A Hard Stop and Fast Go: RUGs-IV to PDPM Transition

September is here, which means October 1st is less than 30 days away. Transitioning the patients receiving care under Medicare Part A to the PDPM September 30th to October 1st will require the planning and attention of the interdisciplinary team (IDT). Here are some IDT considerations for all Medicare A patients admitted prior to October 1st:

  • Payment for the month of September, regardless of admit date, must be transmitted using the RUGs IV classification system.
  • To receive payment for October 1st and beyond, a Transitional Interim Payment Assessment (IPA) must be completed and have an ARD set no later than October 7, 2019.
  • The facility has the normal transmission time frame of 14 days to submit the transitional IPA. Use this time and plan appropriately!
  • Remember! The patient’s care needs and plans do not change on October 1st. Only payment is changing. A therapy recertification or re-evaluation is not necessary, and the facility care plan is still active.
  • Therapy and nursing will need to complete interim Section GG scoring for the 10 Section GG items that produce the PDPM Function Score.
  • Discuss current caseload and any new admissions to identify all necessary comorbidities, clinical conditions and services, restorative nursing needs, primary reason for skilled admission, and surgical interventions during the most recent hospital stay.
  • Ensure timely communication of admissions for screening and/or completion of a holistic evaluation by therapy.
  • Plan for discharge destination and goals upon admission to allow for predictive length of stay and to identify patient specific education and resource needs.
  • Continue to coordinate care between therapy, nursing, and facility support staff to foster outstanding functional outcomes and safe transitions to the next level of care!

Your partners at Reliant Rehabilitation are here to help with the transition to the PDPM.  The Director of Rehabilitation at your facility has been provided extensive training and is equipped to facilitate therapy and collaborate with the facility through the October 1st transition.  Feel free to reach out to your Reliant partners with any questions or to help you problem solve.  Together, we can make this a smooth transition.

Return to Provider Codes and the Patient Driven Payment Model

ICD-10 Codes and PDPM Mapping

The Centers for Medicare and Medicaid Services (CMS) have identified, categorized, and mapped medical conditions through ICD-10 coding which predict payment for physical therapy, occupational therapy, speech therapy, nursing, and non-therapy ancillary needs.

Physical therapy, occupational therapy, and speech therapy will be categorized based on the primary diagnosis for the SNF stay as coded in item I0020B. This single primary diagnosis will then map to 1 of 10 PDPM clinical categories which directly impacts reimbursement.

Are “return to provider” codes allowed?

Certain codes entered in I0020B (primary reason for skilled stay) will map to “return to provider”. If a “return to provider” code is used in I0020B of the MDS, the claim will be returned for revision of the code entered in I0020B.

The “return to provider” codes include symptom codes that may be used by physical, occupational, and speech therapists as treatment diagnoses on their plans of care.

Examples include but are not limited to: M25.561 pain in right knee, M62.81 muscle weakness (generalized), R13.11 dysphagia – oral phase, R27.9 unspecified lack of coordination, R26.81 unsteadiness on feet, and R41.841 cognitive communication deficit.

Symptom codes do not represent the primary reason for the SNF stay; therefore, they are not appropriate for I0020B. However, they do support the highly specified and individualized treatment provided to the patient by therapy and must be coded by therapy as treatment diagnoses and reflected on the UB04 and other areas of the MDS. This coding ensures a full clinical picture of the patient’s clinical characteristics is provided and ensures the claim is supported in the event additional review is requested.

Ten Simple HIPAA Tips

  1. Ensure discussion of PHI (protected health information) is where you cannot be easily overheard. 
  2. ePHI should not be saved on unencrypted devices such as laptops, desktops, servers, USB drives, etc.
  3. When leaving your workstation unattended, logoff or manually lock your workstation.
  4. Computer equipment should not be left unsecured such as in an unattended vehicle or hotel room.
  5. PHI should not be left on a copier or scanner unattended.
  6. Paper PHI should be disposed of properly by shredding.
  7. Keep passwords safe. Do not write down or share your password.
  8. Double check fax numbers and email addresses to ensure you have the correct information before faxing or emailing PHI.
  9. Patient photos or stories require a signed authorization prior to taking or using. Authorization forms can be obtained on the Reliant portal.  
  10. Report suspected HIPAA violations to your supervisor or the company privacy officer.  Reliant employees may contact their Privacy and Information Security Officer at privacy@reliant-rehab.com.

HIPAA Happenings: Holiday Phishing

Cyber criminals take advantage of the holidays to disguise their phishing campaigns and malware as seasonally accepted email. Requests for donations to fraudulent organizations, bogus holiday advertisements, and posing as package delivery services are common this time of year.
Click here to view a real example of a phishing email impersonating Federal Express.

What to Do If You Suspect You Are a Victim of Phishing:

  • Change your password immediately.
  • Contact your IT Department.
  • For Reliant employees contact support@reliant-rehab.com or call 225-767-7670.