Say goodbye to RUG-IV, and hello to the Patient-Driven Payment Model (PDPM).
This is a daunting task, not for the faint of heart. Under PDPM, reimbursement for Medicare Part A patients in SNFs will be driven by patient condition, rather than by therapy minutes provided. Documentation is crucial to a successful Recovery Audit Contractor (RAC) audit.
In the past, therapy documentation has been the focus of RAC audits. Now, nursing documentation is front and center. Do not try to maximize case mix index (CMI). But remember, certain documentation can easily lead to higher reimbursement. For example, if you document when a patient is morbidly obese, suffering from diabetes, and taking intravenous medication, this can lead to three times the reimbursement over the first three days. This article will explore the intricacies of RAC audits and how to maximize reimbursement while successfully maneuvering through the process.
Here is the million-dollar question: how will PDPM affect your business?
The answer is four-fold, for the purposes of this article, although this list is not exhaustive.
- Managing care: Unlike RUG-IV, which incentivizes ultra-high volumes
of therapy to capture maximum payment, PDPM requires you to carefully
manage how you deliver services in order to provide the right level of
care for each patient. This begs the question of whether you’re getting
paid to over-deliver services (or practice “defensive medicine”), or
you’re getting audits and recoupments for under-delivering due to poor
patient outcomes. For this reason, it can seem like you are getting
pulled in two directions.
- Financial: PDPM is designed to be budget-neutral. Your
reimbursements will decrease. SNFs will be able to offset the loss in
therapy reimbursement with higher reimbursement for services already
being provided.
- Staffing: There is less demand for therapists in an SNF setting. But you will be able to retain the best therapy sources.
- Billing:
Under PDPM, you will bill using the Health Insurance Prospective
Payment System (HIPPS) code that is generated from assessments with ARD.
You will still be using a five-digit code, as you did with RUG-IV. But
the characters signify different things. For example, under RUG-IV, the
first three characters represented the patient’s RUG classification, and
the last two were an assessment indicator. With PDPM, the first
character represents the patient’s physical therapy (PT) and
occupational therapy (OT) component. The second is the patient’s
speech-language therapy (SLP) component. The third is the nursing
component classification. The fourth is the NTA component
classification, while the fifth is an AI code.
The upshot to this is that different clinical categories can result in significant reimbursement differences. For example, consider the major joint replacement or spinal surgery clinical category. That clinical category is a major medical service, which can translate to a $42-a-day increase in reimbursement. For a 20-day stay, that clinical category would increase reimbursement by $840. You want to pick up on this type of surgery.
I received a question after a recent program segment asking whether swing beds will be affected by PDPM. In most hospitals, the answer is yes. The exception is critical access hospitals (CAHs), which will remain cost-based for their swing beds.
Final Rule: “Accordingly, all non-CAH swing-bed rural hospitals have now come under the SNF PPS. Therefore, all rates and wage indexes outlined in earlier sections of this final rule for the SNF PPS also apply to all non-CAH swing-bed rural hospitals.”
——————————————————
Photo courtesy of: ICD10 Monitor
Originally Published On: ICD10 Monitor
Follow Medical Coding Pro on Twitter: www.Twitter.com/CodingPro1
Like Us On Facebook: www.Facebook.com/MedicalCodingPro
