ensuring operational excellence and financial …and accurate reimbursement • identify mds coding...

© HDG 2019© HDG 2018

Ensuring Operational Excellence and Financial SustainabilityLeadingAge New Jersey and New Jersey Hospital AssociationNavigating Your Path to Success Under the SNF PDPMJune 27, 2019

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Polling Question: Choose One

1. My team and I have a PDPM action plan in place and routinely prepare

2. My team and I have audited our processes and are developing an action plan

3. My team and I are gathering information on PDPM but have not started a formal plan

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Session Learning Objectives• Understand PDPM’s part in larger context of refining payment systems

• Review basics of PDPM and opportunities it creates

• Identify essential processes and their relationship to clinical outcomes and accurate reimbursement

• Identify MDS coding changes, assessment types and schedules, Non-Therapy Ancillaries (NTAs), and importance of accurate ICD-10 coding

• Review critical therapy changes and how they will change with functional scoring and group & concurrent therapy

• Gain insight on different therapy organizational structures and contract renegotiation

• Learn risk factors that impact reimbursement

• Identify process to evaluate your PDPM success and areas of improvement

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What Does This Represent?

28,800Number of case-mix groups

in PDPM

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How About This?

51Number of NTAs you can code

in PDPM

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I’m Sure You Know This?

96Number of days to PDPM!!

3 months!

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Cost Savings to SNFs

• CMS touts significant cost savings to providers($195.9 million per year) through fewer assessments

• CMS reduced ICD-10 requirements and therapy reporting on discharge assessment as responsible for increasing cost

• Greater potential savings: therapy − Incentive for counting minutes eliminated

− More ability to use group/concurrent

• CMS did not estimate any savings from “provider behavior” changes

Source: Centers for Medicare and Medicaid Services 2018

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Where Are Your Operations Right Now?

Staff who have basic/working understanding of PDPM through current training:

− Attended 1 or more trainings

− Could identify important milestones of changes between programs

Developed action plan for PDPM− QAPI in place

− Analyzing current MDS items that will be important to coding in PDPM (GG, cognition, etc.)

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How Will We Think Differently with PDPM?

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How Will We Think Differently with PDPM?• Hospital preadmission

documentation crucial− Fully, completely understand patient’s

clinical condition− In-depth clinical interview and

documentation review• Scrupulous attention to ICD-10

coding• Intense recognition of NTAs

− Even 1 point missed can make difference in payment

• MDS interviews are paramount • Heightened clinical abilities• Streamlined programs and services

to drive quality outcomes− Ramp up QAPI

• Interdisciplinary team collaboration, especially with section GG− IDT, IDT, IDT!

• Succinct clinical documentation− Support MDS coding− Support presumption of care− Support skilled needs

• Increased attention to cognition, nutritional status

• Integration of restorative, functional maintenance services, and rehab

• Audit, audit, audit!

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Laser Focus and Review

• Despite reduction in MDS schedule under PDPM, the many areas that contribute to CMG payment require critical attention to detail

• Even one NTA point missed can impact reimbursement

• Poor IDT communication can result in reimbursement decline

• Auditing is essential − Familiarizes IDT with program components

− Review, retool, refocus

− Maintain regulatory compliance

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Resource Utilization Varies over Stay

Resource use for certain services is not constant over a stay but varies depending on the point in the stay• PT and OT costs decline steadily over the course of the stay

• NTA costs, driven largely by drug costs, are concentrated at the beginning of a stay and are much lower thereafter

• Analyses showed that SLP costs remain relatively constant over the stay

• No comparable data on nursing costs to measure changes in resource use throughout the stay

Source: Centers for Medicare and Medicaid Services

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Changes in Roles with PDPM

Preadmission/Admission

• Increase scrutiny of preadmission records• Enhance communications flow to streamline workflow

Clinical Operations

• Maintain clinical capabilities in an increasingly medically complex population

• Concentrate on documentation quality and timeliness, especially weekend admissions and section GG

• Change culture: rally staff to understand their heightened responsibility in reimbursement

• Increase attention to subtle clinical changes that may warrant interim payment assessment (IPA)

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Changes in Roles with PDPM (continued)

MDS

• Acquire knowledge of new MDS item sets, NTAs, comorbidities for accurate coding, and reimbursement

• Complete precise ICD-10 coding/sequencing• Pay close attention to clinical changes that may warrant IPA• Adopt care transitions model• Update triple check process to incorporate PDPM billing changes

Therapy Services

• Develop strategy for concurrent/group therapy • Increase communication with clinical staff, especially section G, GG• Refocus on cognition programs via SLP • Collaborate on restorative and therapy programming

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Changes in Roles with PDPM (continued)

Social Services

• Concentrate on cognition guidelines from RAI and increase attention to any subtle changes

• Develop specific role in discharge planning and care transitions

Business Office/Billing

• Update triple check process to incorporate PDPM billing changes• Pay close attention to payor source identification

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Key Nursing Component Drivers

Special Care HighHDE2/1 HBC2/1

Special Care LowLDE2/1 LBC2/1

Clinically ComplexCDE2/1 CBC2/1 CA2/1

• Comatose and activities of daily living dependent

• Septicemia• Diabetes with daily injections and

insulin order changes for 2 days• Quadriplegia (GG <=11)• Parental/Feedings (can occur

anywhere)• Respiratory therapy for 7 days• Fever with: pneumonia or weight

loss or vomiting or feeding tube• COPD and unable to lie flat

• Cerebral palsy or multiple sclerosis or Parkinson’s (GG<=11)

• Respiratory failure and oxygen• Feeding tube (26% of calories and

501 cc or 51% of calories)• 2+ stage or Stage 3 or 4 pressure

ulcer or 2+ venous ulcers or 1 Stage 2 and 1 venous ulcer (all with 2 or more ulcer treatments)

• Foot infections or diabetic foot ulcer or other open lesion of foot with dressing

• Radiation therapy • Dialysis

• Residents with ES, or Special with GG of 15–16

• Pneumonia• Hemiplegia or hemiparesis and

(GG <=11)• Surgical wounds or open lesion

with treatment• Burns (second or third degree)• Chemotherapy• Oxygen therapy• IV medications• Transfusions

Extensive ServicesES3 Tracheostomy care AND ventilatorES2 Tracheostomy care OR ventilator/respirator treatmentES1 Infection isolation


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CMIs by Nursing GroupsExtensive Services Functional CMI Complex Functional CMI

ES3 0–14 4.04 CE/CD 2 0–5 1.86

ES2 0–14 3.06 CE/CD 1 0–5 1.62

ES1 0–14 2.91 CC/CB 2 6–14 1.54

HE/HD 2 0–5 2.39 CC/CB 1 6–14 1.34

HE/HD1 0–5 1.99 CA2 15–16 1.08

HC/HB 2 6–14 2.23 CA1 15–16 0.94

HC/HB 1 6–14 1.85 Behavior & Physical Function 1.47–0 (CA1)

LE/LD 2 0–5 2.07 • Extensive, High, Low must have functional score of 0–14 or will fall into CA grouper

• End Split of 2 for High, Low & Complex are signs of depression (patient health questionnaire [PHQ] 9 of 10 or higher)

LE/LC 1 0–5 1.72LC/LB 2 6–14 1.71LC/LB 1 6–14 1.43


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Preadmission Process

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Preadmission/Admission Process:Operations

• Use of pre-screening/screening form is payment based

• Knowledge base of admissions personnel kept current

• Process in place to maintain control of the referral− Visit/frequency

− Referral is prepared for the care transitions process

• Payor sources verified prior to admission and before billing

• Admissions documents completed prior to or at admission− MSP/Consent to treat are completed

• Audits completed on admission information

• Time frame determined for acceptance or denial

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Preadmission Process Utilization Review: Are You Ready?

Able to describes difference between preadmission process and utilization review

Understand documentation needed for preadmission review

Demonstrate understanding of relationship between primary diagnosis and clinical comorbidities and how each relate

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Interdisciplinary Team Focus

I Drive Teamwork

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The Successful Interdisciplinary Team

• Identifies a leader

• Knows their role

• Develops a plan

• Gets prepared

• Executes successfully

Photo by Matteo Vistocco on Unsplash

https://unsplash.com/photos/Dph00R2SwFo?utm_source=unsplash&utm_medium=referral&utm_content=creditCopyText

https://unsplash.com/search/photos/teamwork?utm_source=unsplash&utm_medium=referral&utm_content=creditCopyText

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IDT Collaboration: Are You Ready?

Identified leader and attendees

Developed meeting outlines and agenda

Streamlined communication; and recognize subtle clinical changes

Modified reports or tracking forms to capture new PDPM information that may reflect need to conduct IPA

Demonstrate PDPM behavior NOW in preparation for October 1

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Utilization Review

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UR Review and Effective 72-Hour Huddle Meeting

• UR data used to assist in completion of MDS through IDT discussion

• Clinical findings imperative to monitor outcomes in clinical recovery process

• Clinical findings used at Medicare meeting to set goals and monitor progress

• Triple check meeting also benefits from UR information

Most important, UR gives baseline on which to develop rapport and to plan goals and timelines with patients & caregivers

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Utilization Review: Are You Ready?

Able to describe difference between preadmission process and utilization review

Understand documentation needed for preadmission review

Demonstrate understanding of relationship between primary diagnosis and clinical comorbidities and how each relate

Able to describe how our IDT will audit MDSs for accuracy and completeness

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Let’s Talk NTAs

How Many Are There?

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Adjustment Factors for NTA Component

• NTA costs are significantly higher in first 3 days of stay; correspondingly there is 3x adjustment factor to the rate

• Drops back to original rate on day 4 throughout remainder of stay

Day in Stay NTA Adjustment Factor

Days 1–3 3.00Days 4–100 1.00


Flat Period Average NTA Per DiemCosts

Days 1–3 $150Days 4–100 $45

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Payment Differences Between NTA Thresholds

You can see huge variances if NTAs are not coded accurately

NTA Threshold Threshold CMI Difference $ Loss

11 0.72 $56.628 0.69 $54.265 0.51 $40.102 0.24 $18.87

$80.240.98

NTA Federal Urban Rate2% sequestration takeback

NTA Score Range NTA Case-Mix Index12+ 3.259–11 2.536–8 1.853–5 1.341–2 0.96

0 0.72

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Frequency and NTA Costs per Day for Six-Group Model

Another way to look at NTA costs


Comorbidity Score No. of Stays* Percent of Stays Avg. NTA Costs

per Day0 382,288 24.0% $34

1–2 490,529 30.8% $463–5 490,787 30.8% $646–8 152,980 9.6% $909–11 55,185 3.5% $12312+ 20,990 1.3% $157

*Includes stays from FY 2017 with 8 or more utilization days

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Costliest NTA Conditions and Services


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Let’s Talk PT/OT

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Average PT/OT Components by Functional Score

Remember!The higher the functional score,

the greater the functional INDEPENDENCESource: Centers for Medicare and Medicaid Services, 2018

PDPM TherapyFunction Score

Avg. PT/OT PDPM Rate Across All Clinical Categories

0–6 $1386–9 $168

10–23 $17724 $127

Wage neutral, approximately FY 2020 dollars

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Vast New Horizon of Speech Therapy

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Speech Therapy

CMS identified 2 swallowing-related MDS items that had a notable impact on SLP costs per day and model:

• Swallowing disorder

• Mechanically altered diet

Source: Centers for Medicare and Medicaid Services, 2018

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SLP-Related Comorbidities• 12 SLP comorbidities identified are predictive of higher SLP

costs:


• Conditions and services combined into single SLP-related comorbidity flag

• Patient qualifies if any of the conditions/services is present

• Mapping between ICD-10 codes and SLP comorbidities available at CMS.gov/PDPM

1. ALS 7. Laryngeal Cancer2. Aphasia 8. Oral Cancers3. Apraxia 9. Speech & Language Deficits4. CVA,TIA, or Stroke 10. Tracheostomy (while resident)5. Dysphagia 11. Traumatic Brain Injury6. Hemiplegia or Hemiparesis 12. Ventilator (while resident)

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Average SLP Costs per Day by Swallowing Disorder


Swallowing Disorder No. Stays % Stays Avg. SLP

Costs per DayNo 1,802,123 94.9% $17Yes 84,129 4.4% $39Missing 12,834 0.7% $16

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SLP Costs per Day by PDPM Cognitive Level


PCPM Cognitive Level No. Stays % Stays Avg. SLP Costs per Day

Cognitively Intact 1,078,460 56.8% $12Mildly Impaired 380,382 20.0% $23Moderately Impaired 309,039 16.3% $29Severely Impaired 72,975 3.8% $29Missing 58,230 3.1% $23

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Average SLP Costs per Day by Mechanically Altered Diet


Mechanically Altered Diet No. Stays % Stays Avg. SLP

Costs per DayNo 1,450,938 76.4% $13Yes 442,822 23.3% $33Missing 5,326 0.3% $16

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What’s It Gonna Cost Ya?

• BIMS not done – get zero points− What’s a BIMS?

− Cognitive functional scale – by staff if BIMS can’t be done

• Threshold GG – IDT collaboration and timing− Accurate coding

− Weekend admissions and timing

− Compare to ADLs

− Reverse coding methodology with G and GG

• Not coding all comorbidities/NTAs

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What’s It Gonna Cost Ya? (continued)

• Missed ARD ‒ default

• Non-supportive/missing daily nursing documentation

• Interim Payment Assessments (IPAs)

• Amount of group therapy; less than 25%

• Minutes of therapy provided

• Average length of stay

• Ancillaries tracked: − OTC, generic, return meds, etc.

− Beds, oxygen, wound care, etc.

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Considerations for Making the Medical Complexity PivotDiversifying Clinical Service Lines & Addressing Pain Points of Referring Hospitals

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Clinical Capabilities PivotNew Competition for Medically Complex Patients

• We are all aware of proliferation of short-term rehab units• Historically cater to lower acuity patients and shorter length

of stay (LOS)• Hospitals now transitioning patients more frequently to

home-based post-acute settings versus SNF stays:− Home health

− Hospice

− Personal care

− Outpatient

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Managing Increasing Acuity—SNF Clinical Operations

• Physician support− Is it working now?− Are they in support of

higher-touch patients?− Confidence in current

practices?

• Efficiency and standardization of care− Orders− Care transition from

hospital− Pathways, matrices,

algorithms− Others

• Outcomes− Regulatory results− Quality measures (QMs)− Readmissions− Length of stay (LOS)

• Care transitions

• Clinical capabilities: communication tool and tracking document− New− Maintenance

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Managing Increasing Acuity—SNF Clinical Operations (continued)

• Staffing− Support and buy-in

• Admission and denial criteria

• Auditing

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What Are Benefits of Managing Higher Complexity Patients?

• Increased value to upstream health systems

• Clinical capabilities and confidence should grow

• Efficiencies will develop through standardized practices

• Outcomes can improve

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Managing Increasing Acuity—Referral Sources

• Gain support from referral sources

• Identify their needs

• Reinforce with data

• Develop a partnership

• Own outcomes

Don’t anticipate what your customers

want

Know what they need

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Understand Hospital Executives’ Pain Points

Manage LOS

Health literacy

Open beds

Changing reimbursement

Highly complex patients

Financial dis-incentives

Minimize readmissions

Quality outcomes

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Placement Options

• Expansion of subacute capabilities

• Cost benefit measures – high ancillary utilization

• Partnerships in population health and CMS innovations, e.g., ACO, BPCI-A, CMS demonstration projects

Care Transitions/ Discharge Planning

• Early identification of post-acute needs especially with highly complex patients

• Integration of care pathways which may initiate in hospital and flow through post-acute services

Quality Outcomes

• Predictable LOS• Positive patient

experience• Readmissions• Timely and effective

care• Efficient transitions

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Talking Health System C-suite: Strategic Priorities

Hospitals all want the same thing:collaborative relationship with the SNF

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For More Information

[email protected]@HDGConsulting

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Katherine Davis, MS, CCM, CDMS, RCP, CRCManager, Consulting Services

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Disclosure

The information provided here is of a general nature and is not intended to address the specific circumstances of any individual or entity. In specific circumstances, the services of a professional should be sought.

HDG refers to Health Dimensions Group, an independently owned, for-profit entity.

© 2019 Health Dimensions Group

ensuring operational excellence and financial …and accurate reimbursement • identify mds coding...

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