How to Successfully Implement and Operate under the

How to Successfully Implement and Operate under the Patient Driven

Payment ModelSponsored by:

ZIMMET HEALTHCARE 2019

About this Program• This program is in NO WAY presented under the auspices of any

government agency or trade association unless explicitly noted.

• ZHSG is a private company and has no influence on Medicare policy development, implementation or interpretation.

• Materials are based on CMS’ 2019 SNF PPS Proposed & Final Rules and subsequent clarifications to the best of our knowledge; we encourage you to notify us of any inconsistencies or errors you may identify within.

• Reimbursement examples use CMI weights and “unweighted urban” base rates from 2018 & 2019; minor variances / rounding errors may exist but are immaterial to this discussion.

• Presenters’ statements / opinions / analysis are based on publicly available information & personal experience only.


Medicare at 50+: Old & New

What’s Changed?

UB-04 Claims MDSCost Reports Eligibility Documentation

Medicare Advantage (image from LEK)

EMR & Analytics


• SNF Proposed Rule and clarifications for 2020 released 4/19/2019 with a Final Rule expected July 2019

• Updates to Medicare Payment rates and Quality programs for Skilled Facilities beginning October 2019

• “How to strengthen” Medicare program through payment alignments, transparency and informed choices for patients

• Three major provisions of the Rule include :

• New SNF case mix model for Prospective Payment System using PDPM

• SNF Value based Purchasing Program (VBP)

• SNF Quality Reporting Program (QRP)

Pertinent Details Pertaining to Medicare


• Includes policies with a commitment to shift Medicare $$$ away from Volume to Value

• Determines Resident care needs and reimbursement Holistically

• Therapy serves as a “resource” to patient-specific services, conditions, characteristics & treatments

• Therapy volume has ZERO impact on rate

• Includes revisions to MDS 3.0 for October 2019 and proposed October 2020

• https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/post-acute-care-quality-initiatives/impact-act-of-2014/impact-act-downloads-and-videos.html

Pertinent Details Pertaining to Medicare

https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/post-acute-care-quality-initiatives/impact-act-of-2014/impact-act-downloads-and-videos.html


• CMS projects increase of payments to SNF by 2.5% = $887 M

• Focus on reducing administrative burden • 5-day MDS assessment sets “PDPM COMPOSITE SCORE”• Thousands of rate combinations applied for entire benefit

period with changes as determined by clinical team

• OBRA requirements for MDS 3.0 assessments not impacted• 48 hour Care Plan • Care Area Assessments must be completed by day 14

PDPM is simply a new “SNF Revenue Delivery System”


• Myths, Misinformation, Opportunists, Rhetoric for Innovative and Historic Changes to payment

• Care is focused on Value not Volume• Identification of both Primary and Secondary diagnostic

indicators become paramount• Reimbursement-Sensitive Comorbidities and appropriate

coding is required


No change to Medicare SNF “Clinical” / “Technical” eligibility!


• CMS to use sub-regulatory processes to ensure ICD 10 codes classify patients into accurate clinical categories under PDPM

• Alignment with IRFs for payments utilizing ICD 10 , HCPCS and tier comorbidities

• Alignment with other PAC settings to provide consistent group therapy definitions of 2-6 patients doing the same activities

• Consistency of payment policies across PAC settings to create opportunities for site neutral payments



• Incentive based payments rewarding SNF for quality measure performance since October 2018

• Program currently scores SNF performance on the all-cause hospital readmission

• Program reduces SNF Medicare payment by 2% and redistributes 60% of funds as incentive payments

• A 30 day deadline for review and corrections

• Will transition to SNF Potentially Preventable Hospital Readmissions after Hospital Discharge for FY 2020 including updated public reporting

Proposed Rule SNF Value-Based Purchasing (VBP)


• Applies to all SNF including free standing, hospital affiliated, all non critical access hospital SNF and swing beds

• Requirement to submit required quality data or subject to 2% reduction in market basket updates

• CMS Interoperability of health information to increase efforts to improve Quality and Safety of SNF operations

• Two proposed measures include • Transfer of Health Information from SNF to another Provider• Transfer of Health Information from SNF to Patient

Proposed Rule SNF Quality Reporting Program (QRP)


• CMS proposes to :• Adopt standardized quality measure patient assessment

data elements regardless of payor source

• Add QM assessment data that includes: • Cognitive function and Mental status• Special Services, Treatments and Interventions• Medical conditions and Comorbidities• Impairments and/or social determinants of health

including race, ethnicity, preferred language, literacy, social isolation

Proposed Rule SNF Quality reporting Program (QRP)


Interoperability

Source: Center for Medicare and Medicaid Services 2016


Let’s Talk RUG-IV - PDPM Rate Model Example

Both score RUB

Rate = $616.68

Using 2018 Unweighted Rate Set


Ms. SmithMr. Jones

PDPM Impact = + $91.75 PDPM Impact = - $81.79Day 1 – 3 Rate = $997.22 Day 1 – 3 Rate = $684.75

RUB = $616.68 RUB = $616.68


PDPM: Some Things Change, Some Don’t• Therapy remains our defining service, but the department will no

longer drive reimbursement, eligibility, manage appeals • Clinical Pathways : “cost-effective” treatment protocols being developed that

must maintain (improve) quality & outcomes

• Clinical profile of a specific facility’s “target” population?

• Reimbursement management team roles / P&Ps• MDSCs / “Assessment Compliance Coordinators”• Strong nursing documentation / care planning is imperative to support

eligibility and protect reimbursement• Utilization Review meetings and frequent monitoring for resident status

and reimbursement-sensitive changes• System, compliance & audit focus areas of concern= QAPI


Clinical Eligibility:

Back to Basics

Skilled Therapy: 5 days / week

Skilled Nursing7 days / week


How to Write a Skilled Care Note for Medicare Part A

• Substantiate daily skilled care provided to the resident• Provide detailed descriptions and assessment of patient condition including

causative factors and/or risk factors• Record treatments, therapies and resident response• Analyze potential outcomes or consequences of care provided• Include evaluation of resident’s response to the plan• Document evidence of physician and responsible party notifications• Include communication between disciplines• Coordinate continuity of care and potential discharge plans

• Coordination of Information at UR meetings


PT/OT 1 of 16

SLP 1 of 12

NTA 1 of 6

Nursing 1 of 25

Just 1 CBSA PDPM

Per DiemComposite

Rate

• “Components” require distinct / different skill sets

• The entire system is predicated on a highly coordinated approach to management –

• There is no “one-size fits all” reimbursement strategy!

Technically ~ 28,880 possible “Composite” combinations but many

are “mutually exclusive”

Components are like independent payment systems


• RUG-IV rehab scores determined by 20 MDS items

• 2017: >90% of covered days fell within 23 codes; >60% were RU

PDPM consists of 160 MDS Component Items & Drivers

Component Drivers Profiles GroupsClinical Category (Dx) 4

Functional Score 4

Presence of Acute Neurologic Condition,

SLP-related Comorbidity or Cognitive Impairment,

Mechanically Altered Diet, Swallowing Disorder 3

Nursing: Same characteristics as under RUG-IV (using GG) 6 25

NTA: Comorbidity Score (count) 51 6

412

PT, OT:

SLP:

16


Major Joint Replacement

or Spinal Surgery

PT/OT: 10 Categories Collapsed into FOUR (4)

Major Joint Rep. or Spinal

Surgery

Non-Surgical Orthopedic/

Musculoskeletal

Acute Neurologic

Non-Orthopedic

Surgery

Orthopedic Surgery (Except

MJR or Spinal)Acute

Infections

Cancer

Pulmonary

Medical Management

Cardiovascular & Coagulations

MedicalManagement

Non-Ortho Surgery &

Acute Neurologic

Other Orthopedic

PT/OT 1 of 16


Let’s Talk ICD-10 Coding • Item I0020 (indicates the resident’s primary medical condition category) will

have no direct impact on patient classification under PDPM. • Serves as a gateway question to reach the I0020B• The ICD-10 Clinical Category Crosswalk will convert the ICD-10 code captured in I0020B

into one of the 10 PDPM primary clinical categories

• Not all diagnoses are considered valid primary diagnoses for the SNF stay.• Invalid primary diagnoses are listed as “return to provider” in the ICD-10 Clinical

Category Crosswalk

• Patient’s clinical category may change depending on the presence of a surgery during the preceding hospital stay

• The column “Default Clinical Category” has a “Surgical correlate” of 30 new items J2100 –J5000 to capture any major surgical procedure that occurred during the qualifying hospital stay and impacts the SNF care plan


Hey, Hey Section J

New MDS Items: Section J: Patient Surgical History: Captures major surgical procedures (from qualifying hospital stay)

which may change PDPM clinical category from I0020B group.

Relevant for PT/OT classification

0


Musculoskeletal

Orthopedic Surgery

(non-MJS, Spinal)

Non-Orthopedic

Surgery


Surgery

Acute Infections

Medical Management

Cancer Pulmonary Cardiovascular & Coagulations

Acute Neurologic



Acute Neurologic

SLP: 10 Categories Collapsed into TWO (2)

Acute Neurologic

Non-Neurologic


Surgery


Musculoskeletal

Non-Orthopedic

Surgery

Orthopedic Surgery (Except

MJR or Spinal)

Acute Infections

Medical Management

Cancer

Pulmonary

Cardiovascular & Coagulations

or

SLP 1 of 12


SLP Component CalculationMechanically Altered Diet

(K0510C2)

Any two

All three

Any one

None

Acute Neuro Diagnosis (I0020B)

SLP-Comorbidity (Misc.)Cognitive Imp. (C; CFS)

Swallowing Disorder (K0100Z)

Neither

Either

Both

All patients score in oneSLP group no matter if

they receive therapy (or how much)

4 profiles

3 profilesNone/Neither = $15.06All three/Both = $92.81


Nursing Case-Mix Classification

• 25 Groups “collapsed” from 43 Nursing RUGs per “ADL Bins”• Reweighted indices but splits & hierarchy remain intact

• Section G (ADLs) replaced by 7 GG (Function) Items: • Eating (1), Toileting (1), Transfer (3), Bed Mobility (2)• 0 – 16 “nominal” scoring scale inversed

• Variable $ offset: PT/OT & Nursing components• 18% HIV/AIDS $ enhancement (Nursing only; B20 code on UB-04)

See handout for complete listing of case-mix groups and comparison of RUG-IV to PDPM CMI weights

Nursing 1 of 25





See handout for complete listing of NTA service / condition drivers and

related Points

Non-Therapy Ancillary Groups• Completion and Accuracy of this section will take the most

time• Based on count of services & conditions• Greatest rate impact for days 1 - 3 Range Group 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

NTA Case-Mix Classification Groups

Patient Driven Payment Model

CMS: SNF stays with NTA score of 12 or above are very rare (about 1% of all stays)

Day Factor

1 - 3 3.00

4 - 100 1.00

NTA VPDA

NTA 1 of 6


Medicare MDS Type Assessment Reference Date Effective Payment

5-day Scheduled PPS Assessment Days 1 - 8 ("Grace Days" no longer distinguished)

All covered days until Part A discharge (unless IPA is completed)

Interim Payment Assessment (IPA) OPTIONAL: No later than 14 days after qualifying change is identified

IPA ARD through Part A discharge (unless another IPA is completed)

PPS Discharge Assessment End Data of Most Recent Medicare Stay (A2400C) or End Date N/A

PDPM Assessment Schedule

Interrupted Stay PolicyResidents discharged from and return

to same SNF by 12am of the end of third day of “interruption window”, Composite & VPDA continue unchanged

Variable Per Diem AdjustmentPT/OT & NTA $ decrease as the

benefit period progresses (see handout for details)

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/MDS-30-Item-Sets-v1-17-0-DRAFT-for-October-1-2019-Release.zip

This is not entire policy – details in support document


•Optional per Final Rule• SNFs to determine when IPAs are completed to address potential

changes in clinical status and what criteria should be used to decide when an IPA is appropriate

• The ARD will be date facility chooses relative to the triggering event• Remember that Component values may offset others (Net $ Impact)!

• Payment effective date = IPA ARD but will not reset VPDA• Will NOT be susceptible to assessment penalties (it is optional)• Effective 10/1/19 in conjunction with PDPM implementation• Requires DAILY monitoring for condition changes

Interim Payment Assessments


• Transition: No transition, phase-in or hold harmless period• RUG-IV billing ends 9/30/19 – PDPM billing begins 10/1/19• IPA with ARD no later than 10/7/19 required for all Part A patients

in-house 9/30/19; otherwise late penalties would apply.• 10/1/19 = Day 1 of VPDA schedule, even if stay began earlier.

• Billing: 5 character code detailed in supporting documents• CMI: CMS will continue to report RUG-III and RUG-IV HIPPS codes,

based on state requirements, in Item Z0200, through 9/30/2020. • Case-mix states also may rely on PPS assessments until 10/1/19,

when all (including OMRAs) will be retired (except the 5- day) • New Optional State Assessment (OSA) may be required by states to

report changes in patient status, per their CMI rules.


PDPM PPS Discharge Assessment• MDS Section O added specific to PT, OT, ST utilization:

• Start & End Dates• Mode (Individual, Concurrent, Group Minutes)• Total Days

• To “allow CMS to both conduct reviews of changes in the volume and intensity of therapy.. compared to that provided under RUG-IV, as well as to assess compliance with the proposed group and concurrent therapy limit.”

• “If we discover that the amount of therapy provided to SNF residents does change significantly under the proposed PDPM… we will assess the need for additional policies to ensure… residents continue to receive sufficient and appropriate therapy services consistent with their unique needs and goals.”


Administrative Presumption of Coverage

• Clinical Eligibility automatically established through the ARD of initial assessment

• The following are designated under the presumption: • PT & OT: TA, TB, TC, TD, TE, TF, TG, TJ, TK, TN, TO• SLP: SC, SE, SF, SH, SI, SJ, SK, SL• Nursing: Clinically Complex RUG or higher• NTA score: NA (12+)

• Patients not assigned one of the above receive an individual determination using the existing administrative criteria


Let’s Talk Work Flow• Pre-admission: Information from hospital

• Admission decisions include • Clinical Eligibility = Evidence of Daily skilled Care needs

• On Admission: Assessment information, H & P on admission• Who, When, How, Where• Determination of skilled care needs • Gathering/documenting of MDS items

• By Day 2/3: Clinical Team meeting• Open MDS assessment• Provision of care and services • On-going assessment & documentation by Clinical Team

• By Day 8: Set ARD • Documentation and completion of MDS thru Day 14


PDPM: Operational Imperatives• Chapter 8 of the Medicare Benefit Policy Manual• Skilled care notes with “evidence of daily skilled care”

• Formalize clinical programs & documentation protocols

• Narratives, flow sheets, frequency, responsibilities

• Manage payment and care drivers: ARD planning & capture

• Identification of ancillary & medical events & services

• Analyzing offsetting lost pre-admission lookback elements (Nursing RUG v. NTA)

• Diagnosis coding skills and responsibilities

• Hospital information vs Reasons for post-acute skilled care

• Primary diagnosis for Clinical Categories v. Secondary

• UB-04 HIPPS coding


Potential Audit Focus Areas• Clinical Eligibility (7 day/week Nursing, 5/Therapy)

• No therapy “levels” to audit – Reasonable & Necessary

• Nursing RUG drivers and “end splits”• Nursing documentation must support all drivers• “Lock & Drop”

• Speech variables• Function scoring / Variance from Section G• NTA drivers: Medical necessity, administration, documentation

• IPA policies, trends, consistency and justification• ICD-10 assignment or omission


Final Thoughts on Preparing• Structured, gradual, repeated training - CMS Resources:• Reimbursement “Sensitivity” & Modeling• Organizational Policies and Procedures for Assessment• Competencies of Staff performing assessments

• New contributors for assessments (e.g. Psychologists, Dieticians, etc.)• Speech Therapy screening for Functional and Neuro based coding

• Review therapy department protocols• MDS management, support, staffing, skill sets• Coding expertise (Primary & Tertiary codes)• Nursing documentation; “Formalize” clinical programs (e.g. RNP)• Tracking condition / changes & policies for IPA opportunities


Significant Resources• https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Measures-and-Technical-Information.html

• https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/PDPM_Fact_Sheet_MDS_Changes_Final.pdf

• MDS 3.0 Item Sets v1.17.0 (DRAFT) for October 1, 2019 Release [ZIP, 3MB]

• From https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIMDS30TechnicalInformation.html

• https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c08.pdf

• https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/IRF-Quality-Reporting/Downloads/GG-Self-Care-and-Mobility-Activities-Decision-Tree.pdf

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Measures-and-Technical-Information.html

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/PDPM_Fact_Sheet_MDS_Changes_Final.pdf

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/MDS-30-Item-Sets-v1-17-0-DRAFT-for-October-1-2019-Release.zip

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIMDS30TechnicalInformation.html

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c08.pdf

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/IRF-Quality-Reporting/Downloads/GG-Self-Care-and-Mobility-Activities-Decision-Tree.pdf

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How to Successfully Implement and Operate under the