PDPM 2019 2019 Rehab Resources & Consulting, Inc. Do not copy or reproduce without written permission 1 PDPM: The Final Countdown Ellen R. Strunk, PT, MS, GCS, CEEAA, CHC Rehab Resources & Consulting, Inc. www.RehabResourcesAndConsulting.com 1 Countdown to PDPM Objectives • Describe the components of the newly proposed Patient‐Driven Payment Model (PDPM). • Understand the impact of self‐care, mobility, cognition, and swallowing in a value‐based world. • Develop action steps to prepare for the implementation of a change in payment to insure quality of care is not sacrificed. 3 How? 4 Law Data 10/1/19 Therapy What is Daily Skilled Need? • Skilled nursing services or skilled rehabilitation services (or a combination of these services) must be needed and provided on a “daily basis,” i.e., on essentially a 7‐days‐ aweek basis. • A patient whose inpatient stay is based solely on the need for skilled rehabilitation services would meet the “daily basis” requirement when they need and receive those services on at least 5 days a week. – < 5 days a week? “Daily” requirement would not be met – “…arbitrarily staggering the timing of various therapy modalities through the week, merely in order to have some type of therapy session occur each day, would not satisfy the SNF coverage requirement for skilled care to be needed on a “daily basis.”” 5 MBPM 100‐2; Chap 8; 30.6 What is Daily Skilled Need? • As a “practical matter”, can the daily skilled services only be provided in the SNF? • A reviewer would consider: – The individual’s physical condition – The availability and feasibility of using more economical alternative facilities or services. e.g. are they not available on an outpatient basis where the individual resides? OR is transportation to the closest facility: • An excessive physical hardship; • Less economical; or • Less efficient or effective than an inpatient institutional setting – What is the availability of capable and willing family – What is the feasibility of obtaining other assistance for the patient at home? 6 MBPM 100‐2; Chap 8; 30.6
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PDPM 2019
2019 Rehab Resources & Consulting, Inc. Do not copy or reproduce without written permission 1
PDPM: The Final Countdown
Ellen R. Strunk, PT, MS, GCS, CEEAA, CHC
Rehab Resources & Consulting, Inc.
www.RehabResourcesAndConsulting.com
1
Countdown to PDPM
Objectives
• Describe the components of the newly proposed Patient‐Driven Payment Model (PDPM).
• Understand the impact of self‐care, mobility, cognition, and swallowing in a value‐based world.
• Develop action steps to prepare for the implementation of a change in payment to insure quality of care is not sacrificed.
3
How?
4
Law Data
10/1/19 Therapy
What is Daily Skilled Need?
• Skilled nursing services or skilled rehabilitation services (or a combination of these services) must be needed and provided on a “daily basis,” i.e., on essentially a 7‐days‐aweek basis.
• A patient whose inpatient stay is based solely on the need for skilled rehabilitation services would meet the “daily basis” requirement when they need and receive those services on at least 5 days a week. – < 5 days a week? “Daily” requirement would not be met
– “…arbitrarily staggering the timing of various therapy modalities through the week, merely in order to have some type of therapy session occur each day, would not satisfy the SNF coverage requirement for skilled care to be needed on a “daily basis.””
5MBPM 100‐2; Chap 8; 30.6
What is Daily Skilled Need?
• As a “practical matter”, can the daily skilled services only be provided in the SNF?
• A reviewer would consider:– The individual’s physical condition – The availability and feasibility of using more economical alternative facilities or services. e.g. are they not available on an outpatient basis where the individual resides? OR is transportation to the closest facility: • An excessive physical hardship; • Less economical; or • Less efficient or effective than an inpatient institutional setting
– What is the availability of capable and willing family – What is the feasibility of obtaining other assistance for the patient at home?
6MBPM 100‐2; Chap 8; 30.6
PDPM 2019
2019 Rehab Resources & Consulting, Inc. Do not copy or reproduce without written permission 2
Illustration of Payment Under PDPM
7
What is Changing?What is Not Changing?
IS
Volume is out
Patient characteristics
are in
IS NOT
3‐night hospital stay
Daily skilled need
Physician Certification
8
Six Components of PDPM
PT OT ST SN NTANon‐
Therapy Case Mix
Federal Base Rate
Case‐Mix Adjusted
Special Adjustors
Variable Per Diem
Adjustment9
1. PT Case Mix2. OT Case Mix
10
16 payment groups
PT and OT: Primary Reason for SNF Stay AVOID: Return to Provider
12
F01.51 Vascular dementia with behavioral disturbance
F02.89 Dementia in other diseases classified elsewhere without behavioral disturbances.
I82.439 Acute embolism and thrombosis of unspecified popliteal vein
J69.8 Pneumonitis due to inhalation of other solids and liquids
J91.8 Pleural effusion in other conditions classified elsewhere
L89.324 Pressure ulcer of left buttock, stage 4
L89.510 Pressure ulcer of right ankle, unstageable
M62.81 Muscle weakness (generalized)
S70.02Xd Contusion of unspecified thigh, subsequent encounter
S72.009P Fracture of unspecified part of neck of unspecified femur, subsequent encounter for open fracture
PDPM 2019
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PDPM Success with I0020B
Clinical Assessment Expertise
ICD‐10 Expertise
13
1. PT Case Mix2. OT Case Mix
14
16 payment groups
PDPM Changes Functional Scoring
x
x
15
RUG‐IV
PDPM
• Section G• 4 items• 7 day lookback• Most support at least 3 times• Higher Score = Less
Independent
• Section GG• 7 Nursing and 11 PT/OT items• Days 1‐3 before intervention• Usual performance• Higher Score = More Independent
Section GG: Rating Scale
16
Code Score Description
6 Independent: If the resident completes the activity by him/herself with no assistance from a helper.
5Set‐Up or Clean‐Up Assistance: If the helper SETS UP or CLEANS UP; resident completes activity. Helper assists only prior to or following the activity, but not during the activity.
4Supervision or Touching Assistance: If the helper provides VERBAL CUES or TOUCHING/STEADYING assistance and/or CGA as resident completes activity. Assistance may be provided throughout the activity or intermittently.
3Partial / Moderate Assistance: If the helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.
2 Substantial / Maximal Assistance: If the helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.
1Dependent: If the helper does ALL of the effort. Resident does none of the effort to complete the activity, OR the assistance of two or more helpers is required for the resident to complete the activity.
Section GG: Rating Scale (If activity was not attempted, code the reason)
17
Code Score Description
7 Resident refused: If the resident refused to complete the activity.
9 Not applicable: Not attempted and resident did not perform this activity prior to the current illness, exacerbation or injury.
10Not attempted due to environmental limitations: The item was unable to be
assessed due to outside influences, such as lack of equipment or weather constraints.
88 Not attempted due to medical condition or safety concerns: If the activity was not attempted due to medical condition or safety concerns.
PDPM Functional Scoring
Level of Assistance Score on MDS “Point Value” under PDPM
Independent 06 4
Set Up or Clean Up Assistance 05 4
Supervision or Touching Assistance 04 3
Partial / Moderate Assistance 03 2
Substantial / Maximal Assistance 02 1
Dependent 01 0
Resident Refused 07 0
Not applicable 09 0
Not attempted due to environmental limitations
10 0
Not attempted due to medical condition or safety concerns
88 0
18
PDPM 2019
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Who does this?
19
“CMS anticipates that an interdisciplinary team of qualified clinicians is involved…”
Section GG: Definitions
• CMS considers Section GG to be an “Assessment” of the patient’s functional status. Therefore:– “Refer to facility, Federal, and State policies
and procedures to determine which staff members may complete an assessment.”
– “Facility staff who are direct employees and facility contracted employees”
• Does not include individuals hired (compensated or not) by persons outside of facility management and administration– Hospice, students, volunteers
20RAI manual v1.17, 3, GG‐10
Section GG: Steps for Assessment
1. Assess resident’s status based on– Direct observation, incorporating resident self‐reports and reports from qualified clinicians, care staff, or family documented in the resident’s medical record during the 3‐day period.
2. Residents should be allowed to perform activities as independently as possible, as long as they are safe.
3. If helper assistance is required because performance is unsafe or of poor quality, consider only facility staff when scoring amount provided
4. Activities may be completed with or without AD21
RAI manual v1.17, 3, GG‐10
Section GG: Steps for Assessment
5. If the resident’s functional status varies, record the “resident’s usual ability to perform each activity. Do not record the resident’s best performance and do not record the resident’s worst performance, but rather record the resident’s usual performance.”
22RAI manual v1.17, 3, GG‐10
Section GG Admission: Steps for Assessment
23
• “The admission function assessment, when possible, should be conducted prior to the resident benefitting from treatment interventions in order to reflect the resident’s true admission baseline functional status.
• If treatment has started, for example, on the day of admission, a baseline functional status assessment can still be conducted.
RAI manual v1.17, 3, GG‐10
RAI GG instructions
321
24
PDPM 2019
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PT and OT: Functional StatusItems Specific Section GG Score SN PT/OT
2 Bed Mobility items
GG0170B1: Sit to LyingGG0170C1: Lying to sitting on side of bed
0 to 4(Avg of 2) Y Y
3 Transfer items
GG9170D1: Sit to standGG0170E1: Chair/bed‐to‐chair transferGG0170F1: Toilet transfer
0 to 4(Avg of 3) Y Y
1 Eating item GG0130A1: Eating 0 to 4 Y Y
1 Toileting item
GG0130C1: Toileting Hygiene 0 to 4 Y Y
1 Oral Hygiene item
GG0130B1: Oral Hygiene 0 to 4 N Y
Gateway: GG0170H: Walk 10 feet NA NA NA
2 Walking items
GG0170J1: Walk 50 feet with 2 turnsGG0170K1: Walk 150 feet
0 to 4(Avg of 2) N Y
TOTAL POSSIBLE SCORE 16 2425
FINAL: 16 PT and OT categories
26
Table 6: SNF 2020 PRClinical Category
Section GG Function Score
PT OT Case Mix Group
PT Case‐Mix Index
OT Case‐Mix Index
Major Joint Replacement or Spinal Surgery
0‐5 TA 1.53 1.49
6‐9 TB 1.70 1.63
10‐23 TC 1.88 1.69
24 TD 1.92 1.53
Other Orthopedic
0‐5 TE 1.42 1.41
6‐9 TF 1.61 1.60
10‐23 TG 1.67 1.64
24 TH 1.16 1.15
Medical Management
0‐5 TI 1.13 1.18
6‐9 TJ 1.42 1.45
10‐23 TK 1.52 1.54
24 TL 1.09 1.11
Non‐Orthopedic Surgery and Acute Neurological
0‐5 TM 1.27 1.30
6‐9 TN 1.48 1.50
10‐23 TO 1.55 1.55
24 TP 1.08 1.09CMI taken from SNF FR FY 2020
3. SLP Case Mix
27
12 payment groups
FINAL: 12 SLP Categories
28
Presence of Acute Neurologic Condition, SLP‐Related Comorbidity,
or Cognitive Impairment
Mechanically Altered Diet or Swallowing
Disorder
SLP Case‐Mix
Group
SLP Case‐Mix Index
None Neither SA 0.68
None Either SB 1.82
None Both SC 2.67
Any one Neither SD 1.46
Any one Either SE 2.34
Any one Both SF 2.98
Any two Neither SG 2.04
Any two Either SH 2.86
Any two Both SI 3.53
Any three Neither SJ 2.99
Any three Either SK 3.70
Any three Both SL 4.21
CMI taken from SNF PR FY 2020CMI taken from SNF FR FY 2020
29
• Tracheostomy Care
• Invasive Mechanical Ventilator
• Isolation or QuarantineExtensive Services
• Comatose
• Septicemia
• Diabetes with daily injections and 2+ MD orders
• Quadriplegia; COPD+SOB when flat; Fever with...
• Parenteral/IV feeding
Special Care High
• CP, MS, Parkinson’s + Low functional score
• Respiratory failure + O2
• Pressure Injury, other wound care
• Radiation or Dialysis
Special Care Low
• Pneumonia
• Hemiplegia/hemiparesis + Low functional score
• Burns, Surgical wounds, Other open wounds
• Chemotherapy, O2, IV, Transfusions
Clinically Complex
• BIMS < 9 or staff assessment shows severe impairment
• Restorative count
Behavioral Sx & Cognitive
Performance
• Toileting program
• Restorative Nursing
Reduced Physical Function
GG
FUNCT I ONAL
L EVE L
Nursing Case Mix under PDPMNon Therapy Ancillary (NTA)
30
M.D.S.
• Diagnoses• Appliances• Treatments• Conditions
50+*
* 1,540 ICD‐10 codes
PDPM 2019
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What Did the Final Rule Say?
PT, OT
Group Therapy: 2‐6 persons doing same/similar
activity
PT, OT, SLP & NTA
ICD‐10 code changes
SubregulatoryOR
Rule‐Making
MDS Nomenclature
5‐day MDS is now known as
the Initial Medicare
Assessment
(IMA)
Rates
Unadjusted Federal Rates were revised from those posted in the Proposed Rule
Wage Indexes were revised from the
Proposed Rule
31
What Did the Final Rule NOT Change?
PT, OT, ST
No change to how student services are recorded on the MDS.
Nursing
No changes
32
To the PAC Provider
Process
Reconciled Med List
To the Patient
Process
Reconciled Med List
Final Rule: SNF QRP Measures for FY 2022
Tran
sfer of Health
Inform
ation
SNF VBP
• The SNF Potentially Preventable Readmission measure (SNF PPR)
To
• SNF Potentially Preventable Readmissions after Hospital Discharge
34
SNF FY 2022 Performance Standards
Payment affects FY 2022
Performance Period FY 2020
Baseline Period FY 2018
10/1/17 ‐9/30/18
10/1/19 ‐9/30/20
10/1/21 ‐9/30/22
Achievement Threshold 0.79476 / 20.524%
Benchmark 0.83212/ 16.788%
WHAT MIGHT BE THE NEW DAY‐TO‐DAY REALITY?
36
PDPM 2019
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Illustration of Payment Under PDPM
37
Key Compliance Areas
C BIMSK
DDepression I
GG FunctionO
38
Active Dx
Swallowing
Special Services
Key Compliance Areas
39
Daily skill Section O
Uses of Quality Measures
Provide information on quality of care – To help choose a healthcare provider
– To inform those who already have a loved one receiving services from a healthcare provider
Facilitate communication between families/patients and the healthcare provider
Give data to the healthcare providers to help them with quality improvement activities
Quality Measures to W
atch
41 Quality Measures to W
atch
42
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Goal of the IMPACT Act PPS and CB for SNF Final Rule
Final Specifications for
SNF QRP
• Measure description
• Purpose/Rationale
• Numerator / Denominator
• Exclusions
• Risk adjustors
• Time windows
• Calculation algorithm
Final Specifications for SNF QRP Measure IMPACT Domain Method SNF LTCH IRF HH
Functional Assmt & Care Plan
Functional Change
Assessment 10/1/16 10/1/16 10/1/16 1/1/19
Change in Self CareFunctional Change
Assessment 10/1/1810/1/16modi
10/1/16 ?
Change in MobilityFunctional Change
Assessment 10/1/1810/1/16modi
10/1/16 ?
Discharge in Self‐Care Score
Functional Change
Assessment 10/1/18 NA 10/1/16 ?
Discharge in Mobility Score
Functional Change
Assessment 10/1/18 NA 10/1/16 ?
Application of Measures in PAC
Support
• “SNF clinicians assess and document resident’s functional status at admission and discharge to evaluate the effectiveness of the rehabilitation care provided to individual residents and the SNF’s effectiveness.”
• “Examination of SNF data shows that SNF treatment practices directly influence resident outcomes.”
Federal Register/Vol. 82, No. 149; 8/4/2017; 36577
47
And….
• “Measuring residents’ functional improvement across all SNFs on an ongoing basis would permit identification of SNF characteristics, such as ownership types or locations, associated with better or worse resident risk‐adjusted outcomes and thus help SNF’s optimally target quality improvement efforts.”
• Excluded residents are those with:– Incomplete stays– Independent with all self‐care or mobility activities at time of admission
– The following conditions: coma, persistent vegetative state, complete tetraplegia, locked‐in syndrome, severe anoxic brain damage, cerebral edema, compression of brain (as coded in B0100, or ICD‐10 codes)
– < 21 yo– Discharged to hospice– Not Med A beneficiaries– Do not receive PT or OT services
54
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UNDERSTANDING THE RISK ADJUSTORS
55
Section GG
• GG0100 Prior Functioning: Everyday Activities
56
• Bathing, dressing, using the toilet, eating
A. Self‐Care
•Walking from room to room
B. Indoor Mobility
• Internal
• ExternalC.
Stairs
• Planning regular tasks, shopping, remembering to take meds
D. Functional Cognition
Section GG: GG0100• “…prior to the current illness, exacerbation,
or injury.”• Only completed on Admission and PPS Discharge
– Interview patient or family– Review patient’s medical records– If no information is available after attempts are made, code 8. Unknown.
• Walker includes all types: Pickup walker; Hemi walker; Rolling walker; Platform walker; Four‐wheel walker; Rollator walker; Knee walker; Walkers for mobilizing while seated in walker
• Mechanical Lift includes: sit‐to‐stand, stand assist and full‐body style lifts
57
Section I
• This item identifies the primary medical condition category that resulted in the resident’s admission to the facility and that influences the resident’s functional outcomes.
58
J0200: Pain Assessment
• Attempt to conduct the interview with ALL residents• Completion is not contingent upon B0700, Makes Self Understood• If the resident interview should have been conducted, but was not
done within the look‐back period of the ARD, item J0200 should be coded 1, Yes, and a dash[‐] entered in J0300‐J0600– J0700, Should the Staff Assessment for Pain be Conducted is coded 0,
No, and J0800‐J0850 should not be completed– Exception‐1 When an interpreter is needed/requested and unavailable.
In this case, code J0200=0 and complete J0800, Staff Assessment of Pain– Exception‐2 Stand alone, unscheduled PPS assessments.
• Resident interview may be conducted up to 2 calendar days after the ARD; or• Previous interview responses may be used if obtained no >14 days prior to the
DATE of completion for the interview items
59RAI manual v1.16, 3, J‐5
J2000: Prior Surgery
• “Major surgery” is one that meets all 3 criteria:
– 1. Resident was an inpatient in an acute care hospital for at least 1 day in the 100 days prior to the admission to SNF; and
– 2. Resident had general anesthesia during the procedure, and
– 3. Surgery carried some degree of risk to the resident’s life or the potential for severe disability
60RAI manual v1.16, 3, J‐36
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Change in Self Care: Risk Adjustors
Age Group;
Comorbidities using the HCCs
Admission SC function score
(continuous form; squared form)
Tube feeding or TPN
I0020: Primary medical condition
(neuro, SCI, progressive conditions,
amputation, ortho, medically complex)
Interactions between primary
medical condition category and SNF admission status
Prior surgery / Major surgery during the 100
days prior to the SNF
Prior Functioning –self-care; Indoor
ambulation
Presence of pressure ulcer at
admission (St 2); or severe PU/injury
at admit (St 3, 4, US)
Prior Device Use: Walker Use;
WC/Scooter use
Prior Device Use: Mechanical lift,
orthotics/prosthetics
Cognitive Abilities: BIMS; ability to
express ideas and wants;
understanding verbal and non-
verbal info
Urinary and Bowel continence
61
Change in Mobility: Risk Adjustors
Age Group;
Comorbidities using the HCCs
Admission mobility score (continuous
form; squared form)Tube feeding or TPN
Primary medical condition (neuro, SCI,
progressive conditions,
amputation, ortho, medically complex)
Interactions between primary medical condition category and SNF admission
Presence of pressure ulcer at admission (St 2); or severe
PU/injury at admit (St 3, 4, US)
Prior Device Use: Walker Use;
WC/Scooter use, Mechanical lift, O/P
History of 1 or more falls in 6 months before admit
Cognitive Abilities: BIMS; ability to express ideas and
wants; understanding verbal and non‐verbal
info
Urinary and Bowel continence
62
Change in SC/Mobility: Different Risk Adjustors
63
Self Care Mobility
Major Infections: Septicemia, Sepsis, etc
Central Nervous System Infections; Other infectious diseases
Diabetes with/without complications Lymphomas and Other Cancers
Other significant endocrine and metabolic disorders
Other Major Cancers: colorectal, bladder, respiratory, heart, digestive and urinary, other
Delirium and Encephalopathy Mental health disorders
Parkinson’s and Huntington’s Diseases
Legally blind
Angina PectorisChronic Kidney Disease – Stages I through IV (and V)
Urinary Obstruction & RetentionMajor Fractures, except of skull, vertebrae or Hip
Section GG Discharge: Steps for Assessment
64RAI manual v1.16, 3, GG‐9
• Code the resident’s discharge functional status, based on a clinical assessment of the resident’s performance that occurs as close to the time of the resident’s discharge from Medicare Part A as possible.
• Must be completed within the last three calendar days of the resident’s Medicare Part A stay.
Final Checklist
Training of staff in important care areas that will improve/maintain quality of care metrics.