Author: Reliant Communications

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Year in Review: Client Connection

Reliant offers education opportunities monthly. Each topic is selected based on your feedback, regulatory changes, and industry trends. 2019’s schedule will be packed with information you don’t want to miss! Below are topics from 2018; let your Regional Director of Operations know if you missed one of these training sessions, and you’d like to know more!

  • Survey Preparedness
  • Therapy Cap Update
  • Discharge Planning: What’s Next?
  • Clinical Appeals Portal Demo
  • CMS Updates: SNF Proposed Rule
  • Fall Prevention: Tips to Make Your “Fall” Numbers Fall
  • 2018 MDS Updates: Section GG
  • Reducing Rehospitalizations Using S.O.S.
  • Partnering for Outcomes Using Reliant’s Model 10 2.0
  • Compliance Department Overview
  • Ringing in the New Year with Resolutions for Regulatory Success
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HIPAA Privacy Rule Refresher

Refresh your memory with some of the Privacy Rule points below.

• HIPAA’s Privacy Rule goal is to protect the confidentiality of patient/resident healthcare information.

• Protected Health Information (PHI) is individually identifiable health information collected from an individual and created or received by a health care provider, health plan, or health care clearing house relating to past, present, or future physical or mental health conditions of an individual.

• Information is “individually identifiable” when any one or more of 18 types of identifiers can be used to identify an individual (e.g. name, address, dates such as birth date, account number etc.)

• The HIPAA Privacy Rule applies to healthcare organizations, healthcare plans, healthcare clearinghouses, and Business Associates with access to Protected Health Information (PHI).

• PHI can be in paper form, electronic as well as in verbal communications.

• Photos and videos of patients/residents are PHI and require documented authorization to take and use. • Access to PHI must be restricted to the minimum access needed to accomplish the intended objective.

• PHI cannot be used or disclosed without documented patient authorization unless it is for any of the following purposes or situations:

o Use or disclosure to the patient

o Use or disclosure for treatment, payment, or general healthcare operations

o Use or disclosure if the individual has the opportunity to agree or object to a disclosure such as a patient bringing a family with them when discussing care with a physician

• Covered Entities (CE) are required to provide residents/patients with a Notice of Privacy Practices (NPP) to tell how the CE may use and share their health information.

• Disposal of documents containing PHI must be rendered unreadable. Shredding is the most common method of disposal. Before disposal, be sure to follow your organization’s data retention policies.

For more information regarding HIPAA Privacy, visit www.hhs.gov.

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CMS’ Calendar Year 2019 Medicare Physician Fee Schedule Final Rule

On November 1, 2018, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that includes updates to payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2019.

Reliant’s Real Time Memo, which summarizes the final rule, can be downloaded here. The following is included in the summary:

  • Conversion factor update
  • Discontinuation of functional status reporting (G-code) requirements for outpatient
  • Update on outpatient physical therapy and occupational therapy services furnished by assistants
  • KX modifier attestation amount
  • Medicare telehealth services update

Payment provisions

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Nursing Facility Case-Mix Payment Changes October 1, 2019

CMS issued an informational bulletin earlier this month notifying providers of changes that will impact states’ payments for Medicaid beneficiaries in the nursing home setting.

The bulletin indicates with the implementation of PDPM in October 2019 a new optional assessment, specific for states that rely on RUG-III and RUG-IV assessment schedule, will be available. The assessment will be active from 10/1/2019 through 9/30/2020, at which time states will have to determine an alternate calculation system for Medicaid payment. Additional detail was provided in the December 11th MLN call. Read full bulletin here.

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SNF PPS: New Patient Driven Payment Model Call

On December 11, 2018, CMS hosted a national Medicare Learning Network call which provided a detailed look at the Patient Driven Payment Model (PDPM).

Some specific details are provided in the article above, and additional resources are available at the PDPM webpage.

Reliant is actively following CMS updates and clarification to ensure our resources and training are up to date and accurate. Watch for education opportunities in early 2019! Full audio recording and transcript are now available on the MLN homepage for download.

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PDPM Part 4: Information Overload, Time to Review

When PDPM was finalized in July’s final rule, there was no stopping the development of training and resources by those in our industry who make us successful. It’s what educators do, dissect, synthesize and disseminate information. However, PDPM’s outline in the final rule lacked detail in certain areas and created questions in others. Chances are, some of the training and resources you have saved (even CMS’) are now inaccurate or incomplete.

During the Medicare Learning Network call earlier this month many elements of PDPM were clarified and a few were introduced including:

1. Mapping to the PDPM clinical category will come from new items set, I0020B (What’s the main reason this person is being admitted to the SNF?) coupled with possible responses to new item set J2100-J5000 (Surgical procedures that occurred during the inpatient hospital stay that immediately preceded the SNF admission).

2. PDPM classification groups designated under administrative presumption including

a. Nursing groups within Extensive Services, Special Care High, Special Care Low, and Clinically Complex,

b. PT and OT groups TA, TB, TC, TD, TE, TF, TG, TJ, TK, TN, and TO,

c. SLP groups SC, SE, SF, SH, SI, SJ, SK, and SL; and d. NTA highest category of 12+.

3. Revised Health Insurance Prospective Payment System (HIPPS) coding algorithm.

4. Further instruction on the Interim Payment Assessment including use of Interim Section GG column for reporting and look back.

5. Addition of Optional State Assessment for Medicaid determination (Not a Part A PPS assessment).

6. Examples to clarify Interrupted stay policy and group and concurrent calculation.

7. Extensive instruction on RUG-IV and PDPM transition and mandated transitional IPA if patient is receiving skilled part A services prior to 10/1/2019 and continuing.

8. RAI Manual draft expected “early” 2019.

So with all of the PDPM chatter, how do we filter for quality and accuracy? How do we trust the resource we have is accurate and up to date? Here are a few tips for just that:

1. Gather information from multiple sources. Subscribe to industry leaders and state associations for updates. Read the Reliant Reveal and Real Time Memos as they arrive.

2. Take it a step at a time. No one becomes an expert overnight. Start with the clinical component and case mix groups, then move on to ICD-10 coding, or assessment time frames and rules, but be confident in one element before you begin learning the next.

3. Look for cited sources (RAI Manual, CMS material) and revision dates to resource materials. CMS has indicated they will begin time stamping the FAQ documents to indicate revisions made. Resources from other entities should do the same.

4. When possible, go to CMS webpage for clinical and NTA crosswalk information. These references are available in savable zip file format but have been updated at least two times since their initial release in August.

5. If something clicks and suddenly makes sense, write it down. Don’t assume you’ll remember.

6. Ask questions! If a comment or statement does not make sense, ask for clarification and citation.

Your partners in patient care should want to support you in your journey for knowledge and a successful transition to PDPM. Reliant is ready to keep you up to date, answer your questions, and problem solve for strategic success!

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Care Matters Spotlight: The Power of Therapy by Kerry Frazier, Director of Rehab, Mineola, TX

Morgan Woods

Morgan Woods was a high spirited life-of-the-party kind of guy. He was always smiling, loved to dance and was an avid wood worker. Prior to his admit he lived in another SNF and was sent out to the hospital with symptoms of Altered Mental Status. He was treated for bacteremia and toxic metabolic encephalopathy and admitted to our facility to be evaluated by Hospice.

I know all of this because at admit, I spoke at length with his daughter, Temika, as she was really on the fence about either trying therapy or admitting to hospice. I explained the process therapy would follow and she decided to give us a chance, and let us see what we could do to help. 

At evaluation, he was bedridden with numerous bed sores, received nutrition via a PEG tube, and was unable to sit up or make purposeful movements. Over the past few weeks, nursing has worked hard to treat his ulcers and they have completely healed. Therapy began with small goals, such as sitting on the side of the bed, reaching out for objects, etc. As therapy progressed this is what we are able to share:

September 6, 2018


He stood in the standing frame for the first time. He fatigued very quickly and would not reach out to engage in any tabletop activity.
September 18, 2018


He took his first steps using a rolling walker and the assistance of two therapists. The week prior he took his first steps in the therapy gym with the assistance of three therapists.

October 17, 2018

He is now walking down the hallway with no assistive device and hand held assistance of two therapists.

Morgan has started tapping his feet and dancing in his wheelchair when we play his favorite music like Michael Jackson or Motown. He will reach out to play balloon toss and will flash you the best smile!
During all of this, he took his first bites of food and is now feeding himself and enjoying food daily. Morgan has worked hard and is making wonderful progress. His family is thrilled and so are we!We look forward to seeing him progress even further and one day be able to dance again!

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No Patient Left Behind

No Patient Left Behind (NPLB) trains our therapists in interpretation of quality indicator reports and the impact of quality measure reporting to aid in the care of facility residents. This month we’ll look a little closer at the final element: Being an Advocate.

Reliant believes it is our moral imperative to do right by our patients and ensure dignity, quality, and the highest level of independence possible. Each care partner plays a role in the resident’s success and it’s important to remember, you don’t have to go to Washington to be an effective advocate for your patients. Advocacy starts at the facility level and means you’ll be the voice for the resident who can’t speak, the movement for the resident who isn’t independently mobile, or the reliable provider for the resident who needs reassurance.

From admission to discharge, your actions are contagious and by advocating for your patients through simple acts, others will want to be a part of that passion. There is purpose in what you do, never forget that!

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Reminder Regarding Phase 2 and 3 Requirements For Participation

Last November, CMS issued a Temporary moratorium on imposing certain enforcement remedies for specific Phase 2 requirements. It was advised that this 18 month moratorium on the imposition of certain enforcement remedies be used to educate facilities about specific new Phase 2 standards.

• The following F-Tags included in this moratorium are:

• F655 (Baseline Care Plan); §483.21(a)(1)-(a)(3)

• F740 (Behavioral Health Services); §483.40

• F741 (Sufficient/Competent Direct Care/Access Staff-Behavioral Health); §483.40(a)(1)- (a)(2)

• F758 (Psychotropic Medications) related to PRN Limitations §483.45(e)(3)-(e)(5)

• F838 (Facility Assessment); §483.70(e)

• F881 (Antibiotic Stewardship Program); §483.80(a)(3)

• F865 (QAPI Program and Plan) related to the development of the QAPI Plan; §483.75(a)(2) and,

• F926 (Smoking Policies). §483.90(i)(5) While this moratorium is still active, providers should have these requirements in place now. In the same memorandum, CMS revealed changes to Nursing Home Compare (NHC) relative to survey and health inspection.

• Freeze on Health Inspection Star Ratings: Following implementation of the new LTC survey process on November 28, 2017, CMS held constant the current health inspection star ratings on NHC for any surveys occurring between November 28, 2017 and November 27, 2018.

• Availability of Survey Findings: The Survey findings of facilities surveyed under the new LTC survey process would be published on NHC, but not incorporated into calculations for the Five-Star Quality Rating System for 12 months. Link to full memorandum.

Chart review of the 3 phases of implementation:

Phase 1: Implemented November 28, 2016 *indicates this section is partially implemented in Phase 2 and/or 3

• Resident Rights and Facility Responsibilities*

• Freedom from Abuse Neglect and Exploitation*

• Admission, Transfer and Discharge*

• Resident Assessment

• Comprehensive, Person-Centered Care Planning*

• Quality of Life • Quality of Care*

• Physician Services • Nursing Services*

• Pharmacy Services*

• Laboratory, radiology and other diagnostic services

• Dental Services*

• Food and Nutrition*

• Specialized Rehabilitation

• Administration (Facility Assessment- Phase 2)*

• Quality Assurance and Performance Improvement* – QAPI Plan

• Infection Control- Program*

• Physical Environment*

Phase 2: Implemented November 28, 2017

• Behavioral Health Services*

• Quality Assurance and Performance Improvement*- QAPI Plan

• Infection Control- Facility Assessment and Antibiotic Stewardship**

• Physical Environment- smoking policies*

Phase 3: Implementation November 28, 2019

• Quality Assurance and Performance Improvement*- Implementation of QAPI

• Comprehensive Person-Centered Care Plan: Trauma informed care

• Infection Control- Infection Control Preventionist*

• Compliance and Ethics Program*

• Physical Environment- Call lights at resident bedside*

• Training Requirements*

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ICD-10 Updates!

Last month we proceeded with our series which dives into critical elements of PDPM by looking at ICD-10 coding. Due to updates provided by CMS we will take one more look at ICD-10 processes for PDPM.

During the open door forum on 11/29/2018, CMS validated information on the PDPM webpage indicating a new MDS item set will be active on October 1, 2019 which will guide the clinical category mapping for the resident. According to CMS’ training materials, new item set I0020B “What is the main reason this person is being admitted to the SNF?” allows for the primary SNF diagnosis to be entered when the response to I0020 “Indicate the resident’s primary medical condition category” is identified as 01-13. The training also provides detailed information about the new items for recording the patient’s surgical history using J2100-J5000. (As of 11/29/2018 CMS notes an error on the PDPM webpage resource New MDS Items which records I0020 as I0200).

It’s important to recognize that although this new item set replaces 18000A as the primary diagnosis mapping line, the codes entered in I8000 and identified throughout section I still require critical thinking and accuracy to ensure accurate reimbursement as these areas contribute directly to SLP comorbidities and conditions, nursing conditions and the non-therapy ancillary comorbidity score.

PDPM Patient Classification Fact Sheet

MDS Changes Fact Sheet

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SNF Open Door Forum: 11/29/2018

In the last open door forum of the year, CMS provided the following information:

• PDPM Webpage is now active. The site provides CMS created fact sheets, FAQ’s, training presentation, and resources specific to PDPM preparation CMS has created as PDPM specific email for questions or clarification needs.

• SNF VBP updates included clarification that providers incentive multipliers are available via CASPER reports. Phase I correction request review is currently in progress. Reconciled corrections will be updated via reports in the CASPER system. The Medicare Administrative Contractor (MAC) will directly apply the incentive percentage when making payment. More information is available on the SNF VBP webpage.

• SNF QRP data now posted on Nursing Home Compare. The next refresh will be in late January. Providers will receive preview reports 30 days prior. CMS directs any questions to the SNF QRP help desk.

• CMS indicated SNF QRP edit 3907 for discharge goal coding will be retired due to stakeholder feedback regarding its relevance; however, edit 3891, warning for discharge coding, will continue.

• CMS reiterated the resources available through the Civil Money Penalty Reinvestment Program (CMPRP). CMPRP is a three-year effort to reduce adverse events, improve staffing quality and improve dementia care in nursing homes.

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PDPM Part 3: Function Scores Here, Function Scores There, PT, OT and Nursing Everywhere!

Unless you’ve slept through the second half of 2018, you’re aware this year introduced updates to Section GG (Functional Abilities and Goals) and are at least familiar with the concept that Section GG plays a role in the Patient Driven Payment Model (PDPM). Today, let’s break down exactly how important of a role Section GG it plays in PDPM and the importance of accurate data collection.

Physical Therapy, Occupational Therapy and Nursing case mix groupers will be directly impacted by Section GG scoring and the PDPM Function Score. Read the full article here so when PDPM officially launches, communication is streamlined and your assessment team is confident in their data.

Reliant’s Section GG Flow Chart

Reliant’s Section GG Reference

CMS PDPM Functional Scoring Fact Sheet

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Care Matters Spotlight: When the Real House Moms of Nocatee Unite After Hurricane Michael

Monday, October 8th: Catherine Schuman (Katie), an SLP at a facility in Ponte Vedra, FL, received notification their facility would be housing displaced residents evacuating from the path of Hurricane Michael. The residents and staff arrived with a few changes of clothes, prepared to return to Port St. Joe after Michael’s dissipation.

Wednesday, October 10th: Hurricane Michael devastated Port St. Joe in a way none of them expected. Homes were destroyed, vehicles flooded, and possessions lost.

Katie recognized the need immediately, not only for the residents, but the CNAs and nursing staff who accompanied them, and now had no idea when they would return home or what would be left. Katie has been part of a moms group in Ponte Vedra for several years now, and when it came time to elicit the generosity of the “Real House Moms of Nocatee” she didn’t hesitate.

The response to her call for adult clothing and toiletries was overwhelming. The donations received filled two rooms in the facility. Today she says “They’re good. There is enough.” Other organizations continue gathering for children and families affected, but Katie’s desire was to ensure her residents and colleagues were comfortable. Katie was insistent in sharing the thanks and praise with her fellow neighborhood moms because without them it wouldn’t have been possible to meet the need.

To the Real House Moms of Nocatee and Katie Schuman, thank you for your compassion and deliberate action to ensure our residents and staff are cared for. Katie, we are honored to have you as one of our own.
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No Patient Left Behind

No Patient Left Behind (NPLB) trains our therapists in interpretation of quality indicator reports and the impact of quality measure reporting to aid in the care of facility residents. This month we’ll look a little closer at the third element: Linking Quality and Care.

Reliant believes in equipping our therapists with the knowledge and resources to address quality measures and changes in resident function timely. NPLB describes the quality indicators identified by Medicare as critical to patient care and dives into the distinct role physical, occupational and speech therapy play for each.

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Updated Rankings Available for SNFs Participating in Value Based Purchasing Program

CMS is providing updated rankings for all SNFs included in the Fiscal Year (FY) 2019 VBP program year.

A list of each SNF’s incentive payment multiplier and updated ranking can be found on the SNF VBP website . The incentive payment multiplier applicable to each SNF is unchanged from the multiplier that CMS previously included in the SNF’s FY 2019 Annual Performance Score Report.That multiplier will be used to adjust the federal per diem rate otherwise applicable to the SNF for services furnished from October 1, 2018 through September 30, 2019. 

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Keep Information Safe with Good Password Practices

These days we’re all overloaded with the number of accounts that require credentials and remembering them is impossible. Using the same password for different accounts is tempting—like having one handy key that opens every lock you use. But reusing passwords is not the solution.

Compromised passwords are one of the leading causes of data breaches, and reusing passwords can increase the damage done by what would otherwise be a relatively small incident. Cybercriminals know that people reuse credentials and often test compromised passwords on commonly used sites in order to expand the number of accounts they can access.

For instance, if you use the same password for your work email as for Amazon or your gym membership, a breach at one of those companies puts your work emails at risk. Reusing credentials is like giving away copies of the key that opens all your locks. Before reusing a password for different accounts, especially across work and personal ones, think of all the data that someone could get into if they got that credential.

Here are some tips to help you avoid falling in this trap:

• Use completely separate passwords for work and personal accounts.

• Avoid words that can easily be guessed by attackers, like “password” or “September2017,” or predictable keyboard combinations like “1234567,” “qwerty,” or “1q2w3e4r5t.”

• Add some complexity with capitalization or special characters if required. “Fido!sAnAwesomeDog” is a stronger password than your pet’s name.

• Just adding numbers or special characters at the end of a word doesn’t increase security much, because they’re easy for software to guess.

• Avoid words like your kids’ names that could easily be guessed by coworkers or revealed by a few minutes of online research.

• Answers to security questions are often easily found— your mother’s maiden name is public record—so pick another word for whenever that question comes up.

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SNF Quality Reporting Program Submission Deadline Approaching

The deadline for the Skilled Nursing Facility (SNF) Quality Reporting Program MDS data submission for April 1, 2018-June 30, 2018 (2nd quarter) is November 15, 2018.
Review resources:

Current data collection (2018 4th quarter) includes new section GG items added on October 1, 2018. Download Reliant’s resource here .CMS recommends that providers run applicable validation/analysis reports prior to each quarterly reporting deadline in order to ensure all required data has been submitted.

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PDPM Part 2: Idioms for ICD-10 Success

ICD-10 coding has never been so daunting! Thanks to search engine crosswalks and funny memes, the 2015 transition to ICD-10 did not leave any permanent scars, and most of us can now recall treatment codes with ease. However, ICD-10’s role in PDPM hasshuffled the deck. Suddenly, we are questioning our own knowledge and wondering if we have the skill set to be successful. 
As we prepare for the transition to PDPM, it’s important to remember, we’re all in the same boat: ICD-10 coding on the MDS directly maps our patients into case mix categories for payment. There is no buffer between coding and reimbursement. CODING IS reimbursement for physical therapy, occupational therapy, speech language pathology, nursing and non-therapy ancillary. CMS says the primary patient diagnosis allows us to identify the patient’s unique conditions and goals which should be the primary driver for care planning and delivery of services.
Many facilities already have the ingredients for a recipe of success: a collaborative effort between nursing and therapy is key in identifying each active condition on admission and changes in condition throughout the episode of care.  Let’s consider these additional idioms:
Don’t put all your eggs in one basket.

  • Having a designated ICD-10 coder is an awesome resource; however, never discount the input from the other skilled professionals interacting with the patient. Coders provide accuracy, but clinicians, physicians, and dietitians provide the details to hone that accuracy.

The devil is in the details.

  • If you’ve ever wondered whether each element on the MDS mattered, PDPM has given you the answer. The ICD-10 code entered in I0020B, the resident’s primary medical condition, will map case mix for physical, occupational, and speech therapy components. Beyond this, information entered into sections C, D, E, GG, H, I, J, K, M and O will contribute to classifying each resident, identifying conditions/comorbidities, and identifying the function score..

The ball is in your court.

  • Begin to put systems in place to identify active conditions of the resident. Reliant therapists perform a full system evaluation, so engage their input for areas which may have been missed. During daily stand up or triple check, include clinical condition conversations to quickly identify changes which may need to be reflected in coding.

Strong partnerships for understanding and implementing processes for ICD-10 is critical. As stated, coding impacts PT, OT, SLP, Nursing, and Non-therapy ancillary case mix groups. Accurate coding ensures resource availability for successful outcomes and patient satisfaction. Just remember, Rome wasn’t built in a day, so let’s start conversations now.