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[Blog Series] Transition to PDPM Part 2: Cost of Errors Related to the SLP Component

December 19, 2019
Documentation, Billing, & Coding By Kay Hashagen, Senior Consultant

In continuation of the 3-Part PDPM Blog Series on the “Transition to PDPM,” part 2 will discuss cost of errors related to documentation and coding for the new Patient Driven Payment Model (PDPM). Part 1 focused on the primary diagnosis and Section GG coding, which primarily effect Physical Therapy (PT) and Occupational Therapy (OT) PDPM Health Insurance Prospective Payment System (HIPPS) coding and, to a lesser extent,  the nursing component. At LW Consulting, Inc. (LWCI), we have been busy assisting clients with PDPM audits to identify whether the PDPM HIPPS code billed on the Minimum Data Set (MDS) and the UB-04 is supported by the documentation. In part 2 of the PDPM Blog Series, we will discuss highlights of errors we have been seeing related to the Speech Language Pathology (SLP) component.

Let’s begin with a brief overview of the clinical metrics for SLP that relate to the PDPM components. There are five different categories that contribute to the SLP PDPM characteristics. They are: 1) the Presence of an Acute Neurologic Condition , 2) a SLP-Related Comorbidity, 3) a Cognitive Impairment, 4) Documentation that Supports a Mechanically-Altered Diet and 5) the Presence of a Swallowing Disorder documented within the 7-day lookback from the Assessment Reference Date (ARD).

 

Transition_to_PDPM_Part_2

 

When reviewing documentation to support PDPM coding the 5-digit HIPPS code that is on the UB-04 must be deciphered. For more information on the outline of what each of the characters in the HIPPS code refer to, read “{Blog Series] Transition to PDPM Part 1: Cost of Errors Related to Diagnosis Coding and Section GG.”

The second character relates to the SLP component. The characters all start with the letter “S,” which may mean “Speech.” The alphabet, from “A” through “L,” is then used to identify payment group codes for SLP. Within the SLP categories, the Centers for Medicare and Medicaid Services (CMS) has outlined three major categories for identification of the SLP Case-Mix Group (CMG). The first category considers whether the following three areas are involved: 1) the Presence of an Acute Neurologic Condition, 2) a SLP-Related Comorbidity or 3) Cognitive Impairment. There are 12 possible scenarios based on whether these components are not present (none), any one is present, any two are present or all three are documented in the patient’s medical record. From this column in the decision tree, the next consideration is whether the patient has a Mechanically Altered Diet or Swallowing Disorder. Again, there are three major choices; neither are present, one of the two (either) is present or both are present. The information for these two components is paired with the information in the first decision tree to come up with a Case Mix Group (CMG) starting with the letter “S” and paired with the corresponding letter of the alphabet “A”  through “L.” This is the SLP CMG and from the CMG, CMS has assigned a SLP Case Mix Index (CMI). This correlates to the SLP rate.

Here is the example for the SLP Component from LWCI’s PDPM Rate Chart that is available for purchase on the LWCI Learning Center.

 

Presence of Acute Neurologic Condition, SLP Related Comorbidity, or Cognitive Impairment
Mechanically Altered Diet or Swallowing Disorder SLP Case Mix Group
SLP Case Mix Index
SLP Rural Rate SlP Urban Rate
None Neither SA 0.68 $19.43 $15.42
None Either SB 1.182 $52.00 $41.28
None Both SC 2.66 $76.28 $60.56
Any one Neither SD 1.46 $41.71 $33.11
Any one Either SE 2.33 $66.85 $53.07
Any one Both SF 2.97 $85.14 $67.59
Any two Neither SG 2.04 $58.28 $46.27
Any two Either SH 2.85 $81.71 $64.86
Any two Both SI 3.51 $100.85 $80.06
Any three Neither SJ 2.98 $85.42 $67.81
Any three Either SK 3.69 $105.71 $83.92
Any three Both SL 4.19 $120.28 $95.48

 

The twelve SLP comorbidities and examples of the ICD-10 codes can be found in the “PDPM Calculation Worksheet for SNFs.”

The Cognitive Impairment is the last category related to the SLP component and is identified via the Brief Interview for Mental Status (BIMS). In cases where the BIMS cannot be completed, providers are required to perform a staff assessment for mental status. The Cognitive Performance Scale (CPS) is then used to score the patient’s cognitive status based on the results of the staff assessment. The following table demonstrates the BIMS scoring. If a patient is deemed to be cognitively intact, there is no additional PDPM reimbursement.  Cognitive levels mild to severe increase the SLP reimbursement.

 

Cognitive Level BIMS Score CPS Score
Cognitively Intact 13 - 15 0
Mildly Impaired 8 - 12 1 - 2
Moderately Impaired 0 - 7 3 - 4
Severely Impaired 5 - 6

 

Documentation of the BIMS scoring, as defined in the RAI Manual, states that it should be completed preferably the day before or the day of the ARD. Only in the case of Prospective Payment System (PPS) assessments, staff may complete the staff assessment for mental status for an interviewable resident when the resident is unexpectedly discharged from a Part A stay prior to the completion of the BIMS. In cases where neither the BIMS or the staff assessment is completed, the patient will be considered “cognitively intact” for classification purposes under PDPM.

Summary of findings related to recent audits for SLP Coding:

  • There were several records where the patient was on a “Dysphagia II” diet, yet, there was no diagnosis of dysphagia. The physician should be queried to identify whether the patient has a swallowing disorder that could qualify for a SLP comorbidity.
  • To verify SLP coding on the CMS list, view the “PDPM ICD-10 Mappings” under PDPM Resources.
  • LWCI auditors found that additional documentation to support SLP codes may be embedded in hospital discharge information. Utilization of hospital discharge information may mean review of the best date for the ARD to be able to capture the hospital information in the 7-day look back period. This requires the Interdisciplinary Team (IDT) to discuss and plan the ARD for assessments.
  • The BIMS interview is almost never included in the medical record to demonstrate when the interview was completed. The MDS Section Z is often signed after the ARD. In this case, the BIMS would appear to be late and upon review, CMS could disallow credit for the PDPM component scoring of cognition.
  • The auditors often located documentation of SLP comorbidities in the SLP evaluation that were not coded on the MDS. If the dietician, or someone who does not have access to the therapy Electronic Medical Records (EMRs), is coding the MDS this might be the reason for the missed coding.
  • Often the records uploaded for review are not complete. If a Recovery Audit Contractor (RAC) or Zone Program Integrity Contractor (ZPIC) requests documentation to be submitted, all documentation should be submitted to support the coding of the MDS. LWCI audits attempt to mirror a CMS audit and facilities need to have a system in place to efficiently upload all documentation.

Example of Financial Impact from an Audit

MDS Findings:

SLP component was different on the MDS billed and the audit of the documentation. There is no documentation of pain or difficulty with swallowing identified in the audited record to support the coding of “B” for the SLP component. There is a possibility that not all documentation was provided for review.

Financial Impact:

Change in the SLP component drops the reimbursement by $32.68 per day. This is an overpayment.

MDS Findings:

The BIMS score was not completed until after the resident was discharged per the signature at Z0400. The discharge was not an unplanned discharge; the BIMS was just not completed timely per the RAI manual. According to CMS rules, the staff assessment can only be completed and utilized if the BIMS is unable to be completed due to an unplanned discharge. In cases where neither the BIMS or the staff assessment is completed, the patient will be considered “cognitively intact” for classification purposes under PDPM.

Financial Impact:

The rate would drop from the originally coded score to the rate of $19.43 for Rural and $15.42 for Urban.

PDPM is a reimbursement system that has many opportunities. Detailed documentation to support coding is required to ensure that payment supports care delivery. The coding on the MDS must be supported by the narrative documentation provided by the physician, nurses and therapists. When the MDS is coded and there is no supporting documentation, this scenario could impose an “overpayment” situation. Now is the time to identify root causes of documentation and coding errors before CMS starts to review records. 

 

For more information on our PDPM support packages to assist you with audits, training, systems and coaching, contact Kay Hashagen at 410-777-5999 or email KHashagen@LW-Consult.com.

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