Judy Wilhide Brandt, RN, BA, RAC-MT, QCP, CPC, DNS-CT judy@judywilhide.com 909-800-9124 www.judywilhide.com Virginia Medicaid Case Mix System RUG-IV 48 January 2018 How it works Virginia LTC Medicaid Commonwealth Coordinated Care CCC+ Resident days paid per diem, like Med A, billed monthly Uses State RUG code from Z0200 of current OBRA MDS OBRA may be combined with any PPS MDS, to include the Part A PPS Discharge Wilhide Consulting, Inc. (c) 1
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Rates vary facility to facility Link to your rates on JudyWilhide.com resources Effect of CMI adjustment on final daily rate Emporia Manor PA1 ES1 RAC Direct Operating Cost (Case Mix Neutral) $69.53 $69.53 $69.53 RUG IV 48 CMI 0.45 2.22 1.36 RUG-Adjusted Direct Operating Rate $31.29 $154.36 94.56 Indirect Operating Rate $62.20 $62.20 $62.20 Capital Rate $12.52 $12.52 $12.52 NATCEPs Rate $- $- $- CRC $0.02 $0.02 $0.02 Total Facility Per Diem by RUG Category $106.03 $229.10 $169.30 *NATCEP = nurse aid training *CRC = criminal records check Wilhide Consulting, Inc. (c) 3
See Handout Booklet Month 1 1 2 3 4 5 6 7 I 8 HD1 9 10 11 12 13 14 Month 2 1 2 3 4 5 6 7 I 8 9 10 11 12 13 14 Month 3 1 2 3 4 5 6 7 I 8 9 10 11 12 13 14 15 16 17 18 19 20 21 15 16 17 18 19 20 21 15 16 17 18 19 20 21 22 23 24 25 26 27 28 22 23 24 25 26 27 28 22 23 24 25 26 27 28 29 30 31 Month 4 1 2 3 4 5 6 7 I COPD + SOB lying flat ADL 11-14 8 9 10 11 12 13 14 29 30 31 Month 5 1 2 3 4 5 6 7 I 8 9 10 11 12 13 14 29 30 31 PD1 Month 6 1 2 3 4 5 6 7 I 8 9 10 11 12 13 14 15 16 17 18 19 20 21 15 16 17 18 19 20 21 15 16 17 18 19 20 21 22 23 24 25 26 27 28 22 23 24 25 26 27 28 22 23 24 25 26 27 28 29 30 31 29 30 31 29 30 31 HD1 = 167.21 x 91 = 15,216.11 COPD (did not check SOB lying flat) PD1 = 148.44 x 91 = 13,508.04 Wilhide Consulting, Inc. (c) 4
Key Point Fun Fact OBRA ARDs may be as close together as you want them. In Virginia, we follow the RAI manual for OBRA timing. No additional requirements. Month 1 1 2 3 4 5 6 7 I 8 HD1 9 10 11 12 13 14 15 16 17 18 19 20 21 Month 2 1 2 3 4 5 6 7 I 8 RAD 9 10 11 12 13 14 Therapy ends 15 16 17 18 19 20 21 Month 3 1 2 3 4 5 6 7 I 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Therapy starts 22 23 24 25 26 27 28 29 30 31 RAD 22 23 24 25 26 27 28 29 30 31 HD1 = 167.21 x 28 = $4,681.88 RAD = 184.60 x 91 = 16,798.60 RAD = 184.60 X 117 = 21,598.20 Plus the Part B income, just sayin Wilhide Consulting, Inc. (c) 5
Key to financial success Knowing which RUGs pay more Robustly monitoring resident events that raise daily rate Reacting quickly to set ARD Let a good RUG ride Can t have late ARD Default rate for number of days OBRA ARD is late Quarterly: Can t be > 92 days ARD to ARD Comprehensive: ARD can t be > 92 days from last ARD Also can t be > 366 days from comprehensive ARD to ARD Wilhide Consulting, Inc. (c) 6
Final Validation Report Reports MDS 3.0 NH Provider MDS 3.0 Assessments with error number XXXX Wilhide Consulting, Inc. (c) 7
Date Criteria: From Thru: Select date range Example: Select preceding month prior to billing Two Reports: Error Number: 1038 (late comprehensives) 1040 (late quarterlies Wilhide Consulting, Inc. (c) 8
Medicaid stay < 14 days Choices Do early Admission Assessment to obtain RUG Bill default for the days If you choose early Admission, must complete CAAs See page V-6 for how to deal with care planning decision when resident leaves between CAA completion and care plan completion. Advocacy opportunity Virginia RUG IV 48 Grouper Nursing RUGs Identical to RUG IV 66 Medicare Grouper Rehab RUGs collapse to 5 categories, No Rehab + Extensive Wilhide Consulting, Inc. (c) 9
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, 2 2 4 -,0,1,2 3 3 or 4 3 4 JudyWilhide.com 19 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 3 2 3 or 4 -,0 or 1 2 3 2 or 3 3 4 2 or 3 4 JudyWilhide.com 20 Wilhide Consulting, Inc. (c) 10
Col 1 Col 2 Score Bed Mobility 1 1 0 Transfers 1 2 0 Eating 1 1 0 Toileting 2 2 1 Total Score 1 A ADL Scores E 15-16 D 11-14 C 6-10 B 2-5 A 0-1 Col 1 Col 2 Score Bed Mobility 1 1 0 Transfers 2 2 1 Eating 1 2 2 Toileting 2 2 1 B Total Score 5 Col 1 Col 2 Score Bed Mobility 3 2 2 Transfers 3 2 2 Eating 1 1 0 Toileting 3 2 2 Total Score 6 Bed Mobility Col 1 Col 2 Score 3 2 2 Transfers 3 2 2 Eating 3 2 3 Toileting 3 3 4 C D ADL Scores E 15-16 D 11-14 C 6-10 B 2-5 A 0-1 Total Score 11 Bed Mobility Col 1 Col 2 Score 3 or 4 3 4 Transfers 3 or 4 3 4 Eating 3 2 3 Toileting 3 or 4 3 4 Total Score 15 E CMI above old Special Care HE2 1.88 HD2 1.69 LE2 1.61 HC2 1.57 HB2 1.55 LD2 1.54 HE1 1.47 Wilhide Consulting, Inc. (c) 11
While a resident Extensive Services ADL > 2: Trach AND Vent ES3 Trach OR Vent ES2 Isolation for Active Infectious Disease ES1 JudyWilhide.com 23 RUG IV-48 Extensive Services ES3 3.00 ES2 2.23 ES1 2.22 Example Manor No vents (283.33) 229.79 229.10 Trach and Vent Trach or Vent Isolation Services while not a resident do not qualify Wilhide Consulting, Inc. (c) 12
(1) Received 150 or more minutes and At least 5 distinct days of any combination of the 3 disciplines, OR (2) Received 45 or more minutes and At least 3 distinct days of any combination of the 3 disciplines and 2 or more restorative nursing programs received for 6 or more days, RAE RAD 15-16 11-14 Rehab RAC 6-10 1.65 RAE 15-16 1.58 RAD 11-14 1.36 RAC 6-10 1.10 RAB 2-5 0.82 RAA 0-1 RAB 2-5 RAA 0-1 JudyWilhide.com 25 Rehab with 3 calendar days, 45 min & two qualifying restorative 2 or more qualifying nursing rehab services at least 15 min, at least 6 days Scheduled toileting &/or bladder retraining* Passive and/or active ROM* Splint/Brace assistance Bed Mobility and/or gait training* Transfer Training Dressing or Grooming Training Eating or Swallowing Training Amputation or Prosthesis Care Communication Training * Count as 1 for RUG purposes Wilhide Consulting, Inc. (c) 13
It s not all about the rehab anymore Medicaid RUG IV-48 1.65 RAE 15-16 1.58 RAD 11-14 1.36 RAC 6-10 1.10 RAB 2-5 0.82 RAA 0-1 5 nursing RUGs pay more than RAE 6 nursing RUGs pay more than RAD 11 nursing RUGs pay more than RAC 24 nursing RUGs pay more than RAB 33 nursing RUGs pay more than RAA No Rehab + Extensive Trach 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. Both can be coded here Wilhide Consulting, Inc. (c) 14
Isolation: O0100M Resident must require transmission-based precautions and single room isolation due to active infection in contagious stage with highly transmissible or epidemiologically significant pathogens that have been acquired by physical contact or airborne or droplet transmission. Examples of when the isolation criterion would not apply include urinary tract infections, encapsulated pneumonia, and wound infections. Resident must remain in room, all services brought into room Special Care Low Clinically Complex Special Care High Learning what to capture Wilhide Consulting, Inc. (c) 15
1.65 RAE 1.58 RAD 1.36 RAC 1.10 RAB 0.82 RAA Same as Rehab, no A E 15-16 D 11-14 C 6-10 B 2-5 Special Care High HE2 1.88 HD2 1.69 HC2 1.57 HB2 1.55 HE1 1.47 HD1 1.33 HC1 1.23 HB1 1.22 Special Care Low LE2 1.61 LD2 1.54 LC2 1.30 LE1 1.26 LB2 1.21 LD1 1.21 LC1 1.02 LB1 0.95 HE2 1.88 HD2 1.69 LE2 1.61 HC2 1.57 HB2 1.55 LD2 1.54 HE1 1.47 HD1 1.33 LC2 1.30 LE1 1.26 HC1 1.23 HB1 1.22 LB2 1.21 LD1 1.21 LC1 1.02 LB1 0.95 ES3 3.00 ES2 2.23 ES1 2.22 It s not all about the rehab RAE RAD RAC RAB RAA Example Manor Rates Depression Interview or Staff Assessment 1: < 10 2: > 10 Is your social worker on-board? $205.46 HE2 1.88 $192.25 HD2 1.69 $186.68 LE2 1.61 $183.90 HC2 1.57 $182.51 HB2 1.55 $181.82 LD2 1.54 $176.95 HE1 1.47 $167.21 HD1 1.33 $165.13 LC2 1.30 $162.35 LE1 1.26 $160.26 HC1 1.23 $159.57 HB1 1.22 $158.87 LB2 1.21 $158.87 LD1 1.21 $145.66 LC1 1.02 $140.79 LB1 0.95 $189.46 RAE $184.60 RAD $169.30 RAC $151.22 RAB $131.75 RAA Wilhide Consulting, Inc. (c) 16
Special Care High ADL 15-16 Signs of Depression HE1 HE2 ADL 11-14 Signs of Depression HD1 HD2 ADL 6-10 Signs of Depression HC1 HC2 ADL 2-5 Signs of Depression HB1 HB2 JudyWilhide.com 33 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 34 Wilhide Consulting, Inc. (c) 17
(Fever and ) IV Fluid Section K: 7 day lookback Either count The image part with relationship ID rid2 was not found in the file. JudyWilhide.com 35 (Fever and ) Qualifying Tube Feeding The image part with relationship ID rid2 was not found in the file. Must have either: 26-50% AND 501cc OR 51% The image part with relationship ID rid2 was not found in the file. JudyWilhide.com 36 Wilhide Consulting, Inc. (c) 18
Septicemia Also called: Sepsis Severe sepsis Septic shock Urosepsis not recognized as septicemia for MD/NPP diagnosis. Must query the MD/NPP: Is it UTI or UTI with sepsis? Sepsis: Systemic disease associated with the presence and persistence of pathogenic micro-organisms or their toxins in the blood. Bacteremia septicemia. Bacteremia can be transient lab finding Bacteremia sually not symptomatic Quadriplegia Quadriplegia = complete paralysis that affects all four limbs caused by injury to the spinal chord in the area of the neck. Quadriplegia, is not coded in Section I when it is not caused by spinal cord injury. Examples: End Stage Azh functionally immobile: Code Alzheimer s and not Quadraplegia Cerebral Palsy, spastic quad: Code Cerebral Palsy and not Quadraplegia Severe rheumatoid arthritis: Code Arthritis and not Quadraplegia If dx functional quadriplegia may use ICD 10 code in I0800 but not Quadraplegia Transcript of commonly asked questions from CMS YouTube Video on coding Section I, Diagnoses: https://www.youtube.com/watch?v=szljjmntcpq&feature=youtu.be Wilhide Consulting, Inc. (c) 19
COPD Shortness of breath lying flat I6200, asthma, chronic obstructive pulmonary disease (COPD), or chronic lung disease (e.g., chronic bronchitis and restrictive lung diseases, such as asbestosis) Common Obstructive Lung Disease COPD Emphysema Chronic bronchitis Asthma Bronchiectasis Check J1100C: if shortness of breath or trouble breathing is present when the resident attempts to lie flat. Also code this as present if the resident avoids lying flat because of shortness of breath. Common Restrictive Lung Disease Interstitial lung disease Sarcoidosis Obesity, including obesity hypoventilation syndrome Scoliosis Neuromuscular disease: MD, ALS COPD Shortness of breath lying flat I6200, asthma, chronic obstructive pulmonary disease (COPD), or chronic lung disease (e.g., chronic bronchitis and restrictive lung diseases, such as asbestosis) Check J1100C: if shortness of breath or trouble breathing is present when the resident attempts to lie flat. Also code this as present if the resident avoids lying flat because of shortness of breath. Is oxygen ordered? Ask why! Discuss restrictive or obstructive lung disease with MD/NPP Wilhide Consulting, Inc. (c) 20
IV fluid Must have supporting documentation that reflects the need for additional fluid intake specifically addressing a nutrition or hydration need. Often coded by dietary, ensure education & oversight Seven day lookback, while and while not a resident count May not code if give in chemo, dialysis, operative/diagnostic procedure or recovery room stay May not code if give in chemo, dialysis, operative/diagnostic procedure or recovery room stay Capturing Respiratory Therapy Definitions 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. Wilhide Consulting, Inc. (c) 21
Capturing Respiratory Therapy Documentation Treatments must be a total of 15 minutes over a 24 hour day Providers should record services for respiratory therapies (Item O0400D) when the following criteria are met: MD/NPP orders the therapy that include frequency, duration & scope of treatment; Services must be directly and specifically related to an active written treatment plan that is based on an initial evaluation performed by qualified personnel Services are required and provided by qualified personnel Services must be reasonable and necessary Page O-14 RAI Manual Capturing Respiratory Therapy Documentation Respiratory observations and assessments commonly completed include but are not limited to: Coughing, wheezing, shortness of breath Tires easily Chest or abdominal pain Chills, fever, excessive sweating Dizziness Swelling of the feet or hands Confusion, anxiety or restlessness Flaring nostrils, cyanotic lips, gums, earlobes, or nails Clubbing of extremities Breathing patterns The presence of tachycardia, bradycardia or sinus arrhythmia or Evidence of CHF such as crackles, rhonchi, edema, abdominal distention Wilhide Consulting, Inc. (c) 22
Capturing Respiratory Therapy Documentation When the order for heated nebulizer is obtained, include interventions on the care plan for monitoring respiratory status before and after treatment and performing respiratory therapy. If applicable, include the performance of skilled respiratory assessment. The TAR could say: Record total minutes spent with resident delivering respiratory therapy. This, coupled with the staff developments records of education on respiratory therapy and a care plan that includes this respiratory therapy that resident requires would meet documentation guidelines. If skilled pulmonary assessment also required, example of TAR wording: Skilled pulmonary assessment: Lung sounds, SaO2, cough and deep breath exercises BID Record total minutes spent with resident in skilled pulmonary assessment If breath sounds, respiratory rate or other data were conducted, I recommend documenting results of that assessment in the narrative notes. Special Care Low ADL 15-16 Signs of Depression LE1 LE2 ADL 11-14 Signs of Depression LD1 LD2 ADL 6-10 Signs of Depression LC1 LC2 ADL 2-5 Signs of Depression LB1 LB2 JudyWilhide.com 46 Wilhide Consulting, Inc. (c) 23
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 47 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 48 Wilhide Consulting, Inc. (c) 24
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 49 Clinically Complex ADL 15-16 Signs of Depression CE1 CE2 ADL 11-14 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 50 Wilhide Consulting, Inc. (c) 25
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 51 RUG IV 48 Clinically Complex CMI 1.39 CE2 1.29 CD2 1.25 CE1 1.15 CD1 1.08 CC2 0.96 CC1 0.95 CB2 0.85 CB1 0.73 CA2 0.65 CA1 Emporia Manor $171.39 $164.43 $161.65 $154.70 $149.83 $141.49 $140.79 $133.84 $125.50 $119.93 CE2 $171.39 RAC $169.30 HD1 $167.21 LC2 $165.13 CD2 $164.43 LE1 $162.35 CE1 $161.65 PE2 $161.65 HC1 $160.26 HB1 $159.57 LB2 $158.87 LD1 $158.87 PE1 $156.09 CD1 $154.70 PD2 $154.70 RAB $151.22 CC2 $149.83 PD1 $148.44 LC1 $145.66 CC1 $141.49 CB2 $140.79 LB1 $140.79 PC2 $138.01 CB1 $133.84 PC1 $133.84 RAA $131.75 BB2 $131.06 BB1 $126.89 CA2 $125.50 PB2 $123.41 CA1 $119.93 Depression Interview or Staff Assessment 1: < 10 2: > 10 ADL Score: Same and Rehab, Special Care High & Low. Added A E 15-16 D 11-14 C 6-10 B 2-5 A 0-1 Wilhide Consulting, Inc. (c) 26
Behavioral Symptoms & Cognitive Performance ADL 2-5 2+ Restorative BB1 BB2 ADL 0-1 2+ Restorative BA1 BA2 JudyWilhide.com 53 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 54 Wilhide Consulting, Inc. (c) 27
Cognitive Performance Scale (When BIMS not completed) ONE of the three following conditions: 1. Coma and ADLs 4 or 8 2. Cognitive skills for daily decision making: Severely impaired 3. B0700, C0700, C1000 Two or more of the following impairment indicators are present: B0700 > 0 Problem being understood C0700 = 1 Short-term memory problem C1000 > 0 Cognitive skills problem and One or more of the following severe impairment indicators are present: B0700 >= 2 Severe problem being understood C1000 >= 2 Severe cognitive skills problem RUG IV 48 Behavior symptoms & cognitive impairment CMI considerations BB2 0.81 BB1 0.75 BA2 0.58 BA1 0.53 ADL Score B 2-5 A 0-1 Example Manor $131.06 $126.89 $115.07 $111.59 If ADL > 5 will group to Reduced Physical Function End-split = 2 if: 2 or more qualifying nursing rehab services at least 15 min, at least 6 days Scheduled toileting &/or bladder retraining* Passive and/or active ROM* Splint/Brace assistance Bed Mobility and/or gait training* Transfer Training Dressing or Grooming Training Eating or Swallowing Training Amputation or Prosthesis Care Communication Training * Count as 1 for RUG purposes Wilhide Consulting, Inc. (c) 28
Reduced Physical Function ADL 15-16 2+ Restorative PE1 PE2 ADL 11-14 2+ Restorative PD1 PD2 ADL 6-10 2+ Restorative PC1 PC2 ADL 2-5 2+ Restorative PB1 PB2 ADL 0-1 2+ Restorative PA1 PA2 JudyWilhide.com 57 RUG IV RUG 48 III 34 Reduced Physical Function CMI considerations Reduced Physical Function: ADL score & restorative nursing PE2 1.25 PE1 1.17 PD2 1.15 PD1 1.06 PC2 0.91 PC1 0.85 PB2 0.70 PB1 0.65 PA2 0.49 $161.65 $156.09 $154.70 $148.44 $138.01 $133.84 $123.41 $119.93 $108.81 ADL Score PA1 0.45 $106.03 E 15-16 D 11-14 C 6-10 2: 2+ qualifying restorative B 2-5 1: < 2 qualifying restorative A 0-1 Wilhide Consulting, Inc. (c) 29
RUG IV 48 Reduced Physical Function CMI considerations Reduced Physical Function: ADL score & restorative nursing PE2 1.25 PE1 1.17 PD2 1.15 PD1 1.06 PC2 0.91 PC1 0.85 PB2 0.70 PB1 0.65 PA2 0.49 PA1 0.45 $161.65 $156.09 $154.70 $148.44 $138.01 $133.84 $123.41 $119.93 $108.81 $106.03 PE2 $161.65 HC1 $160.26 HB1 $159.57 LB2 $158.87 LD1 $158.87 PE1 $156.09 CD1 $154.70 PD2 $154.70 RAB $151.22 CC2 $149.83 PD1 $148.44 LC1 $145.66 CC1 $141.49 CB2 $140.79 LB1 $140.79 PC2 $138.01 CB1 $133.84 PC1 $133.84 RAA $131.75 BB2 $131.06 BB1 $126.89 CA2 $125.50 PB2 $123.41 CA1 $119.93 PB1 $119.93 BA2 $115.07 BA1 $111.59 PA2 $108.81 PA1 $106.03 Not the worst paying if ADL score is up with restorative nursing CCC+ for MDS Coordinators Commonwealth Coordinated Care Plus (CCC Plus) is a statewide Medicaid managed long term services and supports program Almost no one can opt out. It will be mandatory. There is very little straight Medicaid. CCC+ covers Medicaid only. A resident with one CCC+ plan may have: Original Medicare Medicare HMO D-SNP from the resident s CCC+ insurance company (Dual eligible special needs plan): DMAS is requiring the CCC+ provider insurance companies to offer D-SNPs within 18 months of CCC+ operation, but no requirement for beneficiary to use it. Enrollees will be encouraged to enroll in their CCC+ D-SNP, but not required Wilhide Consulting, Inc. (c) 30
CCC+ for MDS Coordinators What an MDSC needs to find out from your organization: 1. Which CCC+ plans are we signing contracts with? 2. When a dual eligible is on a SNF stay, how am I going to know if the resident has selected: 1. Original Medicare A (transmit PPS assessments, must have 3 day qualifying hospital stay) 2. D-SNP or other MA Plan (do not transmit PPS assessments, may not require 3 day qualifying hospital stay) 3. How will I be notified of who the case worker is and his/her expectations for attending the care plan meeting and coordinating care? Next Steps Divide Center into manageable parts: household, wing, unit, etc. Determine current RUG IV 48 RUG for each Medicaid resident Review diagnoses, conditions, ADL score, depression, restorative, therapy for each resident to determine if you need to set an early ARD to capture higher CMI. Review isolation requirements and determine who will notify MDSC when resident meets criteria Wilhide Consulting, Inc. (c) 31
Determine how information will flow to dietary & MDSC when resident receives IV fluid while or while not a resident. Review coding instructions with dietary. Determine who has a restrictive or obstructive lung disease with MD/NPP and ensure correct diagnosis written. Review each resident to see if he/she does not lie flat due to SOB. Document and care plan. Schedule training for licenses nurses for respiratory therapy. Coordinate with pharmacy to print necessary information to capture respiratory therapy Continue emphasis on correct ADL coding Identify residents with Special Care High, Special Care Low, Clinically complex. Review interview techniques with social worker for mood interview or staff assessment. Verify by observing interviews. Verify all RUG diagnoses are properly documented by MD. Ensure coding in correct checkbox in Section I. Determine how MDSC will know when rehab begins, at what level, projected length of course of therapy Determine how MDSC will monitor for fever and pneumonia, vomiting, weight loss Wilhide Consulting, Inc. (c) 32
Review coding of IV Fluid with dietary and determine information flow when IV therapy can be captured. How will MDSC know when it starts? Stops? Get management decision on whether to capture pressure ulcers for CMI or try to avoid them for Five Star QMs Determine how MDSC will know when resident uses PRN oxygen to set ARD Review BIMS interview and staff assessment, and capturing behaviors with social worker. For those who will fall into Reduced physical function, ensure accurate ADL score and determine if restorative nursing is appropriate. If so, ensure it is given correctly during lookback. Monitor monthly Medicaid average rates. Congratulate staff members who contributed: CNA, nurses, therapists, social workers, dietary. Have a Medicaid focus each week as part of the PPS/standup/Nursing/etc. meeting. Ensure reporting of things only nursing will know: PRN oxygen use, Insulin order changes, heavier ADL scores, etc. Have 15 min meeting with MDSC each week to review MDS department and focus on CMI. Wilhide Consulting, Inc. (c) 33
Month 1 1 2 3 4 5 6 7 I 8 HD1 9 10 11 12 13 14 15 16 17 18 19 20 21 Month 2 1 2 3 4 5 6 7 I 8 9 10 11 12 13 14 Isolation ends 15 16 17 18 19 20 21 Month 3 1 2 3 4 5 6 7 I 8 9 10 11 12 13 14 ES1 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ES1 Isolation starts 22 23 24 25 26 27 28 29 30 31 22 23 24 25 26 27 28 29 30 31 HD1 = 167.21 x 22 = $4,681.88 ES1 = 229.10 x 91 = 20, 848. 10 Note: You can set the ARD the day isolation starts, and set another one on day 14 after isolation ends. ES1 = 229.10 X 120 = 27,372.00 Reminder: RAD = 184.60 X 117 = 21,598.20 Best opportunity we have Questions/Discussion Wilhide Consulting, Inc. (c) 34
Prepared by Judy Wilhide Brandt Wilhide Consulting, Inc. Partial Transcript of commonly asked questions from CMS YouTube Video on coding Section I, Diagnoses: https://www.youtube.com/watch?v=szljjmntcpq&feature=youtu.be 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
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.