PDPM Part 3: Function Scores Here, Function Scores There, PT, OT and Nursing Everywhere!

Unless you’ve slept through the second half of 2018, you’re aware this year introduced updates to Section GG (Functional Abilities and Goals) and are at least familiar with the concept that Section GG plays a role in the Patient Driven Payment Model (PDPM). Today, let’s break down exactly how important of a role Section GG it plays in PDPM and the importance of accurate data collection.

Physical Therapy, Occupational Therapy and Nursing case mix groupers will be directly impacted by Section GG scoring and the PDPM Function Score. Read the full article here so when PDPM officially launches, communication is streamlined and your assessment team is confident in their data.

Reliant’s Section GG Flow Chart

Reliant’s Section GG Reference

CMS PDPM Functional Scoring Fact Sheet

Care Matters Spotlight: When the Real House Moms of Nocatee Unite After Hurricane Michael

Monday, October 8th: Catherine Schuman (Katie), an SLP at a facility in Ponte Vedra, FL, received notification their facility would be housing displaced residents evacuating from the path of Hurricane Michael. The residents and staff arrived with a few changes of clothes, prepared to return to Port St. Joe after Michael’s dissipation.

Wednesday, October 10th: Hurricane Michael devastated Port St. Joe in a way none of them expected. Homes were destroyed, vehicles flooded, and possessions lost.

Katie recognized the need immediately, not only for the residents, but the CNAs and nursing staff who accompanied them, and now had no idea when they would return home or what would be left. Katie has been part of a moms group in Ponte Vedra for several years now, and when it came time to elicit the generosity of the “Real House Moms of Nocatee” she didn’t hesitate.

The response to her call for adult clothing and toiletries was overwhelming. The donations received filled two rooms in the facility. Today she says “They’re good. There is enough.” Other organizations continue gathering for children and families affected, but Katie’s desire was to ensure her residents and colleagues were comfortable. Katie was insistent in sharing the thanks and praise with her fellow neighborhood moms because without them it wouldn’t have been possible to meet the need.

To the Real House Moms of Nocatee and Katie Schuman, thank you for your compassion and deliberate action to ensure our residents and staff are cared for. Katie, we are honored to have you as one of our own.

No Patient Left Behind

No Patient Left Behind (NPLB) trains our therapists in interpretation of quality indicator reports and the impact of quality measure reporting to aid in the care of facility residents. This month we’ll look a little closer at the third element: Linking Quality and Care.

Reliant believes in equipping our therapists with the knowledge and resources to address quality measures and changes in resident function timely. NPLB describes the quality indicators identified by Medicare as critical to patient care and dives into the distinct role physical, occupational and speech therapy play for each.

Updated Rankings Available for SNFs Participating in Value Based Purchasing Program

CMS is providing updated rankings for all SNFs included in the Fiscal Year (FY) 2019 VBP program year.

A list of each SNF’s incentive payment multiplier and updated ranking can be found on the SNF VBP website . The incentive payment multiplier applicable to each SNF is unchanged from the multiplier that CMS previously included in the SNF’s FY 2019 Annual Performance Score Report.That multiplier will be used to adjust the federal per diem rate otherwise applicable to the SNF for services furnished from October 1, 2018 through September 30, 2019. 

Keep Information Safe with Good Password Practices

These days we’re all overloaded with the number of accounts that require credentials and remembering them is impossible. Using the same password for different accounts is tempting—like having one handy key that opens every lock you use. But reusing passwords is not the solution.

Compromised passwords are one of the leading causes of data breaches, and reusing passwords can increase the damage done by what would otherwise be a relatively small incident. Cybercriminals know that people reuse credentials and often test compromised passwords on commonly used sites in order to expand the number of accounts they can access.

For instance, if you use the same password for your work email as for Amazon or your gym membership, a breach at one of those companies puts your work emails at risk. Reusing credentials is like giving away copies of the key that opens all your locks. Before reusing a password for different accounts, especially across work and personal ones, think of all the data that someone could get into if they got that credential.

Here are some tips to help you avoid falling in this trap:

• Use completely separate passwords for work and personal accounts.

• Avoid words that can easily be guessed by attackers, like “password” or “September2017,” or predictable keyboard combinations like “1234567,” “qwerty,” or “1q2w3e4r5t.”

• Add some complexity with capitalization or special characters if required. “Fido!sAnAwesomeDog” is a stronger password than your pet’s name.

• Just adding numbers or special characters at the end of a word doesn’t increase security much, because they’re easy for software to guess.

• Avoid words like your kids’ names that could easily be guessed by coworkers or revealed by a few minutes of online research.

• Answers to security questions are often easily found— your mother’s maiden name is public record—so pick another word for whenever that question comes up.

SNF Quality Reporting Program Submission Deadline Approaching

The deadline for the Skilled Nursing Facility (SNF) Quality Reporting Program MDS data submission for April 1, 2018-June 30, 2018 (2nd quarter) is November 15, 2018.
Review resources:

Current data collection (2018 4th quarter) includes new section GG items added on October 1, 2018. Download Reliant’s resource here .CMS recommends that providers run applicable validation/analysis reports prior to each quarterly reporting deadline in order to ensure all required data has been submitted.

PDPM Part 2: Idioms for ICD-10 Success

ICD-10 coding has never been so daunting! Thanks to search engine crosswalks and funny memes, the 2015 transition to ICD-10 did not leave any permanent scars, and most of us can now recall treatment codes with ease. However, ICD-10’s role in PDPM hasshuffled the deck. Suddenly, we are questioning our own knowledge and wondering if we have the skill set to be successful. 
As we prepare for the transition to PDPM, it’s important to remember, we’re all in the same boatICD-10 coding on the MDS directly maps our patients into case mix categories for payment. There is no buffer between coding and reimbursement. CODING IS reimbursement for physical therapy, occupational therapy, speech language pathology, nursing and non-therapy ancillary. CMS says the primary patient diagnosis allows us to identify the patient’s unique conditions and goals which should be the primary driver for care planning and delivery of services.
Many facilities already have the ingredients for a recipe of success: a collaborative effort between nursing and therapy is key in identifying each active condition on admission and changes in condition throughout the episode of care.  Let’s consider these additional idioms:
Don’t put all your eggs in one basket.

  • Having a designated ICD-10 coder is an awesome resource; however, never discount the input from the other skilled professionals interacting with the patient. Coders provide accuracy, but clinicians, physicians, and dietitians provide the details to hone that accuracy.

The devil is in the details.

  • If you’ve ever wondered whether each element on the MDS mattered, PDPM has given you the answer. The ICD-10 code entered in I0020B, the resident’s primary medical condition, will map case mix for physical, occupational, and speech therapy components. Beyond this, information entered into sections C, D, E, GG, H, I, J, K, M and O will contribute to classifying each resident, identifying conditions/comorbidities, and identifying the function score..

The ball is in your court.

  • Begin to put systems in place to identify active conditions of the resident. Reliant therapists perform a full system evaluation, so engage their input for areas which may have been missed. During daily stand up or triple check, include clinical condition conversations to quickly identify changes which may need to be reflected in coding.

Strong partnerships for understanding and implementing processes for ICD-10 is critical. As stated, coding impacts PT, OT, SLP, Nursing, and Non-therapy ancillary case mix groups. Accurate coding ensures resource availability for successful outcomes and patient satisfaction. Just remember, Rome wasn’t built in a day, so let’s start conversations now.

National Rehabilitation Awareness Week 2018!

Last week Reliant Rehabilitation therapists celebrated National Rehabilitation Awareness Week. This year’s theme was “Move Better, Feel Better, Live Better.” Therapy departments from around the country submitted photos of their teams and shared stories of patient satisfaction and facility praises.

We are proud to partner with you for outstanding functional outcomes and patient care. Thank you for choosing Reliant Rehabilitation.

CMS Released Proposed Rule to Promote Program Efficiency

On September 20, 2018 CMS released a proposed rule titled “Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction”. AHCA notes this proposed rule impacts regulations for 12 different types of healthcare providers and suppliers impacted by CMS requirements for emergency preparedness and hospice.

Comments are open through November 19, 2018. View proposed rule here.

Clinical Appeals Corner: Therapeutic Exercise Added to TPE Medical Reviews

Medicare Administrative Contractors (MACs) Palmetto (Jurisdictions J and M), Novitas (JH and JL), and CGS (J15) have each added new issues for their Targeted Probe and Educate (TPE) medical reviews. You can see all of these additions in the table at the end of this article. One new addition for Palmetto JJ and JM Part A (hospitals) is the review of outpatient therapeutic exercise, CPT code 97110. Palmetto does not include details of exactly what they will be looking for in this audit, but as noted above, rehabilitative therapy services have long been the subject of Medicare reviews. Several recently updated articles on the website of another MAC, Wisconsin Physician Services (WPS), identify some of the major concerns traditionally seen with therapy services.

Plan of Care Certification

According to a WPS article from the Comprehensive Error Rate Testing (CERT) A/B MAC Outreach & Education Task Force, “The leading cause of payment errors for therapy services is “insufficient” documentation in the medical records. Documentation is often missing the required elements as outlined in the CMS Internet-Only Manual (IOM) Publication 100-02, Chapter 15, Sections 220 and 230.” Specifically, the plan of care is often missing a legible, dated physician or non-physician practitioner (NPP) signature for certifying the plan of care (POC).

Certification by the physician or NPP certifies that individual needed therapy services are being provided under a POC established by a physician/NPP or by the therapist providing such services and periodically reviewed by a physician/NPP while the individual is or was under the care of a physician. Certification is required for coverage and payment of a therapy claim. Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care. In addition to the physician/NPP’s signature, the legible signature and professional identity of the individual who established the plan, as well as the date it was established, must be recorded with the plan.

Required elements of the plan of care include:

• Diagnoses (both medical diagnosis and patient’s functional limitations);

• Long term treatment goals that are measurable and pertain to the identified functional impairments; and

• Type, amount, duration and frequency of therapy services.

Documentation of Time

Medicare requires that the daily treatment note include total timed code treatment minutes and total treatment time in minutes. Most CPT codes used for therapy services specify the direct (one-on-one) time spent with the patient in per 15-minute intervals. This means the number of billable units for these codes is based on time. When more than one service represented by 15-minute timed codes is performed in a single day, the total number of minutes of all timed services determine the number of timed units billed. The minutes for all timed codes must be summed to determine the appropriate units to bill. Consider only the time actually spent in the delivery of the therapy service or modality. Pre- and post-delivery services are not to be counted in determining the treatment service time. This WPS article includes a chart of the number of units based on the minutes spent treating the patient and several examples of appropriate billing.

Services described by untimed therapy codes are reported as 1 unit. The time spent for these untimed services should also be documented and summed with the timed code minutes to report the total Reliant Rehabilitation Proprietary Information treatment time in minutes. However, do not include the minutes of untimed codes to determine the units of service to bill.

In addition to timed code treatment minutes and total treatment time minutes, the daily treatment notes should include:

• Date of treatment.

• Identification of each specific intervention/modality provided and billed (both timed and untimed codes).

• Signature and professional identification of the qualified professional who furnished the services; or, for incident to services, supervised the services, including a list of each person who contributed to the treatment.

Medical Necessity

Not as objective as the presence of a signature or the number of minutes, but equally important is documentation to support that therapy services are medically necessary and require the skills of a therapist. This is where the story told by the therapists in the evaluation, plan, progress notes, and treatment notes comes together to justify the need for therapy services.

Ask yourself if your documentation sufficiently addresses the following questions:

• Did the patient experience a significant decline in function that requires therapy?

• Would the patient have been able to recover function without therapy?

• Does the documentation include specific, objective measures of the patient’s prior level of function, current level of function, and expected level of function?

• Are the type, frequency, and duration of therapy services appropriate based on acceptable standards of medical practice and the patient’s condition and potential for improvement?

• Is the patient improving or regression prevented due to the therapy treatments?

• Has the patient reached maximum potential?

• Could therapy services or additional therapy services be safely and effectively furnished by nonskilled personnel?

One last WPS article that contains good information for therapy services can be found here.

Re-evaluations

Re-evaluations are not routine, recurring services and are covered only if the documentation supports the need for further tests and measurements after the initial evaluation. Re-evals are appropriate when:

• There are new clinical findings,

• There is a significant change in the patient’s condition, or

• The patient fails to respond to the therapeutic interventions outlined in the plan of care.

With all the attention over the years on therapy services documentation, hopefully your facility’s therapy documentation meets all of Medicare’s requirements and supports the need for skilled therapy services. It will be interesting to see what Palmetto finds on their TPE reviews.

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Reliant Rehabilitation Proprietary Information

PDPM: Qualifying for a Skilled Stay

As promised, each month Reliant will highlight a technical aspect or clinical component of the new Patient Driven Payment Model (PDPM). We believe these discussions will aide in understanding and minimize concerns regarding beneficiaries’ access to care. This month we will start at the beginning, qualifying for a skilled stay.

The criteria for a resident to qualify for a skilled stay has not changed under PDPM . Per the Medicare Benefit Policy Manual, care at the skilled nursing facility level is covered if the following four factors are met:

1. 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; 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. Skilled nursing and/or skilled rehabilitation must

a. Require the skills of qualified technical or professional health personnel such as registered nurses, licensed practical (vocational) nurses, physical therapists, occupational therapists, and speech-language pathologists or audiologists; and

b. Must be provided directly by or under the general supervision of these skilled nursing or skilled rehabilitation personnel to assure the safety of the patient and to achieve the medically desired result.

2. The patient requires these skilled services on a daily basis. Daily basis is defined to be a. “on essentially a 7-days-a-week basis” but clarifies that a beneficiary’s inpatient stay based solely on the need for skilled rehabilitation services would meet the “daily basis” requirement when they need and receive those services on at least 5 days a week.

3. 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.)

4. 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.

Under PDPM, as long as these four conditions are met, the beneficiary will qualify for a stay in your SNF. A review of skilled services defined (section 30.2) is always beneficial and highlights the continued need for therapy involvement in the beneficiary’s care.

As Reliant partners to prepare for PDPM, steps to evaluate current trends should be taken. Reliant recommends conducting a facility assessment of the current skilled needs within your facility. Evaluating important factors such as what percentage of residents are skilled for nursing only, therapy only, or a combination of the two? Within each category, what is the breakdown of services provided? Analysis of the facility assessment will guide in predicting resource needs and planning under PDPM, as well as lead to a seamless transition with successful outcomes.