CMS issued their updated their guidance to Medicare Administrator Contractors (MACs) on November 15, 2019 regarding Medical Review Instructions related to Skilled Nursing Facilities in Publication 100-08 Medicare Program Integrity, Transmittal 924. The effective date of these updates is October 1, 2019 and the implementation date is December 17, 2019. Below is the guidance to Medicare Contractors.

Contractors shall:

• Determine the appropriateness of SNF PPS payments based upon the patient’s condition and the application of the CMS prescribed case-mix model and payment classification system.
• Base their medical review decisions on documentation provided to support the coding and medical necessity of services recorded on the Minimum Data Set (MDS) for the claim period billed.
• Focus on the unique, individualized needs, characteristics and goals of each patient, in conjunction with our payment policies, to determine the appropriateness of the case-mix classifier billed.
• Contractors reviewing demand bills shall– (i) review the medical record to determine that both technical and clinical criteria are met; and (ii) if so, and some or all services provided were reasonable and necessary, use the MDS QC System Software (as necessary) to determine the appropriate case-mix classifier.
• Assess HIPPS codes to ensure accuracy of each HIPPS Code.
• Note that the Interim Payment Assessment (IPA) is an optional assessment that providers may complete to report a change in the patient’s classification. If an IPA has been completed, contractors shall examine the medical documentation as described in this chapter.
• Review for reasonable and necessary determination, determine whether the services indicated on the MDS were rendered and were reasonable and necessary for the beneficiary’s condition as reflected by medical record documentation.
• If the reviewer determines that none of the services provided were reasonable and necessary or that none of the services billed were supported by the medical record as having been provided, deny the claim in full.
  • Note that the previously mentioned policy that allows the 5-day assessment to trigger a presumption of coverage applies only when the SNF admission directly follows discharge from a prior qualifying hospital stay.
• Note that the billed case-mix classifier is supported by the associated provider documentation-considering all available information in determining coverage.
• Determine the continued need for, and receipt of, a skilled level of care based on the beneficiary’s clinical status and skilled care needs for the dates of service under review for days after the assessment reference date of the 5-day assessment.
• Pay claims according to the case-mix classifier value calculated using the MDS QC tool, regardless of whether it is higher or lower than the case mix classifier billed by the provider.
• Verify that the case-mix classifier submitted on the claim matches the case-mix classifier on the MDS imported from the national repository into the MDS QC tool, and:
  • If the facility case-mix classifier obtained through the MDS QC tool matches the case-mix classifier submitted on the claim, pay the claim as billed for all covered days associated with that MDS, even if the level of therapy changed during the payment period.
  • If the facility case-mix classifier obtained through the MDS QC tool does not match the case-mix classifier submitted on the claim, pay the claim at the appropriate level based on the case mix classifier level on the MDS submitted to the repository for all covered days associated with that MDS, even if the services provided changed during the payment period.
• If some skilled services were appropriate while others were not reasonable and necessary or were not supported by the medical record as having been provided as billed, and the reviewer determines (based on data entered from the medical record into the MDS QC System Software) that:
  • The discrepancies are such that they do not result in a change in the case mix classification level as calculated by the MDS QC tool, during the relevant assessment period for the timeframe being billed, accept the claim as billed for all covered days associated with that MDS, even if the level of skilled care changed during the payment period.
  • There is another case-mix classifier for which the beneficiary qualifies, pay the claim according to the correct case-mix classifier calculated using the MDS QC System Software for all covered days associated with that MDS and recoup any overpayments as necessary.
• Deny the claim from the date on which the beneficiary no longer meets level of care criteria if the reviewer determines that the beneficiary falls to a non-skilled level of care at some point during the period under review.
  • Note: A partial denial is defined as either the disallowance of specific days within the stay or reclassification into a lower case mix classifier.
• Make partial denials based on classification into a new case-mix classification code or a full denial because the level of care requirement was not met are considered reasonable and necessary denials and are subject to appeal rights.
  • Note: It is important to recognize the possibility that the necessity of some services could be questioned and yet not impact the case-mix classification. The case-mix classification may not change because there are many clinical conditions and treatment regimens that qualify the beneficiary for the case-mix classifier to which he or she was assigned.

Gina Tomcsik
Director of Compliance and Regulatory Strategy

 

In less than two short weeks the Post Acute Care world will see the biggest change in reimbursement in over 20 years. PDPM here we come.  How daunting is this, most of your employees have never practiced outside of the RUG world.  But remember, the healthcare environment thrives on change.  Imagine practices that did not routinely implement change, patient care would stagnate.  Employees would get frustrated and bored, yes, we healthcare providers, as much as we may complain, also thrive on change.  For we know with change comes better practices and better outcomes.

Despite the inevitable of knowing changes are coming, to be in position for the best opportunity to succeed, staff members must be supported while implementing new processes.  Support your staff and each other by ensuring everyone is aware of the expectations they will be accountable for. 

When the new practices include required documentation changes, it is always best to incorporate those changes into the EHR making it a mandatory field if necessary.  If the new documentation is a regulatory requirement the chances of staff overlooking the field is minimized when the new sections are made mandatory. If the software will not allow advancing to next screen until the mandatory field is addressed, you have a higher chance of success.

Openly discuss the pros and cons with employees.  This will help leaders to understand the fears and concerns of employees and assist with addressing them before you have noncompliance.  It is not helpful to minimize staff members concerns about implementing change.

Transitional times equate to good days and bad days. It’s crucial to stay the course and keep the lines of communication open.  Opt for a “helpline” where employees who are unsure of new processes can make a quick call to an expert for reassurance or guidance.

Use your resources. There is a plethora of excellent resources available, when in doubt, don’t guess… read, ask, call for help.  Remain positive, change takes time.  Despite preparations, when new processes are implemented people initially react slower as they become more familiar with the new ways.  When employees understand that they have leadership support through the upcoming changes it is a smoother transition overall.  Hang in there, it will be smooth sailing soon.

 

Lisa Chadwick
Director of Safety and Risk Management

Well my friends, it is time to seriously review your Patient-Driven Payment Model (PDPM) transition strategy.  October 1st  is just around the corner.  Over the past nine months, at Functional Pathways, we have had a robust educational campaign to prepare and position our staff and clients to be ready to thrive under the PDPM system. From on-site intensive management training, component calculations, Clinical Pathways, and client webinars, we have been working diligently to prepare for this major transition in the Medicare Part A payment model.

Some final transition thoughts for your consideration:

1. Have you fine-tuned your Pre-Admission and Post-Admission Meetings?
2. Are you receiving all necessary clinical documentation from the hospital?
3. Is your nursing and therapy documentation reflective of skilled care to paint a picture of the resident’s condition to support the PDPM clinical categories?
4. How effective is your IDT in identifying the Primary Reason for the SNF admission?
5. What opportunities exist for capturing the entire clinical characteristics of the resident?
6. How effective is your Medicare Meeting?
7. How efficient and effective is your Triple Check process?
8. Do you have an effective Restorative Nursing Program?
9. Does your Therapy Department have Clinical Pathways to focus on functional rehabilitation?
10. Are you ready to complete Interim Payment Assessment when transitioning residents who span from RUG-IV to PDPM?
11. What is your plan for effectively tracking Interrupted Stays?

These are just some things to be thinking about.  But most importantly, we have to be ready to ensure the transition from RUG-IV to PDPM is seamless and portrays the entire clinical picture of each Medicare Part A resident.

What should you be working on the week before October 1st?

1. Develop a list of Medicare Part A residents who will be transitioning from RUG-IV to PDPM (skilled in September and will continue to be skilled October 1st and beyond).
2. The residents on this list must have an IPA ARD set no later than October 7th, 2019.
3. Provide the resident list to the IDT to ensure they are aware of the requirements for the “transition” IPA in order to complete their sections of the MDS IPA item sets.
4. Utilize a transition checklist to ensure you are capturing all clinical characteristics on the IPA that are documented in the resident’s medical record. If you are a Functional Pathways’ client partner, our checklist is available on our client portal.
5. Finalize your Pre- and Post-Admission Meeting process.
6. Finalize the IDT process for determining the primary reason for the SNF admission; ensure all IDT Department heads are aware of the process; finalize how you will be communicating with the IDT on what the primary reason for the SNF admission ICD-10-CM code is.
7. Finalize new RUG-IV Medicare Part A resident’s 5-day MDS.
8. Discuss with your Director of Rehab (DOR) their plan for managing the group and concurrent minutes.

What should you do on October 1st?

1. Finalize/confirm the list of residents who are transitioning from RUG-IV to PDPM with the IDT.
2. Utilizing your transition list of residents, open your “transitional” IPA assessment and set the ARD. *Remember: must be set no later than October 7th (can set the ARD 10/1/19-10/7/19).
3. Ensure all item sets for the IPA are completed as usual.
4. Confirm the BIMS score.
5. Confirm the PHQ-9 score.
6. Confirm the accuracy of capturing SLP related co-morbidities.
7. Confirm accuracy of nursing criteria for the nursing component.

Most importantly, try not to panic! Panicking will produce a feeling of being overwhelmed and mistakes will happen. You got this and we, your therapy partner, are here to help and support you!

Functional Pathways Resources available:

• Your Functional Pathways Director of Rehab;
• Your Functional Pathways Area Director of Operations;
• Your Functional Pathways Regional Vice President of Operations;
• Derhonda Thomas, Functional Pathways’ Vice President of Operations: dthomas@fprehab.com;
• Melissa Ward, Functional Pathways’ Vice President of Clinical and Regulatory Affairs: mward@fprehab.com;
• Karen Welsh, Functional Pathways’ Director of Clinical Outcomes: kwelsh@fprehab.com;
• Gina Tomcsik, Functional Pathways’ Director of Compliance and Regulatory Strategy: gtomcsik@fprehab.com;
• Beth Reigart and Jennifer Callahan, Functional Pathways’ Clinical Outcomes Specialists: breigart@fprehab.com; jcallahan@fprehab.com
• Functional Pathways’ PDPM Academy (Client Portal): com/pdpm-academy
• PDPM@fprehab.com inbox

Let’s get excited about PDPM!  It’s been a long 20 years! But now, we are no longer at the mercy of RUG levels!

Gina Tomcsik
Director of Compliance and Regulatory Strategy

 

“The oldest and strongest emotion of mankind is fear, and the oldest and strongest kind of fear is fear of the unknown.

Howard Phillips Lovecraft

As we approach the implementation of the Patient-Driven Payment Model (PDPM) on October 1, 2019, most of us are beginning to experience the anticipation of this significant change.  Not since the implementation of the Prospective Payment System (PPS/RUGs) in 1998 has the long-term care industry faced change of such magnitude.

For most of us, we have a regular routine in our work life.  Humans prosper in life through monotony and certainty which aligns with a sense of autonomy.  As we start to address the required changes for PDPM, we may find ourselves in a state of ambiguity and resistance. Our dreads arise often due to the fear of the unknown and unfamiliar. However, whether we like it or not, change is inevitable and essential these days for companies to flourish. PDPM will allow therapists to focus on the quality of care they provide, not the minute management of the RUGs system. It will now embrace many ways to provide service including concurrent and group without the limitations imposed under PPS. Collaboration between members of the Interdisciplinary Team will be enhanced to improve patient outcomes.

Efficiently managing change in the workplace is vital for any company’s success. Functional Pathways has created the PDPM Academy, MedBridge, and intranet resources to guide the transition.  Remember, this change will affect everyone in your community, not just our Therapy Teams. Handling all of this transformation can be intimidating. However, being capable of managing change effectively is important for your career. Instead of going astray, begin preparing for effectively managing change and integrating modifications into your professional life with these seven tips.

Keep your emotions under control

Managing change is not an easy feat. It can leave you exhausted and drained not just physically, but mentally as well. While sudden changes in the workplace can be daunting, it is important to keep your emotions in check when dealing with them.

Be prepared

First step to managing change successfully is to accept the fact that change is inevitable. Take advantage of the resources provided by Functional Pathways to become prepared. Remember, change is the only constant in this world. Hence, it is better to be prepared instead of getting caught off guard.

Show flexibility

Be open to the way your SNF and Director of Rehab (DOR) will be moving the dial.  Being flexible is one of the best ways to embrace PDPM.  Comprehensive evaluations, functional outcomes and ways to effectively minimize risk of re-hospitalizations will be key to the new payment model.

State the facts and be honest

Share your thoughts and ideas to help resolve the challenges you will face.  It takes a village – everyone will need to be supportive, honest, and receptive to feedback.

Understanding the change cycle

There is no one-size-fits-all solution when it comes to change management. Every person has a different pace and acceptance level. While some quickly adapt to changes, others may take months to adjust. An open attitude and willingness to be patient will be helpful.  We will master the new system and things will fall into a routine eventually.  Remember, communication is the key.

 

Become part of the change

Implement an approach of enthusiasm and view change as an opportunity instead of hurdle. Concurrent and group therapy will now be an important component of our treatment delivery system.  Commit to becoming engaged in new modes of service delivery. You will feel positive, more empowered, and less dreadful. Shrug off any negative thoughts about change and become a part of it. Believe it or not, you will find these to promote patient engagement and fun!

Diminish stress and nervousness

Too much stress produced by change can make us feel exhausted and drain out all our energies. This may be the optimal time to look at ways to handle the stress.  Concentrate on your own physical and mental fitness to stay healthy. Indulging in quick sessions of meditation or even walking can adequately clear your mind of wary thoughts. Consider creating a method to support your peers through team building activities such as lunchtime walks, cover dish lunches, or live and learn sessions

Change is unavoidable and absolutely necessary for the success of our company and clients. If  every individual is prepared to embrace PDPM, we will emerge with better outcomes, higher levels of patient/family satisfaction, and stronger coordination of care . While change can be terrifying and unsettling, but with the correct approach, viewpoint, and activities, one can find prospects in every change.

As Lao Tzu said:

Life is a series of natural and spontaneous changes. Don’t resist them; that only creates sorrow. Let reality be reality. Let things flow naturally forward in whatever way they like.

Beth Reigart
Clinical Operations Specialist

As we move closer to the new world of PDPM, it is very important that our occupational therapy teams continue focus on functional intervention during their treatment session.  This is a great article from the American Occupational Therapy Association which could easily be implemented with our teams.

 

Hide the Cones & Pegs: How an OT Implemented “Functional Fridays”

AOTA Staff
6/6/2019

We love hearing how AOTA members are implementing the Choosing Wisely® five occupational therapy interventions to question in their practices. Cody LaRue, MS, OTR/L, was so inspired by Choosing Wisely that he instituted a new practice called “Functional Fridays” at his facility, Encompass Health Rehabilitation Hospital of Petersburg in Petersburg, VA.

“Our emphasis is always on function,” LaRue says. “But sometimes having certain preparatory activities within reach can cause temptations to use a less than optimal modality for our clients.”

So the team decided to hide the preparatory items in a closet to challenge each OT practitioner on staff to be more occupation-based with their clients.

How do they make Functional Fridays work? Here are three steps that helped it succeed:

Step 1: They approach it as a learning opportunity for the whole team. 

LaRue shared thoughts and principles he learned while preparing for his presentation at AOTA’s Annual Conference & Expo, “Find Me the Function: Throwing Out the Cones, Pegs, and Putty.” The team discussed some of the challenges they face with using functional treatment (treating clients with limited occupational interests and clients at lower functional levels).

Step 2: They problem solve as a team to come up with ideas. 

During OT meetings, the team discusses new ideas by delving into their patients’ interests to really make the most of the limited time they have with each patient (generally 10 to 14 days).

Step 3: They hide the preparatory items in a closet. 

On Fridays the items are out of reach and out of mind. After we started, “every therapist was in the ADL kitchen and even tabletop activities appeared to be activities one would be performing upon returning home,” LaRue says.

What has been the result? “I’ve witnessed a noticeable increase in overall functional treatment,” says LaRue. “Both because therapists have seen the benefits of providing more creative functional treatments but possibly because of the stigma that may now be associated with some of the preparatory items.”

Providing high quality occupational therapy is even more important as major payment changes are beginning to roll out in Medicare, like the Patient-Driven Payment Model (PDPM) in skilled nursing facilities (SNFs). Starting October 1, SNFs will no longer be reimbursed at higher rates for a higher volume of occupational therapy services; practitioners will need to avoid low-value OT (e.g., ROM exercises) and focus on the high value skilled OT services (e.g., ADLs).

To prepare for the PDPM, you should begin by asking yourself whether you’re providing high value OT interventions to your clients. Implementing a “Functional Friday” can be a great way to encourage high quality interventions at your facility and with your OT team.

“I wanted to challenge the team by really causing them to think outside the box,” LaRue says. “This is truly an area that I have a passion for, from getting patients out into the community regularly on outings to creating the most realistic scenarios in our hospital for our patients to succeed at home.

Beth Reigart
Clinical Outcomes Specialist

Beginning October 1, 2019 providers will need to begin coding a new set of Health Insurance Prospective Payment System (HIPPS) codes in Section Z0100A of the MDS as well as on the Part A claim. This coding of HIPPS codes will identify the resident’s SNF PDPM classification for payment.

Like RUG-IV HIPPS codes, PDPM will also use five characters in the HIPPS code.  Below is a breakdown of what each character represents:

1. The first character represents the resident’s PT and OT payment group.
2. The second character represents the resident’s SLP payment.
3. The third character represents the resident’s nursing payment group.
4. The fourth character represents the NTA payment group.
5. The fifth character represents the resident’s assessment used to classify the resident.

Keep in mind that PT and OT use the same component classification process so they will have the same payment group. For this reason, they will share one character of the HIPPS code.  Another thing to keep in mind is that even though PT and OT use the same classification process, their case-mix is calculated separately. CMS provides this example: a resident who classifies into the TC case-mix group for PT will also classify into the TC case-mix group for OT. But the TC will pay differently for PT than OT due to the base rate difference and Case-Mix Indexes.

 

 

 

Example 1: PT/OT Payment Group: TN SLP Payment Group: SH Nursing Payment Group: CBC2 NTA Payment Group: NE Assessment Type: Initial Medicare Assessment HIPPS Code: NHNE1

Example 2: PT/OT Payment Group: TC SLP Payment Group: SD Nursing Payment Group: NC NTA Payment Group: PBC1 Assessment Type: Initial Medicare Assessment HIPPS Code: CDXC1

 

Keep an eye on CMS PDPM Webpage for updates.

 

Gina Tomcsik
Director of Compliance

PDPM!  I am sure you have heard about this new payment system by now, right? As you prepare and position yourself for this major change, we have to not only understand all of the moving parts, but more importantly, how all of those moving parts affect resident classification. MDS Section J will play a major role in determining resident classification and is no “J”oking matter!

 

Let’s take a look at the current RAI manual instructions for Section J, specifically section J2000, where the question is asking, “Did the resident have major surgery during the 100 days prior to admission?” Why is this important? The RAI manual explains that if the resident had a major surgery during the 100 days prior to the SNF admission, this surgery can affect the resident’s recovery.

 

How to assess? Ask the resident and his or her family or significant other about any surgical procedures in the 100 days prior to the SNF admission.  Review the resident’s medical record to determine whether the resident had major surgery. Review records received from facilities where the resident received care during the previous 100 days. The most recent history and physical, transfer documents, discharge summaries, progress notes, and other resources as available are crucial for proof of the major surgery.  Receiving paperwork from the hospital is extremely important, especially surgical reports.  We need to work diligently to receive the supporting documentation from the hospital to ensure appropriate resident care is provided in the SNF as well as to appropriate classify the resident into an appropriate PDPM classification.

 

CMS defines a ‘major surgery’ that meets all of the following criteria in the MDS 3.0 RAI User’s Manual

1. The resident was an inpatient in an acute care hospital for at least one day in the 100 days prior to admission to the SNF, and
2. The surgery carried some degree of risk to the resident’s life or the potential for severe disability.

 

In the draft item set in section J2100, the MDS asks the question, “Did the resident have a major surgical procedure during the prior inpatient hospital stay that requires active care during the SNF stay?” If the Nurse Assessment Coordinator answers ‘Yes’ (J2100=1), the next step is to check all that apply in the following areas:

 

Major Joint Replacement.

J2300. Knee Replacement – partial or total.

J2310. Hip Replacement – partial or total.

J2320. Ankle Replacement – partial or total.

J2330. Shoulder Replacement – partial or total

 

Spinal Surgery.

J2400. Involving the spinal cord or major spinal nerves.

J2410. Involving fusion of spinal bones.

J2420. Involving Iamina, discs, or facets .

J2499. Other major spinal surgery.

J2599. Other major orthopedic surgery.

 

Other Orthopedic Surgery.

J2500. Repair fractures of the shoulder (including clavicle and scapula) or arm (but not hand).

J2510. Repair fractures of the pelvis, hip, leg, knee, or ankle (not foot).

J2520. Repair but not replace joints.

J2530. Repair other bones (such as hand, foot, jaw).

 

Neurological Surgery.

J2600. Involving the brain, surrounding tissue or blood vessels (excludes skull and skin but includes cranial nerves).

J2610. Involving the peripheral or autonomic nervous system – open or percutaneous.

J2620. Insertion or removal of spinal or brain neurostimulators, electrodes, catheters, or CSF drainage devices J2699. Other major neurological surgery.

 

Cardiopulmonary Surgery.

J2700. Involving the heart or major blood vessels – open or percutaneous procedures.

J2710. Involving the respiratory system, including lungs, bronchi, trachea, larynx, or vocal cords – open or endoscopic.

J2799. Other major cardiopulmonary surgery .

 

Genitourinary Surgery.

J2800. Involving male or female organs (such as prostate, testes, ovaries, uterus, vagina, external genitalia).

J2810. Involving the kidneys, ureters, adrenal glands, or bladder – open or laparoscopic (includes creation or removal of nephrostomies or urostomies).

J2899. Other major genitourinary surgery.

 

Other Major Surgery.

J2900. Involving tendons, ligaments, or muscles.

J2910. Involving the gastrointestinal tract or abdominal contents from the esophagus to the anus, the biliary tree, gall bladder, liver, pancreas, or spleen – open or laparoscopic (including creation or removal of ostomies or percutaneous feeding tubes, or hernia repair).

J2920. Involving the endocrine organs (such as thyroid, parathyroid), neck, lymph nodes, or thymus – open.

J2930. Involving the breast.

J2940. Repair of deep ulcers, internal brachytherapy, bone marrow or stem cell harvest or transplant.

J5000. Other major surgery not listed above

 

Why is it important for classification to ensure proper coding of major surgery under PDPM? By coding appropriately, there may be a change in the component clinical category. Some ICD-10-CM codes can map to a different clinical category if the resident received a surgical procedure during the prior inpatient hospital stay that relates to the primary reason for the SNF Part A admission. In order for this change, the surgical procedure must be recorded in section J of the MDS (J2000).

 

Gina Tomcsik
Director of Compliance and Regulatory Strategy

 

Restorative nursing is important to your facility now and will be under the new Patient Driven Payment Model (PDPM) payment system. Ensuring that our residents have services to improve or maintain their functional abilities is imperative for resident outcomes and to reduce medical risk factors and rehospitalization’s.

The restorative nursing program hasn’t changed over the years. However, instituting a standard of importance regarding restorative nursing programs is needed.

Let’s talk about section O of the minimum data set (MDS) under PDPM and how restorative nursing plays a vital role in calculating the Nursing Component.

In section O of the MDS, Special Treatments, Procedures, and Programs, restorative nursing programming is drafted to be recorded in section O0500, just like it is now. Restorative nursing is important to the Centers for Medicare and Medicaid Services (CMS) and we know this because CMS has included this important resident care programming as criteria to classify the resident in Nursing Categories under PDPM. This last two Nursing Categories, Behavioral Symptoms and Cognitive Performance and Reduced Physical Function, is where Restorative Nursing plays a vital role in establishing the Behavioral Symptoms and Cognitive Performance as well as the Reduced Physical Function Category.  The following will be recorded on the MDS:

• Range of motion (Passive) (MDS section O0500A);
• Range of Motion (Active) (MDS Section O0500B);
• Splint or Brace Assistance (MDS section O0500C);
• Bed Mobility (MDS section O0500D);
• Transfer (MDS section O0500E);
• Walking (MDS section O0500F);
• Dressing and/or Grooming (MDS section O0500G);
• Eating and/or Swallowing (MDS section O0500H);
• Amputation/Prostheses Care (MDS section O0500I); and
• Communication (MDS section O0500J)

Why is it important to revitalize your Restorative Nursing Program?  You probably already know the answer to this question.  If the resident doesn’t fall in any of the other four PDPM Nursing Categories, you won’t be able to capture the true care needs of the residents and appropriately classify them in a PDPM Nursing Category.  But more importantly, residents will suffer without an effective Restorative Nursing Program.  Quality Measures will suffer and the risk of rehospitalizations may increase.  If you provide and capture Restorative Nursing Programs, along with recording at least six days per week and 15 minutes per day per program, you will greatly calculate in to the Behavioral Symptoms and Cognitive Performance and Reduced Physical Function PDPM Nursing Category.

How do I revitalize my Restorative Nursing Program?

Evaluate your current restorative nursing program.

• Is it consistently being done?
• Do you have enough staff to support the restorative needs of your residents?
• Brainstorm on how to incorporate restorative nursing beginning day one of the resident’s stay.
• Revitalize your commitment to ensuring a consistent and effective restorative nursing program.

Why is it important to revitalize your Restorative Nursing Program?  You probably already know the answer to this question.  If the resident doesn’t fall in any of the other four PDPM Nursing Categories, you won’t be able to capture the true care needs of the resident and even though the resident will classify into a PDPM Nursing Category, the financial impact will be minimal.  But more importantly, residents will suffer without an effective Restorative Nursing Program.  Quality Measures will suffer and the risk of rehospitalizations may increase.  If you provide and capture Restorative Nursing Programs, along with recording at least six days per week and 15 minutes per day per program, you will greatly calculate in to the Behavioral Symptoms and Cognitive Performance PDPM Nursing Category or the Reduced Physical Function PDPM Nursing Category.

 

How do I revitalize my Restorative Nursing Program?

Evaluate your current restorative nursing program.

• Is it consistently being done?
• Do you have enough staff to support the restorative needs of your residents?
• Brainstorm on how to incorporate restorative nursing beginning day one of the resident’s stay.
• Revitalize your commitment to ensuring a consistent and effective restorative nursing program.

Preparing yourself for PDPM is extremely important and a piece of that preparation is to ensure you position yourself to be able to effectively categorize residents into a PDPM Nursing Clinical Category and ensure you are consistently and effectively providing preventative medical services. After all, preventing functional declines in communication and swallowing deficits, decreasing falls, decreasing skin integrity issues, to name a few, and maintaining the highest functional level of our residents is not only required but is our duty as health care professionals. 

Restorative Nursing Programming can start on day one of the resident’s stay. Why not explore this new way of thinking? Improving the overall skilled nursing facility experience will ultimately produce great outcomes, decrease rehospitalization’s, and improve resident and family satisfaction.

What could be better than a great community reputation and being the provider of choice because your resident care is superb? I can’t think of anything more satisfying!

 

For our Functional Pathways’ Clients, we offer Restorative Nursing Program auditing services conducted by our Clinical Reimbursement Specialist. 

For more information regarding this service, please contact vbair@fprehab.com.

 

Gina Tomcsik
Director of Compliance and Regulatory Strategy

CMS has updated the patient classification FAQ on February 14, 2019.  In this updated FAQ, CMS clarifies where the primary reason for the SNF stay will be coming from.

It was previously noted that the ICD-10 code that reflects the reason for the SNF stay would pull from form MDS section I8000A.  However, this updated patient classification FAQ clarifies that this critical piece to the patient classification system will now pull from a newly added line item in Section I, I0200B.  This item will ask what the main reason the patient is being admitted to the SNF.  It will be coded with item I0020 when coded as any 1-13 category responses.

This updated fact sheet explains, “ICD-10-CM codes, coded on the MDS 3.0 in Item I0020B, are mapped to a PDPM clinical category. This clinical classification, based on the primary SNF diagnosis, may be adjusted in cases where the patient received a surgical intervention during the preceding hospital stay associated with that diagnosis. These surgical procedures are captured in items J2100 through J5000 on the MDS. On the basis of the patient’s primary diagnosis and presence of a surgical category, the patient is then classified into one of the ten clinical categories listed in the table below”.

PDPM Clinical Categories- no change

Collapsed PT and OT Clinical Categories- no change

A mapping of the ICD-10 diagnosis and/or surgical category used to classify a SNF resident into each of the 10 clinical categories is available on the SNF website at:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html

In addition, there are new items to MDS section J (J2100-J5000).  This section will be used to capture if a surgical procedure was performed during the most recent qualifying hospital stay. Providers will need to check the boxes, and this will be used with the diagnosis code recorded in section I0020B for classification in to the PT and OT case-mix classification groups.

 

 

Gina Tomcsik
Director of Compliance and Regulatory Strategy

With the newly implemented enhancements (10/01/18) to the assessment-based quality measures (Section GG) , it is imperative to take time to time to reflect on our practice patterns.  This new process will provide statistical analysis for CMS to determine the effectiveness of our skilled rehabilitation services. The data will allow functional outcomes to be measured as a part of the national SNF quality performance methodology.  Transparency will become available through the CMS Nursing Home Compare website as the new scores become available.  https://www.medicare.gov/nursinghomecompare/search.html

This standardized approach to care will also promote successful transition to the next level of care.  As a result, we should be preparing our clients to achieve functional improvement in addition to identifying role of family members/caregivers along with assisted devices and durable medical equipment needs.

As we continue to provide excellence in rehabilitation services, do we have the opportunity to further provide therapy in a better way?

Occupational therapy staff should be scheduling regular times for activities of daily living (ADLs).  In addition, late afternoons can be used for practicing reverse ADLs.  During our treatment time in the gym, work on specific impairments can help to move the dial.  First point, residents should be moved out of their wheelchair to promote posture and core strength. Interventions should iclude static and dynamic balancing activities at the edge of bed/mat or while sitting in standard chairs (with or without arms).  Emphasis is place to dynamic movements to mimic the required functional tasks – reaching out of based of support, crossing midline, weight-shifting and flexibility throughout the body.  Practice transfers everywhere – it’s the true key to functional toileting!

 

If you have a treatment mat, physical therapy should  have a line of clients ready to use it! Again,  residents should be moved out of their wheelchair to promote posture and core strength. Rolling, supine to sit, sit to stand and transfers can be fast tracked  using the support of the hard surface and positioning devices as need. Consider use of the Otago fall prevention exercises as a component of your care plan.  Evidenced-base care is the way to go! Consider setting up an area to work on stair stepping and the distances identified in the mobility items in Section GG.  Determine the best way to assess car transfers at your facility.

 

As Functional Pathways continues to meet the changes to our regulatory requirements, find out how your outcomes reflect your clinical excellence.  Check out your facility scores on the CMS Nursing Home Compare website.  The new RightTrack® enhancements, Functional Pathways innovative product, will be rolled out in March, 2019.   It’s time to elevate our clinical reasoning and creativity to meet the needs of our clients.

 

Our new partnership with MedBridge will allow our occupational and physical therapists to obtain Section GG certification through online courses and competency testing.  Get ready … change in on the way!

 

Beth Reigart
Clinical Operations Specialist