Editor’s note: this article was reviewed and revised December 2, 2021.
Without a full understanding of how the SLP component of the Patient-Driven Payment Model (PDPM) is calculated, it can seem complicated. The SLP methodology is detailed in the PDPM Calculation Worksheet for SNFs 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 SLP component methodology has two steps or tiers to achieve the final case-mix group (CMG). CMS’s PDPM calculation worksheet walks the user through how the MDS software calculates the final PDPM case mix groups from what is coded on the minimum data set (MDS). The first step or tier in the calculation of the SLP component determines if the resident has None, Any One, Any Two, or All Three of the first-tier criteria: Acute Neurologic primary diagnosis, specified SLP comorbidities, or cognitive impairment. The second step or tier then determines if the resident has Either, Neither, or Both of the second-tier criteria: mechanically altered diet or a swallowing disorder.
If adequate time is not allotted for researching and completing MDS coding, relevant information can be missed. Because the case-mix index (CMI) multiplier in the SLP component ranges from 0.68 to 4.21, even one MDS coding misstep can be costly. Here are four tips nurse assessment coordinators (NACs) can use to simplify the SLP methodology and reduce confusion about this component, resulting in improved accuracy with MDS coding and reimbursement.
- NACs need to choose the most appropriate primary diagnosis in I0020B.
The primary diagnosis in I0020B is used to determine the clinical category in the Physical Therapy (PT)/Occupational Therapy (OT) component and is used to determine if the resident qualifies for the Acute Neurologic primary diagnosis used in tier one of the SLP calculation. The interdisciplinary team (IDT) should review the selection of I0200B to ensure the most appropriate diagnosis is assigned to accurately reflect the primary reason for the Medicare Part A stay. In addition to the coding requirements for all diagnoses on the MDS, the documentation must also support that this is the primary reason for the skilled stay.
However, there are times when this is not an easy decision. There may be instances where more than one diagnosis meets the criteria for the primary diagnosis. If more than one diagnosis equally contributes to the need for skilled nursing care, the team needs to determine which code to assign based on understanding of the payment categories. For example, consider a resident who has a new cerebrovascular accident (CVA) resulting in hemiplegia, aphasia, and dysphagia; during his hospitalization, he also suffered a fractured hip after a fall. The hip was surgically repaired with an open reduction internal fixation (ORIF). PT is treating the hemiplegia and the hip fracture, OT is treating the hemiplegia, SLP is treating the aphasia and dysphagia, and nursing is treating all of these conditions. The hemiplegia and hip fracture are both primary reasons for the SNF stay, and either could be listed as the primary diagnosis. Using the Clinical Category tab of the CMS PDPM ICD-10 mappings file, a NAC can see that selecting as primary diagnosis a hip fracture with surgical repair will result in the Other Orthopedic clinical category, while hemiplegia will result in the Acute Neurologic category. Although this will be a lower CMI in the PT/OT component, the Acute Neurologic category will positively impact the SLP component. Hemiplegia may be the more financially rewarding diagnosis to use. Again, this would only apply if both the fracture and the hemiplegia equally contributed to the primary reason for skilled care. If the main reason for skilled care was the hip fracture, and the hemiplegia was not an active concern, the hip fracture would be listed as the primary diagnosis in I0020B.
2. NACs must also ensure that additional diagnoses in section I are included that may impact the SLP comorbidities.
To qualify for an SLP-related comorbidity, the resident must have one of the selected comorbidities coded on the MDS. Two of these conditions, tracheostomy care and ventilator or respirator care, are triggered from section O of the MDS, but only if received while a resident in the facility. The remaining conditions are diagnoses.
To code a diagnosis in Section I of the MDS, it must be documented by a physician or physician extender within the last 60 days and must have documentation to support that the diagnosis was active in the last seven days. The designation of “active” means that the diagnosis has a current relationship to the resident’s functional, cognitive, mood or behavior status, medical treatments, nurse monitoring, or risk of death during the seven-day look-back period. It is the responsibility of the NAC or team member who codes section I to verify the accuracy of the MDS, which includes verifying that the documentation supporting the diagnosis is in place. In addition to following the RAI User’s Manual guidance, the staff member responsible for assigning ICD-10-CM codes must also follow the ICD-10-CM Official Guidelines for Coding and Reporting for the appropriate fiscal year.
The PDPM Calculation worksheet lists four diagnosis conditions affecting SLP comorbidity that are calculated from the checkboxes of section I: Aphasia (I4300); CVA, TIA, or Stroke (I4500); Hemiplegia or Hemiparesis (I4900); and Traumatic Brain Injury (I5500). If any of these diagnoses are active but only captured as an ICD-10-CM code in section I8000 rather than the check boxes in I0100 – I7900, the comorbidity will not be calculated. In addition, six conditions are calculated using item I8000 ICD-10-CM assignment: laryngeal cancer, apraxia, dysphagia, amyotrophic lateral sclerosis (ALS), oral cancers, and speech and language deficits. Once again, the CMS PDPM ICD-10 Mappings file demonstrates which ICD-10-CM codes qualify for an SLP comorbidity (using the SLP Comorbidity tab of the file). If the ICD-10-CM code is not on the file, it will not qualify as an SLP comorbidity.
3. NACs and IDT members must be aware of how cognitive impairment is calculated under PDPM.
The Brief Interview for Mental Status (BIMS) interview should be attempted for all residents and is generally used to determine any cognitive impairment under the PDPM methodology. A total summary score of 12 or lower will qualify as cognitively impaired for the first tier of the SLP component. It is vital that the team member responsible for the completion of the BIMS understands all the instructions for completing the interview, including timing and interview techniques. CMS prefers the BIMS interview be completed the day of or the day before the ARD, but it is a valid interview if completed during the 7-day look-back period.
The team member responsible for completion of the BIMS must also be familiar with Appendix D of the RAI User’s Manual, which provides valuable interviewing techniques. Additional interview techniques can be found in CMS’s Video on Interviewing Vulnerable Elders.
If the BIMS cannot be completed due to the resident rarely or never being understood, or due to an incomplete interview (four or more items not answered or answered nonsensically), the Staff Assessment for Mental Status would be completed. However, if the BIMS was not completed due to timeliness issues (the ARD passed, and the interview was never completed on an interviewable resident) then the staff assessment at C0700-C1000 cannot be completed.
Completing the Staff Assessment for Mental Status in C0700-C1000 is not the same as the calculation of the PDPM cognitive level outlined in chapter 6 of the RAI User’s Manual. In addition to using C0700 and C1000 from the Staff Assessment, this methodology also uses MDS items B0100, Comatose, and B0700, Makes Self Understood. To achieve an accurate PDPM cognitive determination, ensure accuracy in those MDS items as well. Review the steps on page 6-13 of the RAI User’s Manual to determine the PDPM cognitive level.
Note: AAPACN’s Resident Cognitive Level Determination Tool also details how a resident qualifies as severely impaired for cognition and how the basic and severe impairment count are calculated in determining the PDPM cognitive level.
4. NACs and the IDT must recognize the role section K plays in the final SLP CMG determination.
The second and final tier in the SLP component is to determine if the resident has Either, Neither, or Both of the second-tier criteria: mechanically altered diet or swallowing disorder. This increased importance of section K can lead to missteps when calculating the SLP component because multiple roles assist with capturing the information for this section.
If the consulting dietician completes section K, the IDT needs to look at the frequency that the dietitian is in the building. If the dietitian is only there one or two times a week, he or she may not be able to interview all of the staff present during the observation period to determine if any possible signs or symptoms of swallowing issues occurred. It is imperative that this information accurately reflects what occurred during the observation period.
Direct care staff should be reminded to notify nurses of any of the signs or symptoms of a possible swallowing disorder, including:
- Loss of liquids/solids from mouth when eating or drinking
- Holding food in mouth/cheeks or residual food in mouth after meals
- Coughing or choking during meals or when swallowing medications
- Complaints of difficulty or pain with swallowing
Any of these noted signs or symptoms should be documented in the medical record so they can be accurately coded on the MDS at K0100.
In addition, the definition of a mechanically altered diet at K0510C must be carefully reviewed. This mechanically altered diet can be given as part of meals or snacks. The RAI User’s Manual defines a mechanically altered diet as “a diet specifically prepared to alter the texture or consistency of food to facilitate oral intake.” The key point is that the alteration of the food is to facilitate oral intake, so intake must be by mouth. Because only alterations to the resident’s diet apply, crushed medications would not qualify. All parts of the medical record must be reviewed to ensure an accurate MDS.
To achieve accurate coding, the MDS must be a true reflection of the resident during the observation period. When the NAC and IDT members take the time to review the resident’s conditions in the full medical record, a more accurate overall assessment emerges. Understanding how the PDPM cognitive level is calculated and identifying the appropriate coding for the items that affect it is vital to the accuracy of the SLP component. Additionally, working with the physician to identify additional comorbidities impacting care and with the dietitian to ensure accurate assessment of section K will result in a more effective care plan. When the NAC and IDT develop this more accurate picture of the resident, more complete reimbursement under the SLP component often follows.
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