United States

Senior Living Health Care Connection: New PDPM case mix (part 1)

SENIOR LIVING HEALTH CARE CONNECTION  | 

Therapy components outlined

Starting on Oct. 1, 2019, the Centers for Medicare and Medicaid Services (CMS) is replacing the current resource utilization group, version IV grouping methodology, with the patient-driven payment model (PDPM). In PDPM there are five case-mix adjusted components: physical therapy (PT), occupational therapy (OT), speech-language pathology (SLP), nontherapy ancillary (NTA) and nursing. Each resident is classified into one group of each of the case-mix adjusted components. So, each resident will be classified into a group within each of the five components: PT, OT, SLP, NTA and nursing. Each separate component has its own case-mix adjusted index and a corresponding per diem rate. There are 16 PT groups, 16 OT groups, 12 SLP groups, six NTA groups and 25 nursing groups. We will review the primary components in the PDPM in four articles.

The first of these articles deals with the therapy components: PT, OT and SLP. PT and OT are driven by two different criteria:

  1. The ICD-10 code for the primary diagnosis, which may also be a surgical procedure done in the hospital
  2. The PT/OT function score

The patients are classified into a clinical category based on the primary diagnosis ICD-10 code in item 10020B on the minimum data set (MDS) and surgical procedures coded in 30 new items J2100–J500. Mapping the ICD-10 code to the PDPM clinical categories can be found on the CMS website. Go to the bottom of the page on the CMS website under PDPM resources and look at the “ICD-10 Clinical Category Crosswalk.”                      

PT and OT components use four “collapsed” clinical categories:

PDPM
clinical categories

PT/OT
clinical categories

PT/OT
function score

PT/OT
group
PT
CMI
OT
CMI

Major joint replacement or spinal surgery

Major joint replacement or spinal surgery

0-5

6-9

10-23

24

TA

TB

TC

TD

1.53

1.69

1.88

1.92

1.49

1.63

1.68

1.53

Nonsurgery orthopedic and musculoskeletal

orthopedic surgery

 

Other orthopedic

0-5

6-9

10-23

24

TE

TF

TG

TH

1.42

1.61

1.67

1.16

 

Medical management

Cancer

Pulmonary

Cardiovascular and coagulations
Acute infections

Medical management

0-5

6-9

10-23

24

TI

TJ

TK

TL

1.13

1.42

1.52

1.09

 

Acute neurologic
Nonorthopedic surgery

Nonorthopedic surgery and acute neurologic

 

0-5
6-9
10-23
24
TM
TN
TO
TP
1.27
1.48
1.55
1.08

 

 

PDPM uses the functional scores for 10 section GG (functional abilities and goals) items:

Section GG item                                                       

Functional score range

Self-care: Eating

0 – 4

Self-care: Oral hygiene

0 – 4

Self-care: Toileting hygiene

0 – 4

Mobility: Sit to lying
Mobility: Sit to stand                                  

0 – 4 Average two items

Mobility: Lying to sitting on side of bed
Mobility: Chair/bed-to-chair transfer
Mobility: Toilet transfer

0 – 4 Average three items

Mobility: Walk 50 feet with two turns
Mobility: Walk 150 feet

0 – 4 Average two items

 

Scoring goes from “set-up assistance, independent” for a score of 4 to “substantial/maximal assistance” for a score of 1. “Dependent,” “refused,” “not applicable” or “not attempted” all have a score of 0. Note that the higher scores in GG reflect increasing independence. While the case mix groups for PT and OT are the same, the case mix indicators are different so the payment is calculated differently.

SLP components contain the following patient characteristics:

  • Acute neurologic clinical classification
  • Certain SLP-related comorbidities

Speech comorbidities

Aphasia

Laryngeal cancer

CVA,TIA or stroke

Apraxia

Hemiplegia or hemiparesis

Dysphagia

Traumatic brain injury

ALS

Tracheostomy (while resident)

Oral cancers

Ventilator (while resident)

Speech and language deficits

  • Presence of cognitive impairment, one of four PDPM cognitive performance levels, is assigned based on the brief interview for mental status or the staff assessment for PDPM cognitive levels
  • Use of a mechanically altered diet
  • Presence of swallowing disorder 

Presence of acute neurologic condition, SLP related comorbidity, or cognitive impairment

Mechanically altered diet or swallowing disorder

SLP case mix group

SLP case mix index

None

Neither

SA

0.68

None

Either

SB

1.82

None

Both

SC

2.66

Any one

Neither

SD

1.46

Any one

Either

SE

2.33

Any one

Both

SF

2.97

Any two

Neither

SG

2.04

Any two

Either

SH

2.85

Any two

Both

SI

3.51

All three

Neither

SJ

2.98

All three

Either

SK

3.69

All three

Both

SL

4.19

 

ICD-10 accuracy is vital for PDPM success. We will review NTA, the nursing groups as well as best practices in subsequent articles.

For additional information, contact Joan McCarthy, RSM health care consultant, at +1 312 634 3479.

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