AHCA PDPM Resident Classification Workbook – Version 3.… · 2019-06-10 · Tables Necessary for...
Transcript of AHCA PDPM Resident Classification Workbook – Version 3.… · 2019-06-10 · Tables Necessary for...
Copyright 2019 American Health Care Association. All Rights Reserved.
AHCA PDPM Resident Classification Workbook – Version 3: Example Resident Name: BETTY W
Other Documents Needed for this Module Today: • AHCA PDPM MDS Form Mock-Up: Resident Example• AHCA PDPM Variable Per-Diem Rate Reference Tables Resource
Other documents needed for this module when you simulate PDPM classification with your own residents: • AHCA PDPM Resident Classification Workbook: Template• AHCA PDPM MDS Form Mock-Up: Template• CMS ICD-10 Clinical Category Crosswalk (Excel file also on CMS and ahcancalED PDPM websites)• CMS ICD-10 NTA Comorbidity Crosswalk (Excel file also on CMS and ahcancalED PDPM websites)
Primary Diagnosis Clinical Category Module (Steps 1-3) Step 1 – Identify ICD-10-CM Code on MDS that represents the Primary Reason for the SNF Stay
MDS Field/Value Action Primary Reason for the SNF Stay
ICD-10-CM Code (enter code value)
I0020 = 01-13 Go to MDS Field I0020B and enter the ICD-10-CM code value into the column to the right Z47.1
AHCA PDPM Academy Workshop Pre-Requisite Webinar Modules
at ahcancalED Provide an Overview of PDPM - and
Guidance on How-To-Use the CMS ICD-10 Crosswalk Excel
Tables Necessary for Steps 2 and 15 of this Workbook
PDPM Resident Classification Workbook_Betty W - Page 1
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Step 2 – Identify the Default Primary Diagnosis Clinical Category from the CMS “ICD-10 Clinical Category Crosswalk” Excel file tool”
cms.gov
Identify row in the CMS ICD-10 Clinical Category Crosswalk Excel file that corresponds to the Primary reason for the SNF Stay ICD-10-CMS Code identified in Step 1 (remove the decimal when examining the Excel file).
Hint: Use the “CTRL-F” function to search the CMS crosswalk file.
Download from ahcancalED: https://educate.ahcancal.org/pdpm or
Download from CMS: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html
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Step 3 – Identify Final Primary Diagnosis Clinical Category after considering if resident is eligible for a surgical adjustment
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Function Score Module (Steps 4-6)
Step 4 – Identify the PDPM Functional Score Points Applicable to Eating, Oral Hygiene, Toileting Hygiene, Bed Mobility and Transfers
Function Eating Oral Hygiene Toileting Hygiene
Bed Mobility Transfers
Sit to Lying Lying to
Sitting on Side of Bed
Sit to Stand Chair/Bed-to-Chair Transfer Toilet Transfer
MDS Field GG0130A1 GG0130B1 GG0130C1 GG0170B1 GG0170C1 GG0170D1 GG0170E1 GG0170F1
MDS Field Value
PDPM Functional
Score Points (circle 1)
PDPM Functional
Score Points (circle 1)
PDPM Functional
Score Points (circle 1)
PDPM Functional
Score Points (circle 1)
PDPM Functional
Score Points (circle 1)
PDPM Functional
Score Points (circle 1)
PDPM Functional
Score Points (circle 1)
PDPM Functional
Score Points (circle 1)
05, 06 4 4 4 4 4 4 4 4
04 3 3 3 3 3 3 3 3
03 2 2 2 2 2 2 2 2
02 1 1 1 1 1 1 1 1 01, 07, 09, 10, 88,
missing 0 0 0 0 0 0 0 0
Average of circled GG0170B1 and GG0170C1
Functional Score Points (round to 2 decimals)
Average of circled GG0170D1 and GG0170E1 and GG0170F1
Functional Score Points (round to 2 decimals)
4.00
PDPM Resident Classification Workbook_Betty W - Page 4
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Step 5 – Identify the PDPM Functional Score Points Applicable to Walking
Step 6 – Identify the PDPM Functional Score Points (Rounded sum) Attributed to the PT, OT and Nursing Components
Function PT and OT Component Function Score
Nursing Component Function Score
Eating Function Score (Step 4) 4
Oral Hygiene Function Score (Step 4) 4 Toileting Hygiene Function Score (Step 4) 2 Average Bed Mobility Function Score (Step 4) 4 Average Transfer Function Score (Step 4) 2.67 Average Walking Function Score (Step 5) 2.5
PDPM Function Score (sum to 2 decimals) 19.17 PDPM Function Score (round to whole number) (range 0-24 for PT and OT, 0-16 for Nursing)
19
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PT and OT Component Module (Step 7) Step 7 – Identify the PDPM PT and OT Component Classification & Base PDPM PT and OT Component Per-Diem Rates
PT and OT Primary Diagnosis Clinical Category (see Steps 2 or 3)
PT and OT Clinical Category
Section GG Function Score
(see Step 6)
PT and OT Case- Mix
Group
FY 2019 PT Component Base Federal Per-Diem Rate
FY 2019 OT Component Base Federal Per-Diem Rate
Urban Rural Urban Rural
Major Joint Replacement
or Spinal Surgery
Major Joint Replacement or Spinal Surgery
0-5 TA $90.77 $103.47 $82.29 $92.54 6-9 TB $100.27 $114.29 $90.02 $101.24
10-23 TC $111.54 $127.14 $92.79 $104.34 24 TD $113.91 $129.85 $84.50 $95.03
Orthopedic Surgery (Except Major Joint
Replacement or Spinal Surgery)
Other Orthopedic
0-5 TE $84.25 $96.03 $77.87 $87.58 6-9 TF $95.52 $108.88 $87.82 $98.75
10-23 TG $99.08 $112.94 $90.58 $101.86 24 TH $68.82 $78.45 $63.51 $71.43
Medical Management, Acute Infections,
Cancer, Cardiovascular and
Coagulations, Pulmonary
Medical Management
0-5 TI $67.04 $76.42 $64.62 $72.67
6-9 TJ $84.25 $96.03 $79.53 $89.44
10-23 TK $90.18 $102.80 $85.05 $95.65
24 TL $64.67 $73.72 $61.31 $68.94
Non-Orthopedic Surgery,
Acute Neurologic
Non-Orthopedic Surgery and Acute
Neurologic
0-5 TM $75.35 $85.89 $71.80 $80.74 6-9 TN $87.81 $100.09 $82.29 $92.54
10-23 TO $91.96 $104.83 $85.61 $96.27 24 TP $64.08 $73.04 $60.20 $67.70
Note: The PDPM PT and OT component base rate is paid in days 1-20, and is reduced by 2% every seven days through the 100-day benefit period
PDPM Resident Classification Workbook_Betty W - Page 6
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SLP Component Module (Steps 8-12) Step 8 – Identify the PDPM SLP Clinical Category
Step 9 – Identify the Presence of a Cognitive Impairment SLP Case-Mix Factor
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Step 10 – Identify the Presence of a SLP Comorbidity Case-Mix Factor (any row qualifies as a SLP comorbidity)
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Step 11 – Identify the Presence of SLP Swallowing Disorder and/or Mechanically Altered Diet Case-Mix Factors
Step 12 – Identify the PDPM SLP Component Classification & PDPM SLP Component Per-Diem Rate
SLP Level 1 Case-Mix Factors Acute Neurologic (Step 8)
Cognitive Impairment (Step 9) SLP Comorbidity (Step 10)
SLP Level 2 Case-Mix Factors Swallowing Disorder (Step 11)
Mechanically Altered Diet (Step 11)
SLP Case-Mix Group
FY 2019 SLP Component Federal Per-Diem Rate
Urban Rural
None Neither SA $15.06 $18.97 Either SB $40.31 $50.78 Both SC $58.92 $74.21
Any one Neither SD $32.34 $40.73 Either SE $51.61 $65.01 Both SF $65.79 $82.86
Any two Neither SG $45.19 $56.92 Either SH $63.13 $79.52 Both SI $77.75 $97.93
Any three Neither SJ $66.01 $83.14 Either SK $81.73 $102.95 Both SL $92.81 $116.90
PDPM Resident Classification Workbook_Betty W - Page 9
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NTA Component Module (Steps 13-18) Step 13 – Identify the NTA Component “Points” from MDS Simple “Checklist” Items (evaluate all rows for NTA points eligibility)
Condition/Extensive Service (check all rows) MDS Field/Value NTA Points
Ostomy, Bladder and Bowel Appliances H0100C = Checked 1 Intermittent Catheterization, Bowel and Bladder Appliances H0100D = Checked 1 Ulcerative Colitis, Crohn’s Disease, or Inflammatory Bowel Disease I1300 = Checked 1 Multiple Drug Resistant Organisms I1700 = Checked 1 Wound Infection I2500 = Checked 2 Diabetes Mellitus I2900 = Checked 2 Multiple Sclerosis I5200 = Checked 2 Malnutrition Code I5600 = Checked 1 Asthma, COPD, Chronic Lung disease I6200 = Checked 2 Feeding Tube K0510B2 = Checked 1 Diabetic Foot Ulcer M1040B = Checked 1 Radiation O0100B2 = Checked 1 Suctioning O0100D2 = Checked 1 Tracheostomy Care O0100E2 = Checked 1 Ventilator/Respirator O0100F2 = Checked 4 IV Medications O0100H2 = Checked 5 Transfusions O0100I2 = Checked 2 Isolation O0100M2 = Checked 1
Sub-Total Points
Step 14 – Identify the NTA Component “Points” from MDS “Conditional” Items (evaluate all rows for NTA points eligibility)Condition/Extensive Service
(check all rows) MDS Field/Value NTA Points
Parenteral/IV Feeding (Level High) (K0510A2 = Checked) AND (K0710A2 = 3) 7
Parenteral/IV Feeding (Level Low) (K0510A2 = Checked) AND (K0710A2 = 2) AND (K0710B2 = 2) 3
Pressure Ulcer Stage 4 (M0300D1 = 1 or more) 1
Infection of foot or open lesions on foot (not diabetic foot ulcer) (M1040A OR M1040C = Checked) 1
Sub-Total Points
PDPM Resident Classification Workbook_Betty W - Page 10
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Step 15 – Identify the Presence of NTA Comorbidity from the CMS “ICD-10 NTA Comorbidity Crosswalk” Excel file tool”
Step 16 – Identify the NTA Component “Points” from MDS “ICD-10-CM” Items (evaluate all rows for NTA points eligibility) Condition/Extensive Service
(check all rows) MDS Field/Value NTA Points
Aseptic Necrosis of the Bone I8000 A-J = 1 Bone/Joint/ Muscle Infections /Necrosis (except Aseptic Necrosis of Bone) I8000 A-J = 2 Cardio-Respiratory Failure and Shock I8000 A-J = 1 Cirrhosis of Liver I8000 A-J = 1 Cystic Fibrosis I8000 A-J = 1 Diabetic Retinopathy and Vitreous Hemorrhage, Proliferative I8000 A-J = 1 Diabetic Retinopathy-except proliferative and vitreous hemorrhage I8000 A-J = 1 Disorders of Immunity (except RxCC97: Immune Disorders) I8000 A-J = 1 Endocarditis I8000 A-J = 1 End Stage Liver Disease I8000 A-J = 1 Epilepsy, Intractable I8000 A-J = 1 Implanted Device or Graft, complications I8000 A-J = 1 Immune Disorders I8000 A-J = 1 Leukemia, myeloid, chronic I8000 A-J = 2 Lung Transplant I8000 A-J = 3 Major Organ Transplant (except lung) I8000 A-J = 2 Metabolic/Immune Disorders, Heredity I8000 A-J = 1 Morbid Obesity I8000 A-J = 1 Myelodysplastic Syndromes and Myelofibrosis I8000 A-J = 1 Narcolepsy or Cataplexy I8000 A-J = 1 Opportunistic Infections I8000 A-J = 2 Pancreatitis, chronic I8000 A-J = 1 Psoriatic Arthopathy and Systemic Sclerosis I8000 A-J = 1 Pulmonary Fibrosis and Other Chronic Lung Disorders I8000 A-J = 1 Respiratory Arrest I8000 A-J = 1 Skin Burn (severe) or condition I8000 A-J = 1 Systemic Lupus Erythematosus, other connective tissue disorders, Inflammatory Spondylopathies I8000 A-J = 1
Sub-Total Points 1
Z6843RxCC43: Morbid Obesity
cms.gov Look up all ICD-
10-CMS Codes inMDS Fields
I8000A-J
Z68.43
Body mass index(BMI) 50-59.9, adult
PDPM Resident Classification Workbook_Betty W - Page 11
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Step 17– Identify the NTA Component “Points” from HIV/AIDS Comorbidity from Claim (circle appropriate NTA point value)
Condition/Extensive Service Claim Source/Value NTA Points
HIV/AIDS
FL 67 = ICD-10-CM Code B20 OR
FL 67 A-Q = ICD-10-CM Code B20 8
Neither 0
Step 18 – Identify the PDPM NTA Component Classification & Base PDPM NTA Component Per-Diem Rate
Note: The PDPM NTA component base rate is paid triple for days 1-3, and is reduced to the base rate days 3-100 of the benefit period
2
0
1
0
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Nursing Component Module (Steps 19-29) Step 19 – Identify Nursing Component Classification Start Point
Step 20 – Identify Nursing Component Extensive Services Case-Mix Group & Per-Diem Rate (if applicable)
If Step 20 Completed –
Proceed to Step 30
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Step 21 – Identify Nursing Component Special Care High Conditions/Services Eligibility & Depression Indicator
Step 22 – Identify Nursing Component Special Care High Case-Mix Group & Per-Diem Rate (if applicable)
If Step 22 Completed –
Proceed to Step 30
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Step 23 – Identify Nursing Component Special Care Low Conditions/Services Eligibility & Depression Indicator
Step 24 – Identify Nursing Component Special Care Low Case-Mix Group & Per-Diem Rate (if applicable)
If Step 24 Completed –
Proceed to Step 30
PDPM Resident Classification Workbook_Betty W - Page 15
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Step 25 – Identify Nursing Component Clinically Complex Conditions/Services & Depression Indicator
Step 26– Identify Nursing Component Clinically Complex Case-Mix Group & Per-Diem Rate (if applicable)
If Step 26 Completed –
Proceed to Step 30
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Step 27 – Identify Nursing Component Behavioral Symptoms & Cognitive Performance Eligibility & Restorative Nursing Count
Step 28 – Identify Nursing Component Behavioral Symptoms & Cognitive Performance Case-Mix Group & Per-Diem Rate (if applicable)
If Step 28 Completed –
Proceed to Step 30
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Step 29 – Identify Nursing Component Reduced Physical Function Restorative Nursing Count, Case-Mix Group & Per-Diem Rate
If Step 29 Completed –
Proceed to Step 30
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Federal Urban and Rural Per-Diem Payment Rate(s) at Different Points of Stay Module
Step 30 –PDPM Federal Urban and Rural Per-Diem Payment Rate(s) at Different Points of Stay Compared to RUG-IV Rates
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