This Countdown to PDPM post continues to build on the prior three postings on Patient Driven Payment Model (PDPM). Last time, we looked at the calculation of the Functional Scores for PT and OT. This session, we will explore how that information is utilized to assign your patients into Case-Mix Classification Groups.
The clinical reason for Skilled Nursing Facility (SNF) stay (MDS item I0020B) is used to assign the resident into one of 10 clinical categories. These 10 categories are collapsed into four PT and OT clinical category groups. If the PDPM clinical category mapping indicates that this primary diagnosis is eligible for one of the surgical categories, then evaluate further which of these PT/OT Clinical Categories is appropriate. Refer to J2100 to determine if a major joint replacement, spinal surgery or other orthopedic surgery occurred during the prior inpatient stay. If the patient has procedure(s) listed in J2100-J2420 coded, then the patient is categorized into the major joint replacement or spinal surgery clinical category. If any of the procedures indicated in items J2500, J2510, J2520, or J2530 were performed, then the patient is categorized into the Orthopedic Surgery category.
After the Collapsed Clinical Category is determined, the Functional Score is utilized to ascertain the PT and OT Case Mix Groupings and the corresponding Case-Mix Index.
Research by CMS determined that resource utilization for both PT and OT was higher at the beginning of the SNF stay, declining over the course of the admission. To help ensure that resource allocation aligned with actual costs, the PT and OT components were given variable per-diem adjustments. To apply this factor, the case-mix adjusted per diem rates for both PT and OT are multiplied by the relevant indices to obtain the adjusted per diem. There is no adjustment factor for days one through twenty of the Medicare stay. Please see the chart below to determine the adjustment factor for subsequent days:
PDPM differs greatly from the current RUG-IV System. RehabVisions is dedicated to assisting our partners to prepare and thrive under this new reimbursement system. Thus far, we have examined coding of GG of the MDS, calculation of the Functional Scores for PT and OT and taken a look at how this information leads to the PT and OT indices. Be sure to watch for our next post, when the Speech-Language Pathology Component will be explored as we Countdown to PDPM together.
Click HERE to print this article.
This post is based upon information currently available from CMS at the time of publication. Please refer to the CMS PDPM page for more information.