Coding the MDS for PDPM - FADONA

Coding the MDS for PDPM Success

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2 Parts to Master

1. PDPM Structure 2. MDS Coding (with supportive documentation)

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LC1

A Quick Look at PDPM

? Patient Driven Payment Model ? Differentiates each patient in terms of their unique characteristic,

comorbidities, and care needs. ? All the components utilized for PDPM reimbursement come from a

single MDS assessment

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Slide 3

LC1 edica

Loni Collard, 2/22/2020

Types of Resident information used in PDPM

Diagnoses The primary reason for admission to the SNF

Other diagnoses that represent comorbidities such as: Diabetes COPD MDRO Liver Cirrhosis Epilepsy Inflammatory Bowel Disease

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Resident Characteristics

For instance:

Swallowing disorder Cognitive Impairment Wounds Foot and Wound

infections Feeding Tube Malnutrition Morbid Obesity Functional Abilities

Behavioral Symptoms Shortness of breath when

lying flat Fever Vomiting Weight Loss Burns

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Care and Services Provided

For instance:

IV/SubQ fluids IV medications Isolation Oxygen therapy Tracheostomy Care Wound dressing changes TPN Restorative Nursing

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Dialysis Transfusion Chemotherapy Radiation Intermittent catheterization Respiratory Therapy Isolation

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A Quick Look at the MDS

? Stands for Minimum Data Set. ? A uniform instrument used in nursing homes. ? The MDS manifest function is foremost to assess resident condition

and needs in order to improve quality of care. ? Serves the purposes of:

? Collecting data to drive care plans ? Statistically describing the resident population ? Generating indicators of quality ? Acting as a data source for payment systems

? Currently there are over 1000 data elements collected on the MDS.

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The RAI Manual

? The MDS "Bible" ? Created and published by CMS ? Revised at least 1 time a year ? The state purpose is to "offer clear guidance about how to use the Resident

Assessment Instrument (RAI) correctly and effectively to help provide appropriate care" ? Chapter 3 contains item-by-item coding instructions

? Chapter 6

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PDPM Structure and the MDS Coding

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The 5 Case-Mix Adjusted Components

Physical Therapy Occupational Therapy Speech-Language Pathology (SLP) Nursing Non-therapy Ancillary (NTA)

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Payment Components: PT and OT

? PT/OT Clinical Categories (determined from

Primary Diagnosis)

Major Joint Replacement or Spinal Surgery Other Orthopedic

Non-Orthopedic Surgery and Acute Neurologic Medical Management

? PT/OT Function Score

Average Bed Mobility Score (2 tasks)

Eating Score

Average Transfer Score (3 tasks)

Oral Hygiene Score

Average Walking Score (2 tasks)

Toileting Hygiene Score

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Payment Component: SLP

5 Classification Components

Acute Neurologic clinical classification Determined by the Primary Diagnosis If the primary diagnosis maps to an Acute Neurologic clinical category, it qualifies for this component

Presence of cognitive impairment Determined by a resident interview (the BIMS) Mild to severe impairment qualifies

Certain SLP-related comorbidities Determined by specific diagnosis codes For example: Oral cancers, dysphagia, speech deficits

Use of a Mechanically Altered Diet Provided per physician order

Presence of a Swallowing Disorder Determined by interview and assessment

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Payment Component : Nursing

A combination of Classification Groups + Function Score + End-split

The Nursing Classification Groups

Extensive Services ? Clinically Complex

Special Care High

? Behavior Symptoms & Cognitive Performance

Special Care Low

? Reduced Physical Function

The Function Score is calculated using 7 self-care and mobility Tasks

The End-Splits

Depression End-Split Restorative End-Split

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Nursing Classification Groups

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Nursing Classification Groups

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Nursing Classification Groups

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Payment Component : NTA (Non-Therapy Ancillary)

50 Conditions and Services

These include 34 diagnoses categories The other 16 condition/services include things like; IV medications,

Bladder/Bowel ostomy, Parenteral IV feeding, and Suctioning

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Look Back

Chapter 3

Chapter 6 PDPM CMG

ARD

MDS Coding

RAI Guidance

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What Really Makes PDPM Tick?

? Timing

? Timing of ARD ? Timing of hospital documentation ? Timing of physician's orders ? Timing of care implementation ? Timing of interviews

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This Photo by Unknown Author is licensed under CC BY-SA

Timing of ARD

? Assessment Reference Date (ARD): Day 1-8 of the SNF stay ? One assessment determines the daily rate for the entire stay ? Look-back time-frame for capturing information

? 7 days (ARD minus 6 days) for most items ? Some items have a longer look-back ? Certain items can be captured from the hospital stay

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