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A First Look at PDPM Claims: Lessons Learned
November 21, 2019
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First Look at PDPM – Lessons Learned
MARK MCDAVID, OTR, RAC-CT, CHCPresident, Seagrove Rehab Partners
Judy Wilhide Brandt, , RN, BA, CPC, QCP, RAC-MT, DNS-CT
Principal, Wilhide Consulting
Understand therapy practice changes occurring in therapy departments
Review and understand group/concurrent documentation requirements and how the facility should be monitoring this mode
Identify and review other therapy-related issues under PDPM
Review of commonly missed Non-Therapy Ancillary (NTA) and Nursing Components
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Today’s Objectives
Review how small changes in process can result in CMI jumps for Speech-Language Pathology (SLP) Component
Discuss how to code surgery and its impact on payment
Review Section GG documentation requirements and common pitfalls
Review the importance of accurate ICD-10 coding
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Today’s Objectives
Go to www.SeagroveRehab.participoll.com
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Audience Participation!
What has been most surprising to you with the transition to PDPM?
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What will CMS Monitor Under PDPM?
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Final Rule issues CMS says they will be watching:
Essentially, we are talking about “provider behavior change” Any potential consequences (e.g., overutilization)
of using cognitive impairment as a payment classifier in the SLP component.
Facilities whose beneficiaries experience inappropriate early discharge or provision of fewer services (e.g., due to the variable per-diem adjustment).
Stroke and trauma patients, as well as those with chronic conditions, to identify any adverse trends from application of the variable per-diem adjustment.
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CMS Will Monitor?
Use of the interrupted-stay policy to identify SNFs whose residents experience frequent readmission, particularly facilities where the readmissions occur just outside the 3-day window used as part of the interrupted-stay policy.
Changes in payment that result from changes in the coding or classification of SNF patients vs. actual changes in case mix.
Changes in the volume and intensity of therapy services provided to SNF residents under PDPM compared to RUGIV. (PBJ may be used to assist here)
Compliance with the group and concurrent therapy limit.
Any increases in the use of mechanically altered diet among the SNF population that may suggest that beneficiaries are being prescribed such a diet based on facility financial considerations, rather than for clinical need. seagroverehab.com9
CMS Will Monitor?
PDPM Implementation and Industry Response!
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Therapy contractor’s “race to the bottom”
Most are paying by % of CMG
What does it mean when you pay less for a service-based product?
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What Have We Done to Ourselves?
Understanding what happened in contract space What does it mean when you pay less for a service-
based product?
Molly Maids charges retail $100 per house for house cleaning
Molly Maids pays its cleaners $75 per house netting them a 25% margin
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What Have We Done to Ourselves?
Understanding what happened in contract space
For various reasons Molly Maids cuts its retail rate to $80 per house.
In order to maintain it’s 25% margin, it has to do something to manage costs:
Cut wages Cut benefits Provide less service Become more efficient
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What Have We Done to Ourselves?
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Therapy Practice Change Post 10/1
As early as late September, the following were being reported: Select Rehab – pay cuts
Encore – cutting several hundred jobs
Genesis – cutting 3,000 jobs (Genesis reports this to be 585) – Quarterly filing as of 11/2019 reports 10,000 therapists vs 14,000 at end of 2018
Reliant Rehab – cutting 3,000 jobs (Reliant would not comment)
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Therapy Practice Change Post 10/1
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Therapy Changes Post 10/1
Within the first week of October, we started seeing disturbing images posted on social media.
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Therapy Practice Change Post 10/1
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Therapy Practice Change Post 10/1
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Therapy Practice Change Post 10/1
“My company has every single patient set with concurrent treatments for each discipline each day. How is this legal? I thought that it was the clinicians determination? My regional who is setting all part As like this live hundreds of miles away and doesn’t know patients. Not to mention we was all part As as ultras before 10/1?”
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Therapy Practice Change Post 10/1
“[T]housands nationally (over 10,000) rehab therapists … as well as assistants … are being laid off this week. 40% of the therapy staff was eliminated at the rehab facility I am employed at. Patients … who were receiving 15 hours of intensive rehabilitation individually last week … are now in groups of 4-6 for reduced time of 3-5 hours a week or less. It is not
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Therapy Practice Change Post 10/1
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Therapy Practice Change Post 10/1
“Stop greedy for profit nursing homes and Rehab companies from interfering in the clinical judgment of Physical, Occupational and Speech Therapist when they are caring for patients.”
“[S]ome Rehab companies are bidding on the amount of Therapy you and your loved ones can receive. Some are promising to only provide 400 minutes a week instead of the 720 minutes they were getting last week to under bid other companies. What that means, is that if you were getting 50-75 minutes of therapy, you may get as little as 15 minutes.”
“[S]ome Rehab companies are mandating that instead of you getting one on one Therapy after a stroke, hip or knee surgery, some of your Therapy will be put in group or concurrent treatments with another patient or group of 6 patients.”
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Change.org petition:“Patients in Nursing Home Rehab Need
your Help”
“Many are also insisting on 100% productivity or better which does not allow for communication with your Dr., nurses, documentation about your care, letting you take your time in the bathroom, help with your shower, making sure you can reach your call bell etc.”
“Some of These companies are harassing your Therapists, threatening them with write ups or firings if they don’t treat patients in a group, or provide too much Therap. Many Therapist have had benefits cut, are mandated to work 7 days a week, a few hours a day.”
“Please sign the petition. They are not asking for raises and most have had pay cuts. They are asking that you let the Professional and the Patient decide what the best Plan of care is.”
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Change.org petition:Over 80k signatures
“Overriding or ignoring clinical judgment through administrative mandates, employer pressure to meet quotas, or inappropriate productivity standards may be a violation of payer rules, may be in conflict with state licensure laws, and may even constitute fraud.”
https://www.aota.org/~/media/Corporate/Files/Practice/Ethics/APTA-AOTA-ASHA-Concensus-Statement.pdf
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Consensus Statement from Therapy Organizations
Examples of such policies or practices that are unacceptable include:o Placing clients/patients on caseload who
do not meet Medicare or other payer coverage criteria;
o Keeping clients/patients on caseload when skilled care is no longer indicated;
o Setting inappropriate administrative requirements regarding treatment frequency, intensity, or duration;
o Delivering treatment without client/patient consent;
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Consensus Statement from Therapy Organizations
o Counting time as treatment that is not permitted by Medicare or other payer regulations as treatment (e.g., rest time or time spent traveling to the client/patient’s room);
o Inappropriately limiting the time spent on evaluations based on payment policy;
o Coding services inappropriately;o Changing coding without the assent of the
treating therapist in an effort to increase payment or conform to internal policies;
o Falsifying or changing documentation to misrepresent time spent or services delivered. [documenting off the clock]seagroverehab.com28
Consensus Statement from Therapy Organizations
www.SeagroveRehab.participoll.com
Have there been any lay-offs in therapy in your facility?
A. YesB. NoC. Don’t Know
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Liabilities
0vote at SeagroveRehab.participoll.comA B C
www.SeagroveRehab.participoll.com
Has there been a spike in group/concurrent utilization in your facility?
A. YesB. NoC. Don’t Know
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Liabilities
0
vote at SeagroveRehab.participoll.com
A B C
Are your therapy services in-house or contract?
A. ContractB. In-House
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Liabilities
0A B
Are any of these things happening in your facilities?
Do you know if they are or aren’t?
Are the responses different from facilities with in-house vs contract therapy providers?
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Liabilities
Group and Concurrent Therapy
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Previously (RUGs), the group definition was 4 patients performing the same or similar activities and minutes were divided by 4.
Concurrent minutes were divided in half.
Less than ½ of 1% of the minutes provided in the country were in either concurrent or group.
Why do you think that is?
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Group and Concurrent Therapy
New Group Definition: 2-6 patients performing the same or similar activities (full minutes count).
Concurrent Definition – 2 patients with one therapist doing different activities (not new definition).
Concurrent is now counted with group in the 25% limitation on therapy minutes per discipline across the patient’s stay.
Why is this a big deal?
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Group and Concurrent Therapy
As you have seen, companies are now pushing therapists to perform concurrent and group.
Why do you think that is?
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Why More Group/Concurrent?
More group/concurrent is happening in facilities. Why do you think that is?
A. The clinical needs of the patient changed on 10/1.
B. Facility can achieve better outcomes in group/concurrent setting than in individual treatments.
C. Contractor can achieve better operational benefits
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Why More Group/Concurrent?
0A B Cvote at SeagroveRehab.participoll.com
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Group Documentation Requirements
As stated in the FY 2012 SNF PPS proposed rule (76 FR 26388) regarding group therapy documentation, because group therapy is not appropriate for either all patients or all conditions, and in order to verify that group therapy is medically necessary and appropriate to the needs of each beneficiary, SNFs should include in the patient’s plan of care an explicit justification for the use of group, rather than individual or concurrent, therapy. This description should include, but need not be limited to, the specific benefits to that particular patient of including the documented type and amount of group therapy; that is, how the prescribed type and amount of group therapy will meet the patient’s needs and assist the patient in reaching the documented goals. In addition, we believe that the above documentation is necessary to demonstrate that the SNF is providing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with
i 1819(b)(2) f h Aseagroverehab.com39
Group Documentation Requirements
The important bits:
Not appropriate for either all patients or all conditions
Medically necessary SNFs should include in the patient’s plan of care an
explicit justification for the use of group, rather than individual or concurrent, therapy.
The specific benefits to that particular patient Including the documented type and amount of group
therapy That is, how the prescribed type and amount of group
therapy will meet the patient’s needs And assist the patient in reaching the documented
goals. seagroverehab.com40
Group Documentation Requirements
Based on the Final Rule, we should be documenting: Purpose of the group
Number of patients in the group
Skilled treatment provided
Goals addressed
Patient’s response
Benefit to the patient from the group
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Group Documentation Requirements
Example #1 Mr. Smith engaged in a Discharge Planning Group for
THR patients x 53 minutes – he was 1 of 6 residents who participated. Focus of the group was to develop and integrate work simplification and energy conservation techniques when engaged in simple home making tasks, ensuring that THR precautions are being maintained. Mr. Holiday was able to verbalize 3 out of 3 THR precautions – no cueing required. Mr. Holiday was able to demonstrate bed making technique on one side of the bed prior to moving to the other side in order to lessen the expenditure of energy; however, he required CGA due to slight instability noted while walking around the foot of the bed because of a narrowed BOS.
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Group Documentation Examples
Example #1 continued Additionally, he was able to verbalize 3 out of the 5
energy conservation techniques discussed at the beginning of the session, but required prompting in order to verbalize the other 2 energy conservation techniques. He maintained appropriate THR precautions throughout the bed making task. He benefitted within the group setting by social interactions and support with other patients who have undergone a similar surgery as well as he was able to model other patient’s behaviors in regards to strategies such as pausing to ensure he has regained his balance prior to continuing with the functional task.
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Group Documentation Examples
Purpose of the group – Discharge planning Number of patients in the group - 6 Skilled treatment provided – Energy conservation
techniques while engaged in simple home making tasks
Goals addressed – verbalizing THR precautions, bed making using energy conservation techniques, verbalize 3/5 energy conservation techniques
Patient’s response – verbalized THR precautions with no cueing, Required CGA during bed making due to slight instability, required prompting for 2 remaining EC techniques
Benefit to the patient from the group – social interaction and support with other patients who have undergone a similar surgery and was able to
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Group Documentation Examples
Example #2 Patient present for group tx session today, with two other
individuals. Focused today’s session on word retrieval at the conversational level with unfamiliar listeners. Patient continues to present with mild expressive aphasia and states she becomes easily flustered beyond just a 1:1 conversation. During today’s task, the patient was able to use strategies, including defining/describing and use of gestures to express her ideas. Feedback received from peers, who report they were able to understand each of the patient’s responses, which has increased the patient’s confidence in carrying on conversations with strangers since once she returns home – she frequently goes to the grocery store in her daily routine.
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Group Documentation Examples
Purpose of the group – word retrieval at conversational level
Number of patients in the group - 3 Skilled treatment provided – facilitated group
focusing on word retrieval at a conversational level Goals addressed – increasing pts confidence in peer
interactions Patient’s response – pt continues to present with
mild expressive aphasia and becomes easily flustered beyond 1:1 conversation
Benefit to the patient from the group – peer interaction that increased the pts confidence
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Group Documentation Examples
Example #3
Purpose of the group
Number of patients in the group
Skilled treatment provided
Goals addressed
Patient’s response
Benefit to the patient from the group
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Group Documentation Examples
Example #4
Purpose of the group
Number of patients in the group
Skilled treatment provided
Goals addressed
Patient’s response
Benefit to the patient from the group
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Group Documentation Examples
Who is auditing your therapy charts when group/concurrent are occurring?
This should be part of your QA process if group/concurrent are occurring to any significant degree in your facility.
DO NOT allow you therapy contractor to be the only entity overseeing the group/concurrent documentation.
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Group Documentation Examples
Section GG Documentation -What is Collaboration?
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Section GG
Assessment Period: Admission This functional assessment must be completed within the first
three days (3 calendar days) of the Medicare Part A stay, starting with the date in A2400B, Start of Most Recent Medicare Stay, and the following two days, ending at 11:59 PM on day 3. The admission function scores are to reflect the resident’s admission baseline status and are to be based on an assessment. The scores should reflect the resident’s status prior to any benefit from interventions. The assessment should occur, when possible, prior to the resident benefitting from treatment interventions in order to determine the resident’s true admission baseline functional status. Even if treatment started on the day of admission, a baseline functional status assessment can still be conducted. Treatment should not be withheld in order to conduct the functional assessment. Current RAI page GG-36 seagroverehab.com
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Section GG
Assessment Period: Admission The assessment should occur, when possible, prior to the
resident benefitting from treatment interventions in order to reflect the resident’s true admission baseline functional status. Draft RAI page GG-10
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Collaboration and Recommended Coding Process
Admission Data collection for Admission (Therapy and Nursing) Section GG meeting between therapy and nursing MDS Coordinator determines level to be coded on MDS
Interim Payment Assessment Notify therapy of possible IPA and that GG scores need to be
collected over X dates. Therapy and nursing collect GG scores over the 3 days in
question. Therapy and nursing meet to discuss Section GG findings MDS Coordinator determines level to be coded on MDS
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Collaboration and Recommended Coding Process
Planned Discharge Data collection by therapy and nursing for Discharge
assessment (last 3 days of stay) Therapy and nursing meet to discuss Section GG findings MDS Coordinator determines level to be coded on MDS
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Collaboration and Recommended Coding Process
This is important! This impacts your annual QRP score
This impacts your daily per diem
Think about the post-payment reviews related to PDPM payments. Imagine how Medical Review will look at Section GG. Do you have documentation to support your coding?
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Here’s what we see happening on admission:
Therapy coding Section GG items on evaluation Very little nursing involvement Generally taking therapy’s GG scores as accurate and
that gets coded on MDS.
With downward pressure from contract therapy providers, some items may not be getting fully assessed. Pressure to have less time in evaluations – particularly eval only
patients.
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Section GG
Here’s what we see happening on discharge:
Therapy coding Section GG items on discharge Often times not coding all items – just leaving some blank This, in turn, makes your outcomes look worse than they
actually may be. Ensure that you therapists are understanding the
importance of all GG items. Ensure that all GG items are getting coded on discharge.
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Section GG
Other Therapy-related Issues
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Daily Skilled Services: Nursing services are considered “daily” when
provided 7 days per week. Therapy services are considered “daily” when
provided 5 days per week. What happens when a patient, skilled for
therapy, misses a day of therapy and now only has 4 days of therapy in that week?
“This requirement should not be applied so strictly that it would not be met merely because there is an isolated break of a day or two during which no skilled rehabilitation services are furnished and discharge from the facility would not be practical.” BPM, Ch8, Section 30.6
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Daily Skilled Services
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Payment for Services not Rendered
Note:
All residents would be classified into PT, OT, and SLP classification regardless of whether they are on therapy case load.
Can therapy use RTP codes on their evaluation?
A. YesB. NoC. Only on IPA assessments
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Return to Provider (RTP) Codes
0A B Cvote at SeagroveRehab.participoll.com
Reports of SLPs being asked to change R codes to I codes in order to capture the SLP comorbidity.
Speech comorbidity credit comes from 5 main groups of conditions plus one dx: ALS – G12.21 Apraxia – related to neurologic condition (I codes) Dysphagia – related to neurologic condition (I codes) Laryngeal cancer (C codes) Oral cancer (C codes) Speech and language deficits – related to neurologic
conditions (I codes)
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SLP Comorbidities
This means that dysphagia of another type does not qualify for the SLP comorbidity.
This means that Apraxia of another type does not qualify for SLP comorbidity.
This means that Speech and Language Deficits of another type do not qualify for the SLP comorbidity.
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SLP Comorbidities
For example:
Patient has dysphagia, oropharyngeal phase (R13.12). This is not the same as a patient who had a subarachnoid hemorrhage with dysphagia (I69.091 –Dysphagia following nontraumatic subarachnoid hemorrhage).
Patient has dysphasia (R47.02). This is not the same as I69.x21 which is Dysphasia following nontraumatic subarachnoid hemorrhage, nontraumatic intracerebral hemorrhage, nontraumatic intracranial hemorrhage, etc.)
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SLP Comorbidities
Unless you have diagnostics reasons… DO NOT ASK YOUR SLP TO CHANGE THE R CODE TO AN I CODE!
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SLP Comorbidities
I have a patient who had a surgery, but the PT/OT clinical category is not mapping to surgical category. Why?
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Postsurgical Patients
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Postsurgical Patients
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Postsurgical Patients
I have a patient who had a surgery, but the PT/OT clinical category is not mapping to surgical category. Why?
Note that J2499, J2599, J2699, J2799, J2899, and J5000 do not map to a surgical category.
If you are paying your therapy contractor by PT, OT, SLP components, what implications might this have?
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Postsurgical Patients
CMS Oversight: other sources
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CMS Oversight: other sources
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Historically, we monitored RUGs distribution, average daily rate, off-schedule MDS assessments (COT, EOT, SOT).
What are you monitoring today?
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Monitoring Your Therapy Program
Monthly (Part A)
Average LOS
Average minutes per day per pt (compare this to last year)
Therapy frequency by discipline
Group/concurrent percentage
Therapy productivityseagroverehab.com73
Monitoring Your Therapy Program
How are therapy minutes determined in your facility? Are you discussing what is appropriate?
How is therapy frequency and duration determined in your facility?
Do you have certain expectations of therapy?
Do you feel that the facility should be involved in setting frequency/duration/minutes of therapy?
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What, Who, How, When, Why?
Is the conversation focused on the patient?
Are you talking about outcomes for that patient?
Is therapy working or not
Are goals realistic – too aggressive, too relaxed?
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What, Who, How, When, Why?
Asking questions of your therapy team – give them a heads up first.
Questions the Administrator may want to ask: How many minutes of therapy are we scheduling this
patient for? Depending on group % you should be able to walk through
the gym and see group therapy occurring.
Questions MDS may want to ask: Why are we only providing OT/PT/ST and not another
discipline? Why is this patient appropriate for group/concurrent?
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What, Who, How, When, Why?
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Be careful – using this form or similar could be a double-edged sword.
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Monitoring Therapy
Ensure that therapy billing matches your billing.
Depending on contract terms/specifics this may mean different things.
Paying therapy by % of therapy CMG? Ensure that your IMA/IPA CMGs and therapy’s CMGs match.
Paying therapy by % of overall PDPM payment? Ensure that your IMA/IPA CMGs match for each component.
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Triple Check
This will be updated in the Program Integrity Manual
Transmittal 924 released 11/15/2019
The purpose of this Change Request (CR) is to ensure the medical review instructions in Publication (Pub.) 100-08 align with the regulatory updates issued in final rule CMS-1696-F that created the Patient Driven Payment Model (PDPM), which replaces the prior Resource Utilization Group (RUG) classification system, effective October 1, 2019.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R924PI.pdf
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Updated Medical Review Guidance
New items of note for Medical Review:
The Interim Payment Assessment (IPA) is an optional assessment that providers may complete to report a change in the patient’s classification. If an IPA has been completed, medical reviewer will examine the medical documentation as described in this section.
Need For Skilled Care Ends: If the reviewer determines that the beneficiary falls to a non-
skilled level of care at some point during the period under review, the Medicare contractor shall deny the claim from the date on which the beneficiary no longer meets level of care criteria.
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Updated Medical Review Guidance
First, I will pose these to all of you, then Judy.
Patient is preparing for discharge so therapy decreases to 3x/week while restorative treats daily in order to determine patient response from therapy treatment and what else may be needed before the actual discharge date.
Assuming documentation from nursing and therapy reflects intent, patient progress, and follow up, would this be considered daily skill under Part A? I would anticipate anyone in this example would be about a week in length.
A. YesB. NoC. Call Judy!
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Questions for Judy!
0A B C
Prior to COTs and EOTs, there were patients who remained in “observation” status after therapy discharge for a number of day to determine how the patient would function without therapy intervention on a regular basis.
Is observation status available under PDPM?
A. YesB. NoC. It was never available, but occurred anyway.
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Questions for Judy!
0A B C
Show PDPM daily rate worksheets provided as a reference
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Tools for you to use!
