Editor’s note: This is the first article in a series on the PDPM categories for the nursing component, covering missteps to avoid in PDPM calculation, as well as essential coding tips. Future articles will address the additional nursing categories of Special Care High, Special Care Low, Clinically Complex, Behavior and Cognitive Performance, and Reduced Physical Functioning.
The nursing component of the Patient-Driven Payment Model (PDPM) has only two steps in the methodology to achieve the final case-mix group (CMG), but within those steps is complexity and a nuanced process that can confuse users. In the first step, the calculation determines the resident’s nursing function score using section GG items. The second step classifies the resident into one of the six clinical categories. Because the nursing component is calculated from multiple sections of the MDS, it is important for the nurse assessment coordinator (NAC) and all interdisciplinary team (IDT) members completing the MDS to understand which items affect the PDPM case-mix groups.
There are only three items (tracheostomy care, invasive mechanical ventilator, and infection isolation) that comprise the Extensive Services category, but don’t be fooled by its small size. The Extensive Services category packs a big punch for reimbursement. The case-mix index (CMI) multipliers for Extensive Services are among the highest in the nursing component, ranging from 2.93 to 4.06. Incorrect MDS coding can therefore result in a big swing in reimbursement from the nursing component. If something that should not have been coded is coded, the facility will receive significantly more than it should; if something that should have been coded is missed, the facility will miss out on money it is due.
Here are three tips to simplify the Extensive Services nursing category and reduce confusion, improving accuracy in MDS coding and reimbursement.
- NACs and the IDT need to understand section GG definitions, timing, and coding requirements.
The nursing component methodology is detailed in chapter 6 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual and simplified in AAPACN’s PDPM At-a-Glance Tool. The first step in the methodology for the nursing component is to calculate the nursing function score. Compared to the 10 section GG items used to calculate the PT/OT component’s function score, the nursing function score uses only seven items (eating, toileting hygiene, two bed mobility, and three transfer items). Unlike the PT/OT function score, the nursing function score does not utilize oral hygiene or the walking items.
The nursing function score is calculated for different performance periods based on the assessment type. The admission performance for the 5-Day PPS assessment is the first three days of the Medicare stay, and the interim performance on the Interim Payment Assessment (IPA) is the ARD and two days prior. These performance periods must be well-communicated to direct care staff for completion of any facility-required documentation. In addition, any interviews to collect section GG information should be conducted during the performance periods and documented in the medical record.
All staff caring for the resident must understand the definitions of the section GG items, as well as how to document the resident’s performance during the three-day performance periods. Usual performance is an important definition to understand, but unfortunately CMS’s definition is vague. The RAI User’s Manual describes usual performance (page GG-10) as:
A resident’s functional status can be impacted by the environment or situations encountered at the facility. Observing the resident’s interactions with others in different locations and circumstances is important for a comprehensive understanding of the resident’s functional status. If the resident’s functional status varies, record the resident’s usual ability to perform each activity. Do not record the resident’s best performance and do not record the resident’s worst performance, but rather record the resident’s usual performance.
While this may be tricky to understand, CMS has also provided many resources for training. In addition to the section GG examples in the RAI User’s Manual, CMS has shared videos, web training, companion job aids, and quick assessment reference pocket guides to assist in section GG understanding and accuracy. These can all be found at the SNF QRP Training page.
Accuracy in assessment of section GG items affects the calculation of the Extensive Services category. To qualify for the Extensive Services category, the nursing function score must be no higher than 14. Residents with scores of 15-16, indicating independence with most of the functional tasks, cannot achieve the Extensive Services category. Rather, if the resident qualifies for one of the clinical items in the Extensive Services category and has a function score of 15-16, he or she will qualify for the Clinically Complex category, which is a significant decrease in CMI.
2. NACs must use diligence in coding tracheostomy care and invasive mechanical ventilator.
Tracheostomy care (O0100E) and Invasive Mechanical Ventilator (O0100F) are two of the three MDS items that will calculate into the Extensive Services category. These services must be delivered while a resident of the facility (column 2 of O0100). This means the services must occur after the date of admission or reentry to the skilled nursing facility. Tracheostomy care need not be provided by the facility staff to code it on the MDS. The RAI User’s Manual allows coding of “treatments, programs, and procedures that the resident performed themselves independently or after set up by facility staff” (page O-2). Residents who perform their own tracheostomy care can have this coded on the MDS as well. In addition, laryngectomy tubes, which are tubes required when a resident has had a laryngectomy, can also qualify as tracheostomy care in O0100E, per the RAI Panel.
Editor’s Note: per Appendix B of the RAI User’s manual, the RAI Panel is a group of experienced RAI Coordinators who assist CMS and other State RAI Coordinators in answering MDS-related questions. Providers, consultants, and industry associations who have MDS questions should always first contact their State RAI Coordinator, who will then forward questions to the RAI Panel, if needed. When forwarding your questions to the RAI Panel, please be sure to send them to at least three Panel members to ensure your questions are responded to as soon as possible. The RAI Panel is in frequent contact with CMS for consultation and clarification.
When coding ventilators, it is important to identify if it is considered invasive or non-invasive. Only invasive mechanical ventilators are included at O0100F. The RAI User’s Manual clarifies that this item includes:
Any type of electrically or pneumatically powered closed-system mechanical ventilator support device that ensures adequate ventilation in the resident who is or who may become (such as during weaning attempts) unable to support his or her own respiration in this item. During invasive mechanical ventilation the resident’s breathing is controlled by the ventilator. (page O-3).
This item also includes residents who were being weaned off an invasive mechanical ventilator in the facility during the 14-day look-back period. However, do not include a ventilator that is used as a substitute for a CPAP or BiPAP—these items are coded at O0100G, Non-invasive Mechanical Ventilator.
3. NAC’s must understand the rules related to capturing isolation on the MDS.
Since the beginning of the COVID-19 public health emergency (PHE), the definition of isolation has been in the spotlight. Although CMS created many waivers related to the PHE, it did not alter the definition of isolation from the RAI User’s Manual. There are very strict criteria that must be met in order to code isolation on the MDS. Per the RAI User’s Manual (page O-5), all four of the following conditions must be met:
- The resident has active infection with highly transmissible or epidemiologically significant pathogens that have been acquired by physical contact or airborne or droplet transmission.
- Precautions are over and above standard precautions. That is, transmission-based precautions (contact, droplet, and/or airborne) must be in effect.
- The resident is in a room alone because of active infection and cannot have a roommate. This means that the resident must be in the room alone and not cohorted with a roommate regardless of whether the roommate has a similar active infection that requires isolation.
- The resident must remain in his/her room. This requires that all services be brought to the resident (e.g., rehabilitation, activities, dining, etc.).
A confusing part of coding isolation is that it has a 14-day observation period, but there is no minimum number of days the isolation must occur in order to code it on the MDS. This means that if all four criteria for isolation were met concurrently at some point during the observation period, and there is documentation in the medical record to support this, then isolation can be coded. However, all of the criteria must be met. A standard quarantine upon admission or due to potential exposure to COVID-19, or other infectious disease, is not enough. There must be active infection, meaning the resident is symptomatic or has a positive test and is in the contagious stage. There also must be documentation to support that the precautions are above and beyond standard precautions.
Another commonly overlooked part of the isolation criteria is single-room isolation. A resident on isolation cannot have a roommate, even if the roommate also has a similar active infection. If at some point the resident does not have a roommate in the 14-day observation period, and the other three criteria are met, isolation can be coded. However, there should be documentation in the medical record to support this. Running the electronic health record census to prove the single room isolation is not enough.
Summary
Understanding the RAI User’s Manual instructions and accurate MDS coding is always vital for the NAC role. MDS completion is not the place to cut corners, as doing so could be costly to the facility’s reimbursement. Miscoding an Extensive Services item may result in underpayment or in recoupment of an overpayment if the services are deemed to be inaccurately coded during a medical review.
If the resident meets the clinical criteria of the Extensive Services nursing category and has a nursing function score of 14 or less, the final case-mix group is determined as follows:
- Ventilator and tracheostomy while a resident – ES3
- Ventilator or tracheostomy care while a resident- ES2
- Isolation with no ventilator or tracheostomy care while a resident- ES1
However, if the resident meets the Extensive Services criteria but has a nursing function score of 15 or 16, the resident will qualify into the Clinically Complex category.
If the resident does not qualify for the Extensive Services category, the next step in the nursing component is to review if the resident qualifies for the Special Care High category. Look for the next installment of this article series focusing on Special Care High in a future edition of the Leader for the NAC newsletter.
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