8/27/2018. PDPM Strategies to Thrive Under the SNF Medicare Reimbursement Overhaul. Objectives. PDPM Introduction

Transcription

1 PDPM Strategies to Thrive Under the SNF Medicare Reimbursement Overhaul Presented by: Cindy Gensamer Vice President, Absolute Rehabilitation & Consulting Services, Inc. Brady Dalrymple Business Owner, Squared Business Solutions Stephanie Christopher Business Owner, Squared Business Solutions Stephanie DeWees Quality & Regulatory Specialist, LeadingAge Ohio Objectives Understand the motivation to change the skilled nursing facility payment model Understand how each component of the daily per diem rate will be established Learn practical methods to prepare for PDPM 2 PDPM Introduction First SNF Medicare reimbursement overhaul in 20 years Similar to RCS-1, with condensing and revisions Retains per diem payment as under PPS No longer RUGs the end result driving the rate No longer will therapy minutes be primary driver of reimbursement Increased number of components, with a rate for each component Intended to be budget neutral (before behavior changes) CMS proclaims MDS cost savings to providers of $1.8B over 10 years Effective date of October 1,

2 FY2019 SNF Final Rule Finalized FY2019 market basket increase at 2.4%, equating to $820 million increase in Medicare payments (Prior to the Sequestration, VBP, and QRP adjustments) No transition period from RUG-IV to PDPM Providers will bill under current RUG-IV model through September 20, 2019 Residents whose stay meets skilled level of care under RUG-IV will meet requirements under PDPM beginning October 1. The 25% limit on group and concurrent therapy is combined. PT, OT, and Nursing component have minor modifications based on Section GG 2018 updates Surgical procedure coding on Admission Assessment modified to identify surgical procedure category within item J2000, is set to be created by CMS, surgical coding will not be required within I8000. Interim Payment Assessment (IPA) is optional instead of required 4 Current Medicare SNF Payment System Compared to Proposed PDPM Current PPS consists of three components Therapy Nursing Proposed payment method consists of six components PT OT SLP NTA Nursing Non- Case Mix Non- Case Mix Source: Proposed Rule, Federal Register, April 27, 2018 Payment Structure under PDPM 6 2

3 Base Rates under PDPM PDPM Base Rates (FY 2019) Urban Rural PT $59.33 $67.63 OT $55.23 $62.11 SLP $22.15 $27.90 NTA $78.05 $74.56 Nursing $ $98.83 NCM $92.63 $ Physical & Occupational Therapy Components Primary Tier Collapsed PT and OT Clinical Category PDPM Clinical Category Major Joint Replacement or Spinal Surgery Major Joint Replacement or Spinal Surgery Non-Orthopedic Surgery Non-Orthopedic Surgery and Acute Neurologic Acute Neurologic Non-Surgical Orthopedic / Musculoskeletal Other Orthopedic Orthopedic Surgery (Except Major Joint Replacement or Spinal Surgery) Medical Management Acute Infections Medical Management Cancer Pulmonary Cardiovascular and Coagulations ICD-10 Code over 65,000 diagnosis codes 8 Physical & Occupational Therapy Components PT and OT Component Case Mix Groups Clinical Category Function Score PT OT Case Mix Group PT CMI OT CMI Major Joint Replacement or Spinal Surgery 0-5 TA Major Joint Replacement or Spinal Surgery 6-9 TB Major Joint Replacement or Spinal Surgery TC Major Joint Replacement or Spinal Surgery 24 TD Other Orthopedic 0-5 TE Other Orthopedic 6-9 TF Other Orthopedic TG Other Orthopedic 24 TH Medical Management 0-5 TI Medical Management 6-9 TJ Medical Management TK Medical Management 24 TL Non-Orthopedic Surgery and Acute Neurologic 0-5 TM Non-Orthopedic Surgery and Acute Neurologic 6-9 TN Non-Orthopedic Surgery and Acute Neurologic TO Non-Orthopedic Surgery and Acute Neurologic 24 TP

4 Physical & Occupational Therapy Components Secondary Tier Section GG ADL Function Score Category - Items Eating GG0130A1 Eating 0-4 Oral Hygiene GG0130B1 Oral Hygiene 0-4 Toileting Hygiene GG0130C1 Toileting Hygiene 0-4 Bed Mobility Bed Mobility Transfer Transfer Transfer Walking Walking GG0170B1 Sit to Lying GG0170C1 Lying to Sitting on Side of Bed GG0170D1 Sit to Stand GG0170E1 Chair/Bed-to-Chair GG0170F1 Toilet Transfer GG0170J1 Walk 50 Feet with Two Turns GG0170K1 Walk 150 Feet 0-4 (average) 0-4 (average) 0-4 (average) Score 10 Physical & Occupational Therapy Components Length of Stay Adjustment Variable Per-diem Adjustment Factors and Schedule Medicare Payment Days Adjustment Factor Changes per diem payment based upon length of stay (LOS) OHIO AVERAGE = 26 days Incentive to drive shorter length of stay? Estimated Impact = $2,200 per SNF per year 11 Physical & Occupational Therapy Components EXAMPLE PT/OT PT & OT Function Length of Case Mix Diagnosis Clinical Category Score Stay Group Resident #1 Acute Infections (L Cellulitis) Medical Management Days TK Resident #2 Major Joint Replacement Major Joint Replacement Days TC TK PT CMI 1.52 OT CMI 1.54 Function Score is the same between TC PT CMI 1.88 OT CMI 1.68 this is the largest point gap between groups 12 4

5 Speech-Language Pathology Component Primary Tier Three Criteria 1. Acute Neurologic Condition nearly 2,000 ICD-10 Codes 2. SLP-Related Comorbidity I4300 Aphasia I4500 CVA, TIA, Stroke I4900 Hemiplegia or Hemiparesis I5500 Traumatic Brain Injury O0100E2 Tracheostomy Care While a Resident O0100F2 Ventilator or Respirator While a Resident I8000 Laryngeal Cancer I8000 Apraxia I8000 Dysphagia I8000 ALS I8000 Oral Cancers I8000 Speech and Language Deficits 3. Cognitive Impairment Staff PDPM Cognitive Level BIMS Score Assessment Score 1 - Cognitively Intact Mildly Impaired Moderately Impaired Severely Impaired *Note: Residents are classified as cognitively impaired when they are assessed to be mildly, moderately, or severely impaired 13 Speech-Language Pathology Component Secondary Tier Two Criteria 1. Swallowing Disorder K0100A Loss of liquids/solids from mouth when eating or drinking K0100B Holding food in mouth/cheeks or residual food in mouth after meals K0100C Coughing or choking during meals or when swallowing medications K0100D Complaints of difficulty or pain with swallowing K0100Z None of the above 2. Mechanically Altered Diet K0510C2 Mechanically Altered Diet While a Resident 14 Speech-Language Pathology Component SLP Component Case Mix Group Presence of Acute Neurologic Condition, SLP- Mechanically Altered Diet or SLP Case Mix Group CMI Related Comorbidity, or Swallowing Disorder Cognitive Impairment None Neither SA 0.68 None Either SB 1.82 None Both SC 2.66 Any one Neither SD 1.46 Any one Either SE 2.33 Any one Both SF 2.97 Any two Neither SG 2.04 Any two Either SH 2.85 Any two Both SI 3.51 All three Neither SJ 2.98 All three Either SK 3.69 All three Both SL

6 Speech-Language Pathology Component EXAMPLE Presence of Acute Neurologic Condition, SLP-Related Comorbidity, or Cognitive Impairment Mechanically Altered Diet or Swallowing Disorder SLP Case Mix Group Resident #1 No No SA Resident #2 No No SA SA - SLP CMI.68 Case Mix Group can be impacted by clinical conditions and diet orders the highest group is SL which would have all three clinical conditions and mechanically altered diet and swallowing disorder 16 Nursing Component Components Used Existing Nursing RUGs Nursing Utilization and STRIVE study CMI recalculated Administrative Presumption Section G replaced with GG - Functional Measurement Reduce nursing case-mix groups from 43 to 25 Combing ADL scoring bins (E,D) and (C,B) Special Care High, Special Care Low, Clinically Complex, Reduced Physical Function RUGs beginning with H, L, C, or P 17 Nursing Component ADL Scoring Bins Example A HE2 = ADL Score HD2 = ADL Score Combined to make HDE2 Example B BB2 = ADL Score 2-5 BA2 = ADL Score 0-1 Combined to make BAB2 18 6

7 Nursing Component Mapping of Section GG to Section G 19 Nursing Component Nursing Classification Conditions/Services Section GG-Based Nursing Category Conditions/Services PDPM RUG CMI Present Function Score Extensive Services Tracheostomy Care and Ventilator/Respirator Yes 0-14 ES Extensive Services Tracheostomy Care or Ventilator/Respirator Yes 0-14 ES Extensive Services Infection Isolation Yes 0-14 ES Special Care High Depressed Yes 0-5 HDE Special Care High Depressed No 0-5 HDE Special Care High Depressed Yes 6-14 HBC Special Care High Depressed No 6-14 HBC Special Care Low Depressed Yes 0-5 LDE Special Care Low Depressed No 0-5 LDE Special Care Low Depressed Yes 6-14 LBC Special Care Low Depressed No 6-14 LBC Clinically Complex Depressed Yes 0-5 CDE Clinically Complex Depressed No 0-5 CDE Clinically Complex Depressed Yes 6-14 CBC Clinically Complex Depressed Yes CA Clinically Complex Depressed No 6-14 CBC Clinically Complex Depressed No CA Behavioral Cognitive Symptoms Restorative Nursing Services 2 or More BAB Behavioral Cognitive Symptoms Restorative Nursing Services BAB Reduced Physical Function Restorative Nursing Services 2 or More 0-5 PDE Reduced Physical Function Restorative Nursing Services PDE Reduced Physical Function Restorative Nursing Services 2 or More 6-14 PBC Reduced Physical Function Restorative Nursing Services 2 or More PA Reduced Physical Function Restorative Nursing Services PBC Reduced Physical Function Restorative Nursing Services PA Section GG Items Included in Nursing Component Functional Measure Functional Area MDS Item Name Mapped To Bed Mobility GG0170B1 G0110A1 Mobility: Sit to lying Bed Mobility GG0170C1 Mobility: Lying to sitting on side of bed G0110A1 Transfer GG0170D1 Mobility: Sit to stand G0110B1 Transfer GG0170E1 Mobility: Chair/bed-to-chair transfer G0110B1 Transfer GG0170F1 Mobility: Toilet transfer G0110B1 Eating GG0130A1 Self-care: Eating G0110H1 Toileting GG0130C1 Self-care: Toileting Hygiene G0110I1 21 7

8 Nursing Component Scoring Response Score 05 Set-up assistance, 06 Independent 4 04 Supervision or touching assistance 3 03 Partial/moderate assistance 2 02 Substantial/maximal assistance 1 01 Dependent, 07 Refused, 09 N/A, 88 Not Attempted 0 22 Nursing Component EXAMPLE Section GG- Nursing Category Conditions/Services Conditions/ Services Present Based Function Score PDPM RUG Resident #1 Special Care High Depressed No 10 HBC1 Resident #2 Special Care High Depressed No 7 HBC1 Diabetes with both daily injections and insulin order changes on 2+ days 23 Non-Therapy Ancillary Component Components Used Data Source of component is diagnosis codes Diagnosis can be derived from acute condition or long-term condition Important to review hospital paperwork and make sure all potential conditions are coded on the medical record Comorbidity conditions There are 50 conditions considered that can impact the NTA score. The conditions are given points 24 8

9 Non-Therapy Ancillary Component Only One Tier Comorbidities Included in NTA Comorbidity Score and Assigned Points Condition/Extensive Service MDS Item Points HIV/AIDS SNF Claim ICD-10 B20 8 Parenteral IV Feeding: Level High K0510A2 K0710A2 7 Special Treatments/Programs: Intravenous Medication Post-admit Code O0100H2 5 Special Treatments/Programs: Ventilator Post-admit Code O0100F2 4 Parenteral IV feeding: Level Low K0510A2 K0710A2 K0710B2 3 Lung Transplant Status I Special Treatments/Programs: Transfusion Post-admit Code O0100I2 2 Major Organ Transplant Status, Except Lung I Active Diagnoses: Multiple Sclerosis Code I Opportunistic Infections I Active Diagnoses: Asthma COPD Chronic Lung Disease Code I Bone/Joint/Muscle Infections/Necrosis - Except: Aseptic Necrosis of Bone I Chronic Myeloid Leukemia I Wound Infection Code I Active Diagnoses: Diabetes Mellitus (DM) Code I Endocarditis I Immune Disorders I End-Stage Liver Disease I Other Foot Skin Problems: Diabetic Foot Ulcer Code M1040B 1 Narcolepsy and Cataplexy I Cystic Fibrosis I Special Treatments/Programs: Tracheostomy Post-admit Code O0100E2 1 Active Diagnoses: Multi-Drug Resistant Organism (MDRO) Code I Special Treatments/Programs: Isolation Post-admit Code O0100M2 1 Specified Hereditary Metabolic/Immune Disorders I Non-Therapy Ancillary Component Only One Tier, cont. Comorbidities Included in NTA Comorbidity Score and Assigned Points Condition/Extensive Service MDS Item Points Morbid Obesity I Special Treatments/Programs: Radiation Post-admit Code O0100B2 1 Highest Stage of Unhealed Pressure Ulcer - Stage 4 M0300X1 1 Psoriatic Arthropathy and Systemic Sclerosis I Chronic Pancreatitis I Proliferative Diabetic Retinopathy and Vitreous Hemorrhage I Other Foot Skin Problems: Foot Infection Code, Other Open Lesion on Foot Code, Except Diabetic Foot Ulcer Code M1040A M1040B M1040C 1 Complications of Specified Implanted Device or Graft I Bladder and Bowel Appliances: Intermittent catheterization H0100D 1 Inflammatory Bowel Disease I Aseptic Necrosis of Bone I Special Treatments/Programs: Suctioning Post-admit Code O0100D2 1 Cardio-Respiratory Failure and Shock I Myelodysplastic Syndromes and Myelofibrosis I Systemic Lupus Erythematosus, Other Connective Tissue Disorders, and Inflammatory Spondylopathies I Diabetic Retinopathy - Except : Proliferative Diabetic Retinopathy and Vitreous Hemorrhage I Nutritional Approaches While a Resident: Feeding Tube K0510B2 1 Severe Skin Burn or Condition I Intractable Epilepsy I Active Diagnoses: Malnutrition Code I Disorders of Immunity - Except : RxCC97: Immune Disorders I Cirrhosis of Liver I Bladder and Bowel Appliances: Ostomy H0100C 1 Respiratory Arrest I Pulmonary Fibrosis and Other Chronic Lung Disorders I Non-Therapy Ancillary Component NTA Component Case Mix Group NTA Comorbidity Score NTA Case Mix Group CMI 12+ NA NB NC ND NE NF

10 Non-Therapy Ancillary Component Length of Stay Adjustment Variable Per-diem Adjustment Factors and Schedule Medicare Payment Days Adjustment Factor Severe tapering on day four the adjustment factor is cut by 2/3 Example NTA * CMI * Adjustment Factor Day 1 to 3 - $78.05 * 1.34 * 3 = $ Day 4. - $78.05 * 1.34 * 1 = $ Non-Therapy Ancillary Component EXAMPLE NTA Comorbidity Score NTA Case Mix Group Resident #1 2 NE Resident #2 2 NE Comorbidities Diabetes, Mellitus Diabetes, Mellitus 29 Payment Structure from Examples Resident #1 Urban Base Adjustment Rate CMI Factor PT $ $90.18 TK OT $ $85.05 TK SLP $ $15.06 SA Nursing $ $ HBC1 NTA $ $97.41 NE Non-Case-Mix $92.63 $92.63 Days 1-3 Days 4-20 TOTAL AVERAGE RATE $ $ $

11 Nursing/NTA Nursing Case Mix Group NTA Case Mix Group HIPPS Code ES3 NA A1 ES3 NB A2 ES3 NC A3 ES3 ND A4 ES3 NE A5 ES3 NF A6 ES2 NA B1 ES2 NB B2 ES2 NC B3 ES2 ND B4 ES2 NE B5 ES2 NF B6 ES1 NA C1 ES1 NB C2 ES1 NC C3 ES1 ND C4 ES1 NE C5 ES1 NF C6 HDE2 NA D1 HDE2 NB D2 HDE2 NC D3 HDE2 ND D4 HDE2 NE D5 HDE2 NF D6 HDE1 NA E1 HDE1 NB E2 HDE1 NC E3 HDE1 ND E4 HDE1 NE E5 HDE1 NF E6 HBC2 NA F1 HBC2 NB F2 HBC2 NC F3 HBC2 ND F4 HBC2 NE F5 HBC2 NF F6 HBC1 NA G1 HBC1 NB G2 HBC1 NC G3 HBC1 ND G4 HBC1 NE G5 HBC1 NF G6 8/27/2018 Payment Structure from Examples Resident #2 Urban Base Adjustment Rate CMI Factor PT $ $ TC OT $ $92.79 TC SLP $ $15.06 SA Nursing $ $ HBC1 NTA $ $97.41 NE Non-Case-Mix $92.63 $92.63 Days 1-3 Days 4-20 TOTAL AVERAGE RATE $ $ $ Payment Structure from Examples Resident #2 Urban Base Adjustment Rate CMI Factor PT $ $ OT $ $92.79 SLP $ $15.06 SA 1 Additional Comorbidity Nursing $ $ HBC $ NTA $ $97.41 NE ND Non-Case-Mix $92.63 $92.63 $ TOTAL AVERAGE RATE $ RUGS to HIPPS PT/OT Case Mix Group TA TB TC TD TE TF TG TH TI TJ TK TL TM TN TO TP HIPPS Code A B C D E F G H I J K L M N O P SLP Case Mix Group SA SB SC SD SE SF SG SH SI SJ SK Resident #1 HIPPS Code - KAG5 Resident #2 HIPPS Code - CAG5 SL HIPPS Code A B C D E F G H I J K L * Partial List of Nursing/NTA 33 11

12 Impact on Providers - Estimated Percent Change in % of Stays Reimbursement Utilization of Days 1-15 days 35.4% 13.7% days 33.8% 0.0% 31+ days 30.9% -2.5% Therapy Level Rehab Ultra 58.4% -8.4% Rehab Very High 22.4% 11.4% Rehab High 6.8% 27.4% Rehab Medium 3.3% 41.1% Rehab Low 0.1% 67.5% Non-Rehab 9.1% 50.5% 34 Impact on Providers - Estimated Percent Change in % of Providers Reimbursement Ownership For Profit 72.0% -0.7% Non-Profit 22.6% 1.9% Government 5.4% 4.2% Number of Certified SNF Beds % 3.5% % 0.6% % -0.2% % -0.3% % -1.8% Location Urban 72.7% -0.7% Rural 27.3% 3.8% 35 MDS Scheduling Reduced Assessment Schedule 5-day assessment Will establish the payment category for entire Medicare stay Grace days included in Interim Payment Assessment (IPA) Will be used to capture significant changes in resident condition during the stay Not anticipated to return to his/her prior clinical status within 14 days Criteria Classification and Payment change Required and if missed will be billed at default rate Discharge assessment Items will be added to Discharge assessment to capture the total amount of therapy provided during Medicare stay 36 12

13 Time to Complete MDS and Care Plan # Assmnts Quarter Hrs # Assmnts Quarter Hrs # Assmnts Quarter Hrs # Assmnts Quarter Hrs # Assmnts Quarter Hrs # Assmnts Quarter Hrs # Assmnts Quarter Hrs # batches Quarter Hrs 8/27/2018 MDS Scheduling Anticipated Savings from Reduced MDS Assessment Estimated savings is $22k annually per provider Average length of stay is 26 days, potential reduction is a 14-day assessment 37 MDS Scheduling What is the potential change in time allocation for MDS nurses MDS Time Study Comprehensive (4.5hr) Quarterly (1.5hr) Discharge (0.5hr) PPS (1hr) OMRA End of PPS Stay Tracking Forms Validation/ Entry/Death in (COT, SOT, EOT) (NPE) Submission Facility (10 (0.5hr) (18min) min) (15 min per batch) Q / Year Q Q Q Q TOTAL MDS Scheduling Considerations IDT Stand-up Weekly Medicare Meeting QAPI Care Conferences Doctor s Rounds Mealtime Support Case Management Working the Floor And All Other Duties As Assigned New Requirement of Participation Baseline CP New LTCSP Matrix Citations Assessment and CP Coding IPA tracking ADL/Function tracking OBRA Schedule 39 13

14 Strategies PT/OT Component Work with therapy staff Restorative Program SLP Component Work with Speech Therapist Work with Dietician Nursing Component Section GG IPA tracking - process NTA Component Diagnosis Interdisciplinary Team should discuss all diagnosis Interdisciplinary Team should discuss all nursing care required by the resident Documentation and Communication will be key to capturing and receiving all potential reimbursement Non-Case Mix Component 40 Next Steps Meet with Therapy Are they educated on PDPM? Outline your strategy Identify Coding Specialist Sign-up for coding education/webinars Home Health typically has coding specialist and/or contract coder Watch for CMS updates Information will continue to be updated 41 Resources Webinars Conference Sessions Documents summaries/white papers Newsletters CMS SNF PPS Payment Model Research html

15 QUESTIONS? 43 Thank You! Cindy Gensamer, MBA, HSE, LNHA Brady Dalrymple, MBA Vice President Business Owner Absolute Rehabilitation & Consulting Services, Inc. Squared Business Solutions Phone: (330) Phone: (614) Stephanie DeWees, HSE, LNHA Stephanie Christopher Quality & Regulatory Specialist Long Term Care Business Owner LeadingAge Ohio Squared Business Solutions Phone: (614) Phone: (614)