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SNF PPS: Patient Driven Payment Model

Acronyms in this Presentation AIDS: Acquired Immune Deficiency SyndromeARD: Assessment Reference DateBIMS: Brief Interview for Mental StatusCMI: Case-mix IndexCMS: Centers for Medicare and Medicaid ServicesCOT: Change of TherapyCFS: Cognitive Function ScaleCPS: Cognitive Performance ScaleHIPPS: Health Insurance Prospective Payment SystemHIV: Human Immunodeficiency VirusICD-10-CM: International Classification of Diseases, Tenth Revision, Clinical ModificationIPA: Interim Payment AssessmentMDS 3.0: Minimum Data Set, Version 3NF: Nursing FacilityNTA: Non-Therapy Ancillary2

Acronyms in this Presentation OBRA: Omnibus Budget Reconciliation Act of 1987OMRA: Other Medicare-Required AssessmentOSA: Optional State AssessmentOT: Occupational TherapyPDPM: Patient Driven Payment ModelPPS: Prospective Payment SystemPT: Physical TherapyRUG-IV: Resource Utilization Group, Version IVSLP: Speech Language PathologySNF: Skilled Nursing FacilityUPL: Upper Payment LimitVPD: Variable Per Diem3

Agenda PDPM OverviewPatient Classification Under PDPMPatient Classification ExampleMDS Related ChangesConcurrent & Group Therapy LimitInterrupted Stay PolicyAdministrative PresumptionPayment for Patients with AIDSRevised HIPPS CodingRUG-IV – PDPM TransitionMedicaid Related IssuesResources4

PDPM Overview5

Project Overview Issues with the current case-mix model, the Resource Utilization Groups, Version IV (RUG-IV)have been identified by CMS, the Office of Inspector General, the Medicare Payment AdvisoryCommission, the media, and others: Therapy payments under the Skilled Nursing Facility (SNF) Prospective Payment System (PPS) are basedprimarily on the amount of therapy provided to a patient, regardless of the patient’s unique characteristics,needs, or goals The Patient Driven Payment Model (PDPM), effective October 1, 2019, will improve paymentsmade under the SNF PPS in the following ways: Improves payment accuracy and appropriateness by focusing on the patient, rather than the volume ofservices provided Significantly reduces administrative burden on providers Improves SNF payments to currently underserved beneficiaries without increasing total Medicarepayments6

RUG-IV Components RUG-IV consists of two case-mix adjusted components: Therapy: Based on volume of services provided Nursing: The nursing Case-Mix Index (CMI) does not currently reflect specific variations in non-therapyancillary (NTA) utilization7

PDPM Components PDPM consists of five case-mix adjusted components, all based on data-driven, stakeholder-vettedpatient characteristics: Physical Therapy (PT) Occupational Therapy (OT) Speech Language Pathology (SLP) Nursing NTA PDPM also includes a “Variable Per Diem (VPD) adjustment” that adjusts the per diem rate over thecourse of the stay8

PDPM Snapshot9

RUG-IV vs. PDPM While RUG-IV (left) reduces everything about a patient to a single, typically volume-driven, case-mixgroup, PDPM (right) focuses on the unique, individualized needs, characteristics, and goals of eachpatient:10

Effect of PDPM By addressing each individual patient’s unique needs independently, PDPM improves paymentaccuracy and encourages a more patient-driven care model:11

Patient Classification Under PDPM12

PDPM Patient Classification Under PDPM, each patient is classified into a group for each of the five case-mix adjustedcomponents: PT, OT, SLP, Nursing and NTA Each component utilizes different criteria as the basis for patient classification: PT: Clinical Category, Functional Score OT: Clinical Category, Functional Score SLP: Presence of Acute Neurologic Condition, SLP-related Comorbidity or Cognitive Impairment,Mechanically-altered Diet, Swallowing Disorder Nursing: Same characteristics as under RUG-IV NTA: NTA Comorbidity Score13

PT & OT Components: RUG-IV & PDPM Under RUG-IV, the number of PT, OT, and SLP therapy treatment minutes are combined for a totalnumber of treatment minutes that is used to classify a given patient into a given therapy RUG Under PDPM, patient characteristics will be used to predict the therapy costs associated with a givenpatient, rather than rely on service use For the PT & OT components, two classifications are used: Clinical Category Functional Status14

PDPM Clinical Categories SNF patients are first classified into a clinical category based on the primary diagnosis for the SNFstay International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes,coded on the Minimum Data Set (MDS) in Item I0020B, are mapped to a PDPM clinical category: Clinical classification may be adjusted by a surgical procedure that occurred during the prior inpatient stay,as coded in Section J ICD-10 mapping available on the PDPM webpagePDPM Clinical CategoriesMajor Joint Replacement or Spinal SurgeryCancerNon-Surgical Orthopedic/MusculoskeletalPulmonaryOrthopedic - Surgical Extremities not Major JointCardiovascular and CoagulationsAcute InfectionsAcute NeurologicMedical ManagementNon-Orthopedic Surgery15

PT & OT Clinical Categories Based on data showing similar costs among certain clinical categories, the PT & OT components usefour collapsed clinical categories for patient classification:PDPM Clinical CategoriesPT & OT Clinical CategoriesMajor Joint Replacement or Spinal SurgeryMajor Joint Replacement or Spinal SurgeryAcute NeurologicNon-Orthopedic SurgeryNon-Surgical Orthopedic/MusculoskeletalOrthopedic - Surgical Extremities Not Major JointNon-Orthopedic Surgery & Acute NeurologicOther OrthopedicMedical ManagementCancerPulmonaryMedical ManagementCardiovascular & CoagulationsAcute Infections16

PT & OT Functional Score PDPM advances CMS’ goal of using standardized assessment items across payment settings byusing items in Section GG of the MDS as the basis for patient functional assessments The functional score for the PT & OT components is calculated as the sum of the scores on tenSection GG items: Two bed mobility items Three transfer items One eating item One toileting item One oral hygiene item Two walking items17

PT & OT Functional Score: GG Items Section GG items included in the PT & OT Functional Score:Section GG ItemFunctional ScoreRangeGG0130A1 – Self-care: Eating0–4GG0130B1 – Self-care: Oral Hygiene0–4GG0130C1 – Self-care: Toileting Hygiene0–4GG0170B1 – Mobility: Sit to LyingGG0170C1 – Mobility: Lying to Sitting on side of bed0–4(average of 2 items)GG0170D1 – Mobility: Sit to StandGG0170E1 – Mobility: Chair/bed-to-chair transfer0–4(average of 3 items)GG0170F1 – Mobility: Toilet TransferGG0170J1 – Mobility: Walk 50 feet with 2 turnsGG0170K1 – Mobility: Walk 150 feet0–4(average of 2 items)18

Nursing Functional Score: GG Items Section GG items included in the Nursing Functional Score:Section GG ItemFunctional ScoreRangeGG0130A1 – Self-care: Eating0–4GG0130C1 – Self-care: Toileting Hygiene0–4GG0170B1 – Mobility: Sit to LyingGG0170C1 – Mobility: Lying to Sitting on side of bed0–4(average of 2 items)GG0170D1 – Mobility: Sit to StandGG0170E1 – Mobility: Chair/bed-to-chair transfer0–4(average of 3 items)GG0170F1 – Mobility: Toilet Transfer19

Functional Score: Item Response Crosswalk (1) PT & OT and Nursing Functional Score Construction (Non-walking Items)Item ResponseScore05, 06 – Set-up Assistance, Independent404 – Supervision or touching assistance303 – Partial/Moderate assistance202 – Substantial/Maximal assistance101, 07, 09, 10, 88, missing – Dependent, Refused, Not applicable, Not attempted due toenvironmental limitations, Not Attempted due to medical condition or safety concerns020

Functional Score: Item Response Crosswalk (2) PT & OT Functional Score Construction (Walking Items)Item ResponseScore05, 06 – Set-up Assistance, Independent404 – Supervision or touching assistance303 – Partial/Moderate assistance202 – Substantial/Maximal assistance101, 07, 09, 10, 88, missing – Dependent, Refused, Not applicable, Not attempted due toenvironmental limitations, Not Attempted due to medical condition or safety concerns,Resident Cannot Walk (Coded based on response to GG0170I1)021

RUG-IV & PDPM Functional Score Differences Notable differences between G and GG scoring methodologies: Reverse scoring methodology: Under Section G, increasing score means increasing dependence Under Section GG, increasing score means increasing independence Non-linear relationship to payment: Under RUG-IV, increasing dependence, within a given RUG category, translates to higher payment Under PDPM, there is not a direct relationship between increasing dependence and increasingpayment Example: For the PT & OT component, payment for three clinical categories is lower for the mostand least dependent patients (who are less likely to require high therapy amounts of therapy),compared to those in between (who are more likely to require high amounts of therapy)22

PT & OT Components: Payment GroupsClinical CategoryMajor Joint Replacement or Spinal SurgeryMajor Joint Replacement or Spinal SurgeryMajor Joint Replacement or Spinal SurgeryMajor Joint Replacement or Spinal SurgeryOther OrthopedicOther OrthopedicOther OrthopedicOther OrthopedicMedical ManagementMedical ManagementMedical ManagementMedical ManagementNon-Orthopedic Surgery and Acute NeurologicNon-Orthopedic Surgery and Acute NeurologicNon-Orthopedic Surgery and Acute NeurologicNon-Orthopedic Surgery and Acute NeurologicPT & OTFunction 10-2324PT & OTCase Mix GroupTATBTCTDTETFTGTHTITJTKTLTMTNTOTPPT CMIOT .171.441.541.111.301.491.551.0923

SLP Component For the SLP component, PDPM uses a number of different patient characteristics that werepredictive of increased SLP costs: Acute Neurologic clinical classification Certain SLP-related comorbidities Presence of cognitive impairment Use of a mechanically-altered diet Presence of swallowing disorder24

SLP-Related Comorbidities Twelve SLP comorbidities were identified as predictive of higher SLP costs: Conditions and services combined into a single SLP-related comorbidity flag Patient qualifies if any of the conditions/services is present A mapping between ICD-10 codes and the SLP comorbidities is available on the PDPM webpageSLP ComorbiditiesAphasiaLaryngeal CancerCVA,TIA, or StrokeApraxiaHemiplegia or HemiparesisDysphagiaTraumatic Brain InjuryALSTracheostomy (while Resident)Oral CancersVentilator (while Resident)Speech & Language Deficits25

PDPM Cognitive Scoring Under RUG-IV, a patient’s cognitive status is assessed using the Brief Interview for Mental Status(BIMS): In cases where the BIMS cannot be completed, providers are required to perform a staff assessment formental status The Cognitive Performance Scale (CPS) is then used to score the patient’s cognitive status based on theresults of the staff assessment Under PDPM, a patient’s cognitive status is assessed in exactly the same way as under RUG-IV(i.e., via the BIMS or staff assessment): Scoring the patient’s cognitive status, for purposes of classification, is based on the Cognitive FunctionScale (CFS), which is able to provide consistent scoring across the BIMS and staff assessment26

PDPM Cognitive Score: Methodology PDPM Cognitive Measure Classification Methodology:Cognitive LevelBIMS ScoreCPS ScoreCognitively Intact13 – 150Mildly Impaired8 – 121–2Moderately Impaired0–73–4-5–6Severely Impaired27

SLP Component: Payment GroupsPresence of Acute Neurologic Condition,SLP Related Comorbidity, or CognitiveImpairmentMechanically AlteredDiet or SwallowingDisorderSLP Case MixGroupSLP Case MixIndexNoneNoneNoneAny oneAny oneAny oneAny twoAny twoAny twoAll threeAll threeAll 81.822.661.462.332.972.042.853.512.983.694.1928