Renee Kinder

We have completed our brackets, we have identified key team players, and the industry is as engrossed in Patient-Driven Payment Model Coding Madness as a true-blue Kentucky fan!

So how are your players lining up?

Are you set for a full court press leading into October or will you be ending with a buzzer beater?

The first step to avoiding defeat is to assess if there are current gaps in your game plan causing your case mix areas to falter.

Here are some quick thoughts to ensure your tip-off yields the right case mix and is as true blue as your patients’ clinical needs.

Tip One: Volume of Coding for functional status is as impactful as accuracy of coding.

Consider the case mix factors for PT, OT, and nursing.

The scoring scale for these areas is based on a 0-to-4 scale with 0 points being given to the following criteria: dependent, refused, n/a, and not attempted. As such, limited coding or simply not having the proper clinical tools to assess areas of self-care and mobility can cause similar scores being obtained for someone at a level of total dependence and a refusal. Furthermore, you could have resulting patients with incorrect or reduced case mix levels simply based on limited data alone.

Are your teams skilled at obtaining data in these areas now for patients, specific to clinical presentation?

Consider what practices you have in place for assessing the following areas and how that differs for an individual with a recent elective joint replacement versus an individual s/p a stroke: Eating; Oral Hygiene; Toileting Hygiene; Sit to Lying; Lying to Sitting on Side of Bed; Sit to Stand; Chair/Bed-to-Chair; Toilet Transfer; Walk 50 Feet with Two Turns; Walk 150 Feet

Tip Two: Cognitive Impairments occur across a spectrum.

Cognitive impairment is not a single yes or no level, and it occurs in a variety of aspects based on location of neurodegeneration and/or neural location of patient’s new onset injury (think right versus left CVA versus TBI).

Assessment will be impactful for SLP case mix under PDPM. As a result, communities should assess current BIMS and staff interview practices to ensure appropriate areas of documented and scored for individuals who are interviewable and non-interviewable. Remember that when this model was initially being created, the first data map for trending care based on cognitive levels was based on a single Section B area alone. We have come a long way in achieving a greater level of specificity for cognition. Now it is our responsibility to document, code correctly and develop appropriate plans of care based on the baseline severity.

Tip Three: There are four phases to swallowing, Section K accuracy accounts for all.

Section K of the MDS outlines the four phases of swallow for which your SLPs should have current baseline data in individuals requiring their skilled level of care. Additionally, greater levels of collaboration in these areas can assist with yielding appropriate case mix for the SLP category. Remember: the SLP component was created slightly differently than PT and OT and is based on number of impairments versus level of impairment or severity. When speaking to SLPs, don’t allow the MDS language to result in coding inaccuracy or misidentification of root cause.

Consider this:

K0100A Loss of liquids/solids from mouth when eating or drinking. An SLP may refer to this and document as oral prep or oral impairment with root cause secondary to impaired labial (lip) or lingual (tongue) reduced strength or ROM

K0100B Holding food in mouth/cheeks or residual food in mouth after meals. The root cause here could be sensory impairment, reduced lingual ROM, or reduced base of tongue retraction.

K0100C Coughing or choking during meals or when swallowing medications. An SLP may see a need for an instrumental assessment to assess this area when noted at bedside. However, coughing alone does not always indicate aspiration is a risk or has occurred.

K0100D Complaints of difficulty or pain with swallowing. This area of impairment is often associated with the esophageal phase of swallow, consider additionally if you are seeing this complaint in individuals where the root cause is due to GERD or other GI impairments.

Tip Four: Reference the CMS Playbook

They have clearly outlined their audit areas around coding accuracy as is impactful to your case mix reimbursement.

These areas include:

  • Changes in payment that result from changes in the coding or classification of SNF patients vs. actual changes in case mix.
  • Changes in the volume and intensity of therapy services provided to SNF residents under PDPM compared to RUG-IV.
  • Compliance with the group and concurrent therapy limit.
  • Any increases in the use of mechanically altered diet among the SNF population that may suggest that beneficiaries are being prescribed such a diet based on facility financial considerations, rather than for clinical need.
  • Any potential consequences (e.g. overutilization) of using cognitive impairment as a payment classifier in the SLP component.
  • Facilities whose beneficiaries experience inappropriate early discharge or provision of fewer services (e.g. due to the variable per-diem adjustment).
  • Stroke and trauma patients, as well as those with chronic conditions, to identify any adverse trends from application of the variable per-diem adjustment.
  • Use of the interrupted-stay policy to identify SNFs whose residents experience frequent readmission, particularly facilities where the readmissions occur just outside the three-day window used as part of the interrupted-stay policy.

What will your community look like when a turnover occurs? Can your data and documentation support your coding?

Maybe you need to shift gears and consider a crossover to realign your direction.

Either way, setting a strong proactive defensive plan is key.

Here’s to taking it man-to-man, involving all team players, matching up and taking responsibility of guarding one another and coming out leading the road to victorious coding in October!

Renee Kinder, MS, CCC-SLP, RAC-CT, is Vice President of Clinical Services for Encore Rehabilitation and is the Silver Award winner in the 2018 American Society of Business Publishing Editors competition for the Upper Midwest Region in the Service/How To Blogs category. Additionally, she serves as Gerontology Professional Development Manager for the American Speech Language Hearing Association’s (ASHA) gerontology special interest group, is a member of the University of Kentucky College of Medicine community faculty, and is an advisor to the American Medical Association’s Relative Value Update Committee (RUC) Health Care Professionals Advisory Committee (HCPAC).