RCS 1
Thank you for joining us today! Irene Henrich Director of Quality and Compliance ihenrich@careventures.net
RCS 1: Highlights and Timelines Resident Classification System, Version I May 2017 CMS released the SNF PPS Advance Notice of Proposed Rulemaking (ANPRM) July 2017 CMS posted a Provider-specific Impact Analysis representing estimated payments under RCS1 August 2017 Deadline for the Comment Period regarding the Proposed Policy October 2018 Earliest that RCS 1 could become FINAL RULE (most likely 2019) April/May 2018 Final Rule may be released or announcement of postponement???
Why Replace RUGS? RUGS is an index-maximizing system has led to 90% of residents having payments primarily driven by therapy services. CMS view that Therapy in SNFs is predicated on financial considerations as opposed to resident needs. Multiple reports and studies published by the OIG and MedPAC expressing concerns with thresholding and Ultra High domination. Insufficient Payment for Nursing Services and Ancillary Services chiefly prescription drugs.
CMS Goals for RCS 1 To improve targeting of resources to medically complex beneficiaries To reduce incentives for SNFs to deliver therapy based on financial considerations To promote consistency with other Medicare and PAC payment settings by basing resident classification on clinical information and minimizing the role of the volume of service provision in determination of payment
RUGS RUGS vs RCS 1 RCS1 Payment Methodology Index-Maximizing Index-Combining Components PPS Assessments Reimbursement 2 case-mix components + 2 non case-mix components 5 scheduled PPS assessments- 5-day, 14-day, 30-day, 60-day, 90-day Rates are constant throughout the patient s length of stay Reimbursement Management relies on Therapy Services 4 case-mix components+ 1 none case-mix component 1 scheduled PPS assessment 5-day Rates decline throughout the patient s length of stay (front loading) Reimbursement Management will shift to Nurses and Coders Diagnosis Coding No direct impact on reimbursement Diagnosis Coding will have a direct impact on reimbursement - Section I8000A of the MDS 3.0 Therapy Provision Reimbursement Engine Outcomes Engine
RCS 1 MDS Assessment Schedule Type Medicare MDS Assessment Schedule Type Assessment Reference Dates Applicable Standard Medicare Payment Days 5-day Scheduled PPS Assessment Significant Change in Status Assessment (SCSA) PPS Discharge Assessment Days 1-8 No later than 14 days after a significant change in identified Equal to the End of Date of Most Recent Medicare Stay (A2400C) All covered Part A days until Part A discharge ARD of the assessment through Part A discharge Therapy minutes rendered during the stay will be reported as part D/C Assessment
MDS Changes coming (October 2018) Section I Primary Diagnosis Category specific change that aligns with RCS 1 requirements Additional items in Section GG Section N - N2001 Drug Regimen Review N2003 Medication Follow-up N2005 Medication Intervention
RUGS
RCS1
Determination of Payment in RCS 1 PT/OT 30 case-mix groups Diagnostic Information (slide 10) Cognitive Status (CFS)(slide 11) Functional Status (slide 12) Variable per diem adjustment 1% every 3 rd day after Day 14 SLP 18 case-mix groups Diagnostic Information (slide 10) Cognitive Status (CFS) (slide 11) SLP-related comorbidities (slide 13) Presence of swallowing disorder or mechanically altered diet (slide 13) Nursing 43 case-mix groups (same as RUGS) Clinical information from SNF stay Extensive services received Restorative nursing services received NTA 6 case-mix groups Comorbidities present (slide 14-16) Extensive services received Variable per diem adjustment First 3 days of the stay 3 % adjustment For days 4-100 1% adjustment
Primary Diagnostic Clinical Categories RCS1 Primary Diagnosis (10 total) Major Joint Replacement or Spinal Surgery PT/OT Clinical Categories (5 total) Major Joint Replacement or Spinal Surgery SLP Clinical Categories (2 total) Non-Neurologic Surgical Procedures on Extremities Other Orthopedic Non-Neurologic Non-Ortho Surgery Non-Orthopedic Surgery Non-Neurologic Acute Infections Medical Management Non-Neurologic Cardiovascular and Coagulations Medical Management Non-Neurologic Pulmonary Medical Management Non-Neurologic Non-Surgical Ortho/Musculoskeletal Other Orthopedic Non-Neurologic Acute Neurologic Acute Neurologic Neurologic Cancer Medical Management Non-Neurologic Medical Management Medical Management Non-Neurologic
Cognitive Functional Scale CFS Levels Cognitively intact Mildly Impaired Moderately Impaired Severely Impaired BIMS score CPS score CFS score 13-15 - 1 8-12 0-2 2 0-7 3-4 3-5-6 4 The Cognitive Functional Scale (CFS) is utilized in RCS 1 for PT/OT and SLP payment components The CFS is calculated based on scores from two other cognitive measures Brief Interview for Mental Status (BIMS) and the Cognitive Performance Scale (CPS). BIMS is determined from MDS 3.0 C0200 Repetition of Words C0300 Temporal Orientation C0400 Recall C0500- BIMS Summary CPS- all MDS based
Functional Status Information needed for PT/OT component 6-point measurement scale 3 ADLs considered- late loss ADLs these ADLs predict resource use most accurately MDS Section G G0110B (transfers) G0110I (toileting) G0110H (eating) ADL Self-Performance Score Transfer Toileting Eating Independent +3 +3 +6 Supervision +4 +4 +5 Limited Assist +6 +6 +4 Extensive Assist +5 +5 +3 Total Dependence +2 +2 +2 Activity Occurred 1-2x +1 +1 +1 Activity Did not Occur +0 +0 +0
Speech Co-Morbidities Speech considerations Presence of either Swallowing disorder (MDS item K0100Z) Mechanical diet (MDS item K0510C2) Presence of either SLP related Comorbidity (see table on right) Mild to Severe Cognitive Impairment (CFS) MDS Item I4300 I4500 I4900 I5500 I8000 I8000 I8000 I8000 I8000 O0100E2 O0100F2 Description Aphasia CVA,TIA, or Stroke Hemiplegia or Hemiparesis TBI Laryngeal Cancer Dysphagia ALS Oral Cancer Speech and Language Deficits Tracheostomy Care Ventilator or Respirator
NTA Comorbidity Score Calculation Condition/Extensive Service MDS Item NTA Tier Points HIV/AIDS n/a (SNF claim) Ultra-High 8 Parenteral/IV feeding High Intensity K0510A2, K0710A2 Very High 7 Parenteral/IV feeding- Low Intensity K0510A2,K0710 A2,K0710B2 High 5 Ventilator/Respirator O0100F2 High 5 IV Medication O0100H2 High 5
NTA Comorbidity Score Calculation Condition/Extensive Service MDS Item NTA Tier Points Multidrug-Resistant Organism (MDRO) I1700 Medium 2 DM I2900 Medium 2 MS I5200 Medium 2 Asthma, COPD or Chronic Lung Disease I6200 Medium 2 Kidney Transplant Status I8000 Medium 2 Major Organ Transplant Status I8000 Medium 2 Chemotherapy O0100A2 Medium 2 Tracheostomy O0100E2 Medium 2 Transfusion O010012 Medium 2
Condition/Extensive Service NTA Comorbidity Score Calculation MDS Item NTA Tier Points Suctioning O0100D2 Low 1 Isolation or quarantine for active infectious disease Wound Infection (other than foot) Osteomyelitis and Endocarditis O0100M2 Low 1 I2500 Low 1 I8000 Low 1 DVT/Pulmonary Embolism I8000 Low 1 Stage 4 Pressure Ulcer M0300D1 Low 1 Diabetic Foot Ulcer M1040B Low 1 Radiation O0100B2 Low 1
NTA Case-Mix Classification Groups NTA Score Range NTA Group NTA Case-Mix Index 11+ NA 3.33 8-10 NB 2.59 6-7 NC 2.02 3-5 ND 1.52 1-2 NE 1.16 0 NF 0.83
Clinical Category Major Joint Replacement or Spinal Surgery Major Joint Replacement or Spinal Surgery Major Joint Replacement or Spinal Surgery Major Joint Replacement or Spinal Surgery PT/OT Case-Mix Groups Functional Score Mod/Severe Cog Impairment PT/OT Case-Mix Group Case-Mix Index 14-18 No TA 1.82 14-18 Yes TB 1.59 8-13 No TC 1.73 8-13 Yes TD 1.45 Major Joint Replacement or Spinal Surgery 0-7 No TE 1.68 Major Joint Replacement or Spinal Surgery 0-7 Yes TF 1.36
PT/OT Case-Mix Groups Clinical Category Functional Score Mod/Severe Cog Impairment PT/OT Case- Mix Group Case-Mix Index Other Orthopedic 14-18 No TG 1.70 Other Orthopedic 14-18 Yes TH 1.55 Other Orthopedic 8-13 No TI 1.58 Other Orthopedic 8-13 Yes TJ 1.39 Other Orthopedic 0-7 No TK 1.38 Other Orthopedic 0-7 Yes TL 1.14
Clinical Category PT/OT Case-Mix Groups Functional Score Mod/Severe Cognitive Impairment PT/OT Case-Mix Group Case-Mix Index Acute Neuro 14-18 No TM 1.61 Acute Neuro 14-18 Yes TN 1.48 Acute Neuro 8-13 No TO 1.52 Acute Neuro 8-13 Yes TP 1.36 Acute Neuro 0-7 No TQ 1.47 Acute Neuro 0-7 Yes TR 1.17
Clinical Category PT/OT Case-Mix Groups Functional Score Mod/Severe Cog Impairment Case-Mix Group Case-Mix Index Non-Ortho Surgery 14-18 No TS 1.82 Non-Ortho Surgery 14-18 Yes TT 1.59 Non-Ortho Surgery 8-13 No TU 1.73 Non-Ortho Surgery 8-13 Yes TV 1.45 Non-Ortho Surgery 0-7 No TW 1.68 Non-Ortho Surgery 0-7 Yes TX 1.36
PT/OT Case-Mix Classification Clinical Category Functional Score Mod/Severe Cog Impairment Case-Mix Group Case-Mix Index Medical Management 14-18 No T1 1.70 Medical Management 14-18 Yes T2 1.55 Medical Management 8-13 No T3 1.58 Medical Management 8-13 Yes T4 1.39 Medical Management 0-7 No T5 1.38 Medical Management 0-7 Yes T6 1.14
SLP Case-Mix Classification Groups Clinical Category Presence of Swallowing Disorder or Mech Altered Diet SLP-related comorbidity or Mild to Severe Cog Impairment Case-Mix Group Case-Mix Index Acute Neuro Both Both SA 4.19 Acute Neuro Both Either SB 3.71 Acute Neuro Both Neither SC 3.37 Acute Neuro Either Both SD 3.67 Acute Neuro Either Either SE 3.12 Acute Neuro Either Neither SF 2.54 Acute Neuro Neither Both SG 2.97 Acute Neuro Neither Either SH 2.06 Acute Neuro Neither Neither SI 1.28
Clinical Category SLP Case-Mix Classification Groups Presence of Swallowing Disorder or Mech Altered Diet SLP-related comorbidity or Mild to Severe Cog Impairment Case-Mix Group Case-Mix Index Non-Neuro Both Both SJ 3.21 Non-Neuro Both Either SK 2.96 Non-Neuro Both Neither SL 2.63 Non-Neuro Either Both SM 2.62 Non-Neuro Either Either SN 2.22 Non-Neuro Either Neither SO 1.70 Non-Neuro Neither Both SP 1.91 Non-Neuro Neither Either SQ 1.38 Non-Neuro Neither Neither SR 0.61
RCS1 Unadjusted Federal Rate Per Diem Urban and Rural Nursing NTA PT/OT SLP Non-case-mix Urban $100.91 $76.12 $126.76 $24.14 $90.35 Rural $96.40 $72.72 $141.47 $31.06 $92.02
Resident Characteristics Length of SNF stay (Utilization Days) IV Meds during stay Receipt of Therapy NTA costs during SNF stay NTA Comorbidity Score Impact Analysis by Resident Population Higher Reimbursement Resident with SNF stays of 1-15 days Residents with IV Meds Residents receiving a single therapy Residents with NTA costs of $150 Percentage Change (GAIN) Lower Reimbursement 15.9% Resident with stays of 31+ days 22.9% Residents without IV Meds 37.3% Residents receiving 3 therapies 19.2% Resident with lower NTA costs ($10-50) Percentage change (LOSS) -2.5% -2.0% -3.9% -3.2% 11+ 25.9% 0 7.7%
Provider Characteristics Bed Size Impact Analysis by Provider Higher Reimbursement Small Facilities 0-49 beds Percentage Change (GAIN) Lower Reimbursement 6.7% Facilities with 200+ beds Percentage Change (LOSS) -0.7% Location Rural 3.7% Urban -0.8% % of SNF utilization days billed as RU SNFs with 1-10% of utilization billed as RU 28.4% SNFs with 90-100% of utilization days billed as RU -9.9% % of SNF stays with 100 day utilization SNFs with 1-10% of their stays utilizing 100 days 0.3% SNFs with 25-100% of their stays utilizing 100 days -3.9%
Implications of RCS 1 A HUGE shift in Concept and Operations for Med A Admissions in the SNF setting The magnitude of the change will be felt at all levels Nursing, Therapy, Ancillary Services, EMR vendors, MACs Volume of Therapy and Mode of Treatment will change significantly more group and concurrent therapy are allowed/encouraged with RCS1 (up to 25% of each per resident, per day) Part A pricing structures will change for Contracted Therapy Providers Per Diem, Per Minute, % of CMI score A more balanced therapy and nursing clinical case-mix will WIN under RCS1!
How should SNFs prepare for RCS 1? Learn More, Get Educated, Be Prepared!!! I. Evaluate the Clinical Capabilities of your current team Clinical Capabilities MDS accuracy Description Identify and capture full spectrum of acuity RCS1 case-mix index Nursing, PT/OT, ST, NTA ICD 10 coding To capture the appropriate Primary Diagnostic Category that an admission falls into Nursing, PT/OT, ST, NTA Acuity Manage more medically complex admissions Nursing, NTA Other Clinical Services Respiratory, Restorative Nursing
How should SNFs prepare for RCS 1? II. Evaluate your Interdisciplinary workflows and systems that impact length of stay and occupancy in your community. Does your Admissions team understand and adhere to the expectations related to LOS? Does your Social Work team understand the expectations related to the LOS and have the tools to support timely discharges to the next level? Does your Nursing team understand the value of providing and optimizing the resident s highest functional level outside of therapy services? Do they understand how correct documentation impacts reimbursement? *Use resources like the CRITICAL PATHWAYS from Gravity
How should SNFs prepare for RCS 1? III. Evaluate and Strengthen your Upstream and Downstream relationships To keep information exchange consistent and timely To keep your occupancy up and to keep the referrals/admissions coming To facilitate safe transitions to the next level in a timely manner in order to maintain appropriate LOS and also minimize hospital readmissions To have systems in place for appropriate discharge follow up To achieve Preferred Provider status
Thank you for participating! Irene Henrich, Director of Quality and Compliance ihenrich@careventures.net 34 34
Additional more comprehensive training and education Gravity Healthcare Consulting www.gravityhealthcareconsulting.com msabo@gravitygealthcareconsulting.com 1-240-803-7999 35 35