slp and nta strategies & opportunities...he 4 slp case mix components 2. strategies for...

Therapy services and intellectual property provided by Functional Pathways. ©2020 All rights reserved. This information and materials was created by and is proprietary to Functional Pathways of Tennessee, LLC. Any unauthorized use, dissemination, distribution, or copying of this information and material, in

whole or in part, is strictly prohibited

PDPMSLP and NTA Strategies & Opportunities

Presented by:Colleen Oakley OTR/L NHA RAC–CT

Clinical Reimbursement SpecialistKaren Welsh CCC-SLP RAC-CT

Director of Clinical Outcomes

ObjectivesParticipants will learn about:

1. The 4 SLP Case Mix components

2. Strategies for capturing and coding the SLP components

3. How to administer and score the BIMS

4. Strategies for accurately capturing cognitive function

5. What NTAs are and what active diagnosis means

6. Strategies for coding NTAs and impacting Case Mix

7. Best practices for optimizing reimbursement and clinical outcomes

Therapy services and intellectual property provided by Functional Pathways. ©2020 All rights reserved. This information and materials was created by and is proprietary to Functional Pathways of Tennessee, LLC. Any unauthorized use, dissemination, distribution, or copying of this information and material, in whole or in part, is strictly prohibited 2

SLP Case Mix

Therapy services and intellectual property provided by Functional Pathways. ©2020 All rights reserved. This information and materials was created by and is proprietary to Functional Pathways of Tennessee, LLC. Any unauthorized use, dissemination, distribution, or copying of this information and material, in whole or in part, is strictly prohibited

The SLP component is one of the 6 buckets that make up the PDPM daily rate

The SLP Case Mix is determined by 4 components1. Clinical Category (Acute Neurologic or Non-Neurologic)2. Speech Comorbidities3. Cognitive Impairment4. Swallowing Disorder and/or Mechanically Altered Diet

3

SLP Case Mix


1. Clinical CategoryAll the valid (not Return to Provider) ICD-10 diagnosis codes map to one of 2 clinical categories

• Acute Neurologic or Non-Neurologic

4

SLP Case Mix


2. SLP Comorbidities• There are 12 conditions that qualify as speech comorbidities. Each of the I8000 diagnoses have

a limited number of ICD-10 codes that map to it.

5

SLP Components – Diagnosis Considerations


SLP Comorbidities

• These are generally related to a neurologic condition or oral/laryngeal cancer that can be acute or late/residual effects

• Consider the definition of “Active Dx”

• Sometimes a diagnosis exists but it does not trigger as a speech comorbidity• Example: Dysphagia - A resident may have a swallowing disorder following surgery for a knee

replacement and be receiving treatment for dysphagia (R13.12 for example). This may trigger for a swallowing problem in Section K, but unless it is one of the following ICD-10 codes, it will not trigger as a speech comorbidity.

6

SpeechComorbidities

7

SLP Component – BIMS


3. Cognitive Impairment

• The presence of a cognitive impairment is determined using the BIMS (the Brief Interview for Mental Status) or the CPS (Cognitive Performance Scale) also known as the staff assessment

• The BIMS is a very basic tool that assesses memory, recall, following directions, orientation and attention.• It is a standardized test that must be administered in a very prescribed

manner.• The assessment has very specific instructions for scoring which must

be followed to accurately capture the resident’s cognitive status. • An attempt must be made to administer the test to ALL residents.• If a resident cannot or does not answer at least 4 of the questions, then

the assessor can proceed to the staff interview.

8

SLP Component – Administering the BIMS• The BIMS must be administered exactly as instructed in the RAI to be a valid, accurate capture of the

patient’s performance.• It is not intended to be punitive, but rather a measure of the need for additional resources/strategies

a patient may require to function safely and as independently as possible.Administering the BIMS• Give an introduction before starting the interview.

• Suggested language: “I would like to ask you some questions. We ask everyone these same questions. This will help us provide you with better care. Some of the questions may seem very easy, while others may be more difficult.”

• If the resident expresses concern that you are testing his or her memory, he or she may be more comfortable if you reply: “We ask these questions of everyone so we can make sure that our care will meet your needs.”

• Directly ask the resident each item in C0200 through C0400 at one sitting and in the order provided. • If the resident chooses not to answer a particular item, accept his or her refusal and move on to the

next questions. For C0200 through C0400, code refusals as incorrect.


SLP Component – Administering the BIMS


1.Say to the resident: “I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed.” Interviewers need to use the words and related category cues as indicated. If the interview is being conducted with an interpreter present, the interpreter should use the equivalent words and similar, relevant prompts for category cues.

2. Immediately after presenting the three words, say to the resident: “Now please tell me the three words.” 3. After the resident’s first attempt to repeat the items:

• If the resident correctly stated all three words, say, “That’s right, the words are sock, something to wear; blue, a color; and bed, a piece of furniture” [category cues]. • Category cues serve as a hint that helps prompt residents’ recall ability. Putting words in context stimulates learning and fosters memory of the words that residents will be asked to recall in item C0400, even among residents able to repeat the words immediately. • If the resident recalled two or fewer words, say to the resident: “Let me say the three words again. They are sock, something to wear; blue, a color; and bed, a piece of furniture. Now tell me the three words.” If the resident still does not recall all three words correctly, you may repeat the words and category cues one more time. (Reminder: Items are scored based on first attempt)

10



1. Ask the resident each of the 3 questions in Item C0300 separately.2. Allow the resident up to 30 seconds for each answer and do not provide clues.3. If the resident specifically asks for clues (e.g., “is it bingo day?”) respond by saying, “I need to know if you can answer this question without any help from me.”

11



1. Ask the resident the following: “Let’s go back to an earlier question. What were those three words that I asked you to repeat?” 2. Allow up to 5 seconds for spontaneous recall of each word. 3. For any word that is not correctly recalled after 5 seconds, provide a category cue (refer to “Steps for Assessment,” pages C-6–C-7 for the definition of category cue). Category cues should be used only after the resident is unable to recall one or more of the three words. 4. Allow up to 5 seconds after category cueing for each missed word to be recalled. • If on the first try (without cueing), the resident names multiple items in a category, one of which is correct, they should be coded as

correct for that item.

• If, however, the interviewer gives the resident the cue and the resident then names multiple items in that category, the item is coded as could not recall, even if the correct item was in the list.

12

SLP Component – BIMS Scoring


Cognitive Impairment

• A score of 12 or less on the BIMS indicates the presence of a cognitive impairment.

13

Strategies to Accurately Capture Cognitive Function


• Why • When administering the BIMS, it is important to understand why we are doing it.• The point is not to catch the patient at their best• We want to understand the patient’s functional level so we can

• Correctly allocate resources• Ensure that we address areas that could impact he residents’ quality of

life• Ensure that we care plan risk areas and put strategies in place to help

the resident be successful

• When• It is very important when we administer that assessment• The RAI manual recommends (NOT requires) that the BIMS be administered as

close to the ARD as possible.• If the resident is confused and disoriented when they first admit, this may be a

good time to administer the BIMS as it will reflect the resident’s level of function and if additional resources are required to adequately care for the resident.

14

Strategies for Accurately Capturing Cognitive Function


• Who• The BIMs should be administered by someone who:

• Has been properly trained on the administration and scoring• Understands how to administer standardized tests• Is comfortable with resident interview and assessment

• How• The BIMS should be administered using the resident’s preferred language and mode of communication• If an interpreter is needed/requested, then one should be provided• Ensure that the environment is free of distractions• Make sure to face the resident so they can see your face • Make sure the resident has their glasses or hearing aides if applicable• Speak clearly and read the questions exactly as they are stated on the assessment – do not lead the patient

• What • What does the score mean? A score of 12 or lower indicates cognitive impairment for purposes of the SLP

component

15

SLP Component - Section K


4a. Swallowing Disorder• There are 4 MDS questions that determine if a resident has a swallowing disorder

• All Direct Care Staff should be educated on these 4 items and should be trained to report and document them

• Utilize a tool for CNAs to record swallowing items with percentage of meal consumed

• A diagnosis of dysphagia is not required in order to code these on the MDS

16



4b. Mechanically Altered Diet

• The RAI manual definition of mechanically altered diet is: “a diet specifically prepared to alter the texture or consistency of the food to facilitate oral intake. Examples include soft solids, pureed foods, ground meat, and liquids. A mechanically altered diet should not automatically be considered a therapeutic diet.”

• A resident can be on an altered diet without having a diagnosis of dysphagia

• Examples of the need to alter diet without a dysphagia dx include:• Edentulous residents or those with other oral issues such as ulcers or candidiasis, may need

food altered to facilitate swallowing and intake• Resident preference as long as it does not relate to a swallowing problem

18

Success Under PDPM• A swallowing disorder or mechanically altered diet can take you from a CMI of 0.68 to 1.82.

Multiply the difference (1.14) by $28.76 (the unadjusted rural rate for ST) = $32.79 per day x 20 days = $655.80


SLP Component - Section K Coding Strategies


• All staff should understand and be familiar with the 4 items that determine a swallowing disorder

• Have the 4 Section K items be part of nursing and CNA documentation daily, especially during the ARD lookback

• Ensure that diet consistency is documented in the medial record (dietician’s notes, food preference assessment, care plans, CNA flow charts)

• Validate that your process for diet orders is consistent and that there is a check system

• Make sure your speech therapists perform screens/evals timely

• If a resident has a swallow disorder but does not have a dysphagia diagnosis, have the speech therapist do a dysphagia medical work-up form and have the physician/NP sign it.

20

Non-Therapy Ancillary Component (NTA)


What are NTAs?

• CMS created a Non-Therapy Ancillary case mix component as they recognized that SNFs often declined to accept patients that were medically complex because the reimbursement did not cover the cost of services and equipment the resident required

• NTAs are a list of 50 ailments or conditions that are assigned points based on the amount of resources required to care for residents with those comorbidities

• For an NTA comorbidity to be coded on the MDS, it must be an active diagnosis, and have an ICD-10 code that maps to the NTAs

• This is an area that is often under coded and is an area of significant opportunity

21

NTA Component – Active Diagnosis


SECTION I: ACTIVE DIAGNOSES

Intent: The items in this section are intended to code diseases that have a direct relationship to the resident’s current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident’s current health status.

Identify diagnoses: The disease conditions in this section require a physician-documented diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 60 days. Medical record sources for physician diagnoses include progress notes, the most recent history and physical, transfer documents, discharge summaries, diagnosis/ problem list, and other resources as available. If a diagnosis/problem list is used, only diagnoses confirmed by the physician should be entered.

22

NTA Component – Active Diagnosis


NTA Component


• It is important to be familiar with the list of NTA comorbidities and where they are coded on the MDS

24

NTA Component


• Examples of ICD-10 codes that map to the NTA comorbidity.

25

NTA Coding Strategies


For optimal NTA component coding, ensure you:

• Get all medical records from the hospital includingMARs, TARs, operation and procedure reports, labs, consultation reports, discharge summaries, etc.

• Make sure all medications and treatments have a diagnosis associated with them• It is important that the nurse consults with the physician to determine and confirm the

correct use of the medication for a resident for accurate recording of the medical conditions and the capturing of active diagnoses on the MDS.

• Get records from the primary care physician as some diagnosis have a look back period that is longer than 7 days (example – UTI and depression)

• Are using an intake tool to reconcile medical history/diagnoses and medications with the resident and/or family

• Thoroughly document assessments, observations, and monitoring of conditions as this constitutes “active”

26

NTA Coding Strategies


• Scour the medical record. Review all the documents that are available. If you see a description of a condition but no accompanying diagnosis, reach out to your physician and physician extenders

• Understand the definitions of the NTA comorbidities and which diagnoses are included

• Confirm accurate coding with good specificity – Choice of ICD-10 codes matter!!!!

• Be familiar with the NTA list. Have it printed, laminated and readily available… Refer to it often

• Understand which sections of the MDS map to the NTAs

• One point on the NTA scale can make a big financial difference

27

NTA CMI – Financial impact


• Example: The difference between “0” (0.72) and “3” (1.34) = 0.62 x $80.45 (unadjusted urban rate) = $49.88 per day . If you assume a 20 day LOS:

• Include the NTA adjustment (factor of 3 for days 1-3) that is $49.88 x 3 =$149.64 per day x3 days = $448.92 + $847.96 (day 4-20) = $1,296.88

28

NTA Coding Opportunities


Areas of opportunity• Coding Diabetes – does resident have a therapeutic diet, blood sugar checks, sliding scale or oral

medications etc.

• Coding Morbid obesity – remember that this diagnosis is based on Body Mass Index (BMI). The dietician usually calculates this on their admission assessment. Educate him/her to request a diagnosis if BMI is over the threshold, OR

• MDS should review dietician’s notes and ask physician or physician extender for a dx as needed

29


• Coding Opportunistic infections

An opportunistic infection is an infection caused by pathogens (bacteria, viruses, fungi, or protozoa) that take advantage of an opportunity not normally available, such as a host with a weakened immune system, an altered microbiota (such as a disrupted gut microbiota) or breached integumentary barriers. Many of these pathogens do not cause disease in a healthy host however, a compromised immune system, or a lack of competition from normal bacteria presents an opportunity for the pathogen to infect.


30

Candida Albicans Clostridium difficile Coccidioides immitisCryptococcus neoformans Cryptosporidium CytomegalovirusGeomyces destructans Histoplasma capsulatum Isospora belliMicrosporidium Mycobacterium tuberculosis Pseudomonas aeruginosaSalmonella Staphylococcus aureus Streptococcus pneumoniaeStreptococcus pyogenes Toxoplasma gondiiLegionnaires’ Disease (Legionella pneumophila)Mycobacterium avium complex (MAC) (Nontuberculous Mycobacterium)Pneumocystis jirovecil, (previously known as Pneumocystis carinii f. hominis)Polyomavirus JC polyomavirus (virus that causes Progressive Multifocal Leukoencephalopathy)Kaposi’s Sarcoma caused by Human Herpesvirus * (HHV8), (also called Kaposi’s sarcoma-associated herpesvirus (KSHV))

More Opportunistic Infections



• Coding Asthma, COPD, chronic lung diseases.• Many patients have a dx of COPD, if they are receiving any treatments, monitoring, inhalants,

nebulizer etc. they could qualify. (Section I6200)

• Coding Opportunities that are often missed:• Malnutrition – again, this is based on BMI and labs (albumin, failure to thrive, cachectic)• Immune disorders is referenced multiple times - MS, Lupus, Rheumatoid arthritis, etc.)• Wound infection• Foot skin problems• Diabetic foot ulcers• Intravenous medication• Isolation post admit


32

Important Take-Aways


• Make sure the BIMS is being administered and scored correctly

• Teach direct care staff how to assess and report swallowing disorder

• Make sure diet consistency is documented and changes are communicated timely

• Know your NTA list and the diagnoses that map to it

• Get all pertinent medical records and review them with a "fine tooth comb"

• Assess residents thoroughly and ensure that all conditions are recorded in the medical record

• Talk to your physician and/or physician extenders to get additional diagnoses as appropriate

• MDS coordinator to review all assessments and consultations documents (psychologist, dietician, therapy, podiatrist, dentist etc.) to ensure nothing is missed

• Remember to be a CSI … a Clinical Status Investigator

34


If you have questions or would like further resources, contact:

Karen Welsh, CCC-SLP, RAC-CT, Director of Clinical OutcomesPhone: (901) 354-4669 or Email: [email protected]

Colleen Oakley OTR/L NHA RAC-CT, Clinical Reimbursement SpecialistPhone: (865) 333-0298 or Email: [email protected]

slp and nta strategies & opportunities...he 4 slp case mix components 2. strategies for...

Documents