Under the Patient-Driven Payment Model (PDPM) that implements on October 1 for the Skilled Nursing Facility Prospective Payment System (SNF PPS), “there has to be a cognitive score in order to calculate the speech-language pathology (SLP) case-mix component and obtain a HIPPS code for billing,” points out Carol Maher, RN-BC, RAC-MT, CPC, director of education for Hansen, Hunter & Co. PC in Vancouver, WA.
The PDPM cognitive performance level (aka cognitive score) is calculated from MDS section C, “Cognitive Patterns” based on the following:
(1) The Brief Interview for Mental Status (BIMS) score derived from BIMS items C0200 – C0500, or
(2) If the BIMS cannot be completed, the Cognitive Performance Scale (CPS) score derived from pieces of the Staff Assessment for Mental Status (C0700 and C1000), as well as Comatose (B0100) and Makes Self Understood (B0700).
The PDPM cognitive measure classification methodology “translates” the BIMS or CPS score into a common PDPM cognitive performance level, assigning fee-for-service Part A residents into one of four PDPM cognitive levels (cognitively intact, mildly impaired, moderately impaired, or severely impaired). For example, a BIMS score of 0 – 7 or a CPS score of 3 – 4 generates a PDPM cognitive level of moderately impaired. Note: To see the classification methodology for all four cognitive levels, see FAQ 5.1 in the Patient-Driven Payment Model: Frequently Asked Questions (FAQs).
FAQ 5.4 officially ties together the section C coding requirements and PDPM classification:
Q: How is the patient classified under PDPM if neither the BIMS nor the CPS staff assessment is completed to determine cognitive level?
A: In order to receive a PDPM classification, all required items must be completed. Either a BIMS score or CPS score is necessary to classify the patient under the SLP component. 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.
The following steps can help nurse assessment coordinators (NACs) ensure that each resident receives the appropriate PDPM cognitive level:
Take advantage of new RAI Manual instructions—when you can
“Currently, the coding instructions in the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual don’t allow providers to complete the staff assessment—even for unplanned discharges—when the resident is interviewable, but the interview isn’t completed timely as required,” says Maher.
However, effective October 1, the new draft v1.17 of the RAI Manual will give providers a little more wriggle room for Part A residents with the addition of the following coding tip under item C0100, Should BIMS be completed?:
Because a PDPM cognitive level is utilized in the speech language pathology (SLP) payment component of PDPM, assessment of resident cognition with the BIMS or Staff Assessment for Mental Status is a requirement for all PPS assessments. As such, only in the case of PPS assessments, staff may complete the Staff Assessment for Mental Status for an interviewable resident when the resident is unexpectedly discharged from a Part A stay prior to the completion of the BIMS. In this case, the assessor should enter 0, No in C0100: Should Brief Interview for Mental Status Be Conducted? and proceed to the Staff Assessment for Mental Status.
“This addition is very welcome,” notes Maher. “For PPS assessments only, the Staff Assessment for Mental Status can be done if the resident interview is not completed due to an unexpected discharge from a Part A stay prior to completion of the BIMS. In other words, when it is outside of your ability to know that the Part A resident will be leaving your facility, you will have the option of doing the staff assessment.”
This new coding tip isn’t a free pass that allows providers to say, “Okay, I don’t need to worry about the BIMS,” stresses Maher. “It applies only in the case of an unplanned discharge from a Part A stay, which would most likely be to the hospital. So you have to focus on getting your BIMS assessment completed in a timely manner for residents who are interviewable.”
For example, if the assessment reference date (ARD) for the 5-day MDS is day 8 and staff simply don’t complete the BIMS in time for a Part A resident who hasn’t had an unplanned discharge, then this instruction doesn’t allow the completion of the staff assessment, says Maher. “Consequently, you wouldn’t be able to obtain a HIPPS code for this resident without doing a late assessment if you meet those requirements.” Note: The rules for completing a late assessment are in the section, Non-compliance with the SNF PPS Assessment Schedule, in Chapter 6, “Medicare SNF PPS,” of the RAI Manual.
CMS drove home the limited nature of the new staff assessment option for unexpected discharges by retaining the following existing coding tip just above the new one: “Do not complete the Staff Assessment for Mental Status items (C0700-C1000) if the resident interview should have been conducted, but was not done.”
In addition, it’s important to note that CMS bolded the word “only” in the new coding tip, says Maher. “So my assumption is that the staff assessment could not be done for an unexpected discharge from Part A if the PPS assessment, the 5-day MDS, is combined with an OBRA assessment. I believe this coding instruction for an unplanned discharge will only apply to standalone PPS assessments or a 5-day PPS MDS combined with an OBRA Discharge MDS or Discharge/Part A PPS Discharge.”
Teach the RAI coding rules
In many facilities, NACs don’t complete section C, notes Maureen McCarthy, BS, RN, RAC-MT, RAC-MTA, DNS-MT, QCP-MT, president/CEO of Celtic Consulting in Torrington, CT. “Instead, a social services staff person or another interdisciplinary team (IDT) member often codes this section, and they are not as familiar with the RAI Manual as the MDS coordinators are.”
Consequently, NACs should make sure that the section C assessor knows when the BIMS needs to be done, says Maher. “Often, IDT members don’t realize that the BIMS must be completed within the seven-day look-back period but preferably the day before or the day of the ARD. They mistakenly think that they can do the BIMS during the completion period (ARD + 14 days), so they don’t prioritize it if, for example, they get busy or have to leave work early. But the BIMS cannot be done after the ARD, and the new RAI Manual coding instruction won’t allow the staff assessment to be completed for an interviewable resident if there’s no unplanned discharge from a Part A stay.”
Another common issue is skipping over the BIMS to do the staff assessment even when the resident is interviewable, points out McCarthy. “Some staff members who complete section C aren’t aware of the coding rules and think it’s their choice to do either the BIMS or the staff assessment. However, assessors are supposed to at least attempt to do the interview timely and then move to the staff assessment if the interview isn’t successful.”
The first line of the first coding tips for C0100 in the RAI Manual still make this requirement clear in v1.17: “Attempt to conduct the interview with ALL residents.” In addition, the coding tips for C0200 – C0500 include the three rules for stopping the interview before it is complete, as well as the four coding steps needed if the interview is stopped.
“Having residents answer questions to measure their cognitive ability is a much more accurate assessment than what an IDT member can determine on their own,” points out Maher. “So getting the BIMS scheduled and accomplished timely needs to be a priority for providers.”
Orient new staff members who will code section C
Section C will play such a key role in PDPM that NACs need to have a process for training new staff members who will complete the BIMS, says Maher. “BIMS education should be a focus in the orientation to the RAI process. New staff need to know how to do the BIMS, who to do it on, and when to do it.”
Consider adding some variety to your ARDs
During the May 7 – 8 Skilled Nursing Facility Quality Reporting Program (SNF QRP) provider training event, CMS officials mentioned that SNFs may want to consider moving some ARDs earlier in the eight-day window for the 5-day MDS, says Maher. Note: Find the training slides from the May event, as well as videos when available, here.
“As of October 1, therapy days and minutes won’t be a factor in SNF PPS payment, so there may be no need to wait to set the ARD on day 8 like many providers do under RUG-IV,” she explains. “You may be able to schedule some 5-day MDSs sooner in the ARD window so that, for example, you can accommodate a resident’s busy schedule or so that you can use a day in the Monday – Friday workweek, not a weekend day, as the ARD.”
SNFs that do set ARDs on weekends will need to have a back-up system for ensuring that the BIMS is completed by the ARD for interviewable residents, adds McCarthy. “If social services completes section C, they are usually a Monday through Friday discipline. So you will need an alternate plan to handle section C for weekend ARDs, and you will need to train any staff who code section C on weekends.”
Assess PDPM transition needs
“All Part A residents who cross over from September to October still on Medicare will need an Interim Payment Assessment (IPA) with an ARD no later than October 7 to obtain a PDPM HIPPS code for billing days October 1 forward,” says Maher. “That first week of October will be extremely busy because not only will you need to set ARDs for all of these Medicare residents and complete the section GG, “Functional Abilities and Goals” assessments timely, you also will need to think about the BIMS.”
NACs should make section C assessors aware of the volume of interviews that will need to be done that first week of October, says Maher. “Depending on how many residents are on Medicare, there may need to be additional team members educated about how to do interviews. For example, if you have an average Medicare caseload of 75 residents, that could mean 75 interviews need to be done in the first week of October—not including any new admissions. So very busy buildings with high populations of Medicare residents will need to do some planning to get those BIMS done.”
In addition, NACs need to be sure that all IDT members who do the BIMS during the transition week know the ARDs for each PPS assessment they code, says Maher. “If the BIMS is not done on or before the ARD because staff aren’t timely, they can’t go to the staff assessment option. Consequently, you won’t be able to obtain a PDPM HIPPS code for that resident unless you move the ARD, which could push you into a default situation for a late assessment.”
IDT members who code the BIMS should receive the PPS assessment schedule on an ongoing basis as well, says Maher. “Sometimes they don’t receive the assessment schedule as a routine practice, which makes it hard to focus on the ARD as the BIMS deadline.”
Doing the staff assessment? Check documentation
“When completing the staff assessment, staff members who code section C often will interview front-line staff and obtain information that isn’t necessarily documented anywhere in the medical record,” says McCarthy. “For example, the social worker may speak to a nurse about a resident’s short-term memory status at the nurse’s station, but doesn’t document that interview to reflect that observations about the resident’s short-term memory status happened during the look-back period for the 5-day MDS. As a result, the documentation may be missing, or it may look like those observations occurred outside of the look-back period.”
In addition, section C assessors need to understand the intent of the staff assessment, which is to substitute for the BIMS, says McCarthy. “This will help them differentiate between what should be coded in the staff assessment vs. other section C items, such as C1310C, Disorganized Thinking. It will also help them understand the need to do a comprehensive assessment and really test long- and short-term memory—not just go by what they think they know about the patient.”
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