2019 State Of The Union
with Liz Almeida-Sanborn, President
An Interdisciplinary Approach to Alphabet Soup
PDPM/QRP/ VBP – an introduction
With the effective date of the Patient Driven Payment Model (PDPM) finalized, and SNF QRP and VBP in place, 2019 is shaping up to be a blockbuster year for the Long-Term Care Industry. By now, many of us are knee deep in preparing for the changes associated with the shift from volume to value. With so much riding on our comprehension of these major fundamental reporting and reimbursement changes, a prepared and well-versed interdisciplinary team is critical to the success of post-acute care providers. Members of the interdisciplinary team, especially clinical leadership, must have an in-depth understanding of how facilities are being (and will be) evaluated and reimbursed and what can be implemented now to safeguard future success. PDPM is the most significant change to SNF reimbursement since, well, the last most significant change to SNF reimbursement; RUGs. The reality is that these changes are intended to be budget neutral across the industry. Practically speaking, that means some facilities will thrive and others may struggle, impacted by reimbursement reductions.
As part of the triple aim, CMS’ goal was to radically shift focus from fee-for-service, based on volume of services, to value-based systems of reimbursement. CMS started by focusing on one of the most costly aspects of caring for the elderly; rehospitalization. They successfully implemented, as part of the VBP program, metrics and methods for rewarding and penalizing facilities for caring (or not) in place. Beginning this past October, every facility was assigned a payment multiplier which was applied to their Medicare rate. Highest scoring facilities realized a bump of up to 1.65% and the lowest scoring facilities saw close to a 2% hit to their reimbursement. Of the 15,306 SNF nationwide, 440 facilities tied for the highest score and the lowest ranking was shared by 3,148. This translated to only 26% of facilities realizing an increase or at the very least, no impact in Medicare rate payments.
Concurrently, CMS began work on quality measures (some new, some old) that they believed would best reflect quality care delivery in the SNF environment: Falls with Major Injury, Changes in Skin Integrity, Discharge to Community, Potentially Preventable 30-Day Post-Discharge Readmission, Drug Regimen Review, Functional Outcome Measures (admission and discharge) for Mobility and Self-Care. Under SNF QRP, SNFs that fail to submit the required quality data to CMS will be subject to a 2% reduction in funding. Not meeting SNF VBP and QRP are impacting SNF reimbursement today and, with 8 months left to go, we now prepare for PDPM and its potential impact. Over the coming months, SNF providers should be outlining their specific plan to their interdisciplinary team. The approach must be interdisciplinary and address not just the shift to Med A PDPM but focus on clinical services to ALL patients and residents to enhance quality and value.
Where do we begin?
As you know, members of the PTS team have been invited speakers and authors regarding PDPM, QRP and VBP through the many industry state associations we affiliate with. We will continue to work collaboratively to ensure wide success, but our focus is more specific to the unique needs of each of our partners. Through our own educational webinars, facility specific strategy meetings, and focused action plans that begin with strategies we can and should implement today, PTS will be with you every step of the way. We will continue this process until the course has been successfully navigated because we know that the keys to success in a value-based system begins and ends with patient outcomes and accurate reporting of patient status. Everyone on the clinical team must have a profound understanding of value based care reimbursement. The ability and clinical competency of providers to implement cost-effective service delivery, deliver outstanding patient outcomes, meet/exceed customer and referral source expectations and accurate reporting will be paramount. This includes appropriate ICD-10 coding, accurate recording of functional capabilities in Section GG, an understanding of the cost of care and achieving strong patient outcomes in a cost-effective manner. Our leadership teams should be gathering to assess clinical competency, communication, LOS management systems, and care delivery systems that include probabilistic risk assessment tools. Through gap analyses, together we can take steps toward PDPM, QRP and VBP success resulting in outstanding patient care and sound financial results. PTS therapists have been tracking patient outcomes for a number of years. We have been utilizing clinical care paths and are experienced in managed care, ACO and BPCI environments. Our therapists have been consistently trained on all Medicare reimbursement systems and regulations and have been effectively coached as leaders within the rehab department and within each care center. Who better to work with you and your nursing teams to ensure strong financial and clinical outcomes as the burden of revenue enhancement now shifts to nursing.
Your PTS team plays a critical role in the approach necessary to thrive under value-based care systems. If you haven’t already, it’s time to look at clinical programming, care pathways that will support QRP and VBP, predictive analytics steeped in evidence-based research, and strengthening clinical partnerships across the continuum. Rehabilitation services under the new alphabet soup of care delivery must move from counting therapy minutes to determining most effective approach to strong clinical outcomes, patient satisfaction, and successful discharges. Change takes time so let’s build our teams, gather our resources and navigate beyond RUGs, together.
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Billing Reminder! CMS 2019 Physician Fee Schedule Final Rule Is Now In Effect!
Physician Fee Schedule Effective January 1, 2019
Background
CMS released the Physician Fee Schedule Final Rule in November 2018 with an effective date of January 1, 2019.
What you need to know
Functional Limitations (G Coding)
As of January 1st, entering of G codes on Medicare B claims is no longer required. However, we have instructed our rehab teams to continue to enter them for any Managed Care provider that requires them unless notified otherwise.
KX Modifier / Threshold
Although CMS repealed the therapy cap in 2018, CMS continues to require a KX modifier be applied to services over the threshold amounts, which for 2019 are as follows: $2040 for PT and ST combined, and $2040 for OT. Our billing exports will continue to include the KX modifier.
Rate Increase
The fee schedule rates were increased by .11% in aggregate; reimbursement for some codes increased, some decreased. Please verify that your software has been updated accordingly.
New Assistant Modifiers
CMS created new modifiers to be entered on claims for Med B beginning Jan, 2020: CQ (for services performed by a Physical Therapy Assistant) and CO (for services performed by an Occupational Therapy Assistant). These modifiers distinguish rehab services that were performed by an assistant versus a registered therapist. This is NOT required at this time. CMS will notify us when the voluntary use of the codes will begin. In the meantime, rest assured that our software will provide the appropriate coding and come through on our billing export.
If you have any questions, please contact Maria Maggi, Vice President of Compliance at:
mmaggi@preftherapy.com
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On The Move With Matt Nash,
VP of Strategic Development
PDPM Strategic Planning and Training
As a leader in rehabilitation management, PTS has been preparing for the transition to value-based care delivery for 2 years. Our teams are in place and we have begun training at all levels within our organization including our facility-based teams to prepare a seamless transition to PDPM. As PTS’ expert on PDPM and value-based care, Matt Nash, PT, has been traveling throughout the northeast as a guest speaker on PDPM and predictive analytics. He has presented at many state association annual conferences, LeadingAge New York Financial Managers Conference, MARCUM Long Term Care Symposium, Maine Health Care Association Fall Health Care Conference & Expo and LeadingAge Maine & New Hampshire Education Committee. Matt was on the move quite a bit in 2018, and the start of 2019 is no different. He is already scheduled to present in New Hampshire, Virginia and Maryland in coming months.
In addition to his travels, he has joined our operations team for facility specific strategy meetings with many more already scheduled while continuing to drive our PDPM education series for our customers. Following a broad overview webinar presented late last year, Matt has begun a more granular presentation of information, breaking down key drivers into separate webinars. The first was on December 12, 2018 with an in-depth look at Section GG. On January 10, 2019 the focus shifted to ICD-10 coding. On the third webinar, January 24, 2019, Matt presented on Non-Therapy Ancillary (NTA) Component of PDPM. Speech Therapy and Cognition, PT & OT components and Nursing components will all be explored in depth on upcoming webinars.
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PDPM IMPACT – What Will It Look Like?
Many of you are already submitting MDS data to us as an opportunity to determine current the impact of PDPM. If you have not already submitted and are interested in learning more, let us know. PTS has the ability to complete an analysis of the projected PDPM impact for your facility. By uploading current MDS’ data files, we are able to project how your specific patients will categorize under PDPM and determine the financial impact. This is an important step in the process as we begin transitioning to PDPM. Keep in mind that this exercise will allow us to identify areas for improvement in coding and data capture which is an important step toward PDPM success.
If you are interested in this assessment and the understanding on how a MDS data analysis can benefit your facility, please provide the following:
- At least one month of MDS files (Medicare A only). The files should be created in the same file format CMS uses for claims submission.
- Facility NPI number.
- Files will need to be sent as a compressed zip folder in an appropriately encrypted email to: PDPMInfo@preftherapy.com or use the embedded link below.
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Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage
Transmittal 4198
In March of 2018 we alerted you about the revised ABN form CMS was implementing that would become mandatory on April 30, 2018. We have an update for you:
On January 11, 2019 CMS released Transmittal 4198 with updated information on the SNF ABN, Form CMS-10055.
What you need to know:
- With this change request, CMS has discontinued the 5 SNF Denial Letters, and the Notice of Exclusion from Medicare Benefits (NEMB-SNF), Form CMS-20014.
- The revised Form CMS-10055 replaces all of the former letters.
- SNFs will continue to use the ABN Form CMS-R-131 for items and services that may be denied by Medicare under Medicare Part B to inform beneficiaries of their potential liability.
- Events triggering issuance of an ABN remain the same:
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initiation of services a SNF believes Medicare will not pay for,
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reduction of services that a SNF believes Medicare will no longer pay for,
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termination of services a SNF believes Medicare will no longer pay for.
- SNFs should follow the same standards and instructions when completing the SNF ABN Form CMS-R-131.
Step by step instructions for notice completion are posted along with the form on the CMS website:
Further detailed information about the ABN may be found in the Medicare Claims Processing Manual- Chapter 30- Financial Liability Protections; Section 70.
If you have any questions, please contact Maria Maggi, Vice President of Compliance at
:
mmaggi@preftherapy.com
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Preferred Therapy Solutions Featured at the
2018 National AOTA Annual Conference and Expo
April is a special month at Preferred Therapy Solutions as we recognize the many Occupational Therapy professionals that are devoted to helping people, through therapeutic interventions, with activities of daily living. Like all professional associations, OTs gather annually for their national conference affording themselves an opportunity to learn from each other, network, and expand clinical practice through evidence based research, etc. Last year we were especially proud of our very own Darlene Piraino, an Occupational Therapist and Regional Director of Compliance and Education at Preferred Therapy Solutions. Darlene was an invited speaker at the 2018 AOTA Annual Conference and Expo held in Salt Lake City, Utah on April 20th, 2018. Darlene and her colleague, Pamela Karp, presented to one of the largest gatherings of Occupational Therapy professionals in the world!
Darlene and Pamela hosted an accredited session to over 300 attendees on “Training the Generalist to Evaluate and Treat Common Shoulder Pathologies in the Geriatric Population.” This educational forum was designed to provide Occupational Therapists, practicing in various settings, with the requisite knowledge and skills necessary to efficiently and effectively assess common shoulder pathologies in the elderly and to develop an appropriate plan of care. We are so proud of you Darlene!
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