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Transcript of PowerPoint Presentation · Identify key operational, training and systems ... Toileting Hygiene...
11/2/2018
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Understanding PDPMDeveloping Your Facility Action Plan
Objectives
1. Review the components, MDS changes, and
key features that will impact payment under the
Patient Driven Payment Model (PDPM).
2. Identify key operational, training and systems
considerations for preparing to transition to
PDPM.
3. Review a framework for developing a facility
specific transition action plan.
© Proactive 2018
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Why PDPM?
• Therapy driven reimbursement -90% Rehab RUGs
• Scrutiny of RU/RV utilization
• Perceived financial considerations as impacting care
decisions
• Thresholding at minimum minutes
• Goal of patient characteristic focused reimbursement
rather than resource utilization
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Final Rule
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• Final Rule/Federal Register :
https://www.federalregister.gov/documents/2018/08/08/2018-
16570/medicare-program-prospective-payment-system-and-
consolidated-billing-for-skilled-nursing-facilities
• Complete replacement of RUGs IV
• Effective Date October 1, 2019
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Acumen Study
RCS-1 PDPM
Re-allocation of Funds
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• Budget Neutral -not Intended to Reduce Medicare Spend
• Reallocates Funds from 2 “Buckets” into 5 “Buckets”
RUG-IV: PDPM:
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Nursing
Therapy
Nursing
PT OT SLP
NTA
RUGs IV vs PDPM
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RUG IV PDPM
2 Case-mix Components (Therapy & Nursing)5 Case-mix Components (PT,OT, SLP, Nursing, Non-Therapy Ancillary)
5 Scheduled PPS Assessments
Plus: SOTs, EOTs, COTs2 Assessments: 5 Day & DC; Optional: IPA
Constant RUG Rates by assessment
across LOS
5 day sets payment for stay and there is a variable rate across LOS
Therapy minute thresholds for RUG levels &
Incentive for higher volume rehab
Therapy minutes are based on clinical need without specific volume tied to rates
Group and concurrent therapy restrictionsGroup and Concurrent Therapy Opportunities (75% is required to be 1:1)
Index maximizingCombination of classification components set payment
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Rate Components
PT*
OT*
SLPNursing
NTA*
+ Non-CaseMix
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PDPM Rate Components
Total Rate
Nursing Base Rate x Nursing
CMI
NTA Base Rate x NTA CMI x Adjustment
Factor
PT Base Rate x PT CMI x
Adjustment Factor
OT Base Rate x OT CMI x
Adjustment Factor
SLP Base Rate x SLP CMI
Non-Case Mix Rate
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Base Rate Components
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FY 2019 PDPM Unadjusted Federal Rate per Diem --- Urban
Rate
componentNursing NTA PT OT SLP
Non-case-
mix
Per Diem
Amount$103.46 $78.05 $59.33 $55.23 $22.15 $92.63
FY 2019 PDPM Unadjusted Federal Rate per Diem --- Rural
Rate
componentNursing NTA PT OT SLP
Non-case-
mix
Per Diem
Amount$98.83 $74.56 $67.63 $62.11 $27.90 $94.34
Source: table 12-13 final rule Federal Register Vol. 83 No. 158 8/8/18
Variable Per Diem Adjustment Factor
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Applies to PT, OT & NTA Components
PT & OT Component:
• After day 20, 2% Reduction Every 7 Days
NTA Component:
• Multiplied x 3 X for Days 1-3
• Day 4 and Beyond — No Multiplier Applied
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PT & OT Variable
Per-Diem Adjustment
Medicare
Payment
Days
Adjustment
Factor
1-20 1.00
21-27 0.98
28-34 0.96
35-41 0.94
42-48 0.92
49-55 0.90
56-62 0.88
63-69 0.86
70-76 0.84
77-83 0.82
84-90 0.80
91-97 0.78
98-100 0.76
MDS Updates
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PDPM MDS Assessments
PDPM Required Assessments
• 5-Day (ARD day 1-8*)
• Discharge
Optional Assessment
• IPA (Interim Payment
Assessment)
Eliminates:
➢ 14, 30, 60, 90 Day
Assessments
• SOTs, EOTs, COTs
OBRA Assessments
unchanged
• Admission, Quarterly,
Significant Change
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* Elimination of “grace days”
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Interim Payment Assessment (IPA)
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• Revise payment during the stay
based on condition changes when
significant enough to result in
payment change
• Optional assessment
• Providers set their own criteria for
determining if indicated
• Payment changes on the ARD
• Same MDS items as the 5-Day
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Discharge Assessment
© Proactive 2018
• Therapy Start & End Dates, Treatment Minutes by Mode
• Monitoring for:
• Significant decreases in therapy provided
• Group and/or concurrent in excess of allowable 25%
• Data for future rule-making / possible payment updates
• Potential Medical Review risks
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Interrupted Stay Rule
© Proactive 2018
• Applied when discharges from SNF, but out less than 3 midnights
• No New MDS required; “Interrupted Stay” continues, resumes prior
Case-Mix Components and payment
• The Variable Per Diem Adjustments do NOT re-set (NTA, PT, OT)
• If resident returns after 3 days, a new MDS completed and
everything starts over
• If patient admits to a different SNF, a new MDS is always
completed/everything starts over
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PDPM Case Mix Component Methodology
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https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/SNFPPS/Downloads/MDS_Manual_Ch_6_PDPM_508.pdf
PT & OT Calculation
Clinical Category Functional Score
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1. Major Joint Replacement
or Spinal Surgery
2. Non-Orthopedic Surgery
& Acute Neurologic
3. Other Orthopedic
4. Medical Management
Eating Sit-to-Stand
Oral HygieneChair/bed-to-chair
Transfer
Toileting Hygiene Toilet Transfer
Sitting-to-LyingWalk 50 feet with 2
Turns
Lying-to-sitting
on side of bedWalk 150 feet
Two Factors Determine the PT & OT Case Mix
The two bed mobility items are averaged; the three transfer items are averaged; & the
two walking items are averaged. This creates equal weighting for all six activities.
PT & OT
Function Scoring
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Scoring Response for GG
Response Score
05, 06- Set-up assistance,
Independent 4
04- Supervision or touching
assistance 3
03- Partial/moderate
assistance 2
02- Substantial/maximal
assistance 1
01, 07, 09, 88- Dependent,
Refused, N/A, Not
attempted, Res. Cannot
Walk 0
Section GG Items Included in PT /OT
Functional MeasuresScore
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
(avg of 2 bed
mobility
items)GG0170C1 – Mobility: Lying to sitting on
side of bed
GG0170D1 – Mobility: Sit to stand 0-4
(avg of 3
transfer
items)
GG0170E1 – Mobility: Chair/bed-to-chair
transfer
GG0170F1 – Mobility: Toilet transfer
GG0170J1 – Mobility: Walk 50 feet- 2 turns 0-4 (avg of 2
walking
items)GG0170K1 – Mobility: Walk 150 feet
• Uses 10 items
• Total score 0-24
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© Proactive 2018
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16 Possible Case-Mix Classification Groups for PT and OT
Clinical Category
Section GG
Function Score
PT-OT Case-
mix Group
PT Case-mix
Index
OT Case-mix
Index
Major Joint Replacement or Spinal
Surgery0-5 TA 1.53 1.49
Major Joint Replacement or Spinal
Surgery6-9 TB 1.69 1.63
Major Joint Replacement or Spinal
Surgery10-23 TC 1.88 1.68
Major Joint Replacement or Spinal
Surgery24 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
Neurologic0-5 TM 1.27 1.30
Non-Orthopedic Surgery and Acute
Neurologic6-9 TN 1.48 1.49
Non-Orthopedic Surgery and Acute
Neurologic10-23 TO 1.55 1.55
Non-Orthopedic Surgery and Acute
Neurologic24 TP 1.08 1.09
Example: PT & OT Payment Calculation
© Proactive 2018
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Case-Mix Classification Groups for PT and OT
Clinical Category
Section GG
Function Score
PT-OT Case-
mix Group
PT Case-
mix Index
OT Case-mix
Index
Major Joint Replacement or Spinal
Surgery6-9 TB 1.69 1.63
1st - Clinical Category Determined: (ICD-10 Code mapped into one of four
possible clinical categories)
2nd - Functional Score Determined:
(Sum of all GG items scores)
Major Joint Replacement
or Spinal Surgery
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Results in PT & OT Case-Mix Group: TB
PT Case-Mix Index: 1.69 OT Case-Mix Index: 1.63
Urban PT per diem: $59.33 Urban OT per diem: $55.23
PT: $59.33 x 1.69 = $100.26/day OT: $55.23 x 1.63 = $90.02/day
MDS Coding: PT/OT Calculation
© Proactive 2018
• Primary Diagnosis: I8000 (ICD-10)
• Surgical Procedure Codes
• Functional Score: Sec. GG
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MDS Coding Critical
© Proactive 2018
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Physical Therapy Per Diem
Highest Possible:
TD: 1.92 CMI
Base Rate X CMI = Per Diem Rate
$59.33 X 1.92 = $113.91/day
Lowest Possible:
TP: 1.08 CMI
Base Rate X CMI = Per Diem Rate
$59.33 X 1.08 = $64.08/day
Difference: $49.83/day
Occupational Therapy Per Diem
Highest Possible:
TC: 1.68 CMI
Base Rate X CMI = Per Diem Rate
$55.23 X 1.68 = $92.79/day
Lowest Possible:
TP: 1.09 CMI
Base Rate X CMI = Per Diem Rate
$55.23 X 1.09 = $60.20/day
Difference: $32.59/day
Speech Therapy Calculation
© Proactive 2018
Factors for Speech Therapy Case-Mix
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Presence of Acute
Neurologic
Condition
Presence of
Cognitive
Impairment
Presence of
SLP-Related
Comorbidity
Presence of
Mechanically Altered
Diet &/or Swallowing
Disorder
Source: table 12-13 final rule Federal Register Vol. 83 No. 158 8/8/18
SLP-Related Comorbidities
• Aphasia
• CVA, TIA, or Stroke
• Hemiplegia or Hemiparesis
• Traumatic Brain Injury
• Tracheostomy Care (while a
resident)
• Ventilator or Respirator
(while a resident)
• Laryngeal Cancer
• Apraxia
• Dysphagia
• ALS
• Oral Cancers
• Speech & Language
Deficits
© Proactive 2018
Source: table 22 final rule Federal Register Vol. 83 No. 158 8/8/18
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Cognitive Impairment
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PDPM Cognitive Measure Classification Methodology
CFS Cognitive Scale BIMS score CPS score
Cognitively Intact 13-15 0
Mildly Impaired 8-12 1-2
Moderately Impaired 0-7 3-4
Severely Impaired - 5-6
Source: table 20 final rule Federal Register Vol. 83 No. 158 8/8/18
© Proactive 2018
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SLP Case-Mix Classification Group Calculation
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
Source: table 23 final rule Federal Register Vol. 83 No. 158 8/8/18
Example: SLP Payment Calculation
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1st - Identify Presence of Acute
Neurologic Condition
(Clinical Category Determined); SLP-Related
Comorbidities; Cognitive Impairment
2nd - Identify Presence of Swallowing
Disorder and/or Mechanically Altered Diet:
2 are Present
Both are Present
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
Any two Both SI 3.51
Results in SLP Case Mix Group: SI
ST Case-Mix Index: 3.51
Urban ST per diem: $22.15
ST: $22.15 X 3.51 = $77.74/day
MDS Coding: SLP Calculation
© Proactive 2018
Presence of…
• Acute Neurologic Diagnosis: I8000 (ICD-10)
• SLP-Related Comorbidities: Items I4300, I4500,
I4900, I5500, O0100E2, I0100F2, I8000
• Swallowing Disorder: Item K0100A-D
• Mechanically-Altered Diet: Item K0510C2
• Cognitive Impairment: BIMS or CPS Score
(PDPM Calculation)
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MDS Coding Critical
© Proactive 2018
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Speech-Language Pathology
Per Diem
Highest Possible:
SL: 4.19 CMI
Base rate X CMI = Per Diem Rate
$22.15 X 4.19 = $92.81/day
Lowest Possible:
SA: 0.68 CMI
Base rate X CMI = Per Diem Rate
$22.15 X .68 = $15.06/day
Difference: $77.75/day
PDPM Group & Concurrent Therapy
© Proactive 2018
• Total of 25% of Therapy may be provided as
Group and/or Concurrent (discipline-specific)
• Group defined as up to 4 patients
• Penalties for Exceeding 25%:• Non-Fatal Error in QIES ASAP System
• Flag providers that consistently exceed—
possible medical review
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Nursing CMI
© Proactive 2018
• 25 Classifications
• Function Score Based on Sec. GG
• No tapering with LOS
• 57% of RUG IV Nursing Component
• 18% increase for HIV/AIDS on claim
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Nursing
Function
Score
© Proactive 2018
MDS Section GG Items Score
GG0130A1 Self Care: Eating 0-4
GG0130C1 Self care: Toilet Hygiene 0-4
GG0170B1
GG0170C1
Mobility: Sit to Lying; Lying to
sitting on Side of Bed
0-4 (avg of 2
items)
GG0170D1
GG0170E1
GG0170F1
Mobility: Sit to Stand;
Chair/bed-to-chair transfer;
Toilet Transfer
0-4 (avg of 3
items)
Source: table 24 -25 final rule Federal Register Vol. 83 No. 158 8/8/18
Scoring Response for GG Score
05
06Set up assistance
Independent
4
04 Supervision or
Touching Assist
3
03 Partial/Moderate
Assist
2
02 Substantial/Maximal
Assist
1
01,07,09,10,8
8,(-)Dependent, refused,
not attempted
0
• Uses 7 items
• Total score 0-16
© Proactive 2018
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Non-Therapy Ancillary (NTA)
© Proactive 2018
• 43% Current Nursing Component
(RUG-IV)
• Points System
• Points Based On Patient Conditions,
Specific Services
• 50 NTA Items
• Significant Per Diem Variable
Payment Adjustment
• Days 1-3 CMI 3X higher
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© Proactive 2018
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NTA Condition/Ext Service Points NTA Condition/Ext. Service Points
HIV/Aids 8 Active Dx: Diabetes Mellitus (DM) 2
Parenteral IV Feeding: Level High 7 Chronic Myeloid Leukemia 2
Special Treatments/Programs: Intravenous
Medication Post-Admit Code
5 Wound Infection Code 2
Special Treatments/programs: Vent or
Respirator Post-admit Code
4 End-Stage Liver Disease 1
Parenteral IV Feeding: Level Low 3 Other Foot Skin Problems: Diabetic
Foot Ulcer Code
1
Lung Transplant Status 3 Narcolepsy and Cataplexy 1
Special Treatments/Programs: Transfusion
Post-admit Code
2 Cystic Fibrosis 1
Major Organ Transplant Status, Except Lung 2 Special Treatments/Programs:
Tracheostomy Care Post-admit
1
Active Dx: Multiple Sclerosis Code 2 Active Dx: Multi-Drug Resistant
Organism Code
1
Opportunistic Infections 2 Special Treatments/Programs:
Isolation Post-Admit Code
1
Active Dx: Asthma COPD Chronic Lung Dis. 2 Specified Hereditary
Metabolic/Immune Disorders
1
Bone/Joint/Muscle Infections/Necrosis—
Except Aseptic Necrosis of Bone
2 Morbid Obesity 1
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NTA Condition/Ext Service Points NTA Condition/Ext. Service Points
Unhealed Pressure Ulcer Stage 4 1 Special Treatments/Programs:
Radiation Post-admit Code
1
Endocarditis 1 Immune Disorders 1
Psoriatic Arthropathy & Systemic Sclerosis 1 Chronic Pancreatitis 1
Systemic Lupus Erythematosus, Other
Connective Tissue Disorders, & Inflammatory
Spondylopathies
1 Other Foot/Skin Problems: Foot
Infection Code, Other Open Lesion,
Except Diabetic Foot Ulcer Code
1
Complications of Specified Implanted Device
or Graft
1 Bladder & Bowel Appliances:
Intermittent Catheterization
1
Inflammatory Bowel Disease 1 Aseptic Necrosis of Bone 1
Special Treatments/Programs: Suctioning
Post-admit Code
1 Proliferative Diabetic Retinopathy &
Vitreous Hemmorrhage
1
Myelodysplastic Syndromes & Myelofibrosis 1 Cardio-Respiratory Failure & Shock 1
Diabetic Retinopathy-Except Proliferative
Diabetic Retinopathy & Vitreous Hemmorrhage
1 Nutritional Approaches While a
Resident-Feeding Tube
1
Severe Skin Burn or Condition 1 Intractable Epilepsy 1
Active Dx: Malnutrition Code 1 Disorders of Immunity-Except
RxCC97 Immune Disorders
1
Cirrhosis of Liver 1 Bladder & Bowel Appliance: Ostomy 1
Respiratory Arrest 1 Pulmonary Fibrosis & Other 1
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NTA Case-Mix Index
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NTA Example: Total points = 4 NTA case-mix group ND (CMI: 1.34)
NTA Urban Base Rate CMI Per Diem
$78.05 1.34 $104.59/Day
NTA Score
Range
NTA Case Mix
Group
NTA CMI
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
*Variable Per Diem Adjustment applies x 3 for days 1-3
Transition
Action Planning
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Action Plan
© Proactive 2018
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1
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3
4
5
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Transition Team
Impact Analysis &
QAPI
Training Plan Stay Informed
Partner Collaboration
Clinical Operations &
MDS Accuracy
Skilled Level of Care Criteria
• All Existing Criteria for Eligibility and Access Remain
• Must require daily skilled service
• Qualifying hospital stay requirement
• Supportive Documentation
© Proactive 2018
Skilled Nursing Services
• Observation & Assessment
• Management & Evaluation of a
Care Plan
• Teaching & Training
• Direct Skilled Nursing Care
PDPM Transition Team
• Administrator
• DON
• MDS
• Business Office
• Therapy
• QAPI
• Marketing
• Admissions
• Case Manager
© Proactive 2018
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Strategic Planning
© Proactive 2018
• PDPM Provider Impact Analysis• https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/therapyresearch.html
• Critical Transition Considerations :
• MDS Coding Accuracy & Efficiency (5 day)
• Medicaid/Managed Care Payers are not required to
change to PDPM
• Market Opportunities for > Clinical Complexity
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General Projections
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PDPM Winners PDPM Losers
Shorter Length of Stay Longer Length of Stay
Smaller Facilities Larger Facilities
Non-profits For-profits
Rural Facilities Urban Facilities
Higher Nursing Needs/Complexity
(Extensive Services)Low Nursing Needs
Conditions with high cost
medications
Conditions without costly
medications
Moderate-Level to Lower-level
Therapy Intensity Likely to
Remain Steady or See Increase
in Funding
Highest Therapy Intensity
(>70% Ultra High Category)
Likely to See Reduction in
Funding
Staffing Considerations
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• MDS Coordinators: Expanded Role and Duties
• Accurate GG Coding (floor observations and training)
• ICD10-Coding Experts
• Coding for NTA items
• Case Management Prepare to care for complex patients,
quality & outcomes focus
• Census Management
• LOS reduction incentives
• Rehab
• Utilization Monitored
• Outcomes Management
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Clinical Systems
• Admission Processes
• Care Planning & Case Management
• Clinical Meetings
• Clinical Pathways
• LOS/ Outcomes
• Restorative Nursing
• MDS Accuracy
• Coding Training Updates
• Supportive Documentation
© Proactive 2018
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Vendor/Partner Collaboration
© Proactive 2018
• Software Updates
• Medical Director/Physicians
• Hospital Partners
• Therapy Vendors
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Understand Compliance Risks
© Proactive 2018
• Provider Behavior Changes
• Decreased therapy provided
• MDS coding
• Negligence/Professional Liability
• Plaintiff’s lawyers and Class Action suits
• Targeted Medical Reviews
• Current claims
• Historical claims (if can provide less therapy now,
potential to review old claims for over-providing)
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CMS ResourcesMedicare Benefit Policy Manual Ch. 8
https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/downloads/bp102c08.pdf
PDPM Technical Report
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/SNFPPS/Downloads/PDPM_Technical_Report_508.pdf
PDPM Provider Impact Analysis Based on FY 2017 Actual Claims:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/SNFPPS/therapyresearch.html
ICD.10-CM Clinical Category Mapping: www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/therapyresearch.html
© Proactive 2018
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© Proactive 2018
Contact Information:[email protected]
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