In less than 6 months, the
long-awaited transition to the Patient Driven Payment Model (PDPM) will occur.
By now you’ve probably participated in multiple webinars and on-site meetings
regarding the shift to this new payment model. One of the most consistent
themes in these trainings is the use of the interdisciplinary team to ensure
accuracy with coding on the MDS. While it may be obvious why the therapy team
needs to contribute information for the physical therapy, occupational therapy,
and speech language pathology components of PDPM, it may be less obvious why
their input is crucial to the nursing and non-therapy ancillary components.
The nursing component within PDPM
employs the familiar hierarchical classification method for case mix
qualification. The most significant change from RUG IV is the removal of
Section G and the ADL score from the classification and the introduction of the
Section GG function score. The nursing, PT and OT function scores factor in
seven of the same GG late loss items. Unlike RUG IV, there is no direct
correlation between the function score and the case mix index (CMI). Therefore,
a lower function score does not necessarily mean a higher CMI. However, subtle
changes in reimbursement for nursing services provided is reflected in PDPM as
seen in the use of restorative programming, extensive services, present
condition, and physical function.
The non-therapy ancillary
component consists of fifty conditions, each assigned a weighted value of 1-8.
The weighted value is in direct proportion to pharmaceutical costs associated
with that condition. These point values are summed to determine the comorbidity
score for the patient. The higher the comorbidity score, the higher the CMI and
reimbursement. Additionally, PDPM accounts for higher pharmaceutical costs
early in the stay by front loading this CMI at 300% for the first 3 days of the
stay. A thorough review of the medical record, full body assessments, and
reconciliation of prescriptions to conditions must be completed to ensure all possible
comorbidities are captured on the MDS.
The rehabilitation team plays a
critical role in identification and accurate coding of clinical characteristics
for the resident in relation to the nursing and NTA components. By establishing
a foundation of understanding in relation to therapy’s role for each component,
as well as fostering clinical skills to conduct holistic, full system
evaluations the therapy team will aid in ensuring comorbidities are accurately
coded and help identify the appropriateness of restorative programming. The
conversations occurring at the interdisciplinary table regarding each new
resident will shift from the projected amount of therapy to review of clinical
conditions and care to allow for appropriate resources for the projected needs
of the resident.
PDPM is in many ways more of a
prospective payment system than RUG-IV has ever been. Therefore, with the
transition to PDPM, it is more important than ever for administration, nursing,
MDS coordinators, and therapy to coordinate together for accurate coding on the
MDS. If one piece of the interdisciplinary team is missing, important patient
information may fall through the cracks.
While an interim payment
assessment is always an option, capturing an accurate picture during the initial
assessment ensures the full intention of the PDPM reimbursement methodology is
captured for each component including the NTA’s variable per diem rate.