PDPM Part 9: The Role of Therapy in the Nursing and Non- Therapy Ancillary (NTA) Components

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.

CMS Improvements to Recovery Audit Process

The size of the Medicare program is astronomical – the system processes over one billion claims a year. CMS uses several types of contractors to verify that Medicare Fee for Service (FFS) claims are paid based on Medicare requirements. One type of contractor is a Recovery Audit Contractor (RAC). The Medicare FFS RAC Program is one of many tools used to prevent and reduce improper payments. RACs identify and correct overpayments made on claims for health care services provided to beneficiaries, identify underpayments to providers, and provide information that allows CMS to prevent future improper payments.

However, in the past there were numerous complaints about the RAC program. Providers found the audits time-consuming, necessitating high administrative expenses, and often requiring lengthy appeals. CMS listened to what providers were telling them and made meaningful changes. That input informed their thinking as they re-examined all aspects of the RAC process. They identified areas where they could reduce provider burden and appeals, and increase program transparency, while enhancing program oversight and effectiveness.

On May 3rd, CMS Administrator Seema Verma, outlined the key improvements and enhancements that were made to the program including:

  • Better Oversite of RACs:
    • Accountable for maintaining a 95% accuracy score.
    • Maintain an overturn rate of less than 10%.
    • Contingency fee will be delayed until after the second level of appeal is exhausted.
  • Reducing Provider Burden and Appeals:
    • Must audit proportionally to the types of claims a provider submits.
    • Conduct fewer audits for providers with low claims denial rates.
    • Allow more time to submit additional documentation before needing to repay a claim.
  • Increasing Program Transparency:
    • Regularly seeking public comment on proposed RAC areas for review.
    • Required enhancements to provider portals for claim status understanding.

While the audits can become cumbersome and overwhelming at times, ensuring that the care being provided is the most appropriate for each individual patient will only continue to assist in getting the health system where it needs to be. The improvements outlined above have helped and will to continue to help make patient care, not paperwork compliance, the main focus of providers.

CMS’ blog regarding recovery audit improvements:

https://www.cms.gov/blog/recovery-audits-improvements-protect-taxpayer-dollars-and-put-patients-over- paperwork

More information on the Medicare FFS Recovery Audit Program can be found at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS- Compliance-Programs/Recovery-Audit-Program/

Indictment of Anthem Breach Hackers

Do you remember hearing about the Anthem breach in 2015? Hackers infiltrated Anthem’s network and breached the personal health information of 78.8 million patients. This was one of the worst data breaches in US history if not the worst. There is some good news being reported. The Department of Justice has indicted two China-based hackers for the Anthem hack and breach.

How did the hackers do it?

The hackers allegedly used methods to hack including spear-phishing emails sent to employees embedded with links. After the employee clicked on the link, the malicious malware was installed to infect and compromise the system. Once inside the system, the hackers installed what is called a “backdoor” which in this case was undetected by the organization infected. This “backdoor” allows the hackers to come and go as they please. Although the hack was discovered in 2015, it began in 2014 with the hackers coming through the back door and conducting reconnaissance to identify information of interest.

What is the Lesson Learned?

Be on the lookout for “phishy” emails. Here are a few tips to assist in identifying Phishing emails.

  1. Does the email invoke a sense of urgency, fear, or curiosity?
  2. Does it ask you to click a link, open an attachment or provide your user Id/password or other sensitive information?
  3. Do you know the person that sent the message and were you expecting it? Hackers can “spoof” messages meaning they make it look like it is coming from a known sender when it is not. If you know the sender but were not expecting it, contact the sender by a means other than email to confirm.

What to do when you suspect a phishing email?

For Reliant employees who use Reliant’s email, a “Phish Alert Button” was recently implemented within the email system. This button is easily accessible within the user’s email and allows the suspicious email to be reported at the click of a button. After clicking this button, it alerts the Reliant support team and allows security measures to be quickly added to prevent others from clicking on similar malicious e-mails.

Customers who don’t have a similar “Phish Alert Button” in place, should report suspicious emails to their support team through established reporting processes.