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Among the many important decisions related to the PDPM transition is the question of whether SNFs and their rehab partners should accept students for clinical affiliations.  As strategy consultants and leaders in therapy, HealthPRO Heritage offers this guidance: 

As PDGM edges closer, there is rising concern and tension around the submission of claims that contain primary diagnoses that do not fall into one of the 12 clinical groupings established by CMS. Such primary diagnoses are known as "Questionable Encounters" (QEs). QE codes are "too vague," meaning the code did not provide adequate information to support the need for home health services. CMS listed 43,287 eligible primary diagnoses codes in their PDGM Grouper Tool. 

Under PDGM, claims for QEs will be sent back to the agency as "Return to Provider" (RTP) since CMS will not be able to assign the 30-day period to one of the 12 PDGM clinical groups. 

Examples of the Top 25 QE Codes:

Decisions. Decisions. Since the industry began wrapping their heads around RCS-1 two+ years ago, SNFs continue to weigh the pros and cons of retaining in-house therapy vs. an outsourced model. Questions arise: What does payment reform mean for SNFs with their own program? Is there a financial or operational advantage to transitioning from full service to in-house or a “managed” in-house model?

It can be easy to get lost in the details of PDGM and forget how vital outcomes and ratings are in driving overall agency success.  It’s one of the biggest reasons why appropriately managing therapy in PDGM is a key competency.

In HealthPRO Heritage at Home's recent survey with the National Association for Home Care and Hospice regarding therapy in PDGM, 48% of respondents anticipate less therapy utilization. Agencies should be cautioned on cutting therapy utilization given the focus on functional assessment and outcomes.  Functional assessments - completed best by a skilled therapist - will contribute significantly to payment in PDGM, while also continuing to drive publicly reported outcome measures and star ratings.

HealthPRO Heritage at Home partnered with the National Association for Home Care and Hospice (NAHC) to conduct a survey of home health providers to gather industry feedback on therapy utilization under PDGM. HealthPRO Heritage co-sponsored the survey as part of its ongoing effort to bring strategies and solutions to agencies as they prepare for PDGM. Nearly 700 people took the survey and were made up of representatives in every state from freestanding, institutional, health system and government based agencies from both for and not-for profit settings. 

The 2019 RAI Manual is here! The SNF world has been on the edge of their seat in anticipation of how the changes would impact the interdisciplinary team and coding of the MDS assessment.  CMS’ message is clear:  No longer is the manual only for MDS coordinators!  More emphasis on clinical characteristic coding for PDPM case mix group assignment means all disciplines must participate in completion of the MDS. The MDS item sets have been adapted for this shift in the Medicare classification system, requiring significant updates in the go to manual for RAI process.

The Patient-Driven Groupings Model (PDGM) is a game changer, requiring home health providers to explore new business models based on the introduction of new risks and potentially significant financial impacts.

HealthPRO Heritage at Home is leading the industry in readiness for the January 1, 2020 change to the Patient-Driven Groupings Model (PDGM). Success for both our partner agencies and employees will be driven through knowledge and implementation of process and strategy around PDGM.

SNFs have been bombarded with changes to many key performance indicators – such as Quality Measures, Five Star Ratings and the Quality Reporting Program – and will be expected to sustain and even grow quality improvements over time.  Read up on all the new changes here. (And have you heard the latest: CMS recently implemented a process whereby the QM thresholds will increase by 50% of the average rate of improvement in QM scores.)  

Based on these obvious smoke signals from CMS, the industry pundits foresee: Quality Measures just might be CMS’s way of monitoring for appropriate levels of skilled rehabilitation services after the October 1 transition to PDPM.   

In light of this prediction, consider your facility’s QM performance in highly monitored areas – such as skin integrity, falls, ADL performance, weight loss, functional mobility, pain, etc. 

Ask:  Are these areas recurrent concerns for your SNF?  

If so, HealthPRO Heritage advises:

Coding will be instrumental to your agency’s success under PDGM. Performing an audit of your coding practices now will provide the opportunity to educate your staff on accurate and cohesive coding guidelines and targeted aspects of the OASIS to ensure you are prioritizing both patient needs and accurate reimbursement.