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PDPM

CMS has updated the PDPM website… Again!

As we in the SNF world eagerly anticipate the 5-Star and the SNF FY 2020 proposed rule this month, the revised RAI Manual in May and the SNF FY 2020 Final Rule in July, on April 4th, CMS updated the PDPM Website… again! Things are really moving at a breakneck pace. You may feel   like it is a challenge to keep up. You are not alone. It’s time to pull out your running shoes and stretch your thinking muscles because the pace is not going to get any slower moving toward October.

As for the PDPM website revisions let’s take a breather and have a closer look. The following are the documents have been revised to reflect clarifications that CMS has made with regard to the new payment system; PDPM FAQ, PDPM Patient Classification Walk Through, PDPM Grouper Logic, PDPM ICD-10-CM Mappings. Here is a summery of the revisions that have been made. The full documents can be found at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html

PDPM ICD-10 Mapping – CMS has done us all a favor here. First, they have combined all of the mapping tools into one Excel workbook. Now we can just access that one tool to do all of our PDPM ICD-10 map searches. Next, they have updated the code sets in response to suggestions industry experts have made since the first edition of these tools. In the Clinical Categories by Dx. tab, ICD 10 codes have now been mapped appropriately.

For example, in the prior versions, there was an incomplete list of dx and some dx that should have mapped to possible surgical procedures did not. For example, dx code S72001D Fracture of unspecified part of neck of right femur, subsequent encounter, maps to a default category of Non-Surgical Orthopedic/ Musculoskeletal and May be Eligible for One of the Two Orthopedic Surgery Categories. This was not the case in prior versions of the mapping tool. There are multiple similar revisions that have been made.

The SLP comorbidity map now contains 102 diagnoses. The prior version only contained 70. Multiple diagnoses have been added to Apraxia, Dysphagia and speech and language deficits categories, further enhancing the variety of diagnoses that classify under these categories. The NTA comorbidity diagnosis map continues to have 1535 diagnoses available to map to the 27 NTA comorbidity categories that use MDS item I8000.

PDPM Patient Classification Walkthrough – This document has had only a minor revision. In the prior versions of this document, the source for the NTA comorbidity, Inflammatory Bowel Disease, was noted to be I8000. However, this was a typo and has been corrected to be I1300.

PDPM FAQ – This document has had several clarifications. CMS has also been very helpful in delineating these clarifications in red so they could be easily spotted. Here is a list of the FAQ’s that have been revised;

1.8 – The term primary diagnosis has been changed to Principle diagnosis as it related to the primary reason the resident is being treated in the SNF. CMS continues to indicate that MDS item I0020B and the UB-04 should match.

5.4 – The question as to whether a HIPPS code can be generated if the BIMS has not been completed has been resolved with this clarification, “If neither the BIMS nor the staff assessment is completed, then the patient will not be classified under PDPM and a PDPM HIPPS code will not be produced for this assessment.” In other words, when the BIMS was not completed because the resident had an unexpected discharge, the staff assessment may be completed. This clarification, however, does not apply to situations in which the BIMS could have been completed but was not. The current rules in the RAI manual page C-2 etc. will still apply.

11.5 – CMS has clarified how the items in J2100 – J5000 will be used for payment under PDPM. They indicate, “These items will be used, along with the patient’s primary diagnosis coded in item I0020B, to classify patients into a PDPM clinical category, which is then used as part of the PT, OT, and SLP case-mix classification groups for PDPM.”

12.10 – CMS continues to reiterate the fact that under PDPM, while there is no requirement that a certain amount of therapy days and minutes are required for a rehab payment category to be generated, it is important to remember that a daily skilled service will still be required. To that point they have added a reference to Chapter 8 of the Medicare Benefit Policy Manual, specifically section 30.6. where daily skilled services are defined.

12.12 – In this FASQ entry, CMS has clarified that, under PDPM, there is no change in the way a therapy student’s time can be captured. In this update they have added a reference to a section in the RAI Manual entitled “Modes of Therapy” which may be found in Chapter 3, Section O.

13.4 – Here CMS has made a substantive clarification as to how therapy data should be captured in section O of the discharge assessment when there have been one or more interrupted stays. To clarify this CMS indicates, “SNFs should report the therapies furnished since the beginning of the Part A stay, including all parts of an interrupted stay, in section O of the MDS for each discharge assessment.” The previous FAQ indicated that only therapies that occurred since the readmission would be included.

14.10 – This FAQ has been completely rewritten. The question is, “How long will the OSA be in place?” To which CMS has responded, “There is currently no definitive timeline for retiring the OSA. Once states are able to collect the data necessary to consider a transition to PDPM, CMS will evaluate the continued need for the OSA, in consultation with the states.” This is good news for states who require RUG III or RUG IV HIPPS data for Medicate rate calculations.

14.13 – As CMS winds down the RUG system calculations in light of PDPM, as in 14.10, CMS here reiterates that after the implementation of the PDPM, states that will need to continue to generate RUG scores on more frequently than the 5-day PPS, OBRA Comprehensive and quarterly types of assessments, will need to use the OSA to do so. CMS added the clarification that, “Beginning October 1, 2020, states must use the OSA as the basis for calculating RUG-III and RUG-IV HIPPS codes.”

PDPM Grouper Logic – While CMS did not provide a document that indicates what has been revised with  regard to the grouper logic, it is safe to say they have updated it with regard to the changes and clarification noted above, in particular, the multiple revisions made to the ICD-10 mapping.

CMS has updated their PDPM educational materials at least 3 times and we can expect more. As we look for the documents that will come our way in the coming months, it will be imperative that providers stay up to date on all of the changes and revisions that CMS provides.

At Broad River Rehab, we are up to date. Our PDPM Navigator® has already been updated to reflect the most recent ICD-10 mapping revisions. We provide state of the art tools and education to all our clients to help them stay current with the shifting LTC reimbursement landscape. We would love to talk with you about how Broad River Rehab can be your knowledgeable and compassionate rehab partner as you prepare for PDPM.

Give us a call at (800) 596-7234, we’d love to chat. Do you have a tough PDPM or other reimbursement question? Ask an expert!

PDPM, Staffing & STRIVE

There is a problem on the horizon. Under PDPM, the staffing study used to determine how many nursing hours to expect for a given RUG level will not longer work. That study, called STRIVE, was originally done between 2005 and 2009. The data from that study is used to estimate how many nursing hours (RN, LPN and aide) to expect for a given RUG level.

The staffing portion of the 5 star rating system depends on expected nursing hours, now called case-mix hours, to scale actual nursing hours by patient acuity prior to assigning stars. (See this post for more detail.)

We’ve contacted CMS to ask how this is going to be handled. As of 4/1/2019, the answer was “We haven’t decided.” CMS has a lot on its plate with the changes to the 5 star system rolling out this month and PDPM happening on October 1st.

A Proposal

One approach CMS could take is to simply mirror the idea used in the nursing portion of PDPM. They could simply combine the nursing RUGs and average the nursing times and use those.

Pros

  • It’s easy to understand and implement.

  • It doesn’t required major overhaul of the star rating system.

  • It’s cheap and fast

Cons

  • It isn’t really rigorous. It could be argued that this is a leap of faith.

I will focus on the con for a moment. While this idea isn’t statistically rigorous, I would argue that the original STRIVE study has some results that raise eyebrows anyway. I am humbly suggesting that the STRIVE study isn’t perfect. That isn’t an excuse to make decisions that aren’t supported by data, but we need to be pragmatic here. Another STRIVE study would be hugely expensive and there isn’t time prior to PDPM anyway.

Also, PDPM already combines these nursing categories. I haven’t seen any justification for this other than to reduce the overwhelming number of patient classifications. Since we’ve already made that decision, this feels like the natural way to go.

What would it look like?

I simply took the required minutes for the RUGs that have been combined and averaged them. All other RUGs are left unchanged. (Note: I am using unweighted averages here. I don’t have the data to do weighting. I would strongly suggest weighting these.)

This image shows the expected overall nursing hours by RUG for all of PDPM. I have overlaid the distribution for total nursing hours for every home in the country.

Averaging the nursing hours (click to enlarge)

How would it change my star rating?

That depends on the acuity at your facility, but the answer is probably not much. (Warning: I am now speculating.) If you watch the animation a few times, you’ll see that overall most RUGs get pulled towards the center of the existing distribution. Unless you have extremely high or low acuity, you’re probably likely to get pulled towards the center, slightly. (Remember: higher acuity will either put negative pressure on your staffing star rating or cause you to spend more in staffing for the same rating. Read the last two sections of this posting for an explanation.) More speculation: Your normal variation in acuity is probably greater than the change you’d see from this proposal.

Conclusion

Perfect is the enemy of good. Although this is clearly a compromise, it’s probably good enough. It definitely isn’t conceptually any more difficult than what we’re doing pre April 2019 change, and only requires a comparatively small leap of faith.

There are much bigger issues to work on, even in 5 star. (Transparency around which assessments are included in the 5 star rating would be an example.) Let’s just fix this and move on.

If you want Broad River Rehab to analyze your staffing and help you figure out how to get that next star, contact me. I’d love to hear from you.

PDPM Navigator Lite™ - Free in the App Store!

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We’ve decided to offer a lite version of our PDPM Navigator™ to everyone FOR FREE! PDPM Navigator Lite™ does everything that our website PDPM Calculator does (and more) but it does it all on your phone. You can use it wherever, whenever, however. No internet is required after the install.

How do you get it?

Simple. Click the links below and download it.

 
Get it on Google Play
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PDPM Navigator™ - Lite versus Pro

Feature Lite Pro
All Default Clinical Categories Yes Yes
All 50 Non-Therapy Ancillaries Yes Yes
Section GG Yes Yes
Speech Comorbidities Yes Yes
Nursing Categories with Requirements Yes Yes
HIPPS Codes Yes Yes
Length of Stay Yes Yes
Wage Indexing (Urban & Rural) Yes Yes
Detailed Summary Yes Yes
Complete ICD-10 Mapping to Default Clinical with FULL Search NO Yes
ICD-10 Mapping to I8000 Speech Comorbidities NO Yes
ICD-10 Mapping to I8000 Non-Therapy Ancillaries NO Yes
Email Reports NO Yes
RAI Manual Explanations & and Reference Pages NO Yes
Increased Compliance at Your Fingertips! NO Yes

When you’re ready to go PRO, contact us to find out how!

PDPM Calculator - Thank You!

Since we launched the PDPM Calculator in May of 2018, we’ve received an incredible amount of positive feedback. We’re truly flattered by the response. What started as a tool to help us understand PDPM has turned into something the entire community is using to get ready for this change.

We’d like to say a HUGE THANK YOU to everyone for their kind words, encouragement and suggestions for improvement!

  • The calculator is currently in use in the 48 contiguous states. (Where are you Alaska and Hawaii? Especially you Hawaii. We see you reading the blog!) I think I’ve spoken to people in nearly every state about it. Keep it coming!

  • A lot of our competitors use our calculator and at least one uses it to train their staff! Let us know if you’d like on-site training!

  • We even have users who may or may not work for CMS. (Don’t worry, we won’t tell.)

  • There are consultants from coast to coast using our calculators to train their customers! We’ve also trained a few of them. (If you are a consultant and we haven’t spoken, please contact me. I’d love to learn more about your business!)

  • The PDPM Calculator is the most popular PDPM tool that isn’t published by CMS according to Big G.

All of this is very humbling. That’s why we’re really excited to be releasing PDPM Navigator! Read more about it. Navigator is basically like the calculator, but with ICD-10 codes, RAI rules and you can use it anywhere on your phone or tablet.

We are looking for industry experts and influencers to try out Navigator and tell us what they think. (Corporate MDS, consultants, journalists, etc)

If you would like to help us shape the future of Navigator sign up right now! (Put ‘Navigator’ in the Subject line.)

PDPM Navigator™

You might have noticed that we’ve been pretty quiet on the blog recently. The reason is that we’ve been very busy building a tool for the future.

Our PDPM Calculator is incredibly popular but it doesn’t work well on a phone. We decided we needed a mobile version. THEN we decided to make it better, WAY better.

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We’re proud to be launching

PDPM Navigator™!

PDPM Navigator ™ does so everything the calculator does AND:

  • It works on your phone, obviously. But not only that, it works even when you don’t have internet access! Want to study PDPM while you’re on a long flight? PDPM Navigator™ can do it.

  • ICD Coding and PDPM Mapping! ICD-10 coding drives everything in PDPM. Imagine having all those codes in the palm of your hand. You can search them and see which PDPM categories they map to, color coded for ease of use!

  • NTA ICD-10 mapping is included! 27 of the NTAs are driven by ICD-10 coding. (Did I mention ICD-10 coding is important?) With one click you can see all the ICD-10s that are valid for each of the 27 non-therapy ancillaries that are ICD-10 driven.

  • Email Reports! With two taps you can email yourself a report that summarizes your PDPM Navigator™ session. You can even email a report to a client or co-worker.

  • Nursing “RUG” Requirements are included. Need to know which conditions and GG functional scores are required to be a CDE2?

    PDPM Navigator™ has it in one touch.

We designed PDPM Navigator™ to be an easy resource to help people who work on the front lines of delivering care. PDPM Navigator ™ will make it easy to get the data you need quickly and efficiently so you can spend more time working with your team to deliver great care and less time digging through manuals and searching Google for codes.