Beginning yesterday, I’ve been following the news regarding CMS’ annual issuance of Final PPS rules for providers. Of greatest interest is the SNF Final Rule as it includes a completely new payment system, departing from the RUGS IV, therapy-centric system currently in-place. I’ve read through the Final Rule (all 424 mind-numbing pages) and summarized what SNFs need to know right now. I will undoubtedly expand upon the PDPM model as more is known and I’ve modeled claims via provider experience data.
RATE: The Final Rule includes a 2.4% increase to SNFs via adjustments to the RUGS IV categories/CMIs. NOTE: Providers that have not met their QRP (Quality Reporting) requirements/data submissions will receive a .04% increase – net of the 2% penalty.
SNF QRP: There were no changes made to the SNF QRPs in this rule. The Claims-Based Measures of, 1) Community/Post-Acute discharge; 2) Preventable re-hospitalizations (30 days post discharge), and; 3) Spending per Medicare beneficiary (SNF) remain. The Assessment-Based Measures of , 1) Falls with injury; 2) New or worsening pressure injuries post-admission, and; 3) Percent of patients with functional admission and discharge assessments and care plans. CMS did indicate that it will adopt a “burden” or return on investment test for adoption or removal of future measures.
SNF VBP: The impact of Value-Based Purchasing begins Oct. 1, 2018. This incorporates an incentive payment or penalty reduction for the lone applicable quality measure: 30 day re-hospitalization rates post SNF discharge. The Final Rule includes notably, an extraordinary circumstances exception policy plus discussion on future baseline periods for measurement, scoring changes, etc.
PDPM: This new payment system (Patient Driven Payment Model) is set to go into effect on October 1, 2019 (FY 2020). It will replace the RUGS IV system. It is case-mix driven, utilizing the MDS assessment tool to categorize resident care needs via five case-mix categories: Physical Therapy, Occupational Therapy, Speech Therapy, Nursing, and Non-Therapy Ancillary requirements. The base non-clinical case-mix category remains which captures the room and board and capital costs for SNFs (technical stuff here so no need for detail). As part of PDPM, only three assessments (MDS) are needed/required. The first is correlated to admission, the second to discharge and the third is related to change in condition/change in need. Payment, regardless of service utilization, is assessment driven via each case-mix category. Also gone from this system is any intensity measure of therapy services (no minute requirements or frequency). Added to the therapy requirements is a provision that as much as 25% (aggregate) of therapy treatment time can be group or concurrent. Based on data provided, the unadjusted Federal Urban PDPM rate (10/1/2019) would be $410.85 (before labor/wage adjustments). The Unadjusted Rural PDPM rate would be $425.37.
As in the Proposed Rule, PDPM incorporates a variable rate concept. The Final Rule maintained this concept unaltered. After day 20, rates begin to decline at a pace equal to 2% every 7 days, starting at day 21. The decline correlates to reductions in PT and OT rates (.03 per day) and a reduction in NTA (Non-Therapy Ancillary). More below on Non-Therapy Ancillary inclusions.
Under PDPM, residents are classified/coded via ICD 10 into one (only one) of ten clinical categories corresponding to the primary reason for the inpatient stay. CMS intends to map ICD-10 codes into the clinical categories for providers.
- Major Joint Replacement or Spinal Surgery
- Cancer
- Non-Surgical Orthopedic/Musculoskeletal
- Pulmonary
- Orthopedic (that doesn’t fall into #1)
- Cardiovascular and Coagulations
- Acute Infections
- Acute Neurologic
- Medical Management
- Non-Orthopedic Surgery
To accommodate higher-cost, sicker patients in the SNF setting, PDPM implements a Non-Therapy Ancillary case-mix. The NTA categories are below. Other than the first category of HIV/AIDS, each NTA is picked-up from a corresponding MDS item. Sorry for the length but I think the list is informative for providers.
HIV/AIDS
Parenteral IV Feeding: Level High
Special Treatments/Programs: Intravenous Medication Post-admit
Special Treatments/Programs: Ventilator or Respirator Post-admit
Parenteral IV feeding: Level Low
Lung Transplant Status
Special Treatments/Programs: Transfusion Post-admit
Major Organ Transplant Status, Except Lung
Active Diagnoses: Multiple Sclerosis Code
Opportunistic Infections
Active Diagnoses: Asthma COPD Chronic Lung Disease Code
Bone/Joint/Muscle Infections/Necrosis – Except Aseptic Necrosis of Bone
Chronic Myeloid Leukemia
Wound Infection
Active Diagnoses: Diabetes Mellitus (DM)
Endocarditis
Immune Disorders
End-Stage Liver Disease
Other Foot Skin Problems: Diabetic Foot Ulcer
Narcolepsy and Cataplexy
Cystic Fibrosis
Special Treatments/Programs: Tracheostomy Care Post-admit
Active Diagnoses: Multi-Drug Resistant Organism (MDRO)
Special Treatments/Programs: Isolation Post-admit
Specified Hereditary Metabolic/Immune Disorders
Morbid Obesity
Special Treatments/Programs: Radiation Post-admit
Highest Stage of Unhealed Pressure Ulcer – Stage 4
Psoriatic Arthropathy and Systemic Sclerosis
Chronic Pancreatitis
Proliferative Diabetic Retinopathy and Vitreous Hemorrhage
Other Foot Skin Problems: Foot Infection Code, Other Open Lesion on Foot
Complications of Specified Implanted Device or Graft
Bladder and Bowel Appliances: Intermittent Catheterization
Inflammatory Bowel Disease
Aseptic Necrosis of Bone
Special Treatments/Programs: Suctioning Post-admit
Cardio-Respiratory Failure and Shock
Myelodysplastic Syndromes and Myelofibrosis
Systemic Lupus Erythematosus, Other Connective Tissue Disorders, and Inflammatory Spondylopathies
Diabetic Retinopathy – Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage
Nutritional Approaches While a Resident: Feeding Tube
Severe Skin Burn or Condition
Intractable Epilepsy
Active Diagnoses: Malnutrition
Disorders of Immunity – Except : RxCC97: Immune Disorders
Cirrhosis of Liver
Bladder and Bowel Appliances: Ostomy
Respiratory Arrest
Pulmonary Fibrosis and Other Chronic Lung Disorders
Summary: Ten clinical categories essentially begin the coding process (reason for admit). From this point, each case-mix category is developed (PT, OT, SLP, Nursing and NTA). This is done via the admission MDS. The rate is constant for days 1-20 of the stay. Beginning on day 21, the rate reduces equal to 2% every additional 7 days. A change of condition MDS can occur, altering the rate variability (reduction) by change in patient need. One more assessment (MDS) is completed to recap the stay at discharge and capture QRP data. In the meantime, stay tuned for additional information and strategic tips on how to prepare for PDPM and what specifically, to know in interpreting the “best path/best-practices” at the facility level.