PDPM began 10/1/2019 followed closely by the onset of the COVID-19 public health emergency. Skilled nursing facilities did not have time to become fluent with the new payment system due to the onset of the PHE. This presentation will focus on the therapy components of PDPM (Physical Therapy, Occupational Therapy and Speech Language Pathology). The Medicare teams are still confused by the fact that the therapy payment is no longer dependent upon therapy days and minutes provided during the MDS look-back. Instead, the P.T. and O.T. components are based solely upon the Section GG functional score and the primary diagnosis coded in MDS item I0020B. The timeframe for assessing the resident functional abilities is limited to the first 3 days of the Medicare A stay when completing a 5-day PPS MDS and on the ARD and the 2 days prior to the ARD of an Interim Payment Assessment. The Functional scoring and payment is expected to be interdisciplinary. This means there should be collaboration between nursing and therapy to determine the residents’ usual function for each of the GG functional items. Documentation must be in the medical record to provide support for MDS coding and to support the claim during Medicare reviews. Negative Medicare reviews have occurred related to Section GG assessment and documentation. The second part of the P.T. and O.T. payment component is the coding of the primary diagnosis. The Medicare team should collaborate to determine the primary diagnosis foreach resident which supports why they require skilled care.
The second half of the presentation will focus on the Speech Language Pathology component. The presentation will discuss the 5 areas that impact payment: primary diagnosis coded in I0020B, S.L.P. comorbid diagnoses (late effects of CVAs, cancers of the oral cavity, ventilator use, tracheostomy care or diagnosis of ALS) and cognitive impairment (BIMS interview or CPS). The end splits affecting payment are the presence of a potential swallowing problem coded in K0100 and/or a mechanically altered diet. The S.L.P. component is frequently found to have errors on Medicare review.
Carol Maher, RN-BC, RAC-MTA, RAC-MT, RAC-CTA, RAC-CT, CPC
Carol Maher is a Board Certified Gerontological Registered Nurse with over 30 years of long term care experience and has worked in long term care in many roles. She worked as the MDS Coordinator in a 300 bed SNF in Pennsylvania for 8 years before moving to CA to become the MDS Coordinator/Director for a 1200 bed SNF in San Francisco. She has also worked as the MDS Coordinator in a SNF that typically had 60-75 residents on Medicare in addition to 160 long-term care residents. Most recently she was the Senior VP of Utilization Services and Director of Reimbursement for large multi-facility organizations.
Carol has worked as one of the Gold Standard nurses for MDS 3.0, serving on the RAP workgroup to prepare the way for the CAAs for MDS 3.0, and participating on a number of Technical Expert Panels related to MDS, Quality Measures and care planning. A sought-after speaker, she has given presentations at AANAC, AHCA and Leading Age national conferences as well as many state organization presentations. She is also a frequent author of articles related to the RAI process and PPS. Carol served as a member of the AANAC Board of Directors for 9 years. She is presently serving as the chair of the AANAC Expert Advisory Panel and as an AANAC Master Teacher of the RAC-CT and RAC-CTA certification courses. Ms. Maher is the Director of Education for Hansen Hunter & Co. P.C., providing MDS and Medicare classes across the country, presenting monthly educational webinars and completing compliance audits. She is the author of Long-Term Care MDS Coordinator’s Field Guide (HCPRO 2016).
- 1.5 credit hours for RNs
- 1.5 credit hours for NABs
This pre-recorded webinar expires on July 29, 2023.