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.

March 2019 Healthcare Data Breaches

The Health and Human Services Office of Civil Rights (OCR) is responsible for enforcing civil right laws. Covered Entities such as Skilled Nursing Facilities and Business Associates must comply with HIPAA regulations which includes reporting breaches of Protected Health Information (PHI). Breaches affecting 500 or more individuals are posted by OCR on a public website. Breaches affecting less than 500 individuals are also required to be reported but are not posted for public viewing.

To give you an idea of the information available on the public site using March 2019 data, there were 32 breaches reported with 500 or more individuals involving 951,252 individuals. Of these 32 breaches, there were 22 Healthcare Providers, 4 Health Plans, and 6 Business Associates involved.

The types of breaches consisted of

  • 20 – Hacking/IT Incidents
  • 8 – Unauthorized Access/Disclosure
  • 4 – Thefts

Breaches involving email and network servers accounted for 893,502 of the impacted individuals (see chart below). This is why security awareness training, good password management practices, and virus protection are so important.

For a list of the names of companies impacted and other information, visit the OCR portal at https://ocrportal.hhs.gov/ocr/breach/breach_report.jsf

FY2020 Skilled Nursing Facility (SNF) PPS Proposed Rule

On Friday, April 19, 2019, CMS released the FY2020 skilled nursing facility (SNF) proposed rule for public inspection and comment.

There is estimated to be a 2.5% market basket increase for FY2020 aggregate payments as calculated through a 3.0% market basket increase and a 0.5% multifactor productivity adjustment resulting in an $887 million annual increase.

The proposed rule includes three proposed changes related to the Patient Driven Payment Model (PDPM). First, CMS proposes changing the definition of group therapy in a SNF setting to match the definition in the IRF setting. Specifically, CMS proposes defining group therapy in the SNF Part A setting as “a qualified rehabilitation therapist or therapy assistant treating two to six patients at the same time who are performing the same or similar activities.”

Second, CMS proposes using a subregulatory process to provide non-substantive updates to ICD-10 codes used in PDPM through the PDPM website, while substantive changes will still be made through the traditional notice and rulemaking process. Non-substantive updates are those made to maintain consistency with the most recent ICD-10 code set. CMS is proposing that this take effect with the start of PDPM on October 1, 2019.

The third and final proposed change is to update the regulation text to reflect changes in the assessment schedule under PDPM which were already finalized in the FY2019 final rule. These changes are to reflect the policy taking effect under PDPM on October 1, 2019. For the initial patient assessment, the proposed regulation changes would state that “the assessment schedule must include performance of an initial patient assessment no later than the 8th day of post-hospital SNF care.” Additional proposed changes to regulation text would reflect the optional interim payment assessment.

SNF Quality Reporting Program

This rule proposes to update the SNF QRP effective October 1, 2020 to include:

  • Expansion of data collection for the SNF QRP quality measures to all skilled nursing facility residents, regardless of their payer.
  • The addition of two Transfer of Health Information quality measures.
  • Exclusion of baseline nursing home residents from the Discharge to Community Measure.
  • Public display of the quality measure, Drug Regimen Review Conducted with Follow-Up for Identified Issues.

Request for information (RFI) on the importance, relevance, appropriateness, and applicability measures of standardized patient assessment data elements (SPADEs) for future years in the SNF QRP.

SNF Value Based Purchasing Program

The SNF VBP Program is proposing to change the name of the program’s measure to the “Skilled Nursing Facility Potentially Preventable Readmissions after Hospital Discharge” measure. The measure will retain its previous abbreviation (SNFPPR).

The proposed rule also includes an update to the public reporting requirements to ensure that CMS publishes accurate performance information for low-volume SNFs.

CMS encourages comments from stakeholders. The comment period is open until June 18, 2019.

Download the proposed rule from the Federal Register. Download the CMS fact sheet.

To learn more about Reliant’s preparedness for PDPM, visit our website today.

PDPM Part 7: Changes in the Interdisciplinary Team Conversation

From an active diagnosis of endocarditis to an aphasia comorbidity, it is evident more than ever that physical therapists, occupational therapists, and speech language pathologists need to thoroughly review full body systems during evaluation for identification of the patient’s underlying conditions and comorbidities.

Under PDPM these holistic assessments extend beyond the impaired system and will allow the clinicians to bring relevant, meaningful clinical information to the interdisciplinary table. This information will contribute directly to the identification of SLP related comorbidities and the non-therapy ancillary comorbidity score to ensure the patient’s clinical classification is accurate and representative of the potential resource use needs during their stay.

A breakdown in this interdisciplinary collaboration may lead to missed opportunities for proper reimbursement. However, with extensive therapy evaluations and interdisciplinary collaboration, these opportunities won’t slip through the cracks.

Begin exploring how team conversations will change under PDPM and identify areas to improve interdisciplinary communication. Be on the lookout for Reliant resources relevant to interdisciplinary team success.

Changes to Nursing Home Compare in April 2019

The Centers for Medicare & Medicaid Services (CMS) has announced updates coming next month to Nursing Home Compare and the Five-Star Quality Rating System including:

  • Lifting the “freeze” on the health inspection star ratings
  • Automatically give one-star staffing ratings to nursing facilities that have four or more days per quarter with no registered nurse (RN) on site, down from the current threshold of seven or more.
  • Establishing separate quality ratings for short-stay and long-stay residents and revising the rating thresholds to better identify the differences in quality among nursing homes making it easier for consumers to find the right information needed to make decisions.

Read on for more information or visit the CMS Nursing Home Compare site.

Guidance Issued Regarding Immediate Jeopardy Situations

Earlier this month, Seema Verma, Administrator for CMS posted a blog entitled “Protecting the Health and Safety of All Americans”. In this blog, Seema states guidance is needed to address violations of health and safety regulations that cause serious harm or death to a patient and require immediate action to prevent further serious harm (immediate jeopardy).

In turn, CMS has issued guidance which clarifies what information is needed to identify immediate jeopardy cases across all healthcare provider types, which they believe will result in quickly identifying and ultimately preventing these situations. This new guidance can be found in Appendix Q of the State Operations Manual that federal and state inspectors use.

Access to CMS training

Revised Guidance Tools Read the full memorandum

SNF Provider Threshold Report (PTR) Now Available

The new Skilled Nursing Facility (SNF) Provider Threshold Report (PTR) is now available. This PTR is a user-requested, on demand report which enables users to obtain the status of their data submission completeness related to the compliance threshold required for the SNF Quality Reporting Program (QRP). For more information, click here.

SNF QRP Provider In-Person Training

The Centers for Medicare & Medicaid Services (CMS) will be hosting a 2-day Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) in-person ‘Train the Trainer’ event for providers on May 7 and 8, 2019. This event will be open to all SNF providers, associations, and organizations. Access more information here.

Guide to Personally Identifiable Information (PHI)

Whether at work, at home, or on the go, data that is often the top target of
cybercriminals is all around us. Protecting that data isn’t a highly technical process, but
rather one that requires common sense and a strong commitment to privacy in every
aspect our lives!


What is PII?
PII, or personally identifiable information, is sensitive data that
could be used to identify, contact, or locate an individual.


What are some examples of PII?
PII includes (but is not limited to) home addresses, personal email addresses,
national ID numbers, credit card numbers, and personal phone numbers.


What are some examples of non-PII?
Info such as business phone numbers and email addresses, race, religion,
gender, workplace, and job titles are typically not considered PII. But they
should still be treated as sensitive, linkable info because they could identify
an individual when combined with other data.


Why is PII so important?
On a personal level, our PII is necessary to acquire some goods and services, such
as medical care and utilities. But in the wrong hands, PII leads to identity theft
and other forms of fraud. On a professional level, you may store PII of customers,
clients, vendors, contractors, employees, and partners. If left unprotected, your
organization could face steep fines and your reputation could be severely damaged.


How do you protect PII at work?
Protecting PII begins and ends with following your organization’s security
policies, which were created to ensure that the data remains
private. Treat all requests for sensitive info with a high degree of scrutiny, stay
alert, think before you click, and if you have any questions, ask them!


How do you protect PII at home?
Develop a home security policy similar to those at work, which calls for common
sense practices, such as not clicking on random links and attachments, guarding
personal info online and in real life, destroying sensitive documents beyond
recognition and setting social media profiles to fully private.

The Customer Connect Webinar Series: A Collaborative Approach to Quality Outcomes

Every month on the third Thursday, Reliant’s Clinical Services offers a webinar to our partners on relevant topics within our industry.

March’s training Restoring Your Restorative Nursing Program provided participants with information regarding the importance of restorative nursing programs, reviewed the criteria for these programs, and identified strategies for successful implementation.

Join us in April for:
A Deep Dive into the PT and OT Components of the
Patient Driven Payment Model (PDPM)

Virginia’s Journey Home

Regan Mclaughlin, OT and Caitlyn Boldt, SLP of Reliant Rehabilitation share Virginia Rannebarger’s journey from stroke to home. Partnering with our facilities for the success of our patients is our passion! Congratulations Virginia, it was a pleasure to be a part of your journey. We know you are enjoying being home and “crafting” again.

PDPM Part 6: High Fives, Whys, Collaboration and Communication

Earlier this month, Reliant hosted regional directors for its annual leadership conference in Plano, Tx. The first day, attendees were inspired by Roy Tuscany of the High Fives Foundation. He offered a patient’s perspective for clinicians and presented a call to shift from the “standard protocol” to the “patient protocol.”

Through his personal story and rehabilitation journey he detailed the importance of cultivating hope in our patients and a killer high five. He emphasized it’s not just the control, attitude, and effort of the patient that effects outcomes and recovery, but the clinician’s control, attitude, and effort that ignites success.

Day two opened with keynote Heath Slawner. Heath passionately detailed the importance of claiming and living out purpose. He led the audience through an exercise to evaluate personal reasoning for our daily choices, during which he stated “start with why.” What is your why? Recognizing and embracing the reason we set out to become a clinician, administrator, or other healthcare professional provides perspective. Knowing your company’s why allows for a common culture and approach to executing product delivery.

These speakers offered the perfect complement to the remainder of the conference which focused greatly on planning and preparing for PDPM. This is the sixth installment of the Reliant Reveal PDPM series. Previous articles have focused on the structural frame work of the model, details surrounding function score calculation, strategies for training, and coding success. Within each article, and the education we have created to date, a complementary theme is emerging: the importance of collaboration and communication.

Success under PDPM may be related to contract considerations, amassed resources, and field education; however, longitudinal success- the success that produces outcomes, will be directly impacted by each care professional’s ability to effectively collaborate and communicate for the patient’s care needs.

Facilities should begin moving from the standard protocol of care to an elevated, patient-driven protocol. This protocol will empower the evaluating therapist to collaborate with nursing to ensure comorbidities are accurately and timely identified. Therapists will bring to the table the clinical characteristics to be identified on the MDS, discharge planning notes, and knowledgeable discussions surrounding the clinical reason for admission.

The successful facility under PDPM will have a clearly defined “why” complemented by Reliant’s why: Care Matters. This is the heartbeat of our daily practice, service delivery, communication and collaborative approach to patient care.

Skilled Nursing Facility Open Door Forum Call

CMS held the first skilled nursing facility (SNF) open door forum (ODF) call for this year on February 14, 2019. The call included updates on CMS’ PDPM website, the SNF Quality Reporting Program (QRP), and Payroll-Based Journaling (PBJ).

SNF QRP Update:

  • CMS announced they are contracting with RTI international to develop and maintain additional SNF QRP quality measures.
  • RTI is convening a Technical Expert Panel (TEP) to inform the direction and development of a claims-based measure of healthcare-associated infections in SNF. For information on this project and nomination steps visit the SNF QRP website.

PBJ Update:

  • Fourth quarter (10/1/18-12/31/18) PBJ staffing data will be considered timely if it was submitted by 2/14/19 and will be posted on Nursing Home Compare.

CMS provided separate emails for questions concerning technical aspects and policy related issues.

Patient Driven Payment Model (PDPM) Updated Wepage

CMS provides a Patient Driven Payment Model (PDPM) web page which houses a variety of resources (comorbidity mapping tools), fact sheets, and a training presentation.

During the open door forum, CMS announced updates to the materials found on the PDPM webpage in response to stakeholder feedback including:

  • The training presentation has been replaced with the National Provider Call from December 2018,
  • The classification walk-through document has been updated, and
  • The FAQ document has been updated.

Skilled Nursing Facility Provider Review Reports

Skilled Nursing Facility (SNF) Provider Preview Reports have been updated and are now available. Providers have until March 4, 2019 to review their performance data prior to the April 2019 Nursing Home Compare site refresh, during which this data will be publicly displayed. Corrections to the underlying data will not be permitted during this time; however, providers can request CMS review of their data during the preview period if they believe the quality measure scores that are displayed within their Preview Reports are inaccurate. 

To view the full memo and data contained within the report click here.

Program for Evaluating Payment Patters Electronic Report (PEPPER)

Clinical Appeals Corner

PEPPER is an educational tool that summarizes provider-specific data statistics for Medicare services that may be at risk for improper payments. Providers can use the data to support internal auditing and monitoring activities. PEPPER provides resources for using the report, including user’s guides, recorded web-based training sessions and a sample PEPPER.

The PEPPER team has recently updated the maps that display the PEPPER retrieval rates by state. See how you compare and download yours today! Visit PEPPER site.