United States

Senior Living Health Care Connection: New PDPM case mix (part 2)

Nursing components outlined

SENIOR LIVING HEALTH CARE CONNECTION  | 

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.

How can we help you?

To discuss how our team can help your business, contact us by phone 800.274.3978 or



Events / Webcasts

IN-PERSON EVENT

17th Annual Healthcare Private Equity & Finance Conference

  • February 19, 2020

LIVE WEBCAST

Health care industry 2019–2020 webcast series

  • January 16, 2020

LIVE WEBCAST

Senior Living PDPM webcast

  • June 19, 2019