A year ago we thought PDPM would be the biggest challenge of 2020. But COVID is not a compliance smokescreen and the devil is in the details and the details are in the rate driver data.
As you reflect on 2020 and plan for 2021, the analysis of your Patient-Driven Payment Model (PDPM) data must remain a high priority. Despite the unique challenges 2020 provided, the expectations of high quality care and compliance remain. So, while we can evaluate the data in the context of COVID and rationalize concerning trends, the reality is that CMS is still watching skilled nursing facility (SNF) provider behavior.
Compliance amidst COVID Chaos
Yes, CMS has been busy with COVID, too, but not so busy that they will not investigate potential compliance issues. The PDPM rate driver data for the final quarter of FY 2020 did not change dramatically from the trends we discussed in earlier blogs, but it is certainly worthy of a revisit so we can start the conversation about what these trends may mean.
Have the rate driver percentages stabilized, or will they decrease once we are past the COVID crisis?
What was COVID-19’s impact on PDPM?
Here’s what a few PointRight clients have shared about positive and negative impact:
- Higher nursing case mix groups due to increase in need for isolation, vents, and trach care
- Higher Non-Therapy Ancillaries (NTAs) due to increase in comorbidities common in patients with COVID
- Opportunity to develop COVID dedicated units to maintain census and develop positive relationships with referral partners
- CMS’ COVID Waivers provided opportunity to deliver skilled care and services “in facility” which typically garner higher reimbursement
- Multiple missed opportunities to capture accurate coding due to pulling MDS Coordinators to cover staffing challenges
- Challenges completing resident interviews due to isolation and quarantine leading to coding inaccuracies
- Physical plant challenges providing isolation that complies with RAI Manual definition
Don’t forget the CMS language in the 2019 SNF PPS Final Rule…“…with regard to the potential impact of PDPM on patient care, specifically the possibility that some providers may stint on care or provide fewer services to patients, we plan to monitor closely service utilization, payment, and quality trends which may change as a result of implementing PDPM. If changes in practice and/or coding patterns arise, then we may take further action, which may include administrative action against providers as appropriate and/or proposing changes in policy (for example, system recalibration, rebasing case-mix weights, case mix creep adjustment) to address any concerns. We will also continue to work with the HHS Office of Inspector General, should any specific provider behavior be identified which may justify a referral for additional action.” [ Source: CMS.gov ]
PDPM Rate Drivers – What do they reveal?
Let’s break down the rate drivers to expose the potential audit vulnerabilities.
I do not think anyone is surprised that there is an increase in coding of this nursing case mix group (CMG) because this is where isolation, trachs, and vents are captured. The jump in ES in FYQ3 aligns perfectly with COVID, but do not be too complacent here. CMS may see this as a potential area of fraud and dig deeper to make sure the definition of isolation in the RAI manual was followed. This case mix group (CMG) could likely remain high through early to mid 2021 depending upon the status of the pandemic.
A huge red flag for all providers should be the more than doubling of MDSs coded with depression and more than tripling of cognitive impairment in FYQ1. It is highly unlikely that the entire nation had a dramatic increase in residents with these conditions suddenly being admitted to their facilities. Now that depression and cognitive impairment drive the rate, there is certainly an incentive to capture them. But if your documentation supports your coding, don’t fret. We all know that if we provide additional training and focus on an area, we typically will see improvement in assessment. But you may want to consider documenting all your unusual trends and subsequent investigation in the QAPI committee minutes and confirm that this is truly the case. Consider any changes you made to the interview process or interviewer as well.
This PDPM rate driver saw a much slower increase but still nearly doubled from pre-PDPM to FYQ3. However, capturing restorative minutes on a PPS assessment is much harder now if Assessment Reference Dates (ARDs) are set early in the stay because it requires 15 minutes per day for at least 6 of the last 7 days. Earlier ARDs could be a logical explanation, but don’t assume. Test your theory especially if your quality measures may indicate declines in Activities of Daily Living (ADL) function.
Swallowing Disorders/Mechanically Altered Diet
The coding of swallowing disorders calculating close to 4x’s the pre-PDPM rate is yet another example of a concerning trend that will likely grab CMS attention. It makes sense that if the swallowing disorders increase, the mechanically altered diets might increase as well. However, not every resident with a swallowing disorder needs a mechanically altered diet, but most residents who are on a mechanically altered diet would have some condition to warrant it such as a recent oral surgery, poor dentition or extreme weakness making chewing difficult. The reason for the altered diet should be clearly documented and re-evaluated for continued need.
Non-Therapy Ancillaries (NTA)
Variability in resident acuity is normal so fluctuations in the distribution of assessments across the 6 NTA case mix groups is expected. Nationally, PointRight customers saw approximately 53% of their assessments land in the lowest two groups. How will CMS perceive high percentages of assessments in the higher CMI groups? We do not have any pre-PDPM comparison since NTAs were not in play prior to October 2019, but it certainly could be a high priority area for auditors. NTAs are a significant multiplier in the per diem calculations so it stands to reason that providing evidence that these comorbidities exist, or services/treatments were provided, will be a crucial step to avoid audit nightmares.
Use of CMS’ COVID related Waivers
The CMS waivers implemented for the public health emergency were a positive approach to helping keep less critical patients out of the heavily burdened hospitals and allowed SNF’s to implement and get reimbursed for the higher level of skilled care provided. However, these waivers will certainly come with retrospective scrutiny.
- Can you defend the need for skilled care for these residents?
- Does your documentation show evidence that the extension or early restart of the benefit period has a direct connection to COVID?
- And do not forget the basics. Do you have all your required Medicare forms completed?
Reviewing your trends in PDPM data is an ongoing process. Your data story can change gradually over time or abruptly with turnover in key positions. How will you monitor to ensure you are telling the real story?