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 Navigator™ Version 0.1.1 Released

On April 4th CMS released updated information about PDPM. On Friday evening we released an updated version of PDPM Navigator™ to include those changes. Pro users will notice that all ICD-10 codes have been updated, including default clinical categories, speech and NTA codes. The latest version of PDPM Navigator is 0.1.1.

A Word About Updates

Depending on the model of your phone, it may or may not update automatically. Be sure to check for updates in your app store to make sure you are on the latest version.

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.

5 Star Staffing Ratings

We’re getting a lot of inquiries about 5 star ratings. It’s understandable because of the changes coming in April. One question we’re getting asked is “What would it take to improve my staffing rating?” or “How can I get another star?”

In this post we’re going to take a look at that, using the new staffing cut points and the latest data from the nursing home compare data. If you are unfamiliar with how those work or the April update, check out this post.

As our example, let’s assume you own a nursing home and your star ratings look like this:

Category Rating
Survey
Quality
Staffing
RN Staffing
Overall

Note: This is an actual facility I have chosen as an illustration. I have no affiliation with this building which I will keep anonymous. The data is real.

As you can see, overall this facility is 3 stars. It received one bonus star due to excellent quality metrics but did not get an extra star from staffing. (4 overall staffing stars would give another bonus star in this case.) So a natural question would be: How many more nurses would it take to generate that bonus star and get this building to 4 overall stars? (We’re ignoring the elephant in the room regarding survey scores.)

The Details

To answer our question we need to know a few things. First off we need to know that stars are assigned based on adjusted hours using the following table:

Cut Points as of April 2019 (click to enlarge)

Next we need to know is where we stand. Our example facility has a adjusted RN hours of 0.574 and overall adjusted nursing hours of 3.467. Looking that up in the table, you can see we have 3 RN stars and 2 total nursing which nets 3 stars for staffing.

Now we need to understand how adjusted hours are calculated.

CodeCogsEqn (1).png

Adjusted hours are simply scaled by the national average hours and the expected hours. (More on both of those later.)

Looking back at the table, there are several ways we can get 4 overall stars. We can keep RN stars at 3 and get overall nursing hours way up. We could run RN hours way up and keep overall nursing hours the same, or even lower. Or we could shoot for 4 RN stars and 4 total nursing stars. That seems like the logical choice: we’ll have more margin when any type of nursing hours fluctuate. (Keep in mind that case-mix hours are moving as well.)

So we now have an objective: raise the adjusted RN hours to ≥ 0.724 AND raise the overall adjusted nursing hours to ≥ 4.038.

Let’s add some additional requirements:

  • Aide, LPN and RN hours should at least meet or exceed the case-mix hours. (These used to be called expected hours so you can see why we’d like to get as close to those as possible.)

  • Minimize the cost. Cost is the reason there aren’t more nurses in facilities anyway so we might as well optimize to get the maximum 5 star rating we can get for our dollar.

For our example facility I am assuming that the hourly costs per nurse type are as follows. Keep in mind that the exact numbers don’t matter much, just the relationship. (Aide hours cost less than LPN hours which cost less than RN hours.)

NurseHourly Rate
Aide$15.00
LPN$22.50
RN$31.25

The Disclosure

To solve this problem I am going to use a technique called linear programming. I’m not going through all the details here because that’s not the point of this post.

The Results

NurseOriginal HoursOptimized HoursFTE ChangeDaily
Aide2.093152.6721+3.9$1,390.33
LPN1.101660.9270-1.2$(629.21)
RN1.25681.5861+2.2$1,647.62
Total$2,408.74

You can see in an attempt to minimize the expense, the optimization reduced the number of LPNs and increased CNAs, because under the star rating system, LPNs and CNAs are the same. (Obviously that’s not true in the facility, just the star ratings.)

Okay, at first glance you’re probably thinking: “$2,408.74 per day?!” The short answer is “yes”. It costs a lot to increase staffing. It’s also the future with PDPM. Check out this article.

Why so much?

One thing I said I would come back to is the “case-mix hours”. Remember this equation?

CodeCogsEqn (1).png

The case-mix hours in the denominator represent the acuity of the patients in your facility. In fact, those hours are useful to compare one facility to any other in the country. You can’t know exactly what RUGs were billed but you can be sure that higher case-mix hours mean more nursing hours are expected. (Acuity, in this case, is based on the STRIVE Study which maps nursing hours to the RUGS IV 66 grouper. It’s actually pretty interesting and a little controversial. Maybe that’s a topic for another time.)

Case-mix hours or “expected” number of total nursing hours per day for all skilled nursing facilities

Case-mix hours or “expected” number of total nursing hours per day for all skilled nursing facilities

This is a histogram of the expected overall nursing hours for every facility in the US. Notice the tight distribution.

One thing I didn’t share earlier about our example facility is the overall case-mix hours are 4.12158. Take a moment to find 4.12 on that histogram. Our example facility is in the 99th percentile for case-mix, or expected hours. (That means our example facility has higher acuity that 99.1% of the facilities in the US.)

If you refer to the equation from earlier, you can see that higher case-mix hours lower your adjusted hours, meaning you need more hours for a given star rating if you have higher average acuity. This is important. Read the part in bold again. Acuity is a moving target and changes each time new star ratings are released, but if your building has a tendency to trend higher, you’ll pay for it in either a lower star rating or higher labor costs.

How much higher? In this case, if our example facility were in the 50th percentile for acuity instead of the 99th, it would become a 5 star staffing facility immediately. In fact they could actually have fewer RNs and LPNs on average (with slightly more CNAs) and still be five stars for staffing. The bottom line is that if this facility were in the 50th percentile, they could potentially save $3,016.93 per day in labor! That’s a $5,425.67 daily difference from our optimized plan to get 4 stars.

Taken further, if this facility were in the 1st percentile instead of the 99th, the potential labor savings would be $5,371.08 per day or $1.96M annually.

While you can’t just change acuity, do keep in mind the effect it is having on your star rating.

Final Thoughts

One more thing I didn’t mention is your adjusted hours are also affected by the national average numbers. That means that if the national averages were to rise for some reason, like say, PDPM, then your adjusted hours would go up without you making any changes. Don’t say CMS never gave you anything.

Contact us today if you would like to analyze your staffing star ratings.

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!