Under PDPM Specifics of the PT, OT, and SLP Classifications Kim - PDF document

5/16/2019 Comprehending and Maximizing Under PDPM – Specifics of the PT, OT, and SLP Classifications Kim Barrows, RN, BSN President of KB Post-Acute Strategic Specialist Mary Braun, RN Nurse Consultant for KB Post-Acute Strategic Specialist 1 PT and OT Case-Mix Classification Groups • What is important in this classification group: “The Criteria” • Primary diagnosis for the SNF stay: Item I0020B • Surgical procedures associated with the primary dx performed during the preceding hospital stay: J2100-J5000 • Functional score: section GG • Variable per diem 2 1

5/16/2019 PT and OT Classification Diagnosis • Primary Diagnosis • Step 1: Classifies the resident into a clinical category • Step 2: Adjustments to the clinical category may be made in cases where the resident received a surgical procedure during the preceding hospital stay associated with that diagnosis. 3 Section J 4 2

5/16/2019 Section J – Cont’d 5 PT/OT Classification Diagnosis • J2100-Recent surgery requiring active SNF car e • If no, resident will remain in the default clinical category derived from Section I • If yes, the resident will convert the resident into a surgical primary clinical category • J2300-J5000 • Only 1 procedure checked is necessary. But check as many that pertain for an accurate assessment • In items with “other” will not affect the clinical category • Ex: 2499 Spinal Surgery - other 6 3

5/16/2019 PT/OT Classification Diagnosis For PT and OT Classification PDPM Clinical Category Major Joint Replacement or Spinal Surgery Non-Orthopedic Surgery Step 3: Based on the primary diagnosis Acute Neurologic and the occurrence of a surgical Non-Surgical Orthopedic/Musculoskeletal intervention the resident is then Orthopedic Surgery (Except Major Joint classified into one of ten clinical Replacement or Spinal Surgery) categories. Medical Management Acute Infections Cancer Pulmonary Cardiovascular and Coagulation 7 PT/OT Classification Diagnosis PDPM Clinical Category Major Joint Replacement or Spinal Surgery Major Joint Replacement or Spinal Surgery Non-Orthopedic Surgery Non-Orthopedic Surgery and Acute Neurologic Acute Neurologic Non-Surgical Orthopedic/Musculoskeletal Other Orthopedic Orthopedic Surgery (Except Major Joint Replacement or Spinal Surgery) Medical Management Acute Infections Cancer Medical Management Pulmonary Cardiovascular and Coagulation 8 4

5/16/2019 PT/OT Classification Diagnosis • Mapping of the ICD-10 diagnosis and/or surgical procedures that will be used to classify the resident into one of the ten clinical categories is located on the SNF website: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html • The spread sheet has 4 columns • ICD-10 DM code - has drop down to sort A - Z or Z - A • Description - has drop down to sort A - Z or Z - A • Default clinical categories- has drop down listing the 10 clinical categories • Return to Provider-invalid primary diagnosis • Will not provide a PDPM classification • The record will reject when submitted 9 PT/OT Classification Diagnosis 10 5

5/16/2019 ICD-10 DM Code 11 Description 12 6

5/16/2019 Default Clinical Category 13 Major Procedure During the Prior Inpatient Stay 14 7

5/16/2019 PT/OT Classification Diagnosis • S22040S - Wedge compression fracture of fourth thoracic vertebra, sequela 15 PT/OT Classification Diagnosis • M80861P - Other osteoporosis with current pathological fracture, right lower leg, subsequent encounter for fracture with malunion 16 8

5/16/2019 PT/OT Classification Diagnosis • M00072 - Staphylococcal arthritis, left ankle and foot 17 PT/OT Classification Diagnosis • H53121 - Transient visual loss, right eye 18 9

5/16/2019 PT/OT Classification Diagnosis • Strategies for Successful ICD-10-CM Barriers • Determine the primary diagnosis as a TEAM • Can start now, day after a new admission meet as a team to determine the primary diagnosis • Updated ICD-10-CM manuals • Triple Check • Maintain an accurate diagnosis list 19 PT/OT Classification Diagnosis • Pitfalls leading to Unsuccessful ICD-10-CM coding • Do not use “unspecified” codes • Do not code resolved diagnosis • Incorrect seventh character (for fractures/injuries) • “A” - Initial encounter • “D” - Subsequent encounter • “S” - Sequela • Coding a diagnosis that has not been documented by a physician 20 10

5/16/2019 Let’s Run Through Section I Diagnosis Example • Hospital COC has Dx M84.345S- • Clinical Mapping - Stress Fracture L finger sequella • Maybe eligible for 1 of 2 orthopedic categories • From the clinical mapping 21 Let’s Run Through Section J -Surgery Related Items • Resident admitted to SNF on 10/30/19 • Hospital records indicate that resident was involved in MVA 10/20/19 where he sustained multiple bone fx and abdominal injuries. Major surgeries include: • Surgery to repair comminuted fx of L wrist • ORIF to repair fx bilateral tibia/fibula, lower legs, • Large Bowel Resection (Partial Colectomy) • ORIF to repair fx L clavicle • Resident admitted to SNF for Nursing, PT, OT services 22 11

5/16/2019 Coding Section J 23 PT/OT Classification Functional Score • Functional Score • Calculated from Section GG • Functional Score will range 0 - 24 • Increasing score now means increased independence • There is no direct relationship between increasing dependence and increasing payment • Promotes CMS goal of standardizing assessment items across all payment settings • Also better coordinates payment with other quality initiatives • For the PT/OT components the score is based on 10 items have been highly related to PT/OT costs per day 24 12

5/16/2019 PT/OT Classification Functional Score 10 Items 1 – 1 – Oral 2 – Bed Eating Hygiene Mobility Item Item 3 – 1 – 2 – Transfer Toileting Walking Items Item Items 25 PT/OT Classification Functional Score Definitions 26 13

5/16/2019 Section GG Self Care Items 27 Section GG Mobility 28 14

5/16/2019 PT/OT Classification Functional Score 29 PT/OT Classification Functional Score • The two tables the first including the 2 walking items • The second table, excluding the walking items; The additional response “Resident cannot walk” • Makes it possible for those residents who cannot walk for their assessments to still calculate a functional score. • Will use: • 07 - resident refused • 09 - not applicable • 10 - not attempted d/t environmental conditions • 88 - not attempted due to medical/safety concerns 30 15

5/16/2019 31 PT/OT Classification Functional Score • The final score: • Average score for 2 mobility items • Average score for 3 transfer items • Average score for average of 2 walking items • Score for eating • Score for oral hygiene • Score for toilet hygiene 32 16

5/16/2019 Calculating the Functional Score • From the MDS previous slide: • Eating - 3 = 2 pts • Oral hygiene - 3 = 2 pts • Toileting hygiene - 2= 1 pt • Sit to lying - 2= 1 pt • Lying to sitting on side of the bed - 2 = 1 pt • Sit to stand - 3 = 2 pts • Chair/bed-to-chair transfer – 2 = 1 pt • Toilet transfer - 3 = 2 pts • Walk 50 ft with 2 turns - 88 = 0 pts • Walk 150 ft - 88 = 0 pts 33 Calculating the Functional Score Do the Math • Eating - 2 pts • Plus • Oral hygiene - 2 pts • Plus • Toilet hygiene - 1 pt • Plus • Average 2 items for bed mobility 1 + 1 = 2 divided by 2 = 1 • Average 3 items for transfers 2 + 1 +2 = 5 divided by 3 = 1.6666 • Average 2 items for walking 0 + 0 = 0 divided by 2 = 0 34 17

5/16/2019 Calculating the Functional Score • 2 + 2 + 1 + 1 + 1.67 + 0 = 7.67 • Rounded up at the end • Functional score 8. 35 PT/OT Case Mix Classification Groups 36 18

5/16/2019 Putting it all together to get a PT/OT Classification Group • MDS completed, coding included: • Section I-I0200B coded: M97.11XS – • Peri prosthetic fx around internal prosthetic R knee joint sequella. • Clinical category from mapping- Major Joint Replacement or Spinal Surgery • Section J-J2000 coded: yes • Section J-J2100 coded: yes • Section J-J2300: checked • Functional score calculated section GG: 6 • What is PT/OT Case Mix Group? • Answer? 37 Variable Per Diem Adjustment/Factors PT/OT Component Medicare Payment Days Adjustment Factor 1-20 1.00 21-27 0.98 28-34 0.96 35-41 0.94 42-48 0.92 49-55 0.90 56-62 0.88 63-69 0.86 70-76 0.84 77-83 0.82 84-90 0.80 91-97 0.78 98-100 0.76 38 19

5/16/2019 Bonus Question: Variable Per Diem Adjustment • Resident admitted on 10/10/19 • 5 Day PPS ARD 10/17/19 with PT/OT Classification Group Score: TB • Date is now 10/21/19 • With the Variable Per Diem • For Medicare Payment Days, what adjustment factor will be applied to the PT/OT classification scores? • Adjustment Factor 1.0 • (100% of the rate) 39 Speech/Language Pathology Case-Mix Classification Group • What is important in this classification group. The Criteria: • Clinical Category • Derived from the primary diagnosis (I0020B) • Acute Neurologic • Cognitive Impairment • Presence of SLP related Comorbidity • Mechanically Altered Diet and/or Swallowing Disorder • Section K – Swallowing/Nutritional Status 40 20