2/20/2018. Resident Classification System RCS-1. CMS Proposal

Transcription

1 Resident Classification System RCS-1 CMS Proposal Resident Classification System I (RCS-I) Complete overhaul of the Medicare A payment system (replacing RUGs-IV) On April 27, 2017 CMS released an Advance Notice of Proposed Rulemaking (ANPRM) Comments were due to CMS by August 28,

2 Why? Concerns through the years OIG Questionable Billing by Skilled Nursing Facilities (December 2010) Inappropriate Payments to Skilled Nursing Facilities Cost Medicare More Than a Billion Dollars in 2009 (November 2012) The Medicare Payment System for Skilled Nursing Facilities Needs to be Reevaluated (September 2015) GAO Pattern of increased billing for higher paying RUGs although beneficiary characteristics are mainly unchanged 3 Features of New Resident Classification System Version 1 (RCS-1) New Payment Drivers RUGs and minutes replaced by mutually-exclusive resident groups based on resident characteristics and additional adjustments Maintains per diem payment Per diems vary by sum of five component resident groups assigned for stay at admission: 1. PT/OT, 2. SLP, 3. Nursing, 4. NTA, and 5. Non-Case Mix Simplifies MDS Only two required MDS at admission and discharge but may request a significant change assessment as needed 4 2

3 Features of New Resident Classification System Version 1 (RCS-1) Cont. Reduces therapy restrictions Concurrent therapy would be limited to 25% of total therapy minutes, in addition to the existing 25% limitation on group therapy, remaining 50+% would be individual therapy Creates an interrupted stay policy Variable per diem adjustment is reset whenever a resident is discharged then readmitted to a different SNF and requires a new five day assessment Less than or equal to 3 days following a discharge and readmission is counted as the same variable per diem adjustment Greater than 3 days following discharge and readmission resets variable per diem adjustment and requires a new five day assessment Creates a budget neutral system, but CMS seeks comments on this point 5 PPS v RCS-1 PPS Therapy Therapy Non Case Mix Nursing Non Case Mix RCS-1 Nursing PT/OT ST Non Therapy Ancillary Non Case Mix Nursing CMI + PT/OT CMI + SLP CMI + NTA CMI + Non-CMI =DAILY RATE 6 3

4 RCS 1 7 Unadjusted Federal Rate Per Diem URBAN RATE RURAL RATE 8 4

5 Nursing Component All residents will be assigned to one of the 43 current non-rehab RUGs, including Extensive Services final group determined by combinations of three extensive services Special Care High/Special Care Low/Clinically Complex final group determined by ADL score and presence of depression Behavioral Symptoms and Cognitive Performance final group determined by ADL score and number of restorative nursing services Reduced Physical Function final group determined by ADL score and number of restorative nursing services 9 Example of Nursing Category 10 5

6 PT/OT Component All patients, including those who do not actually receive therapy, will be placed into one of 30 case mix groups for PT/OT The groups would be calculated based on clinical categories, functional scores and the degree of cognitive impairment Clinical categories include Joint replacement/spinal surgery Other orthopedic Non-orthopedic surgery Acute neurological Medical management The therapy component payment rate will vary by the length of stay with SNFs receiving 100% of the rate for days 1-14, and having the rate reduced by 1% every three days thereafter 11 PT/OT (cont) Functional scores include 3 ADLs: Transfer Eating Toileting Each ADL will be scored between 0 and 6, for a total of 0 to 18 points Cognitive function will be evaluated and residents will be categorized as Moderate/Severe Cognitive Impairment, Yes or No CLINICAL CATEGORIES X FUNCTIONAL SCORE X COGNITIVE IMPAIRMENT = 30 GROUPS 12 6

7 Functional Status Based on Self Performance Score Only: Eating, Toileting, Transfers 13 PT/OT Example 14 7

8 SLP Component Each resident will be placed into one of 18 SLP classifications, based on Clinical Categories Acute neurologic and non-neurologic The presence of a Swallowing Disorder or Mechanically Altered Diet Both, either or neither SLP-related Comorbidity or Mild to Severe Cognitive Impairment Both, either or neither 12 conditions and services qualify as SLP related comorbidity, including Aphasia, CVA/TIA/Stroke, Hemiplegia or hemiparesis, TBI, Tracheostomy as a Resident, Ventilator as a Resident, Laryngeal Cancer, Apraxia, Dysphagia, ALS, Oral Cancers and Speech and Language Deficits CLINICAL CATEGORIES X SWALLOWING DISORDER or Mechanically Altered Diet X SLP COMORBIDITY OR COGNITIVE IMPAIRMENT = 18 Groups 15 SLP Example 16 8

9 Non Therapy Ancillary Component All residents will be classified into one of 6 case mix groups for non-therapy ancillary payments Points will be assigned for certain conditions and extensive services Information will be gathered from the MDS and in the case of HIV/AIDS patients, the SNF claim HIV/AIDS would no longer receive the 120% payment adjustment, but would receive a 19% increase in the nursing component of the RCS-I rate 17 NTA Classification Example 18 9

10 NTA Groups 19 NTA Per Diem Rates For the first three days of a stay, the adjustment factor for the NTA will be 3.0 For days 4-100, the adjustment factor will be 1.0 The variable per-diem rate is designed to offset higher NTA costs at the beginning of a stay 20 10

11 From the ANPRM: In addition, we are considering the possibility of adding certain items to this PPS Discharge Assessment that would allow CMS to track therapy minutes over the course of a resident s Part A stay. the impacts presented here assume consistent provider behavior in terms of how care is provided under RUG IV and how care might be provided under RCS I, as based on the concerns raised during a number of TEPs, we acknowledge the possibility that, as therapy payments under RCS I would not have the same connection to service provision as they do under RUG IV, it is possible that some providers may choose to reduce their provision of therapy services to increase margins under RCS I. (Emphasis added) 21 Getting Prepared Outcomes- Know your data MDS accuracy Special attention to sections B,C,D,G,I Timely and accurate admission assessment Coding Restorative Nursing documentation Function is everyone s job 22 11

12 RCS-1 Payment Model Impact Analysis RUG versus RCS1 Impact comparison for 2014: Service-Payment/SNFPPS/therapyresearch.html (Scroll to Provider Specific Impact Analysis) 23 Acknowledgements Changing SNF Part A Payment: An Afternoon with RCS-1, NASL meeting October 15, 2017 CMS Proposed SNF Payment System Resident Classification System: Version 1, Mike Cheek, October 3, 2017, AHCA/NCAL SNF PPS Payment Model:

13 THANK YOU Liz Barlow, RN, CRRN, RAC-CT, C-NE Senior Director, Quality Kindred Rehab Services/RehabCare