on your screen as well as in your slide deck is our disclaimer we have a disclaimer that we have to show you at the start of every um event that we host and this disclaimer basically says we prepared this education based on the current Medicare laws rules and regulations as they exist but if those laws rules regulations happen to change tomorrow it's your responsibility as a provider to make sure you're following those changes because Medicare rules will be the final determination of coverage also CMS prohibits you from recording either screen recording or taking snapshot um screenshots of this event however we are recording this event for you and pending the outcome of that recording it will be on our YouTube page as an encore within the next um week now Medicare is full of acronyms so I may use any and all of these acronyms as we are talking today if I happen to use an acronym that you do not understand please just refer back to this page my objective for today is that you learn about the sections of the MDS that drives the generation of the pdpm codes and I want to focus on how on how specific sections um and specific items on the MDS affect your Medicare claims um they also can affect payment and we're going to discuss how these impact medical review when they are looking at C claims so as we move on let's talk briefly about what is pdpm the patient driven payment model or pdpm that's a case mix group classification system for classifying Skilled Nursing Facility patients into a Medicare part A covered stay and into payment groups under the sniff perspective payment system it became effective October 1st of 2019 so right for the pandemic and pdpm replaced the case mix classifications and rug groups or resource utilization groups which was um rug version four under rug version 4 most patients were classified into a therapy payment Group which used primarily the volume of Therapy Services provided to that patient as a b basis for the payment classification and this really created an incentive for scub nursing facility providers to furnish therapy to sniff patients regardless of that patient's unique characteristics or their overall goals or needs of that Skilled Nursing Facility so what pdpm did was to eliminate this incentive and improve the overall accuracy appropriateness of sniff payments by actually classifying patients into payment groups based on specific datadriven characteristics while it simultaneously reduced administrative burden for Skilled Nursing Facility providers so pdpm classification system is is structured to include beneficiary interviews and inputs um into the data that's actually submitted on the MDS so as we move on the the REI the resident assessment instrument this actually helps nursing home staff to gather that definitive information on your resident strengths and needs and um things which must be addressed in an individualized care plan disciplinary use of an raai promotes this emphasis on quality of care and quality of life the MBs is a core set of screening and um clinical features functional status elements and includes some common definitions and coding categories which forms the foundation of the comprehensive assessment for all residents of nursing homes that are certified to participate in Medicare or Medicaid so to put that easily the MDS 3.0 is the tool to conduct your assessment so that was just a little background about those items and terminology because I know we have people on that are new to Medicare and new to Skilled nursing facilities so I wanted to give that little bit of background information so now we're going to turn our attention to the sections of the MDS that impact your overall medicare payment on the screen and if um you're following along with the slide deck we've provided a link to the Briggs sample MDS 3.0 and I like to use this sample in training because they've highlighted areas in which um there are Medicare indications which makes it really easy for for you to see which areas affect Medicare I'm going to use the link on the slide and go out and show you their sample now remember this is a sample and it's marked as such I'm not promoting it I have no vested interest in the company I just like the way it is set up and includes the Medicare indicators and I figure if I like it you guys will probably like it too so as that open and I will pull that into view here on your screen is the sample of that Briggs MDS that I was talking about and again you can see that it's marked here as a sample so um as I go through this sample I'm also going to include the information that is included on some of the upcoming slides in your slide deck especially when it comes to sections GGI and O I am actually going to be hosting webinars later in April that are specific to sections GG I and O so watch for for those three webinars to be posted in the next week or so and um we're also going to be hosting an event on scub Nursing Facility certification and recertifications because we're finding we're having a lot of issues within proper certifications and recertifications so again watch for those coming out in the next week or so from our Live Events page all right so starting on the first page of the sample you're going to notice at the top of the screen there's some indicators right here in green noted you know up here in the top left corner the green money bag which is this first one which doesn't want to highlight for me but that's okay um indicates that section affects pdpm payment the general green and the green hexagon indicate sniff Quality Reporting measures so as we stay here in section a there's a green indicator and money bags down here in um A310 that's because for Medicare we need you to Mark what type of assessment you're completing because again that affects your payment the identification information is used by medical review to start their review they need to verify the beneficiary they need to find the MDS assessment that you um stated that you completed and that's locked into the MDS repository and verify that information exists in the documentation so as we scroll down and we'll come to another section under a I'm trying to scroll slowly so not to affect your eyes down here um we get into um section A 2300 and you can see that it starts asking information about that patient's Hospital stay that's important to know because um if the patient did not have a qualifying Hospital stay then Medicare is not going to pay for a part A Skilled Nursing Facility stay so um we have to verify that that patient has had that qualifying Hospital stay we did have a lot of review issues with this during the public health emergency and the inappropriate use of the Dr condition code we had lots of claims that we received in which the Dr condition code was appended to the claim in order to bypass the need for the 3-day qualifying state but there was not any documentation or proof of why the patient could not stay in the hospital for three midnights so like no availability in the hospitals lacking staff um Etc in order to use that condition code during the public health emergency there must have also been proof as to why that stay couldn't happen and in most cases the Dr was used inappropriately and the hospital stay was just bypassed without any indication of why and I bring this up now even though we're no longer in the public health emergency because the use of the Dr condition code could go back into effect if there is some sort of State emergency um or a state emergency declared like a flood or a tornado uh maybe there's another pandemic Etc so wanted to um you know give a little stopping point on that and make sure that you know about it okay so scrolling down into section B which is the hearing speech and vision you'll see that there are indicators in this section as well that may adjust your payment amount so things like comos making themselves understood again upon medical review we must look at the documentation to make sure what you reported on the MDS in this area matches your actual documentation okay oops sorry about that all right and again down here you will see those money bags that cover that we move into section c um cognitive patterns and this is where you complete your bims assessment um we're going to look at this for accuracy that's reflected in your documentation you can complete the bims here and Report the scoring here and that's fine um and we'll verify that through your documentation as well to look for things like the staff is noting any kind of me memory problems recall ISS shoes orientation that exists that reflect the score that you gave in the bims here um we're also going to look for things like speech language pathology involvement if that is is necessary and maybe there's nursing staff or carryover with queuing such as like memory books or indicators on the wall etc for that patient lots of indicators here that are Mark with money when we do reviews and just so you know as we proceed on with this we our staff I shouldn't say we because I am not in medical review but our medical review staff basically recreates your MDS based on your documentation so we will extract the MDS that you have submitted into the repository and go back and make sure everything is correct and we're going to verify your documentation and make sure that if you captured it on your MDS it is verifiable within your documentation if it doesn't exist in the documentation then it can't exist on the MDS by itself and expect that we're going to give you that payment category that it came out to to give you if we can't see that that was done so all right as I scroll on the next section is section D and section D continues with mood so this section also contains the phq9 as well so as with the bims the phq9 can be completed here and doesn't have to be recompleted again in additional documentation however findings should be indicated in the documentation to support the scores that you reporting in your MDS okay so we need to to see those things if there are indicators of depression we need to see what interventions are being done related to that is there need for medication is there a need for therapy Etc based on how they scored on the phq9 so again carryover in your documentation is of utmost importance to make sure you are addressing these items correctly all right as we scroll down into section e we're going to get into Behavior section e um contains additional indic ators that could affect your hips Cod and payment amount these include things like hallucinations delusions the presence and frequency of those symptoms as with the other sections thus far if it is indicated in this section we are going to be looking in your documentation to support this so if you mark any of these potential indicators we need to see that that's also been addressed in your documentation [Music] um oh here's here's one thing I I wrote down some notes um this this was from a you know I know I've said a lot we need to see it in your documentation we need to see it in your documentation this came from uh a tagline that one of one provider um had that I was communicating with via email and I thought it very interesting interesting enough that I wrote it down and stuck it to my computer and and their tagline said remember if you considered it suspected it reviewed it were concerned about it thought about it or monitored it then document it we go back to that old Mantra if it's not documented it's not done all right so section GG section GG is a big one umoney bags in section GG as we as we scroll through so there is um a lot of indication on payment in this area um section GG now includes SE the old section g so just so you know that um make sure you are using the most current MDS your MDS should now not include a section g because that was updated several months ago and everything is now just in section GG which is your functional abilities and goals um category so the issues that are being seen upon review are in the drivers of this section significantly um and specifically play into the info that must be entered in documented within the first three days of the Skilled Nursing Facility admission so as we scroll down and we start reading some of these sections more completely pay attention to your assessment period um section GG is specifically the re the first three days of this day all right so down here in the self-care part again you see money bags in these self-care areas listed down here which means these areas Drive payment indicators which also means we're going to pay very close attention upon medical review to ensure how you Market on the MDS is reflected in the documentation so this means we're going to specifically be focusing on self-care assessment and the resident's level of performance with with the associated code that's documented on admission to the snip so in this column one which is the admission performance and as we scroll down um you can see it continues on to the next page all right so um things up here eating oral hygiene and toileting and then that continues down here with the patient's ability um to go from sit to line line to sitting sit to stand chair to bed to chair transfer and toileting transfer so those are those are the specific items that we're going to be focusing on which means we're going to look very heavily to the nursing documentation to any therapy evaluations any therapy care that has been provided to see how the patient is doing with these items upon a mission um and to make sure that the documentation matches the amount of help you say this patient needs in these specific areas so uh just for an example if the NDS is marked that a patient is completely dependent with sit to lineing but the nursing records indicate that they're supervise only or supervision only we may end up having to change that MDS sometimes this may not affect your hips Cod but often times it does um especially when we're talking about section GG so again we're going to look um for information to support the level of services and and we're going to look and make sure that it is being documented consistently now we do understand that sometimes the way therapy assesses an individual or sees a patient's function can be a little bit different than sometimes how nursing sees a patient function or sometimes a patient may do really really good in the morning but um and de great with therapy and be more independent but when they're with nursing later in the evening and they're tired they may be more dependent on on staff for those cares so just make sure that you um are talking your MDS coordinator is talking with everyone when they are making the decision on how much dependency that these residents truly have and that you're marking it adequately all right so again GG goes on for um a few pages here and again there are green marks so we know those are things that could potentially affect your Medicare and Medicaid claims and as I scroll down we're going to go to the next section which is section H again and don't worry about GG so much right now because we are going to host a whole webinar just on that specific section pull that out of the way so sorry all right so as we move on and let's talk about section H um section H is on bowel and bladder and includes things like ostomy intermittent catheterization toileting programs Etc so in this section we must ensure that the documentation again reflects what's coded here these again could affect your hips code so we really look to your documentation for this information and if it doesn't exist we are going to remove it from your MDS when basically we're recreating it all right section I section I is another big one that also drives a lot of medicare payment so again posting a separate webinar just on Section I next month but I want to hit some of the most important features um because there's so many issues with correct reporting in this section so this is the active diagnosis section first you must choose a primary medical category for the patient up here in section I 0020 um this is based on the reason the patient needs to be at the sniff if you refer back to the REI manual and how to correctly capture the diagnosis in this area of the MDS you only include active diagnosis that have been diagnosed in the last 60 days the items in this section are intended to code diseases that have a direct relationship to the resident current functional status as well as their cognitive status their mood or behavior status any necessary Medical Treatments any necessary nursing monitoring or even potential risk of debt so one of the important functions of the MDS assessment is to generate an updated accurate picture of the resident's current health status that's why this section focuses on those diagnosis that are active this should not include past medical history diagnosis and things that are not a treatment indicator for the Skilled Nursing Facility so for sections I10 um which is the sections that are currently on the screen you're going to look and see if any those noted diagnoses of of one of the following is in the 7-Day look back period um ulcer Dev colitis uh septicemia wound infections Etc all these things that are highlighted with the green and the money bags so again diagnoses identified within the last 60 days and treated in the Sniff and driving patient care and the and the plan of care and is also active within the last seven days so I do encourage you to refer back to the raai manual where it defines active diagnosis um and it's stated in the ri manual that active diagnosis is physician documented diagnosis in the last 60 days that have a direct relationship to the patient's res uh to the patient or resident's current functional status cognitive status mood or behavior medical treatment nursing monitoring or risk of death during the last 7day look back period again we're going to host an entire webinar just dedicated to section eye and active diagnosis next month all right so as we scroll on and we're going to hit section J and section J doesn't have as much um indicators but we still want to talk about those things that are an indicator so things in section J that are an indicator and could affect your payment and drive your payment include things like shortness of breath um if there's documented fever or documented episodes of vomiting within the 7-Day lookback period so it is crucial that your MDS coordinator takes these things into consideration and set your Ard date accurately um so you can capture if any of these things happened in the hospital in that look back period of time so section J also includes surgery that um if the surgery prompted sniff care in the last 100 days prior to the snip admission I'm going to scroll down here a little bit more we get to Prior surgeries and j2100 and on include a list of surgeries to choose from if you marked yes up here so if you marked yes in recent surgery that required active or requiring active skilled care if you marked yes there there is some um a list of surgeries that you can choose from down here again if we can't find it in the documentation it's going to be removed from your MDS upon review all right section K is on swallowing and nutritional status so some of the big drivers here are if the patient has any of the following again noted in the 7-Day look back period like swallowing disorders um documented loss of solid foods from the mouth when they're eating holding food in the mouth Etc all these that are in k010 again they need to be reflected in the documentation as well um other indicators in this section include things like weight loss um and the percentage of weight loss for this patient as we scroll down you can see big drivers also um are parental or IV feeding feeding tubes mechanically altered diets Etc uh like with swallowing disorder um items you know that were listed in K100 uh uh I'm losing my my mind here for a second um regarding feeding I'm sorry you also make sure you need to note if those things had already occurred on a mission um while the patient was a resident of the Skilled Nursing Facility or while they were not a resident of the Skilled Nursing Facility we're going to check your nutritional records we're going to check any speech language pathology records any nursing notes Etc to help verify this information and again the proportion of uh tube feeding that this patient may be getting if they are on Parental or entral feedings um and the average fluid intake per day that is being done so while they're a resident and during the entire seven days so again I can't I can't um stress enough you know pay attention to those indicators and make sure it's captured in your documentation because we are going to go looking for it if it's marked here in green we have to know it exists section M includes information on skin conditions so things that drive this category for Medicare include things like your pressure ulcers or other types of ulcers um including the staging of those ulcers so remember if a pressure ulcer is surgically closed with a flap or a graft it should be coated on the MDS as a surgical wound and not as a pressure uler if the flap or graft fails you're going to continue to coat it on your MDS as a surgical wound and until it's healed other components of skin care that we're going to review um include the treatment of of other skin conditions like pressure um and and the way you're treating those like pressure reducing devices turning repositioning schedules W care Etc and I think that's all down [Music] here um yeah so you can see there um it's not a lot of money bags in this section but if you are coding that you were treating surgical wounds or ulcers that affect your overall payment then we have an expectation of you as a facility to also document how you are working to eliminate those wounds to eliminate that risk of infection Etc so just because it may not drive your money necessarily um you know in in the way of of a higher paining hips code it does affect the way that we look at your documentation because we want to make sure you are treating that patient appropriately all right so as we move on to section n section n is all about insulin so if your patients require insulin things that are going to drive payment are the number of days injections were receiv in the seven day 7day look back um or sense admission and changes to insulin orders during that 7-Day look back um does that information match what's reported in the MDS so does your position documentation of orders and your Administration record match what you captured here if it's not we're going to change that when we do the review all right and then the last big section and again this is the last section that we're going to host a whole separate webinar on and we'll talk about more of this information and that webinar is section o and section o comes down to your special treatments and procedures and and those programs as you know and as you can see here in the sample form there are a lot of things that drive payment that are included in section o again it's important that you pay attention to the look back information in each of these sections and that you're marking things correctly on the MDS because it wants you to capture information about did this occur on a mission did this occur while the patient was a resident um it asks you about discharge as well and depending on you know if you're using this as only one assessment or if you've had changes um will depend on you know how this accurately gets marked so again continuing on with Section o and some of the things that um specifically Drive payments um are these things listed here again in the so we start with things like cancer treatment radiation respiratory respiratory is a big one suctioning trait care IV medications dialysis and isolation isolation is a big one that we often find issues with as well upon review um very often we find that it's marked that the patients in isolation or quar for an active infection but the documentation never lists any type of isolation any type of isolation precautions that are being taken if the isolation was lifted when the when the isolation was lifted often we see in the documentation that the MDF you know again is marked however the documentation shows the patients eating in the dining room sleeping in a shared bedroom that's not with another person isolated for the same issue there's no documentation of additional precautions being taken and no indication that the isolation was ever listed and we're not receiving um look back information to support that either so if the patient was on some sort of isolation for an infectious disease that testing negative is necessary for make sure that those negative test results are included in your documentation when we go to review or if there's a recommended period of time that that person remains quarantined or in isolation your documentation should support that that patient has met that period of time before being released back out into the general public of your um uh of your patients of your patients and residents so the other thing in section o respiratory treatments and therapy and dialysis are also included in section o and I think I already scrolled right by those but um yeah I did scroll right by them but that's okay uh remember for respiratory therapy we're going to need to see the number of days and minutes of therapy for that respiratory treatment because it needs to be at least 15 minutes a day in the last seven days um section o also goes on to include information about ptot and SLP services and this includes things like a valid plan of care um diagnosis treatment diagnoses daily treatments administered those are all things that we're going to look for in your documentation if you are marking that the person's having those now again you see these aren't moneybag drivers but they are a huge component of Skilled Nursing Facility Services so if you are marking that the patient is receiving um those Services we're definitely going to be looking in your documentation for any PT or SLP notes whatever you have marked the patient is receiving we're going to make sure that there's an initial evaluation we're going to make sure there's a plan of care we're going to make sure that they're um receiving services that are noted under the plan of care we're going to look to your physician certificate and make sure that the physician is certifying the plan of care but again don't fret because we will be going over section o um all by itself and some of those drivers in in section O next month all right so that again here are those um restorative nursing program that's kind of the last part if they're in a restorative program restorative nursing program we're going to expect to see that documentation in your um in your overall documentation as well so this time I'm going to go back to the slide deck and I do have some slides in your slide deck as I go through those um again that's focus on those main areas of [Music] and payment and we really talked about how these sections specifically um were impacted by the medical review itself because every Skilled Nursing Facility in the entire United States is subject to a five claim medical review based on CMS indications to all of us Medicare administrative contractors so it's just a way to make sure since PDP M went into effect right before we went into a pandemic and things were a bit crazy we all know CMS wanted us as your Medicare administrative contractors to go back and check in on the skilled nursing facilities do a small little sample of claim reviews and make sure that the um facilities are using the MDS 3.0 and the and the pdpm codes that they're generating are are clear and accurate and their documentation is matching that so at this time that takes us to the question and answer portion time of the call um I am looking to the chat and I don't see anything in the chat but I'm going to verify with Jennifer if um any questions have come in that I have not gotten to um we haven't received any questions as of yet perfect thank you for checking Jennifer and I do see looking over there there is a question um do critical access hospitals follow pdpm and paid in this way uh so if your patient is a swing bed patient of a critical access hospital no you are not paid via the pdpm if you are a in a swing bed of a PPS hospital then yes you follow and are paid um in this manner uh critical access Hospital swing beds I think have some different assessments to complete as well um I don't have that information in front of me but you are paid in a different manner so um not via the pdpm and so I think that was the only question all right Perfect all right so on behalf of myself and Rachel and Jennifer as well as all of Provider Outreach in education and medical review we want to thank you for your participation in today's event