PT & OT Classification

PDPM Bulletin

PT & OT Classification

019

Step 1: Classify into Clinical Category Patients are first classified into a primary PDPM clinical category based on the principle ICD-10 diagnosis coded on the MDS (primary reason for the SNF admission). ICD-10 codes are mapped to a PDPM clinical category. Clinical classification may be changed by a surgical procedure that occurred during the preceding hospital stay. There are 10 primary PDPM clinical categories. For PT and OT, these 10 primary PDPM clinical categories are collapsed into 4 PT/OT clinical categories: Major Joint Replacement/Spinal Surgery, Non-Orthopedic Surgery & Acute Neurologic, Other Orthopedic, or Medical Management. The clinical reason is driven by the MDS principle ICD-10 code for SNF admission on the MDS which classifies a resident into one of 4 PT/OT clinical categories.

Step 2: Calculate Section GG Function Score Function is measured to further classify the resident into the appropriate case-mix classification group. Determination of the patient's functional score is calculated using data from Section GG based on the "usual performance" of 10 Section GG items: 1 eating, 1 oral hygiene, 1 toileting, 2 bed mobility, 3 transfer, and 2 walking. Bed mobility, transfer and walking scores are averaged, then summed with the scores for eating, toileting and oral hygiene. Total summed score will range between 0 - 24.

Step 3: Assign Case-Mix Group (CMG) & Corresponding Case-Mix Index (CMI) There are 16 different case-mix groups for PT and OT, each with a separate case-mix index and payment levels. PT/OT components are calculated together but paid separately based on the case-mix. Each resident is assigned to one of the 16 CMGs for PT and OT.

PDPM Bulletin

SLP Classification

019

Step 1: Determine Presence of Acute Neurological Condition, SLP-Related Clinical Comorbidity, and/or Cognitive Impairment

The first step to determine the SLP Case Mix Index (CMI) classification is determining the presence of one or more of three patient characteristics ?

A. Presence of Acute Neurological Condition as classified by an ICD-10 Principle Diagnosis code on the MDS. B. Presence of one or more of twelve SLP

comorbidities. The patient qualifies if any of the following conditions are present, and must be documented in the medical record and POC by supportive ICD-10s as listed in the "PDPM SLP Comorbidities Mapping Table." C. Presence of a Cognitive Impairment ? Determined by either administering the Brief Interview of Mental Status (BIMS), which assesses immediate memory, temporal orientation, and recall or via staff interview, which rates short term memory, long term memory, recall, and cognitive skills for daily decision making.

Step 2: Determine the Use of a Mechanically-Altered Diet, and/or Presence of Swallowing Disorder Next, determine the use of a mechanically altered diet and/or the presence of a swallowing disorder.

A. Determining the presence of a mechanically-altered diet is based on the following definition: "A diet specifically prepared to alter the texture or consistency of food to facilitate oral intake. Examples include soft solids, pur?ed foods, ground meat, and thickened liquids."

B. If one or more of the following behaviors are observed during the initial look-back period, the patient is classified as having a swallowing disorder. It is important to note that this item is not based on an actual dysphagia diagnosis in the medical record. ? Loss of liquids/solids from mouth when eating/drinking ? Holding foods in mouth/cheeks or residual food in mouth after meals ? Coughing or choking during meals or when swallowing medications ? Complaints of difficulty or pain with swallowing

Step 3: Assign Case-Mix Group (CMG) & Corresponding Case-Mix Index (CMI) Use the answers from Steps 1 and 2 and the below table to determine the SLP Case Mix Group and corresponding CMI:

Presence of Acute Neurologic Condition, SLP-related comorbidity, Cognitive Impairment

None

Any 1 of the 3

Any 2 of the 3

All 3

Mechanically Altered Diet or Swallowing Disorder

SLP Case Mix SLP Case Mix

Group

Index

Neither Either 1 of the 2

Both Neither Either 1 of the 2

Both Neither Either 1 of the 2

Both Neither Either 1 of the 2

Both

SA

0.68

SB

1.82

SC

2.67

SD

1.46

SE

2.34

SF

2.97

SG

2.04

SH

2.86

SI

3.53

SJ

2.99

SK

3.70

SL

4.21

SLP Comorbidity Description

Speech and Language Deficits Speech and Language Deficits Speech and Language Deficits Speech and Language Deficits Speech and Language Deficits Speech and Language Deficits Speech and Language Deficits Speech and Language Deficits Speech and Language Deficits Speech and Language Deficits Speech and Language Deficits Speech and Language Deficits Speech and Language Deficits Speech and Language Deficits Speech and Language Deficits Speech and Language Deficits Speech and Language Deficits Speech and Language Deficits Speech and Language Deficits Speech and Language Deficits Speech and Language Deficits Speech and Language Deficits Speech and Language Deficits Speech and Language Deficits Speech and Language Deficits Speech and Language Deficits Speech and Language Deficits Speech and Language Deficits Speech and Language Deficits Speech and Language Deficits Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers

SLP ICD-10 COMORBIDITY CROSSWALK

ICD-10-CM Code

ICD-10-CM Code Description

I69.020 I69.021 I69.022 I69.023 I69.028 I69.120 I69.121 I69.122 I69.123 I69.128 I69.220 I69.221 I69.222 I69.223 I69.228 I69.320 I69.321 I69.322 I69.323 I69.328 I69.820 I69.821 I69.822 I69.823 I69.828 I69.920 I69.921 I69.922 I69.923 I69.928 C00.0 C00.1 C00.3 C00.4 C00.5 C00.6 C00.8 C00.2 C00.9 C01 C02.0 C02.1 C02.2 C02.3 C02.8 C02.4 C02.8 C02.9 C03.0 C03.1

Aphasia following nontraumatic subarachnoid hemorrhage Dysphasia following nontraumatic subarachnoid hemorrhage Dysarthria following nontraumatic subarachnoid hemorrhage Fluency disorder following nontraumatic subarachnoid hemorrhage Other speech and language deficits following nontraumatic subarachnoid hemorrhage Aphasia following nontraumatic intracerebral hemorrhage Dysphasia following nontraumatic intracerebral hemorrhage Dysarthria following nontraumatic intracerebral hemorrhage Fluency disorder following nontraumatic intracerebral hemorrhage Other speech and language deficits following nontraumatic intracerebral hemorrhage Aphasia following other nontraumatic intracranial hemorrhage Dysphasia following other nontraumatic intracranial hemorrhage Dysarthria following other nontraumatic intracranial hemorrhage Fluency disorder following other nontraumatic intracranial hemorrhage Other speech and language deficits following other nontraumatic intracranial hemorrhage Aphasia following cerebral infarction Dysphasia following cerebral infarction Dysarthria following cerebral infarction Fluency disorder following cerebral infarction Other speech and language deficits following cerebral infarction Aphasia following other cerebrovascular disease Dysphasia following other cerebrovascular disease Dysarthria following other cerebrovascular disease Fluency disorder following other cerebrovascular disease Other speech and language deficits following other cerebrovascular disease Aphasia following unspecified cerebrovascular disease Dysphasia following unspecified cerebrovascular disease Dysarthria following unspecified cerebrovascular disease Fluency disorder following unspecified cerebrovascular disease Other speech and language deficits following unspecified cerebrovascular disease Malignant neoplasm of external upper lip Malignant neoplasm of external lower lip Malignant neoplasm of upper lip, inner aspect Malignant neoplasm of lower lip, inner aspect Malignant neoplasm of lip, unspecified, inner aspect Malignant neoplasm of commissure of lip, unspecified Malignant neoplasm of overlapping sites of lip Malignant neoplasm of external lip, unspecified Malignant neoplasm of lip, unspecified Malignant neoplasm of base of tongue Malignant neoplasm of dorsal surface of tongue Malignant neoplasm of border of tongue Malignant neoplasm of ventral surface of tongue Malignant neoplasm of anterior two-thirds of tongue, part unspecified Malignant neoplasm of overlapping sites of tongue Malignant neoplasm of lingual tonsil Malignant neoplasm of overlapping sites of tongue Malignant neoplasm of tongue, unspecified Malignant neoplasm of upper gum Malignant neoplasm of lower gum

SLP Comorbidity Description

Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Oral Cancers Laryngeal Cancer Laryngeal Cancer Laryngeal Cancer Laryngeal Cancer Laryngeal Cancer Laryngeal Cancer Dysphagia Dysphagia Dysphagia Dysphagia Dysphagia Dysphagia Apraxia Apraxia Apraxia Apraxia Apraxia Apraxia ALS

ICD-10-CM Code C03.9 C03.9 C04.0 C04.1 C04.8 C04.9 C09.9 C09.8 C09.0 C09.1 C10.0 C10.1 C10.8 C10.2 C10.3 C10.4 C10.8 C10.9 C14.0 C14.2 C14.8 C14.8 C06.0 C06.1 C05.0 C05.1 C05.2 C05.9 C05.8 C06.2 C06.89 C06.80 C06.9 C32.0 C32.1 C32.2 C32.3 C32.8 C32.9 I69.091 I69.191 I69.291 I69.391 I69.891 I69.991 I69.090 I69.190 I69.290 I69.390 I69.890 I69.990 G12.21

ICD-10-CM Code Description

Malignant neoplasm of gum, unspecified Malignant neoplasm of gum, unspecified Malignant neoplasm of anterior floor of mouth Malignant neoplasm of lateral floor of mouth Malignant neoplasm of overlapping sites of floor of mouth Malignant neoplasm of floor of mouth, unspecified Malignant neoplasm of tonsil, unspecified Malignant neoplasm of overlapping sites of tonsil Malignant neoplasm of tonsillar fossa Malignant neoplasm of tonsillar pillar (anterior) (posterior) Malignant neoplasm of vallecula Malignant neoplasm of anterior surface of epiglottis Malignant neoplasm of overlapping sites of oropharynx Malignant neoplasm of lateral wall of oropharynx Malignant neoplasm of posterior wall of oropharynx Malignant neoplasm of branchial cleft Malignant neoplasm of overlapping sites of oropharynx Malignant neoplasm of oropharynx, unspecified Malignant neoplasm of pharynx, unspecified Malignant neoplasm of waldeyer's ring Malignant neoplasm of overlapping sites of lip, oral cavity and pharynx Malignant neoplasm of overlapping sites of lip, oral cavity and pharynx Malignant neoplasm of cheek mucosa Malignant neoplasm of vestibule of mouth Malignant neoplasm of hard palate Malignant neoplasm of soft palate Malignant neoplasm of uvula Malignant neoplasm of palate, unspecified Malignant neoplasm of overlapping sites of palate Malignant neoplasm of retromolar area Malignant neoplasm of overlapping sites of other parts of mouth Malignant neoplasm of overlapping sites of unspecified parts of mouth Malignant neoplasm of mouth, unspecified Malignant neoplasm of glottis Malignant neoplasm of supraglottis Malignant neoplasm of subglottis Malignant neoplasm of laryngeal cartilage Malignant neoplasm of other specified sites of larynx Malignant neoplasm of larynx, unspecified Dysphagia following nontraumatic subarachnoid hemorrhage Dysphagia following nontraumatic intracerebral hemorrhage Dysphagia following other nontraumatic intracranial hemorrhage Dysphagia following cerebral infarction Dysphagia following other cerebrovascular disease Dysphagia following unspecified cerebrovascular disease Apraxia following nontraumatic subarachnoid hemorrhage Apraxia following nontraumatic intracerebral hemorrhage Apraxia following other nontraumatic intracranial hemorrhage Apraxia following cerebral infarction Apraxia following other cerebrovascular disease Apraxia following unspecified cerebrovascular disease Amyotrophic lateral sclerosis

Section C Basics:

An SLP's Guide to the Cognitive Patterns Section on the MDS

Section C: The Basics Effective 10/1/19, Medicare will be incorporating the MDS' Section C, Cognitive Patterns, as a part of the patient characteristics profile that is used to define the patient's Case Mix Index for the SLP component of PDPM. While understanding a patient's cognitive status has always been important for care planning and therapeutic interventions, Section C now steps into the reimbursement spotlight. Per the Centers for Medicaid and Medicare Services (CMS), "The items in this section are intended to determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in many care-planning decisions." The MDS Coordinator should review the SLP evaluation, if present, as a comparison to the MDS information and to capture any additional clinical information. Keep in mind that the instructions provided by CMS on the MDS are for the nurse completing the MDS section. The clinical "lookback" for Section C is 7 days. Documentation describing potential signs and symptoms related to each item should be present in the therapy medical record to support correct coding and assist the MDS in capturing the most accurate Case Mix Index.

MDS Section C General Considerations and Instructions

The MDS Coordinator must determine if a Brief Interview for Mental Status (BIMS) should be conducted. Per CMS,

most residents are able to attempt the Brief Interview for Mental Status (BIMS).

The BIMS is a brief screener that aids in detecting cognitive impairment. The BIMS total score is highly correlated

with Mini-Mental State Exam scores. It does not assess all possible aspects of cognitive impairment. Furthermore,

it is not a comprehensive, functional cognitive assessment, which can only be administered by a therapist.

The BIMS briefly assesses the following areas:

o Repetition of Three Words (Immediate Recall) o Temporal Orientation (Orientation to year, date, and day) o Recall (Delayed)

BIMS SCORE

Cognitively Intact

13 ? 15

Mildly Impaired

8 ? 12

The assessor must determine if the resident is able to answer the BIMS questions verbally, in writing, or via another method.

Moderately Impaired Severely Impaired

0 ? 7 -

The assessor must make every effort to administer the BIMS.

If the BIMS cannot be administered, nursing must complete a Staff Assessment for Mental Status, which briefly

assesses the following areas:

o Short Term Memory

o Long Term Memory

o Memory/Recall Ability

o Cognitive Skills for Daily Decision Making

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Section C Basics:

An SLP's Guide to the Cognitive Patterns Section on the MDS

SLP Assessment to Support Cognitive Pattern Coding The following table details related Functional Deficit (FD) areas and possible Underlying Impairments (UI), or underlying causes, which describe the resident's clinical condition and support cognitive pattern coding on the MDS. Each listed FD and UI is an input area in Casamba. SLPs must assess then document these areas on the SLP evaluation:

FUNCTIONAL DEFICITS Cognition Orientation Recall Problem Solving Safety/Judgement

UNDERLYING IMPAIRMENTS Mental Status Immediate Recall Delayed Recall Functional Spoken Language Comprehension Answers Y/N Questions

When to Incorporate as a Goal on the SLP POC If any of the above FDs and related UIs are identified as an issue as a result of a comprehensive SLP

evaluation, a goal to address and/or compensate for the UI should be targeted with the outcome focused on improving the FD.

o Recommended goals related to these FDs/UIs are as follows: Cognition ? Memory/Recall Cognition ? Problem Solving/Safety Awareness Cognition ? Higher Level Tasks Cognition ? Memory Compensation Expressive Language ? General Receptive Language ? Functional Communication

Functional Deficits are re-assessed at the point of completion of the Updated Plan of Care and Discharge Summary. Therapists should take care to ensure that their treatment plan properly addresses the UIs and, in turn, FDs, so that the patient achieves positive functional outcomes.

Summary All members of the interdisciplinary team play an important role in ensuring that each patient's unique set of

clinical characteristics are identified, documented, and captured on the MDS. A comprehensive SLP evaluation includes properly identifying changes in function through the documentation

of Functional Deficits, then assessment to identify the causes for those changes. SLPs must establish long-term goals so that functional outcomes are achieved through remediation or

compensation of Underlying Impairments via the short-term goals.

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Section K Basics:

An SLP's Guide to the Swallowing/Nutritional Status Section on the MDS

Section K: The Basics

Effective 10/1/19, Medicare will be incorporating the MDS' Section K, Swallowing/Nutritional Status, as a part of the patient characteristics profile that is used to define the patient's Case Mix Index. While swallowing and nutritional status have always been important for care planning and interventions, Section K will soon step into the reimbursement spotlight for the speech-language pathology (SLP) component of PDPM.

Per CMS, "the items in this section are intended to assess the many conditions that could affect the resident's ability to maintain adequate nutrition and hydration."

CMS recognizes that the ability to swallow directly relates to patient safety and quality of life. The MDS Coordinator should review the SLP evaluation, if present, as a comparison to the MDS information and to

capture any additional clinical information. While not every item in Section K applies to SLP's scope of practice, this resource details the items that do. The clinical "lookback" for Section K is 7 days. Documentation describing potential signs and symptoms related to each item should be present in the therapy medical

record to support correct coding and assist the MDS in capturing the most accurate Case Mix Index score.

1. Item K0100. Item K0100: "Swallowing Disorders" is a "check all that apply" item. Item K0100 does not require that the resident actually have a diagnosed swallowing disorder. A sub-item is applicable if the resident had the presence of signs and symptoms of a possible swallowing disorder in the seven-day look-back period. Specifically, the coding instructions for Item K0100 state," Observe the resident during meals or at other times when he or she is eating, drinking, or swallowing to determine whether any of the listed symptoms of possible swallowing disorder are exhibited." Keep in mind that these instructions are for the nurse completing the MDS section.

K0100 Sub-Item Coding Instructions. Below are CMS' instructions for completion of K0100. K0100A, loss of liquids/solids from mouth when eating or drinking. When the resident has food or liquid in his or

her mouth, the food or liquid dribbles down chin or falls out of the mouth. K0100B, holding food in mouth/cheeks or residual food in mouth after meals. Holding food in mouth or cheeks

for prolonged periods of time (sometimes labeled pocketing) or food left in mouth because resident failed to empty mouth completely. K0100C, coughing or choking during meals or when swallowing medications. The resident may cough or gag, turn red, have more labored breathing, or have difficulty speaking when eating, drinking, or taking medications. The resident may frequently complain of food or medications "going down the wrong way." K0100D, complaints of difficulty or pain with swallowing. Resident may refuse food because it is painful or difficult to swallow. K0100Z, none of the above. If none of the K0100A through K0100D signs or symptoms were present during the look-back.

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Section K Basics:

An SLP's Guide to the Swallowing/Nutritional Status Section on the MDS

SLP Assessment to Support K0100. The following table details related Functional Deficit (FD) areas and Underlying Impairments (UI), or underlying

causes, which describe the resident's clinical condition and support item K0100 on the MDS. Each listed FD and UI is an input area in Casamba. SLPs should assess then document these areas when

swallowing is an identified problem at the time of referral:

FUNCTIONAL DEFICITS Swallow Status

Affected Phase

Intake Method Diet Level Liquid Level Labial Closure Mastication

Dentition

UNDERLYING IMPAIRMENTS

Signs/Symptoms of Aspiration ? Liquids

Formation of Bolus

Signs/Symptoms of Aspiration ? Solids

Swallow Initiation

Labial Function

Pocketing

Lingual Function

Choking Coughing Sensation of Lips/Oral Cavity

Mandibular Function Labial O/M Assessment Buccal O/M Assessment

Additionally, and complaints of pain when swallowing should be documented in the free-type box under the Underlying Impairments tab to support Sub-Item K0100D, if applicable.

When to Incorporate as a Goal on the SLP POC. If any of the above FDs and related UIs are identified as an issue as a result

of a comprehensive SLP evaluation, a goal to address and/or compensate for the UI should be targeted with the outcome focused on improving the FD. Functional Deficits are re-assessed at the point of completion of the Updated Plan of Care and Discharge Summary. Therapists should take care to ensure that their treatment plan properly addresses the UIs and, in turn, FDs, so that the patient achieves positive functional outcomes.

2. Item K0510. Item "K0510: Nutritional Approaches" is a "check all that were performed" item.

SLP documentation in the medical record should define Sub-Item K0510C, Mechanically Altered Diet.

? 2019 Halcyon Rehabilitation, LLC

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