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Casamba’s PDPM Data Analysis: What clinical picture does your data paint?

Casamba’s PDPM Data Analysis: What clinical picture does your data paint?
  • February 4, 2019
  • PDPM

Casamba has created PDPM Data Analysis tools within our Skilled application that allow customers to upload current MDS assessments and obtain clinical and financial information comparing RUG-IV to PDPM at both the facility and individual patient levels. While the financial comparison of revenue and labor costs is compelling and certainly useful for determining contract parameters and staffing, the clinical information identified by Casamba’s PDPM analytics has been a powerful tool for driving staff education and training about the importance of accurate clinical documentation, interdisciplinary collaboration, and MDS coding.

Under RUG-IV, it is widely known that the vast majority of resident days are billed via a Rehab RUG, with reimbursement rates determined by only 20 items on the MDS from Section O and Section G. The five case-mix adjusted components in PDPM are determined by over 150 MDS items! Due to the hierarchical nature of the RUG-IV methodology, if a resident receives skilled therapy services of a sufficient intensity to meet the threshold for a Rehab RUG, the additional clinical information captured in the MDS typically does not change payment. One could argue that the importance of this “additional information” is therefore not emphasized. The analysis provided by our facility-level reports appears to support this assumption.

Casamba’s clinical analysis of current MDS data from our partners has revealed that MDS coding practices are most likely not creating a true clinical picture of the residents receiving skilled services under Medicare Part A.

The data shows many residents in Rehab RUGs (as many as 30-40% in some facilities) fell into one of the “reduced physical function” nursing case-mix groups (CMGs), the CMGs with the lowest case-mix index (CMI), and therefore the lowest level of reimbursement. The most common non-therapy ancillary (NTA) CMGs seen in our analysis are NE and NF, which correspond to one and zero points respectively – again, groups with the lowest CMI. (For reference, an active diagnosis of Diabetes Mellitus or COPD yields 2 points, and how many residents of a SNF have DM or COPD and therefore should have at least 2 points?) For many facilities, almost 50% of all residents were categorized into one of four Medical Management CMGs for PT and OT, and more than 75% fell into the two lowest CMGs for SLP (SA and SD).

The picture this data paints is of a resident with no complex nursing conditions (such as DM, COPD, wounds, MRSA, or IV medications), no speech-language comorbidities (like dysphagia, speech-language deficits, hemiplegia, or oral cancer), and no cognitive deficits or behavioral issues, who needs help with ADLs and mobility. Is this an accurate picture of most of the residents in your facility? Likely not.

Nurses and therapists in the skilled nursing industry know the level of medical acuity and complexity of the residents they care for. Residents are discharged to SNFs with multiple medical, functional, cognitive, and behavioral conditions. They require round-the-clock supervision by nursing, skilled therapy services to improve self-care and mobility, the involvement of dietitians and social workers, the help of certified nursing assistants, and physician supervision to stabilize and improve their medical condition. The data we’ve seen in our MDS analyses doesn’t support this clinical picture.

Identifying your residents’ clinical picture can guide training and education efforts to improve the accuracy of the information collected and transmitted to CMS via the MDS, ensuring sufficient reimbursement under PDPM to deliver the care each resident will continue to require.

Holly Hester

Holly Hester is Casamba’s Senior Vice President of Compliance & Quality, as well as the Compliance Officer. She provides regulatory guidance and interpretation, clinical programming and content development, education and training steerage, and compliance support for the Company. As a physical therapist for more than 20 years, Holly has multi-venue clinical and management experience, giving her a unique perspective on the integration of compliance and training with therapy service delivery and clinical practice.
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