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The Patient-Drive Payment Model (PDPM) is here, and AANAC will continue to help you through the transition. Visit this page frequently for new tools, education, and resources for ongoing success under PDPM.
Dysphagia coding plays a key role in the Patient-Driven Payment Model (PDPM) through both section I (Active Diagnoses) and section K (Swallowing/Nutritional Status) of the MDS. Here are the keys to getting it right:
Don’t assume IDT members understand PDPM
Sometimes nurse assessment coordinators (NACs) assume that speech-language pathologists and registered dietitians (RDs) already understand PDPM and the Resident Assessment Instrument (RAI) process when they walk in the door, notes Brenda Richardson, MA, RDN, LD, FAND, a long-term care nutrition expert based in Salem, IN, who is the past chair of the Academy of Nutrition and Dietetics Political Action Committee (ANDPAC) and recipient of the 2019 Academy Lenna Frances Cooper Memorial Lecture Award.
“However, dysphagia’s role in PDPM is complex. Not only do IDT members need to understand each resident’s dysphagia diagnosis, they also need to understand how that diagnosis maps—or doesn’t map—to the ICD-10-CM codes that impact PDPM, as well as how that corresponds to the MDS and the coding instructions for sections I and K,” she points out. “Employers, including contract service employers, often do not prioritize training related to payment models, so taking the time to sit down with speech pathologists and RDs to discuss the rules will only improve your ability to capture dysphagia accurately on the MDS.”
Ten subitems in MDS item O0100 (Special Treatments, Procedures, and Programs) can affect from one to three of the case-mix-adjusted payment components in the Patient-Driven Payment Model (PDPM): speech-language pathology (SLP), nontherapy ancillaries (NTA), and/or nursing. The following chart shows the potential impacts:
Potential PDPM Impact
O0100A2 (Chemotherapy While a Resident)
Nursing Clinically Complex
O0100B2 (Radiation While a Resident)
NTA (1 point), Nursing Special Care Low, Nursing Clinically Complex
O0100C2 (Oxygen Therapy While a Resident)
· Must be in combination with I6300 (Respiratory Failure) to qualify for Nursing Special Care Low
Nursing Special Care Low, Nursing Clinically Complex
O0100D2 (Suctioning While a Resident)
NTA (1 point)
O0100E2 (Tracheostomy Care While a Resident)
SLP, NTA (1 point), Nursing Extensive Services, Nursing Clinically Complex
O0100F2 (Invasive Mechanical Ventilator (ventilator or respirator) While a Resident)
SLP, NTA (4 points), Nursing Extensive Services, Nursing Clinically Complex
O0100H2 (IV Medications While a Resident)
NTA (5 points), Nursing Clinically Complex
O0100I2 (Transfusions While a Resident)
NTA (2 points), Nursing Clinically Complex
O0100J2 (Dialysis While a Resident)
O0100M2 (Isolation or Quarantine for Active Infectious Disease (does not include standard body/fluid precautions) While a Resident)
NTA (1 point), Nursing Extensive Services, Nursing Clinically Complex
Note: When more than one nursing category is listed, the resident may be classified into the lower category depending on other MDS data, e.g., the resident’s nursing function score.
MDS item I0020B (ICD Code/Resident’s Primary Medical Condition) sets a Medicare Part A resident’s default primary diagnosis clinical category for determining case-mix classification in the physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) payment components of the Patient-Driven Payment Model (PDPM). However, a major surgery in the resident’s immediately preceding inpatient hospital stay that is coded in MDS items J2100 – J5000 can push the resident into a surgical category that takes precedence over the default category, resulting in a higher-paying case-mix group.
Item J2100 (Recent Surgery Requiring Active SNF Care) is the lynchpin to achieving a surgical clinical category, serving as the gateway question that determines whether or not a surgery can be captured in J2300 – J5000 (Recent Surgeries Requiring Active SNF Care). Note: See the PDPM Calculation Worksheet for SNFs in chapter 6 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual for details on how items in J2300 – J5000 impact classification.
PDPM Cognitive Level Still Confuses Some SNFs
The Patient-Driven Payment Model (PDPM) cognitive level plays a key role in determining a Medicare Part A resident’s speech-language pathology (SLP) case-mix component. The Brief Interview for Mental Status (BIMS), coded in MDS items C0200 – C0500, is its primary driver. If the BIMS cannot be completed, the items C0700 (Short-term Memory OK) and C1000 (Cognitive Skills for Daily Decision-Making) from the Staff Assessment for Mental Status combine with items B0100 (Comatose) and B0700 (Makes Self Understood) to determine the PDPM cognitive level. So it’s no surprise that questions about the PDPM cognitive level came fast and furious at the December 12 Skilled Nursing Facility Long-term Care Open Door Forum (ODF).
Here are the primary issues raised by callers:
If neither the BIMS nor the Staff Assessment is completed, what happens with regard to obtaining a PDPM cognitive level?
The Patient-Driven Payment Model (PDPM) under the Skilled Nursing Facility Prospective Payment System (SNF PPS) pushes providers to implement value-driven care, which gives added significance to the Skilled Nursing Facility Quality Reporting Program (SNF QRP) quality measures (QMs), says Maureen McCarthy, BS, RN, RAC-MTA, RAC-MT, DNS-MT, QCP-MT, president/CEO of Celtic Consulting in Torrington, CT.
“The SNF QRP QMs are now the report card for PDPM,” she explains. “The Centers for Medicare & Medicaid Services (CMS) has made it clear that the agency will be watching quality of care throughout PDPM implementation. If your care model changes and your quality goes down, you are likely to be audited. Nurse assessment coordinators (NACs) and any other interdisciplinary team (IDT) members who complete the MDS need to be mindful as to how that MDS data will impact not only payment but also quality, especially as more QMs continue to be added to the program.”
The nurse assessment coordinator (NAC) often handles the entire Medicare program in the facility, from managing the PPS schedule to leading the skilled coverage decision. With PDPM in full swing, a lot seems to have changed, but some things have not.
“The implementation of the Patient-Driven Payment Model (PDPM) changed the payment system used for traditional Part A residents,” says Suzy Harvey, RN-BC, RAC-CT, managing consultant at BKD in Springfield, MO. “It did not change the coverage policies for skilled services.”
Key requirements that remain in place—and that NACs need to know about—include the following:
The October 1 implementation of the Patient-Driven Payment Model (PDPM) under the Skilled Nursing Facility Prospective Payment System (SNF PPS) for traditional fee-for-service Medicare Part A residents brought quick changes to therapy provision among some providers. Led by Modern Healthcare, multiple news publications reported nationwide lay-offs of therapists and therapy assistants, as well as corporate mandates to provide group or concurrent therapy or to provide a set number of therapy minutes per SNF resident—without regard for a therapist’s clinical judgment of each resident’s individual needs.
The situation is so alarming to therapists that the American Physical Therapy Association (APTA), the American Speech-Language-Hearing Association (ASLHA), the National Association for the Support of Long-term Care (NASL), and the American Occupational Therapy Association (AOTA) banded together to issue a Compliance Statement to help therapists navigate the process for reporting compliance concerns. These organizations also are working directly with the Centers for Medicare & Medicaid Services (CMS) to identify troubling trends, as evidenced by the AOTA’s October 17 statement, An Important Message About PDPM From AOTA.
As a screening tool to identify potential weight problems for adults, body mass index (BMI) has always been important to document, but it gained new importance as a reimbursement factor for Medicare Part A residents under the Patient-Driven Payment Model (PDPM). Here’s what nurse assessment coordinators (NACs) need to know about BMI:
Learn the NTA impact for PDPM
“Residents who are morbidly obese may require a higher degree of nursing effort and skilled nursing care. Likewise, residents at the other end of the scale who are at risk for malnutrition also require more skilled nursing care,” says Pam Duchene, PhD, APRN-BC, NEA, FACHE, RAC-MT, DNS-CT, QCP, vice president of education and training for Harmony Healthcare International in Topsfield, MA.