PDPM Effective Oct 1, 2019 (FY20)

10/29/18

And you shall rise and show respect to the aged

Patient Driven Payment System PDPM

Overview Effective Oct 1, 2019 (FY20)

Nov 2018 Judy Wilhide Brandt, RN, BA, CPC, QCP, RAC-MT, DNS-CT 909-800-9124 judy@

Twitter: @WilhideMDS Facebook: /WilhideConsulting

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Objectives:

? Review the six components of the Patient Driven Payment System ? Discuss role of diagnosis coding and in the PT, OT, SLP, NTA components of a

PDPM payment category ? Explain the variable per diem adjustment schedule ? Review the PPS MDS schedule ? Examine additions to the Part A PPS Discharge and limitations on modes of

therapy ? Explain the Interim Payment Assessment and it's role in adjusting payment ? Review the differences between the PT/OT function score and the Nursing

function score ? Explain how a function score is calculated ? Review the `interrupted stay policy' ? Discuss changes to the nursing component categories ? Explain how presumption of coverage will work

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Patient Driven Payment System (PDPM) Goals: ? Remove therapy minutes as a determinant of

payment and create a new therapy payment model in which payment is linked to differences in clinical characteristics ? Create a separate payment component for nontherapy ancillary (NTA) services, using resident characteristics to predict utilization of these services. ? Will begin Oct 1, 2019

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PT

$50

Overview

OT

$50

ST

$50

NTA

$50

Nursing

$50

Non-

Case

Mix

$50

= $300

Six components in daily rate, all taken from PPS 5 day MDS. Each separate component will be assigned a daily rate based on that component's case mix index (CMI), all added together for that resident's daily rate.

NTA = non-therapy ancillaries

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ST

Nursing NonCase Mix

PT

Full component rate for days 1 ? 20, then both PT and OT each decrease 2% every 7 days OT

NTA

Full component rate for days 1-3, then 70% decrease for days 4 - 100

No variable per diem adjustment for ST, Nursing, Non-Case Mix

NTA = non-therapy ancillaries 6

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PT OT Nursing

ADL score is "end-split." Now called "Function score"

NTA

? PT and OT use a function score derived from 10 ADL activities assessed in Section GG of a

PPS 5 day MDS

ST

? Nursing uses a function score derived from 7 ADL activities assessed in Section GG of a

PPS 5 day MDS

NonCase

Mix

NTA = non-therapy ancillaries

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Section GG Function Score Data Elements:

PT and OT components

Nursing component

Eating Oral Hygiene Toileting Hygiene

Average Bed Mobility

Average Transfer

Average Walking

GG0130A1 Eating GG0130B1 Oral Hygiene

GG0130C1 Toileting Hygiene

GG0170B1 Sit to Lying GG0170C1 Lying to Sitting on Side of Bed GG0170D1 Sit to Stand GG0170E1 Chair/Bed-to-Chair GG0170F1 Toilet Transfer GG0170J1 Walk 50 Feet with Two Turns GG0170K1 Walk 150 Feet

Eating Toileting Hygiene

Average Bed Mobility

Average Transfer

GG0130A1 Eating GG0130C1 Toileting Hygiene

GG0170B1 Sit to Lying GG0170C1 Lying to Sitting on Side of Bed GG0170D1 Sit to Stand GG0170E1 Chair/Bed-to-Chair GG0170F1 Toilet Transfer

Start of PPS Stay Section GG on PPS 5 day MDS 8

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For PT and OT Component: Section GG Responses

Independent or Set-up (05,06) Supervision or touching assistance (04) Partial/moderate assistance (03) Substantial/maximal assistance (02) Dependent, refused, N/A, or cannot walk (01,07,09,10, 88 or "could not walk 10 feet" (GG0170H = any code for "not attempted" 07,07,11,88), missing value

Function Score

4 3 2 1

0

Function Score Range 0 - 24

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Six final elements for PT/OT Function Score

Eating Oral Hygiene

Category - Items G0130A1 Eating GG0130B1 Oral Hygiene

Toileting Hygiene GG0130C1 Toileting Hygiene

Bed Mobility

GG0170B1 Sit to Lying

Admission Performance 06 set-up 06 set-up

02 max assist 03 mod assist

Interim Score

4

4 1 2

Bed Mobility

GG0170C1 Lying/sit

03 mod assist

2

Transfer

GG0170D1 Sit to Stand

03 mod assist

2

Transfer

GG0170E1 Chair/Bed-to-Chair 03 mod assist

2

Transfer

GG0170F1 Toilet Transfer

02 max assist

1

Walking Walking

GG0170J1 Walk 50 ft w/2 Turns 01 dependent

0

GG0170K1 Walk 150 Feet

01 dependent

0

Function

Score: NA

W/averages (round to nearest whole number)

4 4 1

2 1.66 Round to 2

0

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When averaging bed mobility, transfer and walking, round to nearest whole number. 10

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Nursing Function score: 4 final elements

Category - Items

Admission Performance

Eating

GG0130A1 Eating

Toileting Hygiene GG0130C1 Toileting Hygiene

Bed Mobility

GG0170B1 Sit to Lying

Bed Mobility on Side of Bed

GG0170C1 Lying to Sitting

Transfer

GG0170D1 Sit to Stand

Transfer Chair

GG0170E1 Chair/Bed-to-

Transfer

GG0170F1 Toilet Transfer

06 set-up 02 max

assist 03 mod

assist 03 mod

assist 03 mod

assist 03 mod

assist 02 max

assist Function

Score:

Interim Score

4 1 2 2 2 2 1 NA

W/averages (round to

nearest whole number) 4 1

2

1.66 Round to 2

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When averaging bed mobility and transfers, round to nearest whole number. 11

? Every resident is classified into every component, every time, based on PPS 5 day MDS.

? Even if no PT or OT or SLP received, each resident's rate is determined using the CMI achieved for each separate component.

? Each major component is further subdivided into groups, each with a unique CMI.

? The computation for PT and for OT are identical, but the resident will get a separate CMI for PT and for OT, every time.

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Background - Clinical Categories:

? Based on analysis of primary reason for SNF care ten clinical categories were created: 1. Acute Infections 2. Acute Neurologic 3. Cancer 4. Cardiovascular and Coagulation 5. Major Joint Replacement or Spinal Surgery 6. Medical Management 7. Non-Surgical Orthopedic/Musculoskeletal 8. Pulmonary 9. Non-Orthopedic Surgery 10. Orthopedic Surgery (Except Major Joint Replacement or Spinal Surgery)

? Used Medical Severity ? Diagnostic Related Group (MS-DRG) from the prior inpatient stay to define the primary reason for SNF care and assign residents to clinical categories

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Maj Joint Repl/Spinal Surgery

Non-ortho surgery and Acute neurologic

? 10 Categories collapsed into 4 for PT and OT, because cost of care is commensurate

? Acute Neurologic is split out and used as a factor to generate the ST component rate

Other Orthopedic

?Non-surgical orthopedic/musculoskeletal ?Ortho Surg (not Maj Joint Repl/Spinal Surgery)

Medical Management

?Acute infections ?Medical Management

?Cancer ?Pulmonary ?Cardiovascular & Coagulation

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Percentage of SNF stays in PDPM Research

Medical Management 17%

14% 60%

9%

Acute neuro/nonortho surg Other ortho

Maj Joint Repl/Spinal Surg

Rounded to nearest whole number 15

Maj Joint Repl/Spinal Surgery

Non-ortho surgery and Acute neurologic

Other Orthopedic

PT and OT component

Determine "Primary Diagnosis Clinical Category" using only the ICD-10 code listed first I8000A. Some primary diagnosis clinical categories may change if there is a surgical procedure done in hospital

Medical Management

If there was a surgical procedure during inpt stay that relates to primary reason for Part A SNF stay, there will be

checkboxes in J2000 to assign appropriate category

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