This is the second of four articles dealing with the patient driven payment model (PDPM). Under PDPM each patient is classified into a group for each of the five case-mix adjusted components. The payment for each of the case-mix adjusted components is calculated by multiplying the case-mix indicator by the base rate in each group and then taking into consideration the variable per diem schedule when appropriate. Our first article reviewed the physical therapy, occupational therapy and speech language pathology components. This article reviews the nursing component. There are 25 classifications based on the categories that were used for RUG (Resource Utilization Group) IV nursing. The function score is based on Section GG of the Minimum Data Set (MDS) 3.0 and uses the nursing function score that includes seven items to calculate the total function score:
|
Section GG items |
Score |
|---|---|
|
Self care: Eating |
0-4 |
|
Self care: Toilet hygiene |
0-4 |
|
Mobility: Sit to lying; lying to sitting on the bed |
0-4 average of 2 |
|
Mobility: Sit to stand; chair/bed-to-chair transfer; toilet transfer |
0-4 average of 3 |
The total score is 0–16 as shown in the table below:
|
RUG-IV nursing |
Extensive services |
Clinical conditions |
Depression |
Restorative nursing services |
Function score |
Case mix group |
Case mix index (CMI) |
|---|---|---|---|---|---|---|---|
|
ES3 |
Tracheostomy and ventilator |
|
|
|
0-14 |
ES3 |
4.04 |
|
ES2 |
Tracheostomy or ventilator |
|
|
|
0-14 |
ES2 |
3.06 |
|
ES1 |
Infection isolation |
|
|
|
0-14 |
ES1 |
2.91 |
|
HE2/HD2 |
|
Serious medical conditions (e.g., comatose, septicemia, respiratory therapy) |
Yes |
|
0-5 |
HDE2 |
2.39 |
|
HE1/HD1 |
|
Serious medical conditions (e.g., comatose, septicemia, respiratory therapy) |
No |
|
0-5 |
HDE1 |
1.99 |
|
HC2/Hb2 |
|
Serious medical conditions (e.g., comatose, septicemia, respiratory therapy) |
Yes |
|
6-14 |
HBC2 |
2.23 |
|
HC1/HB1 |
|
Serious medical conditions (e.g., comatose, septicemia, respiratory therapy) |
No |
|
6-14 |
HBC1 |
1.85 |
|
LE2/LD2 |
|
Serious medical conditions (e.g., comatose, septicemia, respiratory therapy) |
Yes |
|
0-5 |
LDE2 |
2.07 |
|
LE1/LD1 |
|
Serious medical conditions (e.g., comatose, septicemia, respiratory therapy) |
No |
|
0-5 |
LDE1 |
1.72 |
|
LC2/LB2 |
|
Serious medical conditions (e.g., comatose, septicemia, respiratory therapy) |
Yes |
|
6-14 |
LBC2 |
1.71 |
|
LC1/LB1 |
|
Serious medical conditions (e.g., comatose, septicemia, respiratory therapy) |
No |
|
6-14 |
LBC1 |
1.43 |
|
CE2/CD2 |
|
Conditions requiring complex medical care (e.g., pneumonia, surgical wounds, burns) |
Yes |
|
0-5 |
CDE2 |
1.86 |
|
CE1/CD1 |
|
Conditions requiring complex medical care (e.g., pneumonia, surgical wounds, burns) |
No |
|
0-5 |
CDE1 |
1.62 |
|
CC2/CB2 |
|
Conditions requiring complex medical care (e.g., pneumonia, surgical wounds, burns) |
Yes |
|
6-14 |
CBC2 |
1.54 |
|
CA2 |
|
Conditions requiring complex medical care (e.g., pneumonia, surgical wounds, burns) |
Yes |
|
15-16 |
CA2 |
1.08 |
|
CC1/CB1 |
|
Conditions requiring complex medical care (e.g., pneumonia, surgical wounds, burns) |
No |
|
6-14 |
CBC1 |
1.34 |
|
CA1 |
|
Conditions requiring complex medical care (e.g., pneumonia, surgical wounds, burns) |
No |
|
15-16 |
CA1 |
.94 |
|
BB2/BA2 |
|
Behavioral or cognitive symptoms |
|
2 or more |
11-16 |
BAB2 |
1.04 |
|
BB1/BA1 |
|
Behavioral or cognitive symptoms |
|
0-1 |
11-16 |
BAB1 |
.99 |
|
PE2/PD2 |
|
Assistance with daily living and general supervision |
|
2 or more |
0-5 |
PDE2 |
1.57 |
|
PE1/PD1 |
|
Assistance with daily living and general supervision |
|
0-1 |
0-5 |
PDE1 |
1.47 |
|
PC2/PB2 |
|
Assistance with daily living and general supervision |
|
2 or more |
6-14 |
PBC2 |
|
|
PA2 |
|
Assistance with daily living and general supervision |
|
2 or more |
15-16 |
PA2 |
.7 |
|
PC1/PB1 |
|
Assistance with daily living and general supervision |
|
0-1 |
6-14 |
PBC1 |
1.13 |
|
PA1 |
|
Assistance with daily living and general supervision |
|
0-1 |
15-16 |
PA1 |
.66 |
Note how the CMI changes to a higher amount with the addition of restorative programs. In order to capture the restorative programs on the five-pay MDS, these programs will have to start by day two to document the programs accurately. Restorative programs have a seven-day look back and must be in place for six or seven days per week. Additionally, there is a split for depression. Unlike other categories, the nursing component does not have a variable per diem adjustment.
Our next article will cover the nontherapy ancillary component.
Please contact Joan McCarthy at joan.mccarthy@rsmus.com for more information.
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