RCS 1
Thank you for joining us today! Irene Henrich Director of Quality and Compliance ihenrich@careventures.net
RCS 1: Highlights and Timelines Resident Classification System, Version I May 2017 – CMS released the SNF PPS Advance Notice of • Proposed Rulemaking (ANPRM) July 2017 – CMS posted a Provider-specific Impact Analysis • representing estimated payments under RCS1 August 2017 – Deadline for the Comment Period regarding the • Proposed Policy October 2018 – Earliest that RCS 1 could become FINAL RULE • (most likely 2019) April/May 2018 – Final Rule may be released or announcement • of postponement ???
Why Replace RUGS? RUGS is an index-maximizing system has led to 90% of • residents having payments primarily driven by therapy services. CMS’ view that Therapy in SNFs is predicated on financial • considerations as opposed to resident needs. Multiple reports and studies published by the OIG and • MedPAC expressing concerns with “thresholding” and Ultra High domination. Insufficient Payment for Nursing Services and Ancillary • Services chiefly prescription drugs .
CMS Goals for RCS 1 • To improve targeting of resources to medically complex beneficiaries • To reduce incentives for SNFs to deliver therapy based on financial considerations • To promote consistency with other Medicare and PAC payment settings by basing resident classification on clinical information and minimizing the role of the ‘volume’ of service provision in determination of payment
RUGS vs RCS 1 RUGS RCS1 Payment Methodology Index-Maximizing Index-Combining 2 case-mix components + 2 non 4 case-mix components+ 1 none Components case-mix components case-mix component PPS Assessments 5 scheduled PPS assessments- 5-day, 1 scheduled PPS assessment – 14-day, 30-day, 60-day, 90-day 5-day Reimbursement Rates are constant throughout Rates decline throughout the the patient’s length of stay patient’s length of stay (front loading) Reimbursement Management Reimbursement relies on Therapy Services Management will shift to Nurses and Coders Diagnosis Coding No direct impact on reimbursement Diagnosis Coding will have a direct impact on reimbursement - Section I8000A of the MDS 3.0 Therapy Provision Reimbursement Engine Outcomes Engine
RCS 1 MDS Assessment Schedule Type Medicare MDS Assessment Assessment Applicable Standard Schedule Type Reference Dates Medicare Payment Days 5-day Scheduled PPS Days 1-8 All covered Part A days until Assessment Part A discharge Significant Change in Status No later than 14 days after a ARD of the assessment through Assessment (SCSA) significant change in Part A discharge identified PPS Discharge Assessment Equal to the End of Date of Therapy minutes rendered Most Recent Medicare Stay during the stay will be (A2400C) reported as part D/C Assessment
MDS Changes coming… (October 2018) • Section I – Primary Diagnosis Category – specific change that aligns with RCS 1 requirements • Additional items in Section GG • Section N - N2001 – Drug Regimen Review N2003 – Medication Follow-up N2005 – Medication Intervention
RUGS
RCS1
Determination of Payment in RCS 1 PT/OT SLP Nursing NTA 30 case-mix groups 18 case-mix groups 43 case-mix groups 6 case-mix groups (same as RUGS) Diagnostic Diagnostic Information Clinical information Comorbidities present Information (slide 10) from SNF stay (slide 14-16) (slide 10) Cognitive Status Cognitive Status (CFS) Extensive services Extensive services (CFS)(slide 11) (slide 11) received received Functional Status SLP-related Restorative nursing (slide 12) comorbidities services received (slide 13) Presence of swallowing disorder or mechanically altered diet (slide 13) Variable per diem Variable per diem adjustment adjustment 1% every 3 rd day First 3 days of the stay after Day 14 – 3 % adjustment For days 4-100 – 1% adjustment
Primary Diagnostic Clinical Categories RCS1 Primary Diagnosis PT/OT Clinical Categories SLP Clinical Categories (10 total) (5 total) (2 total) Major Joint Replacement or Spinal Major Joint Replacement or Non-Neurologic Surgery Spinal Surgery Surgical Procedures on Extremities Other Orthopedic Non-Neurologic Non-Ortho Surgery Non-Orthopedic Surgery Non-Neurologic Acute Infections Medical Management Non-Neurologic Cardiovascular and Coagulations Medical Management Non-Neurologic Pulmonary Medical Management Non-Neurologic Non-Surgical Ortho/Musculoskeletal Other Orthopedic Non-Neurologic Acute Neurologic Acute Neurologic Neurologic Cancer Medical Management Non-Neurologic Medical Management Medical Management Non-Neurologic
Cognitive Functional Scale The Cognitive Functional Scale (CFS) is • BIMS CPS CFS utilized in RCS 1 for PT/OT and SLP CFS Levels score score score payment components Cognitively 13-15 - 1 The CFS is calculated based on scores • intact from two other cognitive measures – Brief Mildly 8-12 0-2 2 Interview for Mental Status (BIMS) and the Impaired Cognitive Performance Scale (CPS). Moderately 0-7 3-4 3 BIMS is determined from MDS 3.0 • Impaired C0200 Repetition of Words Severely - 5-6 4 C0300 Temporal Orientation Impaired C0400 Recall C0500- BIMS Summary CPS - all MDS based
Functional Status Information needed for PT/OT • ADL Self-Performance Transfer Toileting Eating component Score 6-point measurement scale • Independent +3 +3 +6 3 ADLs considered- ‘late loss’ • Supervision +4 +4 +5 ADLs – these ADLs predict Limited Assist +6 +6 +4 resource use most accurately Extensive Assist +5 +5 +3 MDS Section G • Total Dependence +2 +2 +2 G0110B (transfers) Activity Occurred 1-2x +1 +1 +1 G0110I (toileting) Activity Did not Occur +0 +0 +0 G0110H (eating)
Speech Co-Morbidities Speech considerations MDS Item Description Presence of either … I4300 Aphasia Swallowing disorder (MDS item I4500 CVA,TIA, or Stroke K0100Z) I4900 Hemiplegia or Hemiparesis Mechanical diet ( MDS item I5500 TBI K0510C2) I8000 Laryngeal Cancer Presence of either … I8000 Dysphagia SLP related Comorbidity (see I8000 ALS table on right) I8000 Oral Cancer Mild to Severe Cognitive I8000 Speech and Language Deficits Impairment (CFS) O0100E2 Tracheostomy Care O0100F2 Ventilator or Respirator
NTA Comorbidity Score Calculation Condition/Extensive Service MDS Item NTA Tier Points HIV/AIDS n/a (SNF claim) Ultra-High 8 Parenteral/IV feeding – High K0510A2, Very High 7 Intensity K0710A2 Parenteral/IV feeding- Low K0510A2,K0710 High 5 Intensity A2,K0710B2 Ventilator/Respirator O0100F2 High 5 IV Medication O0100H2 High 5
NTA Comorbidity Score Calculation Condition/Extensive Service MDS Item NTA Tier Points Multidrug-Resistant I1700 Medium 2 Organism (MDRO) DM I2900 Medium 2 MS I5200 Medium 2 Asthma, COPD or Chronic I6200 Medium 2 Lung Disease Kidney Transplant Status I8000 Medium 2 Major Organ Transplant I8000 Medium 2 Status Chemotherapy O0100A2 Medium 2 Tracheostomy O0100E2 Medium 2 Transfusion O010012 Medium 2
NTA Comorbidity Score Calculation Condition/Extensive MDS Item NTA Tier Points Service Suctioning O0100D2 Low 1 Isolation or quarantine for O0100M2 Low 1 active infectious disease Wound Infection (other I2500 Low 1 than foot) Osteomyelitis and I8000 Low 1 Endocarditis DVT/Pulmonary Embolism I8000 Low 1 Stage 4 Pressure Ulcer M0300D1 Low 1 Diabetic Foot Ulcer M1040B Low 1 Radiation O0100B2 Low 1
NTA Case-Mix Classification Groups NTA Score Range NTA Group NTA Case-Mix Index 11+ NA 3.33 8-10 NB 2.59 6-7 NC 2.02 3-5 ND 1.52 1-2 NE 1.16 0 NF 0.83
PT/OT Case-Mix Groups Functional Mod/Severe PT/OT Case-Mix Case-Mix Clinical Category Score Cog Impairment Group Index Major Joint Replacement or 14-18 No TA 1.82 Spinal Surgery Major Joint Replacement or 14-18 Yes TB 1.59 Spinal Surgery Major Joint Replacement or 8-13 No TC 1.73 Spinal Surgery Major Joint Replacement or 8-13 Yes TD 1.45 Spinal Surgery Major Joint Replacement or 0-7 No TE 1.68 Spinal Surgery Major Joint Replacement or 0-7 Yes TF 1.36 Spinal Surgery
PT/OT Case-Mix Groups Functional Mod/Severe Cog PT/OT Case- Case-Mix Clinical Category Score Impairment Mix Group Index Other Orthopedic 14-18 No TG 1.70 Other Orthopedic 14-18 Yes TH 1.55 Other Orthopedic 8-13 No TI 1.58 Other Orthopedic 8-13 Yes TJ 1.39 Other Orthopedic 0-7 No TK 1.38 Other Orthopedic 0-7 Yes TL 1.14
PT/OT Case-Mix Groups Functional Mod/Severe PT/OT Case-Mix Score Cognitive Case-Mix Index Clinical Category Impairment Group Acute Neuro 14-18 No TM 1.61 Acute Neuro 14-18 Yes TN 1.48 Acute Neuro 8-13 No TO 1.52 Acute Neuro 8-13 Yes TP 1.36 Acute Neuro 0-7 No TQ 1.47 Acute Neuro 0-7 Yes TR 1.17
PT/OT Case-Mix Groups Functional Mod/Severe Case-Mix Case-Mix Clinical Category Score Cog Group Index Impairment Non-Ortho Surgery 14-18 No TS 1.82 Non-Ortho Surgery 14-18 Yes TT 1.59 Non-Ortho Surgery 8-13 No TU 1.73 Non-Ortho Surgery 8-13 Yes TV 1.45 Non-Ortho Surgery 0-7 No TW 1.68 Non-Ortho Surgery 0-7 Yes TX 1.36
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