem Percentage of residents classifying into RU category increased steadily Percentage of residents receiving just enough therapy to surpass RU & RV thresholds also increased. Increased from 5% in FY 2005 to 33% in FY 2013 & trend has continued Increase in thresholding is strong indication of service provision predicated on financial considerations rather than resident need. 84 JudyWilhide.com (c) 42

43 SNF RUG Reform: Goals To create model that compensates SNFs accurately based on the complexity of the particular beneficiaries they serve and the resources necessary in caring for those beneficiaries To address concerns about current incentives for SNFs to deliver therapy to beneficiaries based on financial considerations, rather than the most effective course of treatment for beneficiaries To maintain simplicity by limiting the number and type of elements we use to determine case-mix, as well as limiting the number of assessments necessary under the payment system 85 RCS-1 per diem rate components ADL Score for PT/OT: Self-Performance in transfers, eating, toileting Nursing 43 existing nursing RUGs NTA 6 NTA categories using conditions and services from the 5 day MDS PT/OT 30 Case Mix Groups based on clinical reason for SNF stay, New ADL score, & cognitive impairment SLP 18 Case Mix Groups based on clinical reason for SNF stay, swallowing disorder or mechanically altered diet, SLP-related comorbidity, & cognitive impairment Non-Case Mix Similar to current computation 86 JudyWilhide.com (c) 43

44 RCS-1 Payment PPS MDS schedule simplified: PPS 5 day: Obtain per diem rate that decreases by set factors over the course of the 100 day stay SCSA: May adjust rate but will not reset the declining per diem rate based on day of SNF stay PPS Discharge: Quality measurements 87 RCS-1: Rehab Clinical Categories PT/OT Clinical Categories Major joint replacement or spinal surgery Other orthopedic Non-orthopedic surgery Acute neurologic Medical Management SLP Clinical Categories Acute neurologic Non-neurologic CMS considering using item I8000 on MDS 3.0 to allow providers to report the resident's primary diagnosis. More specifically, the first line in item I8000 would be used by providers to report the ICD-10-CM code which represents the primary reason for the resident's SNF Part A stay. (Major payment component based on this diagnosis) 88 JudyWilhide.com (c) 44

45 Comparison RUG IV: RUB for both PT/OT SLP Nursing NTA Resident A TN SE LC1 NC Resident B TA SR HC2 NE Per diem rate would be the rate for each component added together. Full rate for first 14 days of stay. Declining rate for remainder of SNF stay. 89 Questions/Discussion JudyWilhide.com (c) 45

46 RUG-IV 66 REHAB + EXT ULTRA HIGH VERY HIGH HIGH MEDIUM ADL 2-10 ADL ADL ADL RUX RUL RVX RVL RHX RHL RMX RML LOW ADL 2-16 RLX ULTRA HIGH ADL RUC RUB RUA REHAB VERY HIGH HIGH ADL ADL RVC RVB RVA RHC RHB RHA MEDIUM ADL RMC RMB RMA LOW ADL 0-10 RLB RLA EXTENSIVE SERVICES TRACH, VENT, ISOLATION WHILE RESIDENT ADL 2-16 RS3 RS2 RS1 SPECIAL CARE HIGH 2 DEPRESSED ADL 1 NOT DEPRESSED ADL HE2 HD2 HC2 HB2 HE1 HD1 HC1 HB Edmonds Rd. Virginia Beach, VA judy@judywilhide.com

47 RUG-IV 66 SPECIAL CARE LOW 2 DEPRESSED ADL 1 NOT DEPRESSED ADL LE2 LD2 LC2 LB2 LE1 LD1 LC1 LB1 CLINICALLY COMPLEX 2 DEPRESSED ADL 1 NOT DEPRESSED ADL CE2 CD2 CC2 CB2 CA2 CE1 CD1 CC1 CB1 CA BEHAVIORS & CONGNITION 2 NURSING REHAB 2+ 1 NURSING REHAB ADL ADL BB2 BA2 BB1 BA1 REDUCED PHYSICAL FUNCTION YES 2 NURSING REHAB 2+ 1 NURSING REHAB 0-1 ADL ADL PE PD PC2 2-5 PB2 0-1 PA PE PD PC1 2-5 PB1 0-1 PA Edmonds Rd. Virginia Beach, VA judy@judywilhide.com

48 Prepared by Judy Wilhide Brandt Wilhide Consulting, Inc. Partial Transcript of commonly asked questions from CMS YouTube Video on coding Section I, Diagnoses: Quadriplegia If there is a physician-documented diagnosis of quadriplegia within the last 60 days and it is still an active diagnosis in the last seven days, it is to be coded on the MDS. Quadriplegia is the complete paralysis that affects all four limbs caused by injury to the spinal chord in the area of the neck. It is usually identified by which vertebrae have been injured in the cervical spine and how complete the severing of the spinal chord may be. A diagnosis of quadriplegia unspecified may be used if an injury is old and there's no medical documentation related to how the spinal chord injury actually happened. Facilities in general should work to clarify any nonspecific diagnoses as much as possible. For MDS 3.0, item I-5100, quadriplegia, is not coded as a primary diagnosis in Section I when it is not caused by spinal chord injury. Let's consider a specific example that may help to clarify this point further. Mrs. Z has end stage Alzheimer's disease and can no longer move any of her limbs. Mrs. Z is dependent on facility staff to assist her with all of her activities of daily living. In this case, Ms. Z is an individual who has a severe debilitating diagnosis with a functional deficit that can render her functionally immobile. This functional immobility may seem comparable with what would be seen in a quadriplegic. However, it is the diagnosis of end stage Alzheimer's that would be coded on the MDS in I4200, Alzheimer's disease, and not I5200, quadriplegia. It would be inappropriate to code the functional status or ADL deficit associated with Alzheimer's disease under I-5100, quadriplegia. Similarly, a resident with a diagnosis of cerebral palsy, spastic quad type, would be coded under I- 4400, cerebral palsy, and not under I-5100, quadriplegia. A resident with severe rheumatoid arthritis would be coded under I-3700, arthritis, and not under I-5100, quadriplegia. If there is a physiciandocumented diagnosis of functional quadriplegia that is secondary to a debilitating disease, this diagnosis can be coded under I-800, other additional active diagnoses. Hemiplegia/Hemiparesis secondary to CVA Regarding a resident with hemiplegia or hemiparesis secondary to cerebral

49 Prepared by Judy Wilhide Brandt Wilhide Consulting, Inc. vascular accident, CVA, or a stroke, the CVA is not considered the active diagnosis if the CVA itself has resolved. That is, the resident is receiving no treatment such as medications and or therapy to manage continued symptoms from the stroke. However, deficits, as in the case of Mr. F, the hemiparesis are a result of the stroke that occurred two years. If the current plan of care is addressing deficits associated with hemiplegia or hemiparesis and all the requirements for coding the diagnosis as active are met, this should be captured in item I4900, hemiplegia or hemiparesis, and not under I4500, cerebral vascular accident. One thing that is really important to remember is that the RAI User's Manual does not provide definitions of diagnoses. This was an intentional omission as it's up to the physician that must make a determination and document the active diagnoses for all residents in the facility according to their assessment of the resident.

50 Prepared by Wilhide Consulting, Inc SNF Ambulance Transportation Tip Sheet: Transportation during a SNF Part A Stay: Ambulance Must Be Medically Necessary To SNF for Admission From SNF to Home after Discharge To Dialysis Facility To Hospital for inpatient Admission To ED for Emergency To a Diagnostic or Therapeutic Site for Medicare Covered Service To MD office visit SNF Pays X X Vendor bills MAC X X X X X Round Trip Ambulance Services for the following EXCLUDED services: (MUST be performed in a hospital outpatient facility) Cardiac Cath CT scans MRI Ambulatory Surgery using hospital OR Radiation Angiography Lymphatic Procedure Venous Procedure SNF Pays Vendor bills MAC X X X X X X X X SNF to SNF transfer on same day: When beneficiary leaves SNF 1 and arrives at SNF 2 prior to midnight on the same day, the reason for transfer determines who pays. If the transfer is to receive needed medical services not available at SNF 1, then SNF 1 pays. If the transfer is not because needed medical services are not available at the SNF, e.g., beneficiary personal preference, the transfer is not medically necessary and SNF 1 is not required to pay for the ambulance. Non-ambulance transport is not a Medicare covered service. Examples of non-covered transport include: Wheelchair vans, Ambulette, Litter Van. The SNF is not responsible to pay for non-ambulance transport Reference: MLN Article: SE0433 Revised 11/14/13