Medicare Provider Education Overview

Disclaimer

• Education prepared based on current Medicare laws, rules, and regulations.
• Providers must keep updated with changes.
• Recording of the event by attendees is prohibited.
• Event recording will be available on YouTube.

Key Objectives

• Understand sections of the MDS (Minimum Data Set) influencing PDPM (Patient Driven Payment Model) codes.
• Examine effects on Medicare claims and payments.
• Discuss impact on medical review of claims.

PDPM Overview

• Definition: Patient Driven Payment Model.
• Implementation: Since October 1, 2019, replacing RUG-IV system.
• Purpose: Classifies patients based on data-driven characteristics.
• Benefits: Eliminates therapy volume incentives, improves payment accuracy, lowers administrative burden.

Resident Assessment Instrument (RAI)

• Function: Helps nursing home staff gather resident information.
• MDS 3.0: Tool for conducting assessments for Medicare/Medicaid certified nursing homes.

MDS Sections Impacting Payments

Section A

• Indicators: Green marks for PDPM payment and quality measures.
• A310 Section: Type of assessment impacts payment.
• Hospital Stay (A2300): Affects Part A SNF coverage eligibility.

Section B (Hearing, Speech, and Vision)

• Payment adjustments based on communication and understanding capabilities.

Section C (Cognitive Patterns)

• BIMS Assessment: Accuracy is crucial.
• Documentation: Must align with MDS reporting.

Section D (Mood)

• PHQ9: Scores to be supported with documentation.
• Indicators of depression should match interventions noted.

Section E (Behavior)

• Behavioral Indicators: Must be documented consistently in patient records.

Section GG (Functional Abilities and Goals)

• Incorporates old Section G: Focus on first three days of SNF admission.
• Drivers: Admission performance indicators must match documentation.

Section H (Bowel and Bladder)

• Indicators: Ostomy, catheterization, toileting programs impact Hips Code.

Section I (Active Diagnoses)

• Primary Medical Category: Must be active within last 7 days.
• Coding: Should reflect treatment-related diagnoses.

Section J (Health Conditions)

• Indicators like shortness of breath and recent surgery impact payment.

Section K (Swallowing and Nutritional Status)

• Swallowing disorders and nutritional methods like tube feeding must be documented.

Section M (Skin Conditions)

• Pressure Ulcers: Staging and treatment must match documentation.

Section N (Medications)

• Insulin administration frequency and changes must be documented accurately.

Section O (Special Treatments and Procedures)

• Payment Drivers: Consider cancer treatment, respiratory care, dialysis, etc.
• Isolation Precautions: Must be clearly documented.

Medical Review

• Process: Verification of MDS against documentation.
• Objective: Ensure MDS 3.0 and PDPM codes are accurately used in SNFs.

Upcoming Events

• Webinars on specific MDS sections (GG, I, O) and SNF certifications.
• Watch for announcements on Live Events page.

Q&A Highlights

• Critical Access Hospital swing beds do not follow PDPM; different payment structure.

Conclusion

• Acknowledgement of participation from Provider Outreach and Education team.