Patient-Driven Payment Model (PDPM)

Preparing for Payment Reform

Webinar Objectives

Learner will:

Identify key opportunities for

success at the site level for PDPM implementation

Identify key differences

between current and future payment

models for Medicare Part A patients in skilled nursing facilities

Understand key components of

payment that will not change in the PDPM payment

model

Identify effective strategies to

implement in order to be prepared for

October 1st

implementation of PDPM

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Understanding the CMS PDPM philosophy…

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Volume to

Value

Based on

Patient

Characteristics

Budget

Neutral

Implementation

Date:

October 1, 2019

Decrease in

Provider Burden PDPM model will

save providers

$200M per year or

$2B over 10 years

PPS pays for Volume PDPM attempts to pay for Value

Payment Model Comparison

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Payment = Diagnosis +

Clinical Complexities

+ ADL

PT CMI

OT CMI

NTA Payment

Non Case-Mix

Payment

SLP CMI

Nursing CMI

Payment = Therapy

Volume + Clinical

Complexities + ADL

NSG for Non-

Rehab RUG

Non Case Mix

PT Min

OT Min

SLP Min

ADL Score

It is important to stay focused on what hasn't changed...

Criteria for Skilled Services and Presumption of Coverage DOES NOT change

LTC Population Still Needs Therapy Services

Need to Stay Patient Centered

Need Comprehensive Nursing & Therapy Assessment

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What Can Go Wrong If You’re Not Prepared for PDPM?

If you deliver care that is not patient-

motivated or according to clinical needs =

AUDITS

If you do not enter MDS and claim

information correctly =

INCORRECT PAYMENT/

AUDITS

If you do not have appropriate staffing for

case mix =

LOWERQUALITY

OUTCOMES

If you do not optimize staffing and

contracting resources properly =

BUDGET ERRORS AND MARGIN SHORTFALLS

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1. Establish your PDPM Task Force

KEYS TO SUCCESS

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Financial Coding Quality

Performance Workforce Capability

Payer Mix Evaluation

Operational Requirements

Policies & Procedures

Referral Patterns

IT & Technology

Your workgroup must cover the following areas…

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Who are the members of your task force?

Administrator Director of Nursing CFO/Business OfficeDirector of

Quality/Compliance

Director of Therapy Director of EducationDirector of IT/Systems

Director of Admissions

Director of Reimbursement/Case

ManagementMDS Coordinator ?????

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2. Identify your gaps, and break the workload up into manageable pieces

KEYS TO SUCCESS

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You must have a structured, objective way to identify where you have gaps in process under today’s current payment structure and what

process changes need to occur to be successful under the new payment models. Consider:

How will the content of your meetings need

to change?

Are there different

reports that you will need

from your systems for meetings? Who will be

responsible for bringing them?

Are there different levels

of accountability that will need

to be in place?

Who is going to be responsible

for updating your

documentation, your clinical policies and procedures, your billing

SOPs?

Who is responsible for creating your

facility training plan?

How will you know where

you are at any point in time?

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One Example…Our Response

“THE ROADMAP TO PDPM MOMENTUM (RPM) ASSESSMENT”

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Roadmap To PDPM Momentum

To help support our partners, we have developed the Roadmap for PDPM Momentum (RPM) assessment to ensure they know exactly where they are in the PDPM transition journey.

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We complete the assessment together with our partners

How RPM Works

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RPM Assessment Results

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We use data analytics baked into our model to analyze results – on the spot!

ON-TRACKin your PDPM Preparedness

G R E E N

CAUTION-LAPmeaning work needs

to be done to getyour organization

back on-track

Y E L L O W

AT-RISKmeaning you need

to immediately stop,refocus and correctyour PDPM course

R E D

How RPM Works

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1 2 3

Step 4: We’ll take your results and develop an Action Plan to get you on-track for success

We educate your entire staff on the new

therapy requirements so you’re prepared to

deliver the highest quality outcomes, while

being reimbursed accurately for the care

your team delivers

We help you manage under PPS while we’re

getting you ready to “flip the switch” to

PDPM

We guide and support you, and even provide resources to ensure

you’re on-track

We outline areas of gaps or risk in terms of your PDPM readiness

How RPM Works

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3. Consider areas that you can focus on today that will drive success for your team today AND under PDPM

KEYS TO SUCCESS

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Determinants of Payment in PDPM

PT OT SLP Nursing NTA

• Primary reason for SNF

care

• Functional status

• Primary reason for SNF

care

• Functional status

• Primary reason for SNF

care

• Cognitive status

• Presence of swallowing

disorder or mechanically

altered diet

• Other SLP-related

comorbidities

• Clinical information from

SNF stay

• Functional status

• Extensive services

received

• Presence of depression

• Restorative nursing

services received

• Comorbidities present

• Extensive services

received

• Point in the stay

(variable per diem

adjustment)

• Point in the stay

(variable per diem

adjustment)

• Point in the stay

(variable per diem

adjustment)

Case Mix Components

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Clinical Condition of Stay

Extensive Services Special Care High Special Care Low

Clinically ComplexBehavioral Symptoms & Cognitive Performance

Reduced Physical Function

Nursing Classification Case Mix Groups

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RUG IV Based - Combined to 25 RUGS

Clinical Condition

of Stay

Functional Scores

Extensive Services

Depression

Restorative

Nursing

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Key Drivers | Nursing Category

Section I

Section GG

Section C

Section D

Restorative

• Special Care - Septicemia, Diabetes, COPD, Quadriplegia

• Function

• Nursing Behavioral Symptoms/ Cognitive Performance

• ST

• Impacts Special Care High/Low

• Clinically Complex

• Behavioral Symptoms/Cognitive Performance

• Reduced Physical Function

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NTA*

Condition/Extensive Service Source Points

HIV/AIDS SNF Claim 8

Parenteral IV Feeding: Level HighMDS Item K0510A2,

K0710A27

Special Treatments/Programs: Intravenous Medication

Post-admit CodeMDS Item O0100H2 5

Special Treatments/Programs: Ventilator or Respirator

Post-admit CodeMDS Item O0100F2 4

Parenteral IV feeding: Level LowMDS Item K0510A2,

K0710A2, K0710B23

Lung Transplant Status MDS Item I8000 3

Special Treatments/Programs: Transfusion Post-admit

CodeMDS Item O0100I2 2

Major Organ Transplant Status, Except Lung MDS Item I5200 2

Active Diagnoses: Multiple Sclerosis Code MDS Item I8000 2

Bone/Joint/Muscle Infections/Necrosis – Except Aseptic

Necrosis of BoneMDS Item I8000 2

Chronic Myeloid Leukemia MDS Item I8000 2

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*incomplete list

Condition/Extensive Service Source Points

Wound Infection Code MDS Item I2500 2

Active Diagnoses: Diabetes Mellitus (DM) Code MDS Item I2900 2

Endocarditis MDS Item I8000 1

Immune Disorders MDS Item I8000 1

End-Stage Liver Disease MDS Item I8000 1

Other Foot Skin Problems: Diabetic Foot Ulcer Code MDS Item M1040B 1

Narcolepsy and Cataplexy MDS Item I8000 1

Cystic Fibrosis MDS Item I8000 1

Special Treatments/Programs: Tracheostomy Care Post-

admit CodeMDS Item O0100E2 1

Active Diagnoses: Multi-Drug Resistant Organism

(MDRO) CodeMDS Item I1700 1

Special Treatments/Programs: Isolation Post-admit Code MDS Item O0100M2 1

Specified Hereditary Metabolic/Immune Disorders MDS Item I8000 1

Morbid Obesity MDS Item I8000 1

Special Treatments/Programs: Radiation Post-admit Code MDS Item O0100B2 1

NTA

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NTA NTA Base Rate NTA CMI NTA Adjustment Factor

NTA Score Range NTA Case-Mix Group NTA Case-Mix Index

12+ NA 3.25

9-11 NB 2.53

6-8 NC 1.85

3-5 ND 1.34

1-2 NE 0.96

0 NF 0.72

Days in Stay NTA Adjustment Factor

1-3 3.00

4-100 1.00

Step #2: Functional Score

Section GG ItemADL

Score

GG0130A1 Self-care: Eating 0 - 4

GG0130C1 Self-care: Toileting Hygiene 0 - 4

GG0170B1 Mobility: Sit to lying 0 - 4 (average of

2 items)GG0170C1 Mobility: Lying to sitting on side of bed

GG0170D1 Mobility: Sit to stand

0 - 4 (average of

3 items)

GG0170E1 Mobility: Chair/bed-to-chair transfer

GG0170F1 Mobility: Toilet transfer

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

Nursing Functional Scoring

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Nursing Nursing Base Rate Nursing CMI

HE1/HD1Serious medical conditions e.g. comatose,

septicemia, respiratory therapyNo 0-5 HDE1 1.99

HC2/HB2Serious medical conditions e.g. comatose,

septicemia, respiratory therapyYes 6-14 HBC2 2.23

HC1/HB1Serious medical conditions e.g. comatose,

septicemia, respiratory therapyNo 0-5 HBC1 1.85

LE2/LD2Serious medical conditions e.g. radiation

therapy or dialysisYes 0-5 LDE2 2.07

LE1/LD1Serious medical conditions e.g. radiation

therapy or dialysisNo 0-5 LDE1 1.72

Nursing Example

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Nursing GG

Section GG ItemADL

Score

GG0130A1 Self-care: Eating 0 - 4

GG0130C1 Self-care: Toileting Hygiene 0 - 4

GG0170B1 Mobility: Sit to lying 0 - 4 (average of

2 items)GG0170C1 Mobility: Lying to sitting on side of bed

GG0170D1 Mobility: Sit to stand0 - 4

(average of

3 items)

GG0170E1 Mobility: Chair/bed-to-chair transfer

GG0170F1 Mobility: Toilet transfer

PT/OT GG

Nursing GG v PT/OT GG

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Section GG Item Score

GG0130A1 Self-care: Eating 0 - 4

GG0130B1 Self-care: Oral Hygiene 0 - 4

GG0130C1 Self-care: Toileting Hygiene 0 - 4

GG0170B1 Mobility: Sit to lying 0 - 4 (average of

2 items)GG0170C1 Mobility: Lying to sitting on side of bed

GG0170D1 Mobility: Sit to stand0 - 4

(average of

3 items)

GG0170E1 Mobility: Chair/bed-to-chair transfer

GG0170F1 Mobility: Toilet transfer

GG0170J1 Mobility: Walk 50 feet with 2 turns 0 - 4 (average of

2 items)GG0170K1 Mobility: Walk 150 feet3 Additional Areas for PT/OT

Nursing CMI moves inversely to therapy CMIs

Table 1: Determinants of Payment in PDPM

PT OT SLP Nursing NTA

• Primary reason for

SNF care

• Functional status

• Primary reason for

SNF care

• Functional status

• Primary reason for

SNF care

• Cognitive status

• Presence of

swallowing disorder

or mechanically

altered diet

• Other SLP-related

comorbidities

• Clinical information

from SNF stay

• Functional status

• Extensive services

received

• Presence of

depression

• Restorative nursing

services received

• Comorbidities

present

• Extensive services

received

• Point in the stay

(variable per diem

adjustment)

• Point in the stay

(variable per diem

adjustment)

• Point in the stay

(variable per diem

adjustment)

Case Mix Components

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PDPM Case-Mix Adjusted Payment

Per Diem Payment

Non-Case-Mix Non-Case-Mix Base Rate

Nursing Nursing Base Rate Nursing CMI

SLP SLP Base Rate SLP CMI

NTA NTA Base Rate NTA CMI NTA Adjustment Factor

OT OT Base Rate OT CMI OT Adjustment Factor

PTReduced by 2% every 7

days, starting at

day 21

PT Base Rate PT CMI PT Adjustment Factor

4. Have open discussions with your therapy team now

KEYS TO SUCCESS

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PDPM: Impact to Therapy

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Utilization Based System Patient Centered Payment

System

Outcomes Focused: Comprehensive plans

of care that allow patients to achieve

goals efficiently

Accuracy of GG Scoring

ICD-10 Coding accuracy

Clinical Flexibility with use of Group and Concurrent

Utilization of Therapy Based Services

Important and being tracked

Function is (still) an important driver

Documentation support to nursing

based on experience

PDPM total reimbursement declines with therapy CMI

Proposed PT and OT Case-mix Classification Groups

Clinical 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

Major Joint Replacement or Spinal Surgery 6-9 TB 1.69 1.63

Major Joint Replacement or Spinal Surgery 10-23 TC 1.88 1.68

Major Joint Replacement or Spinal Surgery 24 TD 1.92 1.53

Other Orthopedic 0-5 TE 1.42 1.41

Other Orthopedic 6-9 TF 1.61 1.59

Other Orthopedic 10-23 TG 1.67 1.64

Other Orthopedic 24 TH 1.16 1.15

Medical Management 0-5 TI 1.13 1.17

Medical Management 6-9 TJ 1.42 1.44

Medical Management 10-23 TK 1.52 1.54

Medical Management 24 TL 1.09 1.11

Non-Orthopedic Surgery and Acute Neurologic 0-5 TM 1.27 1.30

Non-Orthopedic Surgery and Acute Neurologic 6-9 TN 1.48 1.49

Non-Orthopedic Surgery and Acute Neurologic 10-23 TO 1.55 1.55

Non-Orthopedic Surgery and Acute Neurologic 24 TP 1.08 1.09

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TABLE 23: Proposed SLP Case-Mix Classification Groups

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 2.66

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 4.19

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Example

PT OT ST NSG NTA Non Case Mix

Case Mix Group TK TK SD CBC1 ND Xx

Case Mix Index 1.52 1.54 1.46 1.34 1.34 xx

Rural Base Rate 67.63 62.11 27.90 98.83 74.56 94.34

Subtotal102.79

(100.74)

95.64

(93.73)40.73 132.43

99.91

(299.73)94.34

DAYS

1-3 $765.66

4-20 $565.84

21-27 $561.88

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Therapy Medical Necessity

• Therefore, for these reasons, under the proposed PDPM, we propose to require that SNFs continue to complete the PPS Discharge Assessment, as appropriate, for each SNF Part A resident at the time of Part A or facility discharge. Under the current instructions in the MDS 3.0 RAI manual, the Part A PPS Discharge assessment is completed when a resident’s Medicare Part A stay ends, but the resident remains in the facility (MDS 3.0 RAI Manual Chapter 2.7). However, we are proposing to require this assessment to be completed at the time of facility discharge for Part A residents as well. Thus, we would continue to collect data on therapy provision as proposed in section V.F. of this proposed rule, to assure that residents are receiving therapy that is reasonable, necessary, and specifically tailored to meet their unique needs.

Final Rule:

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Clarifications?

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Feel Free to Email Me

glenda.mack@rehabcare.com

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