Understanding October 1 st MDS Changes and PEPPER Letters 2013

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Erica Nichols
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1 Understanding October 1 st MDS Changes and PEPPER Letters 2013

2 Agenda Changes in the MDS MDS Item Changes Reporting Rehab Minutes Hospital Inpatient Criteria (Two Midnight Provision) Reading PEPPER Letters How to Respond

3 RehabCare is Committed To Providing Quality Care to Each Patient We Serve Providing Accurate Assessment and Care Planning info for Each Patient Completing Accurate Documentation to Support the Skilled Care Provided

4 MDS 3.0 Changes Version

5 Transition MDS Assessments All ARDs 09/30/13 or before will use the current item set All ARDs after 10/01/13 will use the new item set

6 Changes to A1500 It is important to understand how your beds are certified, talk to your business office to be sure you know how to answer this question

7 Rule of Three Changes When an activity occurs at various levels, but not three times at any given level, apply the following: When there is a combination of full staff performance, and extensive assistance, code extensive assistance When there is a combination of full staff performance, weight bearing assistance and/or non-weight bearing assistance code limited assistance (2)

8 What Does That Mean? Changes may be necessary to your ADL coding/capturing process Per shift charting may not be sufficient to capture the accurate ADL score for patients who vacillate between supervision, limited, and extensive assistance You may need to work with your therapy team on documentation to ensure another resource for documenting ADL status

9 Changes in the ADL Coding It is important to capture all instances of care when a patient is vacillating between two care levels

10 Section K: Intake by Artificial Route

11 Section M: Skin Removed Non-Epithelialized

12 Section M: Skin

13 New Items Added to Section O - Rehab Reminder: As with all care provided to patients: The method and type of care delivered should always be based on the patient s individual needs, care plan, and goals for recovery

14 Rehab: Co-treatment

15 Co-treatment Medicare Part A Two clinicians from different disciplines Treat one patient at the same time With different treatments All policies regarding mode, modalities and student supervision must be followed

16 Co-treatment Medicare Part B Therapists/assistants working together as a team to treat one or more patients cannot each bill separately for the same or different service provided at the same time to the patient* *CMS s RAI Version 3.0 Manual page O-21

17 Co-treatment Requirements Documentation of co-treatment is still required to be included in medical record by both disciplines Each discipline is required to report cotreatment minutes in section O of the MDS

18 Rehab Medium Rehab Medium 150 minutes of rehab 5 Distinct days of rehab Not 5 treatments Any combination of PT, OT, ST

19 Distinct Calendar Days Treatment day must consist of one discipline providing 15 minutes of care SUN MON TUE WED THU FRI SAT 1 OT PT PT OT PT OT PT 2 PT PT OT PT OT OT PT

20 RU, RV, and RH When we miss 5x/week In the past, it defaulted to RM Now, if it is not five distinct days, it will become a nursing RUG

21 Rehab Scheduling Five treatment days per week Impacts about 5% of our patient s RUG days currently Many of them are RU, RV, and RHs that missed the 5x/week criteria

22 This Still Goes Back to Basics Skilled care requires 5x/week of rehab and/or 7x/week of nursing PPS meetings must happen daily Timely notifications of admissions is critical to complete evaluations Staff should communicate about missed treatment sessions immediately Patient scheduling is critical Remember schedule rehab, appointments, nursing treatments, etc. Pt. scheduling requires the entire IDT. Remains critical around holidays, family visits, patient preferences, and missed treatment sessions.

23 Hospital Inpatient Admission Two - Midnight Provision Surgical procedures, diagnostic tests, and other treatments are typically inappropriate for payment under Part A when the physician does not expect the patient to stay in the hospital for a period of time that crosses two midnights. The two-midnight benchmark clock begins when the beneficiary begins to receive hospital services. This may include observation care or care provided in the emergency department. While the physician may consider such time in deciding to admit a patient, the time does not covert to inpatient time once the order is written. The time proceeding the inpatient admission will remain outpatient time. Therefore, such outpatient time does not count as inpatient time for purposes of qualifying for skilled nursing facility coverage. This time may only be used for the purpose of determining if the expectation of a stay less than at least two midnights is reasonable.

24 What Does This Mean to the SNF? Essentially nothing has changed Patient s require 3 consecutive midnights in inpatient care to qualify for SNF skilled care Make sure you ask the right questions Hospitals may view this change as skilled care because it is for them. Make sure you clarify 3 consecutive midnight in-patient days (cannot include observation or ER stays)

25 Program for Evaluating Payment Patterns Electronic Report PEPPER LETTERS

26 PEPPER Letters The SNF PEPPER report summarizes an individual SNF s Medicare claims data in areas that CMS considers at risk for abuse or improper payment PEPPER cannot identify the presence of improper payments; only a review of the medical record can determine whether services are medically necessary and appropriately billed Remember there is no right or wrong only patterns on the PEPPER

27 What is Being Evaluated? Target Areas? Rehab RUGs with high ADLs Non-therapy RUGs with high ADLs Number of COT Assessments Rehab Ultra High Total Rehab RUGs 90+ Day Episodes of Care

29 Reviews Data Points in Time Based on the fiscal year which starts on October 1 Data reflects Medicare Billing from 10/01/2009 to 09/30/2012

30 What is an Episode of Care All claims submitted by a SNF for a beneficiary are collected and sorted from the earliest Claim From date to the latest If the patient discharge status code on the latest claim in a series indicates that the beneficiary was discharged or did not return for continued care, that beneficiary s EOC is included in the time period in which the latest Through Date falls If there is a gap between one claim s Through Date to the next claim s From Date of more than 30 days, then that is considered the ending of one EOC and the beginning of a new EOC If the latest claim in the series ends in the last month of the latest time period (Sept. 1-30, 2012 for the Q4FY12 release) and indicates that the beneficiary was still a patient (patient discharge status code 30 ), then that beneficiary s EOC is not included Each EOC is included in the time period in which the latest Through Date falls Claims are collected for four months prior to each time period so that the longer lengths of stay may be evaluated

31 Percents and Percentiles There are two terms at the heart of PEPPER: Percents and Percentiles It s a lot like going back to math and statistics class

32 Target Area Percents Target Area Percents are calculated by dividing the number of target discharges/episodes of care by the number of denominator discharges/episodes of care for each provider for each time period, then multiplying by 100 Example: Numerator count = 20, and Denominator count = 100 X 100, = 20 Target Area Percent is 20%

33 Percentiles The Target Area Percent lets the provider know its billing patterns The Percentiles give context by helping a provider understand how it compares to other providers Definition of a Percentile: The percentage of providers with a lower target area percent

34 Percentiles To calculate percentiles for all providers in a comparison group (nation, jurisdiction or state) the target area percents are sorted from largest to smallest for each time period Example: If 40% of the providers target area percents were lower than provider A, then provider A would be at the 40 th percentile

35 Percentile Calculation Example 80 th percentile 20 th percentile If a provider s percent is at or above the 80th percentile, it is considered an outlier. 80% of providers had a lower percent. Red Bold Print If a provider s percent is at or below the 20th percentile, it is considered an outlier (areas at risk for undercoding). 20% of providers had a lower percent. Green Italic Print

36 What Can Make Your Center Different from Peers? Specialty programs Higher acuity patients Higher need for rehab services Census

37 What Should Your Center Do? Provide quality care to each patient we serve Complete accurate assessments and care planning for each patient Complete accurate documentation to support the skilled care provided Accurate billing for every claim

38 The MDS Impact The MDS accuracy drives the accuracy of the Quality Measures The MDS establishes the Care Plan Goals for patients The MDS drives a large portion of you Five-Star Ratings (QM) The MDS impacts greater than 75% of the reimbursement for most centers Medicare, Managed Care, and Medicaid Accurate MDSs take time and a commitment to excellence

39 Thanks for joining us today, and we hope you have benefitted from the presentation.

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