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.