to Value in Post...NCH HHA LUPA code) and PEPs (identified as patient discharge status code equal to...

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From Volume to Value in Post Acute Care: Your New Compliance Data Points

Shawn Halcsik DPT, MEd, RAC‐CT, CPC, CHC

Kim Hrehor, MHA, RHIA, CHC, PMP

Kathryn Krenz, RN, BSN, CPC, CHC, CHPC

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Health Care Reform

Improved Health

Improved Healthcare

Cost Containment

Health Care Paradigm Shift

Historical

• Provider centric

• Incentives for volume

• Siloed care

• Fee for service

Reforming

•Patient centric•Incentives for outcomes•Coordinated care•Value based/ alternative payment

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What is PEPPER?Program for Evaluating Payment Patterns Electronic Report (PEPPER)

PEPPER summarizes Medicare claims data statistics for one provider in “target areas” that may be at risk for improper Medicare payments

PEPPER compares the provider’s Medicare claims data statistics with aggregate Medicare data for the nation, MAC jurisdiction and the state

PEPPER cannot identify improper Medicare payments!

History of PEPPER• 2003: Developed by TMF for short‐term acute care and later long‐term acute care hospitals, it was provided by Quality Improvement Organizations (QIOs) through 2008.

• 2010: TMF began distributing PEPPERs to all providers in the nation; developed PEPPER for other providers:

– 2011: Critical access hospitals, inpatient psychiatric facilities, inpatient rehabilitation facilities

– 2012: Partial hospitalization programs and hospices

– 2013: Skilled nursing facilities

– 2015: Home health agencies

• 2019: RELI Group, and partners TMF and CGS, continue distribution of PEPPERs

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CMS is tasked with protecting the Medicare Trust Fund from fraud, waste and abuse

Why are providers receiving PEPPER?

The provision of PEPPER supports CMS’ program integrity activities

PEPPER is an educational tool that is intended to help providers assess their risk for improper Medicare payments

SNF• PDPM implementation Oct. 1, 2019 (FY2020)

• PEPPER releases:• Q4FY18 SNF PEPPER – Apr. 2019• Q4FY19 SNF PEPPER – Apr. 2020• Q4FY20 SNF PEPPER – Apr. 2021

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HHA• PDGM• Implemented CY2020 (Jan. 1, 2020)

• Q4CY18 HHA PEPPER – Jul. 2019• Q4CY19 HHA PEPPER – Jul. 2020• Q4CY20 HHA PEPPER – Jul. 2021

When will the PEPPER Reflect the new Payment Models?

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Current HHA Target Areas

Target Area Target Area Definition

Average Case Mix Numerator (N): sum of case mix weight for all episodes paid to the HHA during the report period, excluding LUPAs (identified by Part A NCH HHA LUPA code) and PEPs (identified as patient discharge status code equal to ‘06’)

Denominator (D): count of episodes paid to the HHA during the report period, excluding LUPAs and PEPs

Note: reported as a rate, not a percent

Average Number of Episodes

N: count of episodes paid to the HHA

D: count of unique beneficiaries served by the HHA

Note: reported as a rate, not a percent 9

Current HHA Target Areas, 2

Target Area Target Area Definition

Episodes with 5 or 6 Visits

N: count of episodes with 5 or 6 visits paid to the HHA

D: count of episodes paid to the HHA

Non‐LUPA Payments N: count of episodes paid to the HHA that did not have a LUPA payment


High Therapy Utilization Episodes

N: count of episodes with 20+ therapy visits paid to the HHA (first digit of HHRG equal to ‘5’)


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Current HHA Target Areas, 3Target Area Target Area Definition

Outlier Payments N: dollar amount of outlier payments (identified by the amount where Value Code equal to ’17’) for episodes paid to the HHA

D: dollar amount of total payments for episodes paid to the HHA

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What might be changing in the HHA PEPPER?• Nothing has been finalized or approved yet.

– Discontinue “Episodes with 5 or 6 Visits”?

– Discontinue “High Therapy Utilization Episodes”?

– Focus on clinical groups?

– Add comorbidities?

– Functional impairment?

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How can you monitor your data?• Discussion

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Bringing New Life to Senior Living® 14

Monitoring and Auditing3

Home Health Quality Measures2

Other Considerations4

PPS, PDGM and a Unified Payment Model1

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Bringing New Life to Senior Living®

• MedPac annual reports for 2011, 2015, 2017 noted that home health payments should not be based on therapy thresholds and should be based on patient characteristics

• The Affordable Care Act Report to Congress noted that the current payment system did not reimburse HHAs fairly for certain patients with high use of resources

• TPN

• Wounds or ulcers

• Patients needing substantial assist with bathing

• Patients admitted from an acute or post‐acute stay

• Patients with poorly controlled conditions

• Dual eligible

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Why change the payment model?


• HHAs complete Outcome and Assessment Information Set (OASIS) for each patient

• The OASIS groups the patient into one of 153 Home Health Resource Groups (HHRGs)• Timing of the episode

• Clinical domain

• Functional domain

• Service Utilization

• Determines case‐mix and payment level

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Current Home Health Prospective Payment System

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• Re‐examined the payment reform principles• Improve the payment accuracy for HH services

• Provide fair compensation to the HHAs

• Increase the quality of care for beneficiaries

• Increase access to home health services for high‐needs patients

• Initial work was conducted• Utilization of current payment system was analyzed

• Alternative methods to construct case‐mix were considered

• Payment reform was determined by Bipartisan Budget Act of 2018• Payment is based on 30 day periods and not 60

• Therapy thresholds were eliminated

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Development of PDGM


• Will take effect January 1, 2020

• Periods of care will continue to be 60 days, but payment periods will be 30 days

• No changes to the requirements for certification/recertification

• No changes to OASIS completion requirements

• No change to requirements for updating patient plan of care

• 5 main case‐mix variables result in 432 case‐mix groups (as opposed to the 153 under PPS)

• LUPA thresholds vary from 2‐6 visits based on the payment group

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PDGM

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1. Admission Source Source

• Institutional Acute inpatient

Post‐acute (SNF, IRF, long‐term care hospital or inpatient psychiatric facility)

30 day periods with this admission source were noted to have higher resource use than periods with a community admission source

• Community No acute or post‐acute care in the 14 days prior to the HH admission

Other Considerations• A post‐acute stay in the 14 days prior to a late home health period would not be classified as in institutional admission unless the patient was discharged from home health prior to the post‐acute stay

• Information from the Medicare systems during claims processing will automatically assign admission source categories

• HHAs have the option of including an occurrence code on their claims to identify an admission source

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PDGM Case-mix Structure


2. Timing• Early – the first 30 day period in a sequence of HH periods

• Late – the second and later 30 day periods in a sequence of HH periods

SequencingPeriods with no more than 60 days between the end of one period and the start of the next period will be contiguous (no change from the current PPS system)

Other Considerations• Late periods will always be classified as community admissions – unless there was an acute hospitalization within the last 14 days

• Information from Medicare payment systems during claims processing will automatically assign timing categories

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PDGM Case-mix Structure continued

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3. Periods are grouped by the primary reason for home health• Defined by the primary diagnosis reported on the claim

• Clinical groups are intended to reflect the primary reason for the period

• There are 12 clinical groups• Neuro rehab

• Wounds

• Complex nursing interventions

• MS rehab

• Behavioral health

• MMTA – other

• MMTA – Surgical aftercare

• MMTA – Cardiac and circulatory

• MMTA – Endocrine

• MMTA – GI/GU

• MMTA – Infectious disease

• MMTA – Respiratory

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4. Periods are grouped by functional impairment level• OASIS items are used to group the patient into low, medium or high levels

• Uses OASIS items M1810‐M1860 (as in PPS) M1810 – Current ability to dress upper body safely

M1820 – Current ability to dress lower body safely

M1830 – Bathing

M1840 – Toilet transferring

M1850 – Transferring

M1860 – Ambulation/locomotion

• Also adds 2 OASIS items not currently part of the PPS payment system M1800 – Grooming

M1033 – Risk for hospitalization

• The functional impairment level is assigned a score determined using 2017 data for each diagnosis grouping, which is split into thirds (low, medium, high)

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5. Periods are grouped by a comorbidity adjustment• A comorbidity is defined as a medical condition coexisting with the primary diagnosis and is tied to poorer health outcomes, more complex medical needs and higher care costs

• This adjustment takes factors into account

• Each 30 day period receives one of three adjustments: No adjustment – no reported secondary diagnosis that falls into the low or high category

A low adjustment – the patient has one reported secondary diagnosis that is associated with higher resource use

A high adjustment – the patient has two or more reported secondary diagnoses that are associated with higher resource use when both are reported together compared to if they were reported separately

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• Medicare will move to PDGM to better align post‐acute care away from the four separate prospective payment systems that currently exist for SNF, HH, IRF and LTCHs

• The aim is to unify the post‐acute payment systems based on patient characteristics rather than site of service with standardization of the data elements allowing for better transitional care measures

• Fosters PAC payment reform through data uniformity

• Will increase the equity across different types of patients and the providers that treat them because profitability across types of stays would be more narrow

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Patient Driven Groupings Model and the unified payment model

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• There are OASIS‐based, claims‐based outcome measures and process measures

• Oasis‐based outcome measures include:• End result outcome of functional measures, like improvement in bathing or stabilization in grooming

• End result outcome in health, like improvement in pain interfering with activity or improvement in frequency in confusion

• Utilization outcome ‐ discharged to community

• Claims‐based outcome measures include:• Utilization outcome, such as acute hospitalization in the first 30 days of home health and discharge to the community

• Cost/Resource use – Medicare spending per beneficiary

*Some, but not all contribute to the Quality of Patient Care Star Ratings

** Check https://www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐Assessment‐Instruments/HomeHealthQualityInits/Spotlight‐and‐Announcements.html

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Home Health Quality Measures


• Process measures include:• Timely care

• Assessment completion – depression and fall risk

• Care plan implementation – diabetic foot care during all episodes of care

• Education – drug education during all episodes of care

• Prevention – flu and pneumonia shot received, offered, contraindicated and drug regimen review conducted with follow‐up for issues

All process measures are included in the HH Compare except:• Flu shot offered and refused

• Flu shot contraindicated

• Pneumonia shot offered and refused

• Pneumonia contraindicated

*Application of percent of LTCH patients with an assessment with an admission and discharge assessment and care plan that addresses function will be added to the HH Compare in January 2021

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Home Health Quality Measures continued

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• Know your data PEPPERs https://www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/HomeHealthPPS/HH‐PDGM.html

• Home health interactive grouper tool

• PDGM Case Mix Weights and LUPA Thresholds

• PDGM Agency Level Impacts

Quality outcomes

Star ratings – do patient surveys align with your Quality of Care Rating

• Know your risk areas• What are your primary diagnoses not on the approved list

• What are your risky utilization patterns

• What are your clinical challenges

• What are your problem referral sources

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Monitoring and Auditing Data Points

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• Know your people Who are your best, most efficient coders

Who are your best clinicians at patient assessments and OASIS

Who are your best care planners and case managers that can drive the episode in the most efficient way to achieve the best outcomes

Find and support your champions

• Know your agency challenges Are your policies and procedures reviewed and updated How do you communicate changes to rules and regulations out to staff/clinicians

What are your agency training needs

Are your marketers bringing quality referrals – how will you train them

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Monitoring and Auditing Data Points continued


Monitoring should be done by operational managers in alignment with your policies and procedures and identified risk areas

• Are managers monitoring what they should be

Auditing done by people independent of the operational processes

Develop monitoring and auditing projects • Coding accuracy, completeness

• Primary diagnosis

• Comorbidities

• OASIS • Particularly M items related to functional status – do the admission and discharge results make sense

• Outcomes• OASIS‐based items

• Claim‐based items

• Process items

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Monitoring and Auditing Data Points continued

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Title 44





Don’t shy away from complex patients• Beef up your clinician base with experts

• Assessments

• Teaching

• Complex patients – wounds, TPN, infusions, multiple comorbidities, behavioral health* Remember you will be responsible for supplies related to these patients

• Coding, coding, coding

• OASIS

• Quality programs

• Now is the time to think about:• Developing more institutional relationships

• What is your therapy utilization• Can you do with fewer therapists and more assistants

• How would telehealth work in your company

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Other Considerations

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Skilled Nursing Facility

Current SNF Target AreasTarget Area Target Area Definition

Therapy RUGs with High ADLs

Numerator (N): count of days billed with RUG equal to RUX, RVX, RHX, RMX, RUC, RVC, RHC, RMC, RLBDenominator (D): count of days billed for all therapy RUGs

Nontherapy RUGs with High ADLs

N: count of days billed with RUG equal to SSC, CC2, CC1, BB2, BB1, PE2, PE1, IB2, IB1 in RUG III; HE2, HE1, LE2, LE1, CE2, CE1, BB2, BB1, PE2, PE1 in RUG IVD: count of days billed for all nontherapy RUGs

Change of Therapy Assessment

N: count of assessments with AI second digit “D” D: count of all assessments

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Current SNF Target Areas, cont.Target Area Target Area Definition

Ultrahigh Therapy RUGs

Numerator (N): count of days billed with RUG equal to RUX, RUL, RUC, RUB, RUADenominator (D): count of days billed for all therapy RUGs

20‐day Episodes of Care(new as of Q4FY17)

N: count of episodes of care ending in the report period with a length of stay of 20 daysD: count of episodes of care ending in the report period

90+ Day Episodes of Care

N: count of episodes of care at the SNF with LOS 90+ daysD: count of all episodes of care at the SNF

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What might be changing in the SNF PEPPER?• Nothing has been finalized or approved yet.

– Discontinue “Ultrahigh Therapy RUGs”?

– Add comorbidities?

– PDPM categories?

– Interrupted stays?

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How can you monitor your data?• Discussion

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MDS Section PDPM QMs‐Short Stay QRP‐Short Stay QMs‐Long Stay QRP‐Long Stay Survey Critical Pathways

A

B

C

D

E

F

G

GG 10/1/18

H

I

J

K

L

M

N

O

P

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Skilled Nursing Facility Quality Measures2

PPS, PDPM and a Unified Payment Model1

Why is CMS changing from RUG‐IV to PDPM?

• Under RUG‐IV, most patients are classified into a therapy payment group, which uses primarily the volume of therapy services provided to the patient as the basis for payment classification. This creates an incentive for SNF providers to furnish therapy to SNF patients regardless of the patient’s unique characteristics, goals, or needs. PDPM eliminates this incentive and improves the overall accuracy and appropriateness of SNF payments by classifying patients into payment groups based on specific, data‐driven patient characteristics, while simultaneously reducing administrative burden on SNF providers.

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PDPM Overview • Coverage Guidelines for SNF remain

• Care in a SNF is covered if all of the following four factors are met:• The patient requires skilled nursing services or skilled rehabilitation services, i.e., services that must be performed by or under the

supervision of professional or technical personnel (see §§30.2 ‐ 30.4); are ordered by a physician and the services are rendered for a condition for which the patient received inpatient hospital services or for a condition that arose while receiving care in a SNF for a condition for which he received inpatient hospital services;

• The patient requires these skilled services on a daily basis (see §30.6); and• As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF.

(See §30.7.)• The services delivered are reasonable and necessary for the treatment of a patient’s illness or injury, i.e., are consistent with the nature

and severity of the individual’s illness or injury, the individual’s particular medical needs, and accepted standards of medical practice. The services must also be reasonable in terms of duration and quantity.

• ADR/Denial Reasons? Impact on Contracts?• Recent OIG report found that IRFs complied with all Medicare coverage and documentation requirements specified for

reasonable and necessary care for 45 of the 220 sampled stays. However, for 175 of the sampled stays, corresponding to 135 IRFs, medical record documentation did not support that IRF care was reasonable and necessary in accordance with Medicare’s requirements. These errors occurred because many IRFs did not have adequate internal controls to prevent inappropriate admissions. On the basis of our sample results, we estimated that Medicare paid IRFs nation‐wide $5.7 billion for care to beneficiaries that was not reasonable and necessary.

• Must meet Rules of Participation

• Held accountable to QRP, VBP, and other QMs that impact ratings or are publically reported

• This is a PAYMENT model change• Personnel Qualifications remain

• State Practice Act Implications

• Verifiable Patient Characteristics

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PT

•PT ‐‐‐all patients will be assigned to a case mix level

• 16 case mix levels based on clinical category (4) and functional level (Section GG items)

OT

•OT– all patients will be assigned to a case mix level

• 16 case mix levels based on clinical category (4) and functional level (Section GG items)

SLP

• SLP—all patients will be assigned to a case mix level

• 12 case mix levels based on Presence of acute neuro condition, SLP related co‐morbidity, or cognitive impairment & mechanically altered diet or swallowing disorder

Nursing

•Nursing—all patients will be assigned to a case mix level

• 25 case mix levels based on clinical conditions, depression, # restorative services, function (section GG)

NTA

•NTA—all patients will be assigned to a case mix level

• 6 case mix levels based on conditions

Non Case Mix

•Non Case Mix

5 Day

Discharge

5 Day

14 Day

30 Day

60 Day

90 Day

Discharge

Proposed

Current

COT COT COTCOT COT

EOT ??? SOT ??

Optional IPA

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MDS Key Areas for Assessment Accuracy

• Section B

• Section C

• Section D

• Section E

• Section G

• Section GG

• Section H

• Section I

• Section J

• Section K

• Section M

• Section N

• Section O

PT & OT Components

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PT & OT Component Case Mix Groups are defined based on the clinical category (4) & functional score (Section GG)

Major Joint Replacement/Spinal Surgery

Other Ortho

Non Ortho Surgery &

Acute Neuro

Medical Management

0‐5

6‐9

10‐23

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16 Case Mix Groups

Clinical Categories Functional Score

KEY MDS Areas: PT &

OT Components

• I0020B Clinical Category

• J2100 Surgical Procedure• If J2100 = yes, complete J2300‐J5000

• Section GG: • GG0130A1 Eating

• GG0130B1 Oral Hygiene

• GG0130C1 Toileting Hygiene

• GG0170B1 Sit to Lying

• GG0170C1 Lying to Sitting on Side of Bed

• GG0170D1 Sit to Stand

• GG0170E1 Chair/Bed‐to‐Chair

• GG0170F1 Toilet Transfer

• GG0170J1 Walk 50 Feet with Two Turns

• GG0170K1 Walk 150 Feet

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Missing information will score a “0”. GG0170I1 (walk 10 feet) will be used to ID those who can’t walk

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Variable Rate: 2% decrease every 7 days after day 20

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What Will CMS Monitor?

• Changes in payment that result from changes in the coding or classification of SNF patients vs. actual changes in case mix.

• Changes in the volume and intensity of therapy services provided to SNF residents under PDPM compared to RUG‐IV.

• Compliance with the group and concurrent therapy limit.

• Any increases in the use of mechanically altered diet among the SNF population that may suggest that beneficiaries are being prescribed such a diet based on facility financial considerations, rather than for clinical need.

• Any potential consequences (e.g., overutilization) of using cognitive impairment as a payment classifier in the SLP component.

• Facilities whose beneficiaries experience inappropriate early discharge or provision of fewer services (e.g., due to the variable per‐diem adjustment).

• Stroke and trauma patients, as well as those with chronic conditions, to identify any adverse trends from application of the variable per‐diem adjustment.

• Use of the interrupted‐stay policy to identify SNFs whose residents experience frequent readmission, particularly facilities where the readmissions occur just outside the 3‐day window used as part of the interrupted‐stay policy.

SLP Component

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SLP Component Case Mix Groups

None

Any One

Any Two

All Three

Neither

Either

Both

12 Case Mix Groups

Presence of acute neurologicCondition, SLP related comorbidity, or cognitive impairment

Mechanically alteredDiet or swallowing disorder

Key MDS Areas: ST

Component

• Section K: Swallowing and Nutritional Status

• K0100A Loss of liquids/solids from mouth when eating or drinking

• K0100B Holding food in mouth/cheeks or residual food in mouth after meals

• K0100C Coughing or choking during meals or when swallowing medications

• K0100D Complaints of difficulty or pain with swallowing

• K0100Z None of the above

• K0510C2 Mechanically Altered Diet While a Resident

• Sections B & C: Cognition

• BIMS

• C0200 Repetition of three words

• C0300 Temporal orientation

• C0400 Recall

• CFS

• B0100 Coma and completely dependent or ADL did not occur

• C1000 Severely impaired cognitive skills (C1000 = 3)

• B0700, C0700, C1000 Two or more of the following: B0700 >0 Problem being understood; C0700 =1 STM problem; C1000>0 Cognitive skills problem AND one or more of the following: B0700 >=2 severe problem being understood; C1000 >=2 severe cognitive skills problem

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Key MDS Areas: ST

Component

• Sections I & O: Clinical Category & SLP Related Comorbidity

• I0020B Clinical Category

• J2100 Surgical Procedure• If J2100 = yes, complete J2300‐J5000

• I4300 Aphasia

• I4500 CVA, TIA, Stroke

• I4900 Hemiplegia or Hemiparesis

• I5500 Traumatic Brain Injury

• I8000 Laryngeal Cancer

• I8000 Apraxia

• I8000 Dysphagia

• I8000 ALS

• I8000 Oral Cancers

• I8000 Speech & Language Deficits

• O0100E2 Tracheostomy Care While a Resident

• O0100F2 Ventilator or Respirator While a Resident

Comorbidities Included in SLP Component

Condition ICD-10-CM Code DescriptionALS G12.21 Amyotrophic lateral sclerosisApraxia I69.990 Apraxia following unspecified cerebrovascular disease

Dysphagia I69.991Dysphagia following unspecified cerebrovascular disease

Laryngeal Cancer C32.0 Malignant neoplasm of glottisLaryngeal Cancer C32.1 Malignant neoplasm of supraglottisLaryngeal Cancer C32.2 Malignant neoplasm of subglottisLaryngeal Cancer C32.3 Malignant neoplasm of laryngeal cartilageLaryngeal Cancer C32.8 Malignant neoplasm of other specified sites of larynxLaryngeal Cancer C32.9 Malignant neoplasm of larynx, unspecifiedOral Cancers C00.0 Malignant neoplasm of external upper lipOral Cancers C00.1 Malignant neoplasm of external lower lipOral Cancers C00.3 Malignant neoplasm of upper lip, inner aspectOral Cancers C00.4 Malignant neoplasm of lower lip, inner aspectOral Cancers C00.5 Malignant neoplasm of lip, unspecified, inner aspectOral Cancers C00.6 Malignant neoplasm of commissure of lip, unspecifiedOral Cancers C00.8 Malignant neoplasm of overlapping sites of lipOral Cancers C00.2 Malignant neoplasm of external lip, unspecifiedOral Cancers C00.9 Malignant neoplasm of lip, unspecifiedOral Cancers C01 Malignant neoplasm of base of tongueOral Cancers C02.0 Malignant neoplasm of dorsal surface of tongueOral Cancers C02.1 Malignant neoplasm of border of tongueOral Cancers C02.2 Malignant neoplasm of ventral surface of tongue

Oral Cancers C02.3Malignant neoplasm of anterior two-thirds of tongue, part unspecified

Oral Cancers C02.8 Malignant neoplasm of overlapping sites of tongue

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Oral Cancers C02.9 Malignant neoplasm of tongue, unspecifiedOral Cancers C03.0 Malignant neoplasm of upper gumOral Cancers C03.1 Malignant neoplasm of lower gumOral Cancers C03.9 Malignant neoplasm of gum, unspecifiedOral Cancers C03.9 Malignant neoplasm of gum, unspecifiedOral Cancers C04.0 Malignant neoplasm of anterior floor of mouthOral Cancers C04.1 Malignant neoplasm of lateral floor of mouthOral Cancers C04.8 Malignant neoplasm of overlapping sites of floor of mouthOral Cancers C04.9 Malignant neoplasm of floor of mouth, unspecifiedOral Cancers C09.9 Malignant neoplasm of tonsil, unspecifiedOral Cancers C09.8 Malignant neoplasm of overlapping sites of tonsilOral Cancers C09.0 Malignant neoplasm of tonsillar fossaOral Cancers C09.1 Malignant neoplasm of tonsillar pillar (anterior) (posterior)Oral Cancers C10.0 Malignant neoplasm of valleculaOral Cancers C10.1 Malignant neoplasm of anterior surface of epiglottisOral Cancers C10.8 Malignant neoplasm of overlapping sites of oropharynxOral Cancers C10.2 Malignant neoplasm of lateral wall of oropharynxOral Cancers C10.3 Malignant neoplasm of posterior wall of oropharynxOral Cancers C10.4 Malignant neoplasm of branchial cleftOral Cancers C10.8 Malignant neoplasm of overlapping sites of oropharynxOral Cancers C10.9 Malignant neoplasm of oropharynx, unspecifiedOral Cancers C14.0 Malignant neoplasm of pharynx, unspecifiedOral Cancers C14.2 Malignant neoplasm of waldeyer's ring

Oral Cancers C14.8Malignant neoplasm of overlapping sites of lip, oral cavity and pharynx

Oral Cancers C14.8Malignant neoplasm of overlapping sites of lip, oral cavity and pharynx

Oral Cancers C06.0 Malignant neoplasm of cheek mucosaOral Cancers C06.1 Malignant neoplasm of vestibule of mouthOral Cancers C05.0 Malignant neoplasm of hard palateOral Cancers C05.1 Malignant neoplasm of soft palateOral Cancers C05.2 Malignant neoplasm of uvulaOral Cancers C05.9 Malignant neoplasm of palate, unspecifiedOral Cancers C05.8 Malignant neoplasm of overlapping sites of palateOral Cancers C06.2 Malignant neoplasm of retromolar area

Oral Cancers C06.89Malignant neoplasm of overlapping sites of other parts of mouth

Oral Cancers C06.80Malignant neoplasm of overlapping sites of unspecified parts of mouth

Oral Cancers C06.9 Malignant neoplasm of mouth, unspecified

Speech and Language Deficits I69.928Other speech and language deficits following unspecified cerebrovascular disease

Speech and Language Deficits I69.920 Aphasia following unspecified cerebrovascular diseaseSpeech and Language Deficits I69.921 Dysphasia following unspecified cerebrovascular diseaseSpeech and Language Deficits I69.922 Dysarthria following unspecified cerebrovascular disease

Speech and Language Deficits I69.923Fluency disorder following unspecified cerebrovascular disease

Speech and Language Deficits I69.928Other speech and language deficits following unspecified cerebrovascular disease

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Cognitive Impairment*

PDPM Cognitive Level BIMS Score Staff Assessment Score

1 - Cognitively Intact 13-15 0

2 - Mildly Impaired 8-12 1-2

3 - Moderately Impaired 0-7 3-4

4 - Severely Impaired - 5-6

*Note: Residents are classified as cognitively impaired when they are assessed to be mildly, moderately, or severely impaired

SLP Component

Presence of Acute Neurologic Condition, SLP-

Related Comorbidity, or Cognitive Impairment

Mechanically Altered Diet or Swallowing Disorder

SLP Case Mix Group CMI

None Neither SA 0.68

None Either SB 1.82

None Both SC 2.66

Any one Neither SD 1.46

Any one Either SE 2.33

Any one Both SF 2.97

Any two Neither SG 2.04

Any two Either SH 2.85

Any two Both SI 3.51

All three Neither SJ 2.98

All three Either SK 3.69

All three Both SL 4.19

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Modes of Treatment

• Limits concurrent and group to no more than 25%, COMBINED, by discipline

• Will require completion of a discharge MDS to collect therapy minutes for compliance monitoring of 25% concurrent and group

• Utilization of group &/or concurrent must be based on needs of resident and must be well documented

• Non fatal warning edit on validation report if exceed threshold

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Section O AdditionsRequiring reporting of minutes and days will allow for Compliance monitoring by CMS of daily intensity (pg 242)

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Nursing Component

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Nursing Classification

Nursing Category Conditions/Services Conditions/Services Present Section GG-Based Function Score PDPM RUG

Tracheostomy Care and Ventilator/Respirator Yes 0-14 ES3

Extensive Services ( Sections O & GG) Tracheostomy Care or Ventilator/Respirator Yes 0-14 ES2

Infection Isolation Yes 0-14 ES1

Special Care High (Sections B, GG, I, J, K, O, D)

Depressed Yes 0-5 HDE2

Depressed No 0-5 HDE1

Depressed Yes 6-14 HBC2

Depressed No 6-14 HBC1

Special Care Low (Sections I, O, K, M, D, GG)

Depressed Yes 0-5 LDE2

Depressed No 0-5 LDE1

Depressed Yes 6-14 LBC2

Depressed No 6-14 LBC1

Clinically Complex (Sections I, M, O, D, GG)

Depressed Yes 0-5 CDE2

Depressed No 0-5 CDE1

Depressed Yes 6-14 CBC2

Depressed Yes 15-16 CA2

Depressed No 6-14 CBC1

Depressed No 15-16 CA1

Behavioral Cognitive Symptoms (Sections GG, C, B, E, H, O)Restorative Nursing Services 2 or More 11-16 BAB2

Restorative Nursing Services 0-1 11-16 BAB1

Reduced Physical Function (Sections H, O, GG)

Restorative Nursing Services 2 or More 0-5 PDE2

Restorative Nursing Services 0-1 0-5 PDE1

Restorative Nursing Services 2 or More 6-14 PBC2

Restorative Nursing Services 2 or More 15-16 PA2

Restorative Nursing Services 0-1 6-14 PBC1

Restorative Nursing Services 0-1 15-16 PA1

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Nursing Category Conditions/ServicesConditions/Services Present

Section GG‐Based Function Score

PDPM RUG CMI

Special Care High

Must have NURSING FUNCTION score of 14 OR LESS. If Function score is 15‐16 then see clinically complex category. Must have one of the following conditions or services: comatose (B0100) and completely ADL dependent or ADL did not occur; septicemia (I2100); diabetes (I2900) with both: insulin injections (N0350A) and insulin order changes (N0350B); quadriplegia (I5100) with FUNCTION SCORE <= 11, COPD & SOB with when lying flat (I6200, J1100C); fever (J1550A) with one of the following: pneumonia (I2000), vomiting (J1550B), weight loss (K0300), or tube feeding meeting intake requirement (K0510B1 or K0510B2); parenteral/IV feeding (K0510A1 or K0510A2); or respiratory therapy for 7 days (O0400D2)

Depressed Yes0‐5 HDE2 2.39

Depressed No0‐5 HDE1 1.99

Depressed Yes6‐14 HBC2 2.23

Depressed No 6‐14 HBC1 1.85

Differs from PT & OT: no walking and no oral hygiene

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Non Therapy Ancillary (NTA) Component

Non Therapy Ancillary—Sections H, I, K, M, O

• HIV/AIDS

• Parenteral / IV feeding high intensity K0510A2, K0710A2

• IV medication O0100H2

• Ventilator or Respirator Post admit code O0100F2

• Parenteral / IV feeding low intensity K0510A2, K0710A2 & K0710B2

• Lung Transplant Status I8000

• Transfusion Post admit code O0100I2

• Major Organ Transplant Status, except lung I8000

• Multiple Sclerosis I5200

• Opportunistic Infections I8000

• Asthma, COPD, Chronic Lung Disease I6200

• Bone/Joint/Muscle Infections/Necrosis (except aseptic necrosis of bone) I8000

NTA Score Range NTA Case Mix Group NTA Case Mix Index

12+ NA 3.25

9‐11 NB 2.53

6‐8 NC 1.85

3‐5 ND 1.34

1‐2 NE .96

0 NF .72

8 points

7 points

5 points

4 points

3 points

2 points

1 point

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Non Therapy Ancillary

• Chronic Myeloid Leukemia I8000

• Wound Infection I2500

• Diabetes Mellitis I2900

• Endocarditis I8000

• Immune disorders I8000

• End Stage Liver Disease I8000

• Diabetic foot ulcer M1040B

• Narcolepsy and Cataplexy I8000

• Cystic Fibrosis I8000

• Tracheostomy Care Post Admit Care O0100E2

• Multi drug resistant organism (MDRO) I1700

• Isolation Post Admit O0100M2

• Specified Hereditary Metabolic/Immune Disorders I8000


12+ NA 3.25

9‐11 NB 2.53

6‐8 NC 1.85

3‐5 ND 1.34

1‐2 NE .96

0 NF .72

8 points

7 points

5 points

4 points

3 points

2 points

1 point


• Morbid Obesity I8000

• Radiation Post Admit O0100B2

• Highest Stage of Unhealed Pressure Ulcer Stage 4 M0300X1

• Psoriatic Arthropathy and Systemic Sclerosis I8000

• Chronic Pancreatitis I8000

• Proliferative Diabetic Retinopathy and Vitreous Hemorrhage I8000

• Foot infection code, other open lesion on foot code, except diabetic foot ulcer code M1040A, M1040B, M1040C

• Complications of Specified Implanted Device or Graft I8000

• Bladder and Bowel Appliances: Intermittent Catheterization H0100D

• Inflammatory Bowel Disease I8000

• Aseptic Necrosis of Bone I8000

• Suctioning Post Admit O0100D2


12+ NA 3.25

9‐11 NB 2.53

6‐8 NC 1.85

3‐5 ND 1.34

1‐2 NE .96

0 NF .72

8 points

7 points

5 points

4 points

3 points

2 points

1 point

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• Cardio Respiratory Failure and Shock I8000

• Myelodysplastic Syndromes and Myelofibrosis I8000

• Systemic Lupus Erythematosus, other connective tissue disorders and inflammatory spondylopathies I8000

• Diabetic retinopathy, except proliferative diabetic retinopathy and vitreous hemorrhage I8000

• Nutritional approaches while a resident: feeding tube K0510B2

• Severe skin burn or condition I8000

• Intractable epilepsy I8000

• Malnutrition Code I5600

• Disorders of immunity, except RxCC97: Immune Disorders I8000

• Cirrhosis of Liver I8000

• Bladder and bowel appliances: ostomy H0100C

• Respiratory arrest I8000

• Pulmonary Fibrosis and other chronic lung disorders I8000


12+ NA 3.25

9‐11 NB 2.53

6‐8 NC 1.85

3‐5 ND 1.34

1‐2 NE .96

0 NF .72

8 points

7 points

5 points

4 points

3 points

2 points

1 point

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Measure QM QRP VBP Five Star Nursing Home Compare

Self‐Report Moderate to Severe Pain

Pressure Ulcers that are New or Worsened

Newly Received an AntipsychoticMedication

Made Improvements in Function

Assessed and Given Appropriately the Seasonal Influenza Vaccine

Assessed and Given Appropriately the Pneumococcal Vaccine

Short Stay


Falls with a Major Injury

Self Reported Moderate to Severe Pain

High Risk Residents with Pressure Ulcers

Urinary Tract Infection

Catheter

Residents Who Lose Control of Their Bowel or Bladder

Physically Restrained

Need for Help with Daily Activities has Increased

Who Lose Too Much Weight

Long Stay

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Long Stay


Depressive Symptoms

Who Received an Antipsychotic Medication

Ability to Move Independently Worsened

Prevalence of Falls

Who Used an Antianxiety of Hypnotic Medication

Prevalence of Antianxiety/Hypnotic Use

Prevalence of Behavior Symptoms Affecting Others

Assessed and Given Appropriately the SeasonalInfluenza Vaccine


Admission and Discharge Functional Assessment and Care Plan


Drug Regimen Review

Changes in Skin Integrity Post‐Acute Care: Pressure Ulcer/Injury

Change in Self Care

Change in Mobility

Discharge Self Care

Discharge Mobility

QRP FY2020: Approved Measures with Data Collection Which Began Oct. 1, 2018

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Monitoring and Auditing Data Points• Know your data PEPPERs Quality Measures QRP Readmission Rates Star ratings – do surveys align with your Quality of Care Rating Current Nursing RUG levels Deep Dive into MDS

Develop schedule by section that will impact PDPM and QM

• Know your risk areas• What are your primary diagnoses not on the approved list• What are your utilization patterns• What are your clinical challenges• Is the documentation present for capture of Nursing and NTA

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Monitoring and Auditing Data Points continued• Know your people

Who are your best, most efficient coders Who are your best clinicians at patient assessments and MDS Who are your best care planners and case managers that can drive the episode in the most efficient way to achieve the best outcomes

Find and support your champions

• Know your facility challenges Are your policies and procedures reviewed and updated How do you communicate changes to rules and regulations out to staff/clinicians

What are your facility training needs How will you communicate MDS coding to all necessary departments

Primary clinical category GG Score Sections B, C, and K

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PDPM Audit Focus Areas

• Accurate Coding of MDS ‐‐ Develop schedule by section that will impact PDPM and QM• Section K Any increases in the use of mechanically altered diet among the SNF population that may suggest that beneficiaries are being prescribed such a diet based on

facility financial considerations, rather than for clinical need.

• Sections B/C Any potential consequences (e.g., overutilization) of using cognitive impairment as a payment classifier in the SLP component.

• Section GG

• Nursing and NTA

• Accurate diagnosis coding

• Section O Therapy Delivery Changes in the volume and intensity of therapy services provided to SNF residents under PDPM compared to RUG‐IV.• Average care every 7 days

• CONCURRENT & GROUP• Appropriate Use of Group and Concurrent based on Clinical Appropriateness


• Facilities whose beneficiaries experience inappropriate early discharge or provision of fewer services (e.g., due to the variable per‐diem adjustment).• LENGTH OF STAY

• COMMUNITY DC

• READMISSION RATES

• Functional Outcomes • GG, labor, time

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Quality Audit for Accuracy

• Numerator: Top number of the fraction; the actual number of residents who had the QM condition

• Denominator: Bottom number of the fraction; the number of eligible facility residents who were at risk of being in the numerator

• Exclusions: Residents removed from calculations if outcomes are not under the facility control (e.g., outcome evident on admission) or if outcomes are unavoidable (e.g., end‐stage disease or comatose).

• Covariates: A set of resident clinical characteristics that adjust for potential differences in residents between facilities and thereby level the playing field

Quality Audit for Accuracy

• STEP 1: Obtain CASPER report: MDS Facility Level Quality Measure Report

• Identify all QMs that are at or above the 75th percentile (comparison group national percentile)

• STEP 2: Obtain CASPER report: MDS Resident Level Quality Measure Report

• Identify all residents who triggered the QM

• STEP 3: Determine which areas of MDS to audit for accuracy

• STEP 4: Review each resident’s medical record to determine if MDS was coded correctly

• STEP 5: Add to your QAPI plan and Complete root cause analysis

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Measure Audit for Accuracy

Self‐Report Moderate to Severe Pain Numerator: J0400, J0600A, J0600B

Pressure Ulcers that are New or Worsened

Numerator: M0800A, M0800B, M0800CCovariates: G0110A1, H0400, I0900, I2900, K0200A, K0200B

Newly Received an AntipsychoticMedication

Numerator: N0410AExclusions: I6000, I5350, I5250

Made Improvements in Function Numerator: G0110B1, G0110D1, G0110E1Exclusions: B0100, J1400, O0100K2, A0310GCovariates: A0800, A0900, C0500, C0700, C1000, G0110A1&B1, G0110D1&E1, G0110G1–J1, I0600, I3900, I4000, I4500

Assessed and Given Appropriately the Seasonal Influenza Vaccine

Numerator: O0250A, O0250C


Numerator: O0300A, O0300B

Short Stay: Audit for Accuracy


Falls with a Major Injury Numerator: J1900CExclusions: J1800

Self Reported Moderate to Severe Pain Numerator: J0400, J0600A, J0600BExclusions: J0200, J0300Covariates: C0500, C1000

High Risk Residents with Pressure Ulcers

Numerator: M0300B1, M0300C1, M0300D1High Risk: G0110A1, G0110B1, B0100, I5600

Urinary Tract Infection Numerator: I2300

Catheter Numerator: H0100AExclusions: I1550, I1650Covariates: H0400, M0300B1, M0300C1, M0300D1

Long Stay

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Residents Who Lose Control of Their Bowel or Bladder

Numerator: H0300, H0400Exclusions: C0500, C0700, C1000, G0110A1, G0110B1, G0110E1, B0100, H0100A, H0100C

Physically Restrained Numerator: P0100B, P0100C, P0100E, P0100F, P0100G

Need for Help with Daily Activities has Increased

Numerator: G0110A1, G0110B1, G0110H1, G0110I1Exclusions: B0100, J1400, O0100K2

Who Lose Too Much Weight Numerator: K0300

Long Stay

Long Stay

Measure

Depressive Symptoms Numerator: D0200A2, D0200B2, D0300, D0500A2, D0500B2, D0600Exclusions: B0100

Who Received an Antipsychotic Medication Numerator: N0410AExclusions: I5250, I5350, I6000

Ability to Move Independently Worsened Numerator: G0110E1Exclusions: B0100, O0100K2, J1400Covariates: G0110B1, G0110D1, G0110H1, G0110I1, C1000, C0500, C0700, A0800, A0900, B1000, O0100C2

Prevalence of Falls Numerator: J1800

Who Used an Antianxiety of Hypnotic Medication Numerator: N0410B, N0410DExclusions: J1400, O0100K2

Prevalence of Antianxiety/Hypnotic Use Numerator: N0410B, N0410DExclusions: E0100A, E0100B, I5250, I5350, I5700, I5900, I5950, I6000, I6100

Prevalence of Behavior Symptoms Affecting Others Numerator: E0200A, E0200B, E0200C, E0800, E0900

Assessed and Given Appropriately the SeasonalInfluenza Vaccine

Numerator: O0250A, O0250C

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Long Stay

Measure


Numerator: O0300A, O0300B

Admission and Discharge Functional Assessment and Care Plan

Numerator: A2100, A2000, A2400C, GG0130A1‐3, GG0130B1‐3, GG0130C1‐3, GG0130E2,GG0130F2, GG0130G2, GG0130H2, GG0170A2, GG0170B1‐3, GG0170C1‐3, GG0170D1‐3, GG0170E1‐3, GG0170F1‐3, GG0170G2, GG0170I1‐3, GG0170J1‐3, GG0170K1‐3, GG0170L2,GG0170M2, GG0170N2, GG0170O2, GG0170P2, GG0170R1‐3, GG0170RR1 & 3,GG0170S1‐3, GG0170SS1 & 3

Measure

Drug Regimen Review Numerator: N2001, N2003, N2005Denominator: A0310H

Changes in Skin Integrity Post‐Acute Care: Pressure Ulcer/Injury

Numerator: M0300B1–2, M0300C1–2, M0300D1–2, M0300E1–2, M0300F1–2, M0300G1–2Covariates: GG0170C, H0400, I0900, I2900, K0200A–B

Discharge Self Care Numerator: GG0130A3, GG0130B3, GG0130C3, GG0130E3, GG0130F3,GG0130G3, GG0130H3Exclusions: A0310G, A0900, A2100, A2400, B0100, O0100K2, O0400B1–3,O0400C1–3Covariates: A0900, B0700, B0800, C0500, C0900, C1310, G0600D, GG0100A–B, GG0110, GG0130A1–H1, H0100D, H0300, H0400, I0020, I0100I0400, I1500, I2100, I2900, I4300, I4500, I4800, I4900, I5000, I5100, I5200, I5250, I5300, I8000, J2000, K0510A–B, M0300A–G, O0100J1, O0100M2,O0500I

QRP FY2020: Approved Measures Data Collection Began Oct. 1, 2018

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Measure

Discharge Mobility Numerator: GG0170A‐P (Column 3)Exclusions: A0310G, A2100, A2400, B0100, O0100K2, O0400B1–3, O0400C1–3Covariates: A0900, B0700, B0800, B1000, C0500, C0900, G0600D, GG0100B, C, & D, GG0110, GG0170A1–P1, H0300, H0400, I0020, I0100, I0400, I1500, I2000, I2100, I3900, I4300, I4500, I4800, I4900, I5000, I5100, I5200, I5800I5900, I5950, I6000, J1700, J2000, K0510A–B, M0300A–G, O0100J1, O0100M2, O0500I


Measure

Change in Self Care Numerator: GG0130A‐H (Columns 1 & 3)Exclusions: A0310G, A2100, A2400, B0100, O0100K2, O0400B1–3, O0400C1–3Covariates: A0900, B0700, B0800, C0500, C0900, C1310, G0600D, GG0100A & B, GG0110, GG0130A1–H1, H0100D, H0300, H0400, I0020, I0100, I0400,I1500, I2100, I2900, I4300, I4500, I4800, I4900, I5000, I5100, I5200, I5250,I5300, J2000, K0510A–B, M0300A–G, O0100J1, O0100M2, O0500I

Change in Mobility Numerator: GG0170A‐P (Columns 1 & 3)Exclusions: A0310G, A2100, A2400, B0100, O0100K2, O0400B1–3, O0400C1–3Covariates: A0900, B0700, B0800, B1000, C0500, C0900, G0600D, GG0100B, C, & D, GG0110, GG0170A1–P1, H0300, H0400, I0020, I0100, I0400, I1500,I2000, I2100, I3900, I4300, I4500, I4800, I4900, I5000, I5100, I5200, I5800,I5900, I5950, I6000, J1700, J2000, K0510A–B, M0300A–G, O0100J1, O0100M2, O0500I


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Audit GG MDS Accuracy

• Why?• PDPM Category Implications

• PT• OT• Nursing

• QRP• The IMPACT (Improving Medicare Post‐Acute Care Transformation) Act of 2014 required standardized data

collection across post‐acute care settings: skilled nursing facilities (SNF), long‐term care hospitals (LTCH), inpatient rehabilitation facilities (IRF), and home health agencies (HHA). In response to the reporting requirements under the IMPACT Act, CMS established the SNF Quality Reporting Program (QRP). SNFs that do not submit the required measure data may receive a 2% reduction to their annual payment update (APU) for the applicable payment year. The measure cannot be calculated if the MDS item set is missing (e.g., PPS Part A Discharge assessment not submitted) or if the MDS item was not assessed (e.g., dashed).

• Will be publically reported in 2020• Change in Self Care• Change in Mobility• Discharge Self Care• Discharge Mobility

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How does PEPPER apply to providers?

PEPPER is a roadmap to help you identify potentially vulnerable or improper payments

Providers are not required to use PEPPER or to take any action in response to their PEPPER statistics

But:Why not take advantage of this free comparative report provided by CMS?

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Obtaining Your PEPPER• PEPPER is distributed annually in electronic format.

• PEPPER Resources Portal:– Visit PEPPER.CBRPEPPER.org.

– Click on the “PEPPER Distribution – Get Your PEPPER” link.

– Review instructions and access portal.

• Each release of PEPPER will be available for approximately two years from its original release date.

• PEPPER cannot be sent via email.

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New Website: PEPPER.CBRPEPPER.org

PEPPER User’s Guides

National‐ and state‐level data

Recorded PEPPER training sessions

Sample PEPPERs

Success Stories

Help Desk

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Questions?

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