Section GG Coding for PDPM and SNFQRP QMs

Transcription

1 Section GG Coding for PDPM and SNFQRP QMs for clients of: Content developed and presented by: 3030 N. Rocky Point Drive, Suite 240 Tampa, FL

2 Section GG Coding for PDPM and SNFQRP QMs Limited Copyright: December 2018, Polaris Group All materials are protected under the copyright laws. The limited copyright allows the purchaser to copy for use but not for distribution. FH49 - Developed by Polaris Group Page 1 of 119

3 Section GG Coding for PDPM and SNFQRP QMs POST TEST 1. The four new Measures calculated from GG measure functional outcomes at discharge? a. True b. False 2. There are Risk Adjustments applied to the Discharge Outcomes? a. True b. False 3. Which of the following apply? a. New QRP QMs will impact 5 Star b. Section GG has a 3-day observation period based on ARD c. None of the above 4. For GG Performance Items, document usual performance at admission and discharge: a. True b. False 5. Function Score calculation is the same for Nursing Component as it is for PT Component of the rate: a. True b. False FH49 - Developed by Polaris Group Page 2 of 119

4 Section GG Coding for PDPM and SNFQRP QMs POST TEST ANSWERS 6. The four new Measures calculated from GG measure functional outcomes at discharge? a. True b. False 7. There are Risk Adjustments applied to the Discharge Outcomes? a. True b. False 8. Which of the following apply? a. New QRP QMs will impact 5 Star b. Section GG has a 3-day observation period based on ARD c. None of the above 9. For GG Performance Items, document usual performance at admission and discharge: a. True b. False 10. Function Score calculation is the same for Nursing Component as it is for PT Component of the rate: a. True b. False FH49 - Developed by Polaris Group Page 3 of 119

5 Section GG for PDPM & SNFQRP QMs 1 CODING DIRECTIONS GG 2 FH49 - Developed by Polaris Group Page 4 of 119

6 Section GG at Start of Stay Section GG completed with first Traditional Medicare (5-day MDS) upon admission or readmission (if discharged return anticipated) 5-day MDS has Medicare Start Date A2400B Look-back is Medicare Start Date plus 2 more days OR stated another way - Starting with Medicare Start day, days 1, 2, 3 3 Section GG at Part A Discharge MDS Last Three days of stay with Medicare End Date as third day. Item set for GG part of Planned Discharge MDS combined with Part A Discharge Designation or stand alone Part A Discharge MDS. Only applies to Planned Discharges (Skip pattern applies if unplanned discharge so no Section GG). 4 FH49 - Developed by Polaris Group Page 5 of 119

7 Collected at SOC 5-day MDS 5 Coding Definitions Code 3, Independent, if the resident completed the activities by himself or herself, with or without an assistive device, with no assistance from a helper Code 2, Needed Some Help, if the resident needed partial assistance from another person to complete the activities Code 1, Dependent, if the helper completed the activities for the resident or the assistance of two or more helpers was required for the resident to complete the activity Code 8, Unknown, if the resident s usual ability prior to the current illness, exacerbation, or injury is unknown Code 9, Not Applicable, if the activity was not applicable to the resident prior to the current illness, exacerbation, or injury 6 FH49 - Developed by Polaris Group Page 6 of 119

8 Section GG0100 Self-Care: Ms. R was admitted to an acute care facility after sustaining a right hip fracture and subsequently admitted to the SNF for rehabilitation. Prior to the hip fracture, Ms. R was independent in eating, bathing, dressing, and using the toilet. Ms. R used a raised toilet seat because of arthritis in both knee joints. Both she and her family indicated that there were no safety concerns when she performed these everyday activities in her home. 7 Section GG0100 Self-Care: Code 3 Independent 8 FH49 - Developed by Polaris Group Page 7 of 119

9 Section GG0100 Self-Care: Mr. F was admitted with a diagnosis of stroke and a severe communication disorder. Mr. F is unable to communicate with staff using alternative communication devices. Mr. F had been living alone prior to admission. The staff has not been successful in contacting either Mr. F s family or his friends. Mr. F s prior self-care abilities are unknown. 9 Section GG0100 Self-Care: Code 8 Unknown 10 FH49 - Developed by Polaris Group Page 8 of 119

10 Section GG0100 Indoor Mobility (Ambulation): Mrs. L had a stroke one year ago that resulted in her using a wheelchair to self-mobilize, as she was unable to walk. Mrs. L subsequently had a second stroke and was transferred from an acute care unit to the SNF for skilled services. 11 Section GG0100 Indoor Mobility (Ambulation): Code 9 Not applicable 12 FH49 - Developed by Polaris Group Page 9 of 119

11 Section GG0100 Stairs: Prior to admission to the hospital for bilateral knee surgery, followed by his recent admission to the SNF for rehabilitation, he experienced severe knee pain upon ascending and particularly descending his internal and external stairs at home. Required assistance from wife when using the stairs to steady him in the event his left knee would buckle. Wife was interviewed about her husband s functioning prior to admission, and the therapist noted prior functional level information in his medical record. 13 Section GG0100 Stairs: Code 2 Needed Some Help 14 FH49 - Developed by Polaris Group Page 10 of 119

12 Section GG0100 Functional Cognition: Mr. K has mild dementia and recently sustained a fall resulting in complex multiple fractures requiring multiple surgeries. Mr. K has been admitted to the SNF for rehabilitation. Mr. K s caregiver reports that when living at home, Mr. K needed reminders to take his medications on time, manage his money, and plan tasks, especially when he was fatigued. 15 Section GG0100 Functional Cognition: Code 2 Needed Some Help 16 FH49 - Developed by Polaris Group Page 11 of 119

13 Section GG0100 Functional Cognition: Mrs. R had a stroke. Since hospitalization and continuing during her SNF stay, she has had a severe communication disorder. Her family members have not returned phone calls requesting information about Mrs. R s prior functional status. Her medical records do not include information about her functional cognition prior to the stroke. 17 Section GG0100 Functional Cognition: Code 8 Unknown 18 FH49 - Developed by Polaris Group Page 12 of 119

14 Collected at SOC - 5-day MDS Check all that apply. Interview resident/family, review records. Only code device used immediately before current illness. 19 Section GG0110 For GG0110D, Prior Device Use - Walker: Walker refers to all types of walkers (for example, pickup walkers, hemi-walkers, rolling walkers, and platform walkers). Consider what is being documented in Prior Level of Function These are Risk Factors for the new functional SNFQM 20 FH49 - Developed by Polaris Group Page 13 of 119

15 CODING DIRECTIONS GG 21 Section GG Coding Changes Change New 22 FH49 - Developed by Polaris Group Page 14 of 119

16 Admission and Discharge Performance Coding Directions Based on direct observation, resident s self report, family reports, and direct care reports as documented in medical record. Helper must be a facility staff or contracted employee by facility Not Hospice staff, students, or private staff by family If family/private duty gives all care, then code as 07 Resident Refuses or 09 Not Applicable 23 Admission and Discharge Performance Coding Directions May be completed with or without a device Usual performance is not most independent or most dependent; if there is a fluctuation, code to the most usual for that resident. average care Coding on admission should reflect the person s baseline admission functional status, and is based on a clinical assessment that occurs soon after the resident s admission CMS focuses on therapy initial evaluation as assessment 24 FH49 - Developed by Polaris Group Page 15 of 119

17 Section GG The admission functional assessment, when possible, should be conducted prior to the person benefitting from treatment interventions in order to determine a true baseline functional status on admission. CMS has made it clear that treatment should not be withheld in order to conduct the functional assessment: If treatment has started, for example, on the day of admission, a baseline functional status assessment can still be conducted Coding considers set-up and cleanup, touching assistance, verbal cues. 25 Admission and Discharge Performance Coding Directions CMS states this is an assessment and should focus on baseline at time of admission or discharge. 26 FH49 - Developed by Polaris Group Page 16 of 119

18 Admission and Discharge Performance Coding Directions CMS states this is an assessment and should focus on baseline at time discharge. Discharge best reflection of performance status at discharge. CMS focused on Therapy Discharge note. 27 Assistance in Coding 28 FH49 - Developed by Polaris Group Page 17 of 119

19 Assistance in Coding 29 Assistance in Coding 30 FH49 - Developed by Polaris Group Page 18 of 119

20 Assistance in Coding 31 Assistance in Coding 32 FH49 - Developed by Polaris Group Page 19 of 119

21 Assistance in Coding Independent - Similar to coding Independent Section G without set-up help support. 05 Set-up or Clean-up Assistance - Similar to coding Independent in Section G but WITH set-up only support. Could easily apply to oral hygiene, or eating skills. No physical help or cueing needed most of the time. 34 FH49 - Developed by Polaris Group Page 20 of 119

22 Similar to coding Supervision in Section G Similar to coding limited assist in Section G This is verbal cueing or Contact Guard support. This is clearly non-weight bearing support to provide safety to complete task. Again, usual care, versus most dependent. 35 Weight Bearing Support usually provided 03 More like Minimum Assist used by Rehab Extensive Assist in Section G one person 02 More like Moderate to Maximum Assist by Rehab so more weight bearing support provided Extensive Assist in Section G one person 36 FH49 - Developed by Polaris Group Page 21 of 119

23 First Step: Determine if weight bearing support is usually provided (does not usually require two staff) Second Step: If yes, then does resident perform less than half the activity/half the effort or more than half of the activity/more than half the effort (tasks with most weight bearing effort) Three subtasks - resident perform two, staff one or visa versa. 37 Dependent code on MDS Section G Usually resident does not participate in activity Even if resident performs some of activity, if it requires two or more staff to assist, code as dependent. 38 FH49 - Developed by Polaris Group Page 22 of 119

24 07 - Document refusal if applies 09 - Document reason, info indicates not performed prior to current status 10 Not Attempted due to environmental limitations 88 - Not attempted, Medical Condition supports coding 39 Assistance in Coding 40 FH49 - Developed by Polaris Group Page 23 of 119

25 Coding Self Care New 41 Aligns with Eating in Section G Independent for most of meal, then requires some physical help to finish: Code 03 - Partial/moderate assistance Physical help to eat more than half the meal: Code 02 Substantial/maximal assistance Both of the above provide weight bearing support Encouragement, reminders, handing utensils/cup: Code 04 Supervision/touching Fed entire meal: Code 01- Dependent 42 FH49 - Developed by Polaris Group Page 24 of 119

26 Clinicians may code the eating item using the appropriate response codes if the resident eats using his/her hands rather than using utensils (e.g., can feed himself/herself using finger foods). If the resident eats finger foods with his/her hands independently, for example, the resident would be coded as 06, Independent. 43 Subtask of Personal Hygiene in Section G Staff puts toothpaste on toothbrush, then brushes teeth without cueing: Code 05 Set-up or clean-up assistance Starts to brush teeth, but stops and completed by staff; Code 02 Substantial/Maximal Assistance since more than half the activity by staff Brushes gums and starts dentures but staff completes: Code 03 Partial/Moderate Assistance Fully dependent: Code 01 - Dependent Brushes teeth/dentures with set-up but needs cueing to complete: Code 04 - Supervision/Touching assistance 44 FH49 - Developed by Polaris Group Page 25 of 119

27 Aligns with Toilet Use in Section G minus the transfer itself to toilet/commode; this item is only hygiene tasks. Uses commode, aide only provides steadying assistance while resident wipes self, and pulls up pants: Code 04 - Supervision/touching assistance Staff lifts gown, and pulls down pants, but resident wipes and pulls pants back up: Code 03 - Partial/Moderate assistance Staff wipes and pulls pants down, resident only lifts gown: Code 02 - Substantial/Maximal assistance Staff do all activities: Code 01 - Dependent 45 Shower/bathe self: Includes the ability to wash, rinse, and dry the face, upper and lower body, perineal area, and feet Does not include washing, rinsing, and drying the resident s back or hair Does not include transferring in/out of a tub/shower Assessment of shower/bathe self can take place in a shower or bath, at a sink, or at the bedside (i.e., sponge bath) 46 FH49 - Developed by Polaris Group Page 26 of 119

28 If the resident bathes himself or herself and a helper sets up materials for bathing/showering, then code as 05, Setup or clean-up assistance If the resident cannot bathe his or her entire body because of a medical condition, then code shower/bathe self based on the amount of assistance needed to complete the activity 47 Coding GG0130E Shower/bathe self: Mr. J sits on a tub bench as he washes, rinses, and dries himself. A certified nursing assistant stays with him to ensure his safety, as Mr. J has had instances of losing his sitting balance. The certified nursing assistant also provides lifting assistance as Mr. J gets onto and off of the tub bench. How would you code GG0130E. Shower/bathe self? 48 FH49 - Developed by Polaris Group Page 27 of 119

29 Coding GG0130E Code 04, Supervision or touching assistance Code 03, Partial/moderate assistance Code 02, Substantial/maximal assistance Code 01, Dependent 49 Coding GG0130E Answer Code 04, Supervision or touching assistance Code 03, Partial/moderate assistance Code 02, Substantial/maximal assistance Code 01, Dependent 50 FH49 - Developed by Polaris Group Page 28 of 119

30 Upper Body Dressing--Tips Upper Body Dressing includes: Clothing, blouse, shirt, bra, sweater. Buttons, Snaps, Zippers Prosthesis, Braces, Binders Includes Pajamas, but NOT hospital gowns. 51 Upper body dressing: GG0130F Mr. K sustained a spinal cord injury that has affected both movement and strength in both upper extremities. He places his left hand into one - third of his left sleeve of his shirt with much time and effort and is unable to continue with the activity. A certified nursing assistant then completes the remaining upper body dressing for Mr. K. How would you code GG0130F. Upper body dressing? 52 FH49 - Developed by Polaris Group Page 29 of 119

31 Coding GG0130F Code 04, Supervision or touching assistance Code 03, Partial/moderate assistance Code 02, Substantial/maximal assistance Code 01, Dependent 53 Coding GG0130F Answer Code 04, Supervision or touching assistance Code 03, Partial/moderate assistance Code 02, Substantial/maximal assistance Code 01, Dependent 54 FH49 - Developed by Polaris Group Page 30 of 119

32 Lower Body Dressing -- Tips Lower Body Dressing Includes: Clothing: Underwear, shorts, slacks, briefs, PJ s Knee/Leg Braces Lower Extremity Prosthesis Lower Extremity Shrinker 55 Lower body dressing: Mrs. R has peripheral neuropathy in her upper and lower extremities. Each morning, Mrs. R needs assistance from a helper to place her lower limb into, or to take it out of (don/doff), her lower limb prosthesis. She needs no assistance to put on and remove her underwear or slacks. How would you code GG0130G. Lower body dressing? 56 FH49 - Developed by Polaris Group Page 31 of 119

33 Coding GG0130G Code 05, Setup or clean - up assistance Code 04, Supervision or touching assistance Code 03, Partial/moderate assistance Code 02, Substantial/maximal assistance 57 Coding GG0130G Answer Code 05, Setup or clean - up assistance Code 04, Supervision or touching assistance Code 03, Partial/moderate assistance Code 02, Substantial/maximal assistance 58 FH49 - Developed by Polaris Group Page 32 of 119

34 Putting on/taking off footwear: Mr. M is undergoing rehabilitation for right - side upper and lower body weakness following a stroke. He has made significant progress toward his independence and will be discharged to home tomorrow. Mr. M wears an ankle - foot orthosis (AFO) that he puts on his foot and ankle after he puts on his socks but before he puts on his shoes. He always places his AFO, socks, and shoes within easy reach of his bed. While sitting on the bed, he needs to bend over to put on and take off his AFO, socks, and shoes, and he occasionally loses his sitting balance, requiring staff to place their hands on him to maintain his balance while performing this task. How would you code GG0130H. Putting on/taking off footwear? 59 Coding GG0130H Code 05, Set-up or clean-up assistance Code 04, Supervision or touching assistance Code 03, Partial/moderate assistance Code 02, Substantial/maximal assistance 60 FH49 - Developed by Polaris Group Page 33 of 119

35 Coding GG0130H Answer Code 05, Set-up or clean-up assistance Code 04, Supervision or touching assistance Code 03, Partial/moderate assistance Code 02, Substantial/maximal assistance 61 Putting on/taking off footwear: Mrs. F was admitted to the SNF for a neurologic condition and experiences visual impairment and fine motor coordination and endurance issues. She requires setup for retrieving her socks and shoes, which she prefers to keep in the closet. Mrs. F often drops her shoes and socks as she attempts to put them onto her feet or as she takes them off. Often a certified nursing assistant must first thread her socks or shoes over her toes, and then Mrs. F can complete the task. Mrs. F needs the certified nursing assistant to initiate taking off her socks and unstrapping the Velcro used for fastening her shoes. How would you code GG0130H. Putting on/taking off footwear? 62 FH49 - Developed by Polaris Group Page 34 of 119

36 Coding GG0130H Code 05, Set-up or clean-up assistance Code 04, Supervision or touching assistance Code 03, Partial/moderate assistance Code 02, Substantial/maximal assistance 63 Coding GG0130H Answer Code 05, Set-up or clean-up assistance Code 04, Supervision or touching assistance Code 03, Partial/moderate assistance Code 02, Substantial/maximal assistance 64 FH49 - Developed by Polaris Group Page 35 of 119

37 Section GG Mobility Items New 65 Roll left and right: Mr. Z had a stroke that resulted in paralysis on his right side and is recovering from cardiac surgery. He requires the assistance of two certified nursing assistants when rolling onto his right side and returning to lying on his back and also when rolling onto his left side and returning to lying on his back. How would you code GG0170A. Roll left and right? 66 FH49 - Developed by Polaris Group Page 36 of 119

38 Coding GG0170A Code 01, Dependent Code 04, Supervision and touching assistance Code 09, Not applicable, not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury Code 88, Not attempted due to medical condition or safety concerns 67 Coding GG0170A Answer Code 01, Dependent Code 04, Supervision and touching assistance Code 09, Not applicable, not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury Code 88, Not attempted due to medical condition or safety concerns 68 FH49 - Developed by Polaris Group Page 37 of 119

39 Roll left and right: Mrs. R has a history of skin breakdown. A nurse instructs her to turn onto her right side, providing step-by-step instructions to use the bedrail, bend her left leg, and then roll onto her right side. Mrs. R attempts to roll with the use of the bedrail, but indicates she cannot perform the task. The nurse then rolls her onto her right side. Next, Mrs. R is instructed to return to lying on her back, which she successfully completes. Mrs. R then requires physical assistance from the nurse to roll onto her left side and to return to lying on her back to complete the activity. 69 Coding GG0170A Code 01, Dependent Code 04, Supervision and touching assistance Code 09, Not applicable, not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury Code 88, Not attempted due to medical condition or safety concerns 70 FH49 - Developed by Polaris Group Page 38 of 119

40 Coding GG0170A Answer Code 01, Dependent Code 02 Substantial/Maximal assistance Code 09, Not applicable, not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury Code 88, Not attempted due to medical condition or safety concerns 71 B & C are subtasks of Bed Mobility in Section G. 72 FH49 - Developed by Polaris Group Page 39 of 119

41 Requires assistance from sitting on bed to lying on bed, staff lifts up legs, but resident uses arms to position upper body; weight bearing support for less than half of tasks: Code 03 - Partial/Moderate assistance Staff support trunk when lying down and lifts legs weight bearing support for all tasks: Code 02 - Substantial/Maximal assistance 73 Resident pushes up from bed from lying to sitting; staff only provides steadying support: Limited assistance: Code 04 - Supervision or Touching Assistance Staff provide much of the lifting assistance to get from lying to sitting position, weight bearing support: Code 02 - Substantial/Maximal Assistance Resident rolls to side and pushes self up from lying to sitting with verbal cues: Code 04 - Supervision or Touching Assistance Full staff support: 01 - Dependent 74 FH49 - Developed by Polaris Group Page 40 of 119

42 75 D & E are subtasks of Transfer in Section G 76 FH49 - Developed by Polaris Group Page 41 of 119

43 Resident transitions from sitting to standing with only contact limited assistance: Code 04 - Supervision or Touching assistance Two person assistance: Code 01 Dependent Staff provide weight bearing support to rise to standing position and balance: Code 02 - Substantial/maximal assistance Staff provide weight bearing support to initially start to rise but resident does most of work: Code 03 - Partial/moderate assistance 77 Transfers safely once wheelchair positioned, with set-up only: Code 05 Set-up or clean-up assistance Pivots and transfers to wheelchair with only contact limited assistance: Code 04 - Supervision or Touching assistance Resident requires weight bearing support but pushes self and moves own feet to pivot: Code 03 - Partial/Moderate assistance 78 FH49 - Developed by Polaris Group Page 42 of 119

44 Transfer to toilet/commode is subtask of Toilet Use in Section G; ONLY transfer to toilet or commode applies Transfers safely to toilet after putting wheelchair by commode: Code 05 Set-up or clean up assistance Transfers on and off toilet with contact limited assistance for safety: Code 04 - Supervision or Touching assistance Weight bearing assistance on and off toilet or commode; so more than half of effort: Code 02 - Substantial/maximal assistance Staff provides full assist to rise, and resident lowers self with grab bars by toilet: Code 03 - Partial/Moderate assistance 79 Car transfer: During her rehabilitation stay, Mrs. N works with an occupational therapist on transfers in and out of the passenger side of a car. On the day before discharge, when performing car transfers, Mrs. N requires verbal reminders for safety and light touching assistance. The therapist instructs her on strategic hand placement while Mrs. N transitions to sitting in the car s passenger seat. The therapist opens and closes the door. How would you code GG0170G. Car transfer? 80 FH49 - Developed by Polaris Group Page 43 of 119

45 Coding GG0170G Code 05, Set-up or clean-up assistance Code 04, Supervision or touching assistance Code 02, Substantial/maximal assistance Code 01, Dependent 81 Coding GG0170G Answer Code 05, Set-up or clean-up assistance Code 04, Supervision or touching assistance Code 02, Substantial/maximal assistance Code 01, Dependent 82 FH49 - Developed by Polaris Group Page 44 of 119

46 Car transfer: Mrs. W uses a wheelchair and ambulates for only short distances. She requires lifting assistance from a physical therapist to get from a seated position in the wheelchair to a standing position. The therapist provides trunk support when Mrs. W takes several steps during the transfer turn. Mrs. W lowers herself into the car seat with steadying assistance from the therapist. She lifts her legs into the car with support from the therapist. 83 Coding GG0170G Code 05, Set-up or clean-up assistance Code 04, Supervision or touching assistance Code 02, Substantial/maximal assistance Code 01, Dependent 84 FH49 - Developed by Polaris Group Page 45 of 119

47 Coding GG0170G Answer Code 05, Set-up or clean-up assistance Code 04, Supervision or touching assistance Code 02, Substantial/maximal assistance Code 01, Dependent 85 Walk 10 Feet 86 FH49 - Developed by Polaris Group Page 46 of 119

48 Walk 10 feet: Coding GG0170I Mr. L had bilateral amputations 3 years ago, and prior to the current admission, he used a wheelchair and did not walk. Currently, Mr. L does not use prosthetic devices and uses only a wheelchair for mobility. Mr. L s care plan includes fitting and use of bilateral lower extremity prostheses. How would you code GG0170I. Walk 10 feet? 87 Coding GG0170I Code 01, Dependent Code 09, Not applicable, not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury Code 88, Not attempted due to medical condition or safety concerns Code 07, Refused 88 FH49 - Developed by Polaris Group Page 47 of 119

49 Coding GG0170I Answer Code 01, Dependent Code 09, Not applicable, not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury Code 88, Not attempted due to medical condition or safety concerns Code 07, Refused 89 Coding GG0170I Walk 10 feet: Mrs. C has Parkinson s disease and walks with a walker. A physical therapist must advance the walker for Mrs. C with each step. The physical therapist assists Mrs. C by physically initiating the stepping movement forward, advancing Mrs. C s foot, during the activity of walking 10 feet. How would you code GG0170I. Walk 10 feet? 90 FH49 - Developed by Polaris Group Page 48 of 119

50 Coding GG0170I Code 01, Dependent Code 02, Substantial/maximal assistance Code 09, Not applicable, not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury Code 88, Not attempted due to medical condition or safety concerns Code 07, Refused 91 Coding GG0170I Answer Code 01, Dependent Code 02, Substantial/maximal assistance Code 09, Not applicable, not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury Code 88, Not attempted due to medical condition or safety concerns Code 07, Refused 92 FH49 - Developed by Polaris Group Page 49 of 119

51 J - Walks around 60 feet with two turns, therapy only provided cueing and contact limited assistance: Code 04 - Supervision or Touching assistance J - Walks around 70 feet with crutches, and staff provides some weight bearing support to trunk: Code 03 - Partial/moderate assistance J Walks 50 feet with two turns, loses balance and requires significant supports: Code 02 - Substantial/Maximal Assistance 93 Coding Clarifications Turn is 90 degree turn Can be in same direction such as two 90 degree turns to right; or different directions; and can include use of assistive device such as a cane RAI does not say what to code if can walk but only 10 feet with no turns. Suggest code 88 Activity not attempted due to medical condition or safety concerns 94 FH49 - Developed by Polaris Group Page 50 of 119

52 K Cannot walk 150 feet due to CHF: Code 88 - Activity not attempted due to medical concerns (but can walk shorter distance) K Walks length of hallway, weight bearing support that prevents from falling, provides more than half the effort: Code 02 - Substantial/maximal assistance K Walks length of hallway, using quad cane, requires some weight bearing support: Code 03 - Partial/moderate assistance 95 Coding Clarification Bottom line: If can walk, but not up to 50 feet with two turns, and/or up to 150 feet - code as 88 Activity Not attempted due to Medical condition or safety. Exception: resident refuses code 07 Resident Refuses, or code 09 Not Applicable if not walking now but you hope they will. 96 FH49 - Developed by Polaris Group Page 51 of 119

53 All New 97 Walking 10 feet on uneven surfaces: Mrs. N has severe joint degenerative disease and is recovering from sepsis. Upon discharge, Mrs. N will need to be able to walk on the uneven and sloping surfaces of her driveway. During her SNF stay, a physical therapist takes Mrs. N outside to walk on uneven surfaces. Mrs. N requires the therapist s weight - bearing assistance less than half of the time during walking to prevent Mrs. N from falling as she navigates walking 10 feet over uneven surfaces. How would you code GG0170L. Walking 10 feet on uneven surfaces? 98 FH49 - Developed by Polaris Group Page 52 of 119

54 Coding GG0170L Code 04, Supervision or touching assistance Code 03, Partial/moderate assistance Code 02, Substantial/maximal assistance Code 01, Dependent 99 Coding GG0170L Answer Code 04, Supervision or touching assistance Code 03, Partial/moderate assistance Code 02, Substantial/maximal assistance Code 01, Dependent 100 FH49 - Developed by Polaris Group Page 53 of 119

55 If you answer M with 07, 09, 10 or 88, you skip to P (picking up object). If you answer it with an assessment, you proceed to N. If you answer N with a 07, 09, 10 or 88 you skip to P. If you answer it with an assessment, you proceed to O. Regardless of whether you answer O with 07, 09, 10 or an assessment, you still proceed to P. 101 Coding GG0170M 1 step (curb): Mrs. Z has had a stroke; she must be able to step up and down one step to enter and exit her home. A physical therapist provides standby assistance as she uses her quad cane to support her balance in stepping up one step. The physical therapist provides steadying assistance as Mrs. Z uses her cane for balance and steps down one step. How would you code GG0170M. 1 step curb? 102 FH49 - Developed by Polaris Group Page 54 of 119

56 Coding GG0170M One Step/curb Code 04, Supervision or touching assistance Code 03, Partial/moderate assistance Code 02, Substantial/maximal assistance Code 01, Dependent 103 Coding GG0170M Answer One Step/curb Code 04, Supervision or touching assistance Code 03, Partial/moderate assistance Code 02, Substantial/maximal assistance Code 01, Dependent 104 FH49 - Developed by Polaris Group Page 55 of 119

57 Coding GG0170N or O 4 Steps or 12 Steps - only complete 12 steps if able to complete 4 steps; otherwise skip patterns applies Ms. Y is recovering from a stroke resulting in motor issues and poor endurance. Ms. Y s home has 12 stairs, with a railing, and she needs to use these stairs to enter and exit her home. Her physical therapist uses a gait belt around her trunk and supports less than half of the effort as Ms. Y ascends and then descends 12 stairs. How would you code GG0170O. 12 steps? 105 Coding GG0170N or O Code 05, Set-up or clean-up assistance Code 04, Supervision or touching assistance Code 03, Partial/moderate assistance Code 02, Substantial/maximal assistance 106 FH49 - Developed by Polaris Group Page 56 of 119

58 Coding GG0170N or O Answer Code 05, Set-up or clean-up assistance Code 04, Supervision or touching assistance Code 03, Partial/moderate assistance Code 02, Substantial/maximal assistance 107 Picking up object: Ms. C has recently undergone a hip replacement. When she drops items, she uses a long-handled reacher that she had been using at home prior to admission. She is ready for discharge and can now ambulate with a walker without assistance. When she drops objects from her walker basket, she requires a certified nursing assistant to locate her long-handled reacher and bring it to her in order for her to use it. She does not need assistance to pick up the object after the helper brings her the reacher. How would you code GG0170P. Picking up object? 108 FH49 - Developed by Polaris Group Page 57 of 119

59 Coding GG0170P Code 06, Independent Code 05, Set-up or clean-up assistance Code 04, Supervision or touching assistance Code 03, Partial/moderate assistance 109 Coding GG0170P Answers Code 06, Independent Code 05, Set-up or clean-up assistance Code 04, Supervision or touching assistance Code 03, Partial/moderate assistance 110 FH49 - Developed by Polaris Group Page 58 of 119

60 Picking up object: Mr. P has a neurologic condition that has resulted in balance problems. He wants to be as independent as possible. Mr. P lives with his wife and will soon be discharged from the SNF. He tends to drop objects and has been practicing bending or stooping from a standing position to pick up small objects, such as a spoon, from the floor. An occupational therapist needs to remind Mr. P of safety strategies when he bends to pick up objects from the floor, and she needs to steady him to prevent him from falling. 111 Coding GG0170P Code 06, Independent Code 05, Set-up or clean-up assistance Code 04, Supervision or touching assistance Code 03, Partial/moderate assistance 112 FH49 - Developed by Polaris Group Page 59 of 119

61 Coding GG0170P Answers Code 06, Independent Code 05, Set-up or clean-up assistance Code 04, Supervision or touching assistance Code 03, Partial/moderate assistance 113 Q1 Does resident use wheelchair and/or scooter 114 FH49 - Developed by Polaris Group Page 60 of 119

62 Coding Wheelchair R - Once in w/c resident propels self in wheel chair 60 feet with two turns with no help: Code 06 Independent R - Staff must make frequent adjustments of hand positions, and resident becomes stuck near walls, but when repositioned, can propel and turn self: Code 03 - Partial/moderate assistance R - Can wheel self only 10 feet, then asks aide to push them: Code 02 - Substantial/maximal assistance 115 Coding Wheelchair S Motorized w/c requires safety reminders, and requires staff assistant to backing up when barriers present: Code 03 - Partial/moderate assistance S Uses motorized scooter around SNF with only cues for safety issues: Code 04 Supervisions or touching assistance S Uses w/c around SNF after positioned by bed: Code 05 Set-up only 116 FH49 - Developed by Polaris Group Page 61 of 119

63 Coding Clarification If resident uses wheelchair but never propels themselves, then for each distance (assuming they are pushed both distances) code 01 Dependent. Once propels self in wheelchair any distance, like their example of 10 feet, then staff complete distance, code 02 Substantial/maximal assistance. If uses any type of motorized scooter, code as motorized. 117 Section GG 118 FH49 - Developed by Polaris Group Page 62 of 119

64 Section GG 119 Section GG 120 FH49 - Developed by Polaris Group Page 63 of 119

65 Discharge Goal Coding 5-day MDS Use same scale Established at time of admission when coding 5-day MDS, based on discussions with resident, family, staff, and professional judgement. Goal is part of overall care plan Only code a Discharge Goal if there is one; Only need ONE goal coded across all performance items to meet criteria for QM. 121 Section GG Coding Changes Additions to Activity Not Attempted 07 Resident refused 09 Not Applicable Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury 10 Not Attempted due to environmental limitations (e.g. lack of equipment, weather constraints) 88 Not attempted due to medical condition or safety concerns. 122 FH49 - Developed by Polaris Group Page 64 of 119

66 Section GG Coding Changes Can use codes for Activity Not Attempted for Discharge Goals on 5-day MDS This allows more options for coding Goals Enter a Performance Code if a Goal exists for this care area (a minimum of one for QM) should be supported in Therapy POT or Nursing Care Plan Or Use applicable Code for Activity Not Attempted is suggested instead of blank or dash FH49 - Developed by Polaris Group Page 65 of 119

67 125 GG SNFQRP QMs 126 FH49 - Developed by Polaris Group Page 66 of 119

68 This is a process measure; complete coding got all Performance items and at least one Goal coded at Start of Care No change, don t dash performance codes & one Goal needed 127 Four New GG related Quality Measures 128 FH49 - Developed by Polaris Group Page 67 of 119

69 Functional Measures - Final Measures in Rules for FY 2018 That Could Impact Payment FY 2020 Data gathering could begin Oct. 1, 2018 Outcome Measure: Change in Self-Care Score Outcome Measure: Discharge Self-Care Score Outcome Measure: Change in Mobility Score Outcome Measure: Discharge Mobility Score Note: These are OUTCOME measures, not PROCESS measures. Functional outcomes expected and/or achieved. 94 CHANGE in Self-Care or Mobility Score How it works!!! 130 FH49 - Developed by Polaris Group Page 68 of 119

70 CHANGE in Self Care or Mobility Overview of how it works Adds up coding for Self Care at SOC (5-day) Adds up Coding for Self Care at End of Care Adjustments for risk factors, compares the expected to achieved and creates a score Adds up coding for Mobility at SOC (5-day) Adds up coding for Mobility at End of Care Adjustments for risk factors, compares the expected to achieved and creates a score 131 All count as One Point Scores for Performance are added up; Assign 1 point for Activity not attempted: 132 FH49 - Developed by Polaris Group Page 69 of 119

71 Score Calculated at Admission for Self-Care Score All Criteria Apply =22 points Scores for performance are added up for a total score (Activity not Attempted scores 1) Range End of Stay Coding and Self-Care Score =33 points Improved! Calculates End of Stay Score and compares to Start of Stay score to create a change score 134 FH49 - Developed by Polaris Group Page 70 of 119

72 Activity Not Attempted Codes count as 1 Point =32 points this will count as only 1 point, NOT 7 Remember Activity Not Attempted codes count as only Mobility Items Used in Measure at Start and End of Stay Total Score range is FH49 - Developed by Polaris Group Page 71 of 119

73 Mobility Items Used in Measure for both Start and End of Stay Total Score range is Mobility Items Used in Measure at Start and End of Stay = 34 Scores for performance are added up for a total score (Activity not Attempted scores 1) Range FH49 - Developed by Polaris Group Page 72 of 119

74 Mobility Items Used in Measure at Start and End of Stay = 41 Scores for performance are added up for a total score (Activity not Attempted scores 1) Range Change in Self-Care or Mobility Score Calculation Calculates Score at Admission Calculates Score at Discharge Calculates the difference between scores Calculates expected change scores based on risk factors for each resident 140 FH49 - Developed by Polaris Group Page 73 of 119

75 Change in Self-Care or Mobility Score Calculation Calculates Score at Admission Calculates Score at Discharge Calculates the difference between scores Calculates expected change scores based on risk factors for each resident 141 CHANGE in Self-Care or Mobility Score Calculation Calculates an average observed change score Calculates an average expected change score Calculates difference between observed and expected change scores to create an observed minus expected difference - Value of 0 means no difference; value greater than 0 means better than expected and below 0 means worse than expected. Adds up all SNFs, creates risk adjusted mean score for comparison. 142 FH49 - Developed by Polaris Group Page 74 of 119

76 DISCHARGE Self-Care and Mobility Scores 143 Discharge Self-Care or Mobility Score Calculation Calculate discharge score using same scoring method as is used for Change measure Calculates an observed score Calculate an expected discharge Score Compare each residents observed and expected discharge score and classify the difference as Observed is equal to or higher than expected Observed is lower than expected 144 FH49 - Developed by Polaris Group Page 75 of 119

77 Discharge Self-Care or Mobility Score Calculation The total sum of residents with equal to or greater than expected is the numerator Denominator is Medicare Stays minus exclusions Percentage is then calculated 145 Exclusions Generally the Same for all Four Measures 1. Incomplete stays Death Unplanned discharge LOS less than 3 days 2. Resident was independent in all Self-Care OR All Mobility Care areas at admission 3. Resident younger than 21 years 4. Residents discharged to Hospice (A2100+7) 146 FH49 - Developed by Polaris Group Page 76 of 119

78 Exclusions Generally the Same for all Four Measures 5. Residents with certain medical conditions: coma, persistent vegetative state, complete tetraplegia, locked-in syndrome, severe anoxic brain damage, cerebral edema, or compression of brain. 6. Resident is not traditional Medicare Part A 7. Residents who do not receive PT or OT services as demonstrated 0 PT or OT minutes on Start of Care 5-day MDS 147 Risk Factors for Change and Discharge Self Help Risk Adjustment The risk adjustors used for this finalized quality measure are the following: Age group at SNF admission (A1600, Entry Date A0900, Birth Date) Younger than 54 years 55 to 64 years 65 to 74 years (reference category) 75 to 84 years 85 to 90 years >90 years of age and older Admission self-care function score: continuous form Admission self-care function score: squared form 148 FH49 - Developed by Polaris Group Page 77 of 119

79 Risk Factors for Change and Discharge Self Help Primary medical condition category Stroke (I0020, Primary medical condition category = 01) Non-traumatic brain dysfunction (I0020, Primary medical condition category = 02) and traumatic brain dysfunction (I0020, Primary medical condition category = 03) Non-traumatic spinal cord dysfunction (I0020, Primary medical condition category = 04) Traumatic spinal cord dysfunction (I0020, Primary medical condition category = 05) Progressive neurological conditions (I0020, Primary medical condition category = 06) Other neurological conditions (I0020, Primary medical condition category = 07) 149 Risk Factors for Change and Discharge Self Help Primary medical condition category Amputation (I0020, Primary medical condition = 08) Hip and knee replacement (reference category)(i0020, Primary medical condition category = 09) Fractures and other multiple trauma (I0020, Primary medical condition category = 10) Other orthopedic conditions (I0020, Primary medical condition category = 11) Debility and cardiorespiratory conditions (I0020, Primary medical condition category = 12) Medically complex conditions (I0020, Primary medical condition category = 13) Other medical condition (I0020, Primary medical condition category = 14) Interactions between primary medical condition category and SNF admission self-care score 150 FH49 - Developed by Polaris Group Page 78 of 119

80 Risk Factors for Change and Discharge Self Help Prior Surgery: Major surgery during the 100 days prior to the SNF admission (J2000, Prior surgery = 1) Prior Functioning: Self-care Dependent (GG0100A = 1) Some help (GG0100A = 2) Independent (GG0100A = 3), unknown (GG0100A = 8), not applicable (GG0100A = 9), or not assessed/no information (GG0100A = [-])(reference category) Prior Functioning: Indoor ambulation Dependent or some help (GG0100B = 1 or 2) Independent (GG0100B = 3), unknown (GG0100B = 8), not applicable (GG0100B = 9), or not assessed/no information (GG0100B = [-])(reference category) 151 Risk Factors for Change and Discharge Self Help Prior Device Use: Walker Yes (GG0110D is checked) No (GG0110D not checked)(reference category) Prior Device Use: Wheelchair/scooter Yes (GG0110A, manual wheelchair is checked or GG0110B, motorized wheelchair and/or scooter is checked) No (GG0110A, manual wheelchair is not checked and GG0110B, motorized wheelchair and/or scooter is not checked)(reference category) 152 FH49 - Developed by Polaris Group Page 79 of 119

81 Risk Factors for Change and Discharge Self Help Prior Device Use: Mechanical lift Yes (GG0110C, mechanical lift is checked) No (GG0110C, mechanical lift not checked)(reference category) Prior Device Use: Orthotics/prosthetics Yes (GG0110E, orthotics/prosthetics is checked) No (reference category)(gg0110e, orthotics/prosthetics not checked) 153 Risk Factors for Change and Discharge Self Help Presence of Stage 2 pressure ulcer(s) at admission (M0300B1 1) Presence of severe pressure ulcer/injury at admission Stage 3 (M0300C1, Number of Stage 3 pressure 1), Stage 4 (M0300D1, Number of Stage 3 pressure ulcers 1) or Unstageable pressure injury (M0300E1, Number of unstageable pressure ulcers due to non-removable dressing 1 or M0300F1, Number of these unstageable pressure ulcers due to slough and/or eschar 1 or M0300G1, Number of these unstageable pressure ulcers due to deep tissue injury 1) 154 FH49 - Developed by Polaris Group Page 80 of 119

82 Risk Factors for Change and Discharge Self Help Cognitive Abilities: Brief Interview for Mental Status (BIMS) score Severely impaired = C0500, BIMS Summary Score 7 or C0900Z, None of the above were recalled is checked or only one of the following is checked: C0900A, C0900B, C0900C, C0900D; Moderately impaired: if C0500, BIMS Summary Score = 8,9,10,11,12 or 2 of the following are checked: C0900A, C0900B, C0900C, C0900D; Intact (reference category): if C0500, BIMS Summary Score = 13,14 or 15 or 3 or 4 of the following are checked: C0900A, C0900B, C0900C, C0900D) 155 Risk Factors for Change and Discharge Self Help Communication Impairment: Ability to express ideas and wants and Understanding verbal and non-verbal content Moderate to severe communication limitations: Rarely/never understands (B0800, Ability to understand others = 3); or sometimes understands (B0800, Ability to understand others = 2); or rarely/never understood (B0700, Makes self understood = 3); or sometimes understood (B0700, Makes self understood = 2); Mild to no communication limitations (reference category): Usually understands (B0800, Ability to understand others = 1), understands (B0800, Ability to understand others = 0); and usually understood (B0700, Makes self understood = 1), understood (B0700, Makes self understood = 0), or Not assessed/no information (B0700 =[-] or B0800 =[-]) 156 FH49 - Developed by Polaris Group Page 81 of 119

83 Risk Factors for Change and Discharge Self Help Urinary Continence Occasionally (H0300, Urinary continence = 1), frequently incontinent (H0300, Urinary continence = 2) or always continent (H0300, Urinary continence = 3) Continent (H0300, Urinary continence = 0), catheter, ostomy or no urine output (H0300, Urinary continence = 9), or Not assessed/no information (H0300, Urinary continence =[-])(reference category) 157 Risk Factors for Change and Discharge Self Help Bowel Continence Occasionally (H0400, Bowel continence = 1), frequently incontinent (H0400, Bowel continence = 2) or always continent (H0400, Bowel continence = 3) Continent (H0400, Bowel continence = 0) or had ostomy or did not have a bowel movement for the entire 7 days (H0400, Bowel continence = 9), or Not assessed/no information (H0400, Bowel continence =[-])(reference category) Tube feeding (K0510B1 = 1) or total parenteral nutrition (K0510A1 = 1) 158 FH49 - Developed by Polaris Group Page 82 of 119

84 Risk Factors for Change and Discharge Self Help Comorbidities (hierarchical condition categories): Major Infections: Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock; and other infectious diseases Metastatic Cancer and Acute Leukemia Diabetes: Diabetes with Chronic Complications; Diabetes without Complication; Type I Diabetes Mellitus Other Significant Endocrine and Metabolic Disorders Delirium and Encephalopathy Dementia: Dementia with Complications; Dementia without Complications Tetraplegia (excluding complete tetraplegia) and paraplegia Multiple Sclerosis Parkinson s and Huntington s Diseases 159 Risk Factors for Change and Discharge Self Help Comorbidities (hierarchical condition categories): Angina Pectoris Coronary Atherosclerosis/Other Chronic Ischemic Heart Disease Hemiplegia, Other Late Effects of Cerebrovascular Accident: Hemiplegia/Hemiparesis; Late Effects of Cerebrovascular Disease, Except Paralysis Dialysis Status and Chronic Kidney Disease Stage 5 Urinary Obstruction and Retention Amputations: Traumatic Amputations and Complications; Amputation Status, Lower Limb/Amputation Complications; Amputation Status, Upper Limb 160 FH49 - Developed by Polaris Group Page 83 of 119

85 Risk Factors for Change and Discharge Mobility Risk Adjustment The risk adjustors used for this finalized quality measure are the following: Age group at SNF admission (A1600, Entry Date A0900, Birth Date) Younger than 54 years 55 to 64 years 65 to 74 years (reference category) 75 to 84 years 85 to 90 years 90 years of age and older Admission mobility function score: continuous form Admission mobility function score: squared form 161 Risk Factors for Change and Discharge Mobility Primary medical condition category Stroke (I0020, Primary medical condition category = 01) Non-traumatic brain dysfunction (I0020, Primary medical condition category = 02) and traumatic brain dysfunction (I0020, Primary medical condition category = 03) Non-traumatic spinal cord dysfunction (I0020, Primary medical condition category = 04) Traumatic spinal cord dysfunction (I0020, Primary medical condition category = 05) Progressive neurological conditions (I0020, Primary medical condition category = 06) Other neurological conditions (I0020, Primary medical condition category = 07) 162 FH49 - Developed by Polaris Group Page 84 of 119

86 Risk Factors for Change and Discharge Mobility Primary medical condition category Amputation (I0020, Primary medical condition = 08) Hip and knee replacement (reference category)(i0020, Primary medical condition category = 09) Fractures and other multiple trauma (I0020, Primary medical condition category = 10) Other orthopedic conditions (I0020, Primary medical condition category = 11) Debility and cardiorespiratory conditions (I0020, Primary medical condition category = 12) Medically complex conditions (I0020, Primary medical condition category = 13) Other medical condition (I0020, Primary medical condition category = 14) Interactions of medical condition category and admission mobility score and primary 163 Risk Factors for Change and Discharge Mobility Prior Surgery: Major surgery during the 100 days prior to the SNF admission (J2000, Prior surgery = 01) Prior Functioning: Indoor Mobility (ambulation) Dependent (GG0100B = 1) Some help (GG0100B = 2) Independent (GG0100B = 3), unknown (GG0100B = 8), not applicable (GG0100B = 9), or not assessed/no information (GG0100B = [-])(reference category) Prior Functioning: Stairs Dependent (GG0100C = 1) Some help (GG0100C = 2) Independent (GG0100C = 3), unknown (GG0100C = 8), not applicable (GG0100C = 9), or not assessed/no information (GG0100C = [-])(reference category) 164 FH49 - Developed by Polaris Group Page 85 of 119

87 Risk Factors for Change and Discharge Mobility Prior Functioning: Functional Cognition Dependent (GG0110D = 1) Independent (GG0110D = 3), some help (GG0100D = 2), unknown (GG0110D = 8), not applicable (GG0100D = 9), or not assessed/no information (GG0100D = [-])(reference category) Prior Device Use: Walker Yes (GG0110D is checked) No (GG0110D not checked)(reference category) Prior Device Use: Wheelchair/scooter Yes (GG0110A, manual wheelchair is checked or GG0110B, motorized wheelchair and/or scooter is checked) No (GG0110A, manual wheelchair is not checked and GG0110B, motorized wheelchair and/or scooter is not checked)(reference category) 165 Risk Factors for Change and Discharge Mobility Prior Device Use: Mechanical lift Yes (GG0110C, mechanical lift is checked) No (GG0110C, mechanical lift not checked)(reference category) Prior Device Use: Orthotics/prosthetics Yes (GG0110E, orthotics/prosthetics is checked) No, or unknown (reference category)(gg0110e, orthotics/prosthetics not checked) 166 FH49 - Developed by Polaris Group Page 86 of 119

88 Risk Factors for Change and Discharge Mobility Communication Impairment: Ability to express ideas and wants and Understanding verbal and non-verbal content Moderate to severe communication limitations: Rarely/never understands (B0800, Ability to understand others = 3); or sometimes understands (B0800, Ability to understand others = 2); or rarely/never understood (B0700, Makes self understood = 3); or sometimes understood (B0700, Makes self understood = 2); Mild to no communication limitations (reference category): Usually understands (B0800, Ability to understand others = 1), understands (B0800, Ability to understand others = 0); and usually understood (B0700, Makes self understood = 1), understood (B0700, Makes self understood = 0), or Not assessed/no information (B0700 =[-] or B0800 =[-]) 167 Risk Factors for Change and Discharge Mobility Cognitive Abilities: Brief Interview for Mental Status (BIMS) score: Severely impaired: C0500, BIMS Summary Score 7 or C0900Z, None of the above were recalled is checked or only one of the following is checked: C0900A, C0900B, C0900C, C0900D); Moderately impaired: C0500, BIMS Summary Score = 8,9,10,11,12 or 2 of the following items are checked: C0900A, C0900B, C0900C, C0900D); Intact (reference category): C0500 BIMS Summary Score = 13,14 or 15 or 3 or 4 of the following are checked: C0900A, C0900B, C0900C, C0900D) 168 FH49 - Developed by Polaris Group Page 87 of 119

89 Risk Factors for Change and Discharge Mobility Urinary Continence Occasionally (H0300, Urinary continence = 1), frequently incontinent (H0300, Urinary continence = 2) or always continent (H0300, Urinary continence = 3) Continent (H0300, Urinary continence = 0), catheter, ostomy or no urine output (H0300, Urinary continence = 9), or Not assessed/no information (H0300, Urinary continence =[-])(reference category) Bowel Continence Occasionally (H0400, Bowel continence = 1), frequently incontinent (H0400, Bowel continence = 2) or always continent (H0400, Bowel continence = 3) Continent (H0400, Bowel continence = 0) or had ostomy or did not have a bowel movement for the entire 7 days (H0400, Bowel continence = 9), or Not assessed/no information (H0400, Bowel continence =[-])(reference category) 169 Risk Factors for Change and Discharge Mobility Presence of Stage 2 pressure ulcer(s) at admission (M0300B1 1) Presence of severe pressure ulcer/injury at admission Stage 3 (M0300C1, Number of Stage 3 pressure 1), Stage 4 (M0300D1, Number of Stage 4 pressure ulcers 1) or Unstageable pressure ulcer/injury (M0300E1, Number of unstageable pressure ulcers (due to non-removable dressing) 1 or M0300F1, Number of these unstageable pressure ulcers (due to slough and/or eschar) 1 or M0300G1, Number of these unstageable pressure ulcers (due to deep tissue injury) 1) 170 FH49 - Developed by Polaris Group Page 88 of 119

90 Risk Factors for Change and Discharge Mobility Tube feeding (K0510B1 = 1) or total parenteral nutrition (K0510A1 = 1) History of Falls: history of one or more falls in the 6 months prior to admission (J1700A, fall any time in the last month prior to admission/entry or reentry = 1 or J1700B, fall any time in the last 2-6 months prior to admission/entry or reentry = 1) 171 Risk Factors for Change and Discharge Mobility Comorbidities (hierarchical condition categories): Major Infections: Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock; and other infectious diseases Metastatic Cancer and Acute Leukemia Diabetes: Diabetes with Chronic Complications; Diabetes without Complication; Type I Diabetes Mellitus Other Significant Endocrine and Metabolic Disorders Delirium and Encephalopathy Dementia: Dementia with Complications; Dementia without Complications Tetraplegia (excluding complete tetraplegia) and paraplegia Multiple Sclerosis Parkinson s and Huntington s Diseases 172 FH49 - Developed by Polaris Group Page 89 of 119

91 Risk Factors for Change and Discharge Mobility Comorbidities (hierarchical condition categories): Central nervous system (CNS) Infections: Bacterial, Fungal, and Parasitic Central Nervous System Infections; Viral and Late Effects Central Nervous System Infections Other Infectious Diseases (HCC 7) Metastatic Cancer and Acute Leukemia Lymphoma and Other Cancers Other Majors Cancers: Colorectal, Bladder, and Other Cancers; Other Respiratory and Heart Neoplasms; Other Digestive and Urinary Neoplasms; Other Neoplasms Dementia: Dementia with Complications; Dementia without Complications Mental Health Disorders: Schizophrenia; Major Depressive, Dipolar, and Paranoid Disorders; Reactive and Unspecified Psychosis; Personality Disorders 173 Risk Factors for Change and Discharge Mobility Comorbidities (hierarchical condition categories): Tetraplegia (excluding complete tetraplegia) and paraplegia Multiple Sclerosis Coronary Atherosclerosis/Other Chronic Ischemic Heart Disease Hemiplegia/Other Late Effects of Cerebrovascular Accident: Hemiplegia/Hemiparesis; Late effects of Cerebrovascular Disease, Except Paralysis Aspiration, Bacterial, and Other Pneumonias: Aspiration and Specified Bacterial Pneumonias; Pneumococcal Pneumonia, Empyema, Lung Abscess Legally Blind Dialysis Status and Chronic Kidney Disease Stage FH49 - Developed by Polaris Group Page 90 of 119

92 Risk Factors for Change and Discharge Mobility Comorbidities (hierarchical condition categories): Chronic Kidney Disease Stages 1-4, Unspecified: Chronic Kidney Disease, Severe (Stage 4); Chronic Kidney Disease, Moderate (Stage 3); Chronic Kidney Disease, Mild or Unspecified (Stages 1-2 or Unspecified) Major Fracture, except of Skull, Vertebrae or Hip Amputations: Traumatic Amputations and Complications; Amputation Status, Lower Limb/Amputation complications; Amputation Status, Upper Limb 175 Calculating PDPM Function Scores 176 FH49 - Developed by Polaris Group Page 91 of 119

93 Nursing Component Calculate Function Score Performance Score for seven (7) GG functional items creates Function Score 177 Function Score - Performance Coding 178 FH49 - Developed by Polaris Group Page 92 of 119

94 Average Function Score from 5-day MDS Section GG Item GG0130A1 Self-care: Eating 0-4 GG0130C1 Self-care: Toileting 0-4 Hygiene GG0170B1 Mobility: Sit to lying GG0170C1 Mobility: Lying to sitting on side of bed GG0170D1 Mobility: Sit to stand GG0170E1 Mobility: Chair/bed-tochair transfer GG0170F1 Mobility: Toilet transfer FUNCTION SCORE RANGE (average of 2 items) 0-4 (average of 3 items) 179 Performance Coding on 5-day MDS Admission Performance Function Score = (Column 1) = 05, , 07, 09, 10, 88 0 Range for Function Score is 0-16 Performance Coding determines average Function Score 180 FH49 - Developed by Polaris Group Page 93 of 119

95 Section GG Item Average Functional Score Coding Function Score GG0130A1 Self-care: Eating 06 Function Score 4 GG0130C1 Self-care: Toileting Hygiene GG0170B1 Mobility: Sit to lying 04 GG0170C1 GG0170D1 GG0170E1 GG0170F1 Mobility: Lying to sitting on side of bed Mobility: Sit to stand Mobility: Chair/bedto-chair transfer Mobility: Toilet transfer 02 Function Score Total Function Score = =4 divided by 2 = Average Function Score =4 divided by 3 = Average 1.3 rounded to Average Function Score Clinical Category Extensive Services Nursing Index Under PDPM Model PDPM Nursing Case-Mix Group Clinical Conditions Depression # of Restorative Nursing Services GG-based Function Score Nursing Case-Mix Index ES3 Tracheostomy & Ventilator ES2 Tracheostomy or Ventilator ES1 Infection Serious medical Special Care conditions e.g. HDE2 High comatose, septicemia, Yes respiratory therapy Serious medical HDE1 conditions e.g. comatose, septicemia, No respiratory therapy Serious medical HBC2 conditions e.g. comatose, septicemia, Yes respiratory therapy Serious medical conditions e.g. 182 HBC1 No comatose, septicemia, respiratory therapy FH49 - Developed by Polaris Group Page 94 of 119

96 Clinical Category Special Care Low Clinically Complex Nursing Index Under PDPM Model PDPM Nursing Case- Mix Group LDE2 LDE1 LBC2 LBC1 CDE2 Clinical Conditions Serious medical conditions e.g. radiation therapy or dialysis Serious medical conditions e.g. radiation therapy or dialysis Serious medical conditions e.g. radiation therapy or dialysis Serious medical conditions e.g. radiation therapy or dialysis Conditions requiring complex medical care e.g. pneumonia, surgical wounds, burns Conditions requiring complex medical care e.g. pneumonia, surgical Depression # of Restorative Nursing Services GG-based Function Score Nursing Case-Mix Index Yes No Yes No Yes CDE1 No wounds, burns Clinical Category Clinically Complex Nursing Index Under PDPM Model PDPM Nursing Case- Mix Group CBC2 CA2 CBC1 CA1 Clinical Conditions Conditions requiring complex medical care e.g. pneumonia, surgical wounds, burns Conditions requiring complex medical care e.g. pneumonia, surgical wounds, burns Conditions requiring complex medical care e.g. pneumonia, surgical wounds, burns Conditions requiring complex medical care e.g. pneumonia, surgical wounds, burns Depression # of Restorative Nursing Services GG-based Function Score Nursing Case-Mix Index Yes Yes No No Behavior SX Cognition BAB2 Behavioral or cognitive symptoms - 2 or more Behavioral or cognitive BAB POLARIS GROUP Strategic symptoms Solutions For Healthcare FH49 - Developed by Polaris Group Page 95 of 119

97 Clinical Category Reduced Physical Function Nursing Index Under PDPM Model PDPM Nursing Case-Mix Group PDE2 PDE1 PBC2 PA2 PBC1 PA1 Clinical Conditions Assistance with daily living and general supervision Assistance with daily living and general supervision Assistance with daily living and general supervision Assistance with daily living and general supervision Assistance with daily living and general supervision Assistance with daily living and general supervision Depression # of Restorative Nursing Services GG-based Function Score Nursing Case-Mix Index - 2 or more or more or more PT/OT Component Calculate Function Score Performance Score for ten (10) GG functional items creates Function Score 186 FH49 - Developed by Polaris Group Page 96 of 119

98 Function Score - Performance Coding 187 Average Function Score from 5-day MDS Section GG Item GG0130A1 Self-care: Eating 0-4 FUNCTION SCORE RANGE 0 24 GG0130B1 Self Care: Oral Hygiene 0-4 Additional GG0130C1 Self-care: Toileting Hygiene 0-4 GG0170B1 Mobility: Sit to lying GG0170C1 Mobility: Lying to sitting on side of bed 0-4 (average of 2 items) GG0170D1 Mobility: Sit to stand GG0170E1 Mobility: Chair/bed-to 0-4 (average of 3 items) -chair transfer GG0170F1 Mobility: Toilet transfer 188 FH49 - Developed by Polaris Group Page 97 of 119

99 Average Function Score from 5-day MDS Section GG Item GG0170I1 Mobility: Walk 50 feet with two turns GG0170J1 Mobility: Walk 150 Feet FUNCTION SCORE RANGE (average of 2 items) 189 Performance Coding on 5-day MDS Admission Performance Function Score = (Column 1) = 05, , 07, 09, 10, 88 0 Range for Function Score is 0-24 Performance Coding determines average Function Score 190 FH49 - Developed by Polaris Group Page 98 of 119

100 Section GG Item Coding Function Score GG0130A1 Self-care: Eating 06 Function Score 4 GG0130B1 GG0130C1 Self Care: Oral Hygiene Self-care: Toileting Hygiene GG0170B1 Mobility: Sit to lying 04 GG0170C1 GG0170D1 GG0170E1 GG0170F1 Average Functional Score Mobility: Lying to sitting on side of bed Mobility: Sit to stand Mobility: Chair/bedto-chair transfer Mobility: Toilet transfer 04 Function Score 3 02 Function Score Additional 3+1=4 divided by 2 = Average Function Score =4 divided by 3 = Average 1.3 rounded to Average Function Score Average Function Score from 5-day MDS Section GG Item GG0170J1 Mobility: Walk 50 Feet with two turns GG0170K1 Mobility: Walk 150 Feet Coding Function Score Range for Function Score is 0-24 Function Score Adds up to =1 divided by 2 =.5 Average Function Score FH49 - Developed by Polaris Group Page 99 of 119

101 PT and OT Case-mix Classification Groups Clinical Category Section GG Function Score PT OT Case-mix Group PT Casemix Index OT Casemix Index Major Joint Replacement or Spinal Surgery 0-5 TA Major Joint Replacement or Spinal Surgery 6-9 TB Major Joint Replacement or Spinal Surgery TC Major Joint Replacement or Spinal Surgery 24 TD Other Orthopedic 0-5 TE Other Orthopedic 6-9 TF Other Orthopedic TG Other Orthopedic 24 TH Medical Management 0-5 TI Medical Management 6-9 TJ Medical Management TK Medical Management 24 TL PT and OT Case-mix Classification Groups Clinical Category Non-Orthopedic Surgery and Acute Neurologic Non-Orthopedic Surgery and Acute Neurologic Non-Orthopedic Surgery and Acute Neurologic Non-Orthopedic Surgery and Acute Neurologic Section GG Function Score PT OT Case-mix Group PT Casemix Index OT Casemix Index 0-5 TM TN TO TP FH49 - Developed by Polaris Group Page 100 of 119

102 Summary IDT approach to coding GG for accuracy as to baseline at admission and discharge Consider coding at admission as compared to improvement at discharge for QMs Coding on MDS should be supported in record, especially PDPM Self-Care and Mobility items since impact on CMG G - ADL coding is gone with PDPM 195 FH49 - Developed by Polaris Group Page 101 of 119

103 Patient-Driven Payment Model (PDPM): Quick Reference The PDPM establishes a rate on the 5-day MDS for the entire stay by combining five different case-mix components (PT, OT, SLP, Nursing, and Non-Therapy Ancillary) with the non-case mix component (a total of 6 components). A variable rate applies for three components based on length of stay). The rate may be changed during the Medicare Part A stay by completing the voluntary Interim Payment Assessment (IPA) for substantial changes. Use the following tools to identify the case-mix group for each component and improve your understanding of the Patient-Driven Payment Model. Final Rule inspection.federalregister.gov/ pdf Non Case Mix Group Non- Case- Mix Group Non- Therapy Ancillary Case-Mix Group = Resident s Total Rate Nursing Case- Mix Group OT PT PT Case Mix Case- Mix Group Group Case- Mix Group SLP Case- Mix Group OT FH49 - Developed by Polaris Group Page 102 of 119

104 Nursing Component Patient-Driven Payment Model (PDPM) Clinical Category Extensive Services PDPM Nursing Case-Mix Group ES3 ES2 Clinical Conditions Tracheostomy & Ventilator Tracheostomy or Ventilator Depression # of Restorative Nursing Services GGbased Function Score Nursing Case- Mix Index ES1 Infection Special Care High HDE2 Serious medical conditions e.g. comatose, septicemia, respiratory therapy Yes HDE1 Serious medical conditions e.g. comatose, septicemia, respiratory therapy No HBC2 Serious medical conditions e.g. comatose, septicemia, respiratory therapy Yes HBC1 Serious medical conditions e.g. comatose, septicemia, respiratory therapy No Special Care Low LDE2 Serious medical conditions e.g. radiation therapy or dialysis Yes LDE1 Serious medical conditions e.g. radiation therapy or dialysis No LBC2 Serious medical conditions e.g. radiation therapy or dialysis Yes Resources: FY 2019 SNF PPS Final Rulemaking and CMS Draft PDPM Calculation Worksheet for SNFs. FH49 - Developed by Polaris Group Page 103 of 119

105 Nursing Component Patient-Driven Payment Model (PDPM) Clinical Category Special Care Low PDPM Nursing Case-Mix Group LBC1 Clinical Conditions Serious medical conditions e.g. radiation therapy or dialysis Depression # of Restorative Nursing Services GGbased Function Score Nursing Case- Mix Index No Clinically Complex CDE2 Conditions requiring complex medical care e.g. pneumonia, surgical wounds, burns Yes CDE1 Conditions requiring complex medical care e.g. pneumonia, surgical wounds, burns No CBC2 Conditions requiring complex medical care e.g. pneumonia, surgical wounds, burns Yes CA2 Conditions requiring complex medical care e.g. pneumonia, surgical wounds, burns Yes CBC1 CA1 Conditions requiring complex medical care e.g. pneumonia, surgical wounds, burns Conditions requiring complex medical care e.g. pneumonia, surgical wounds, burns No No Behavior SX Cognition BAB2 Behavioral or cognitive symptoms - 2 or more BAB1 Behavioral or cognitive symptoms Resources: FY 2019 SNF PPS Final Rulemaking and CMS Draft PDPM Calculation Worksheet for SNFs. FH49 - Developed by Polaris Group Page 104 of 119

106 Nursing Component Patient-Driven Payment Model (PDPM) Clinical Category PDPM Nursing Case-Mix Group Clinical Conditions Depression # of Restorative Nursing Services GGbased Function Score Nursing Case- Mix Index Reduced Physical Function PDE2 PDE1 Assistance with daily living and general supervision Assistance with daily living and general supervision - 2 or more PBC2 Assistance with daily living and general supervision - 2 or more PA2 Assistance with daily living and general supervision - 2 or more PBC1 Assistance with daily living and general supervision PA1 Assistance with daily living and general supervision Scoring Response for Section GG Items Score Section GG items Score 05, 06 Set-up assistance, independent 4 GG0130A1 Self-care: Eating 0-4 Supervision or touching Self-care: Toileting 04 3 GG0130C1 0-4 assistance hygiene 03 Partial/moderate assistance 2 GG0170B1 Mobility: Sit to lying Substantial/maximal assistance 1 GG0170C1 01, 07, 09, 10, 88, [-] Dependent, refused, not attempted Mobility: Lying to sitting on side of bed 0 GG0170D Mobility: Sit to stand GG0170E1 GG0170F1 Mobility: Chair/bed-tochair transfer Mobility: Toilet transfer (avg. of 2 bed mobility items) 0-4 (avg. of 3 transfer items) *Nursing Component: See the CMS PDPM calculation worksheet for inclusion criteria for each nursing classification. Resources: FY 2019 SNF PPS Final Rulemaking and CMS Draft PDPM Calculation Worksheet for SNFs. FH49 - Developed by Polaris Group Page 105 of 119

107 Steps for ICD-10 to PDPM Clinical Mapping You can search by ICD-10 code, code description, A to Z, or Z to A. Not all codes are listed, so if actual code doesn t come up, search by another method. May be necessary to scroll down to locate code manually. Do not use decimal when searching by ICD-10 code. To determine a resident s clinical category, complete the following steps: 1. Locate the ICD-10 code for the primary reason for SNF care in the tab SNF_clinical_categories_by_dx 2. Use the mapping in this tab to determine the default category, in column C 3. Did the resident receive a surgical procedure during the prior inpatient stay that relates to the SNF care plan? NO N/A Clinical Category is the default clinical category - STOP YES 4. Use column D to determine if the resident is eligible for a different clinical category from the default. 5. Is the resident eligible for a different clinical category? NO Clinical Category is the default clinical category - STOP YES, NON-ORTHO SURGERY YES, ORTHO SURGERY 6. Use the tab Non_Ortho_Surgery to see if the resident had a qualifying inpatient procedure. 7. Did the resident have a qualifying non-orthopedic procedure? NO YES Clinical Category is the default clinical category - STOP Clinical category is Non-Orthopedic Surgery - STOP 8. If the resident is eligible for one of the two orthopedic surgery categories, then use the Orthopedic_Surgery tab to determine if the resident had a qualifying inpatient procedure. 9. Did the resident have a qualifying orthopedic procedure? NO YES Clinical Category is the default clinical category - STOP Use column C to determine the clinical category based on the ICD-10-PCS code corresponding to the inpatient procedure STOP FH49 - Developed by Polaris Group Page 106 of 119

108 Physical Therapy & Occupational Therapy Component Patient-Driven Payment Model (PDPM) PT & OT Clinical Category (Collapsed) Major Joint Replacement or Spinal Surgery GG Function Score Other Orthopedic Medical Management Non-Orthopedic Surgery & Acute Neurologic PT & OT Case Mix Group TA TB TC TD TE TF TG TH TI TJ TK TL TM TN TO TP PT CMI OT CMI Primary Diagnosis (PDPM Clinical Category) Major Joint Replacement or Spinal Injury Orthopedic Surgery (except major joint replacement or spinal surgery) Non-surgical orthopedic/ musculoskeletal Acute infections Cardiovascular and Coagulations Pulmonary Cancer Medical Management Non-orthopedic surgery Acute Neurologic *PT Component and OT Component: PT and OT components will always result in the same case-mix group; however, the PT and OT case-mix indices/payment levels differ. Scoring Response for Section GG Items Score Section GG Items Score 05, 06 Set-up assistance, independent 4 GG0130A1 Self-care: Eating Supervision or touching assistance 3 GG0130B1 Self-care: Oral hygiene Partial/moderate assistance 2 GG0130C1 Self-care: Toileting 0-4 hygiene 02 Substantial/maximal assistance 1 GG0170B1 Mobility: Sit to lying 0-4 GG0170C1 (avg. of 2 bed Mobility: Lying to mobility items) sitting on side of bed 01, 07, Dependent, refused, not attempted, 0 GG0170D1 Mobility: Sit to stand , 10, 88, [-] resident does not walk** GG0170E1 Mobility: Chair/bed-tochair transfer (avg. of 3 transfer items) GG0170F1 Mobility: Toilet transfer GG0170J1 GG0170K1 Mobility: Walk 50 feet with 2 turns Mobility: Walk 150 feet 0-4 (avg. of 2 walking items) ** If a resident is coded as not attempted (07, 09, 10, or 88) for GG0170l1 (Walk 10 feet), then walking items for GG0170J1 (Walk 50 feet with 2 turns) and GG0170K1 (Walk 150 feet) will be scored as zero points. Resources: FY 2019 SNF PPS Final Rulemaking and CMS Draft PDPM Calculation Worksheet for SNFs. FH49 - Developed by Polaris Group Page 107 of 119

109 Physical Therapy & Occupational Therapy Component Patient-Driven Payment Model (PDPM) Medicare Payment Days Adjustment Factor Resources: FY 2019 SNF PPS Final Rulemaking and CMS Draft PDPM Calculation Worksheet for SNFs. FH49 - Developed by Polaris Group Page 108 of 119

110 Presence of Acute Neurologic Condition/ SLP-Related Comorbidity/ OR Cognitive Impairment (Mild, Moderate, Severe) Speech-Language Pathology Component Patient-Driven Payment Model (PDPM) Mechanically Altered Diet OR Swallowing Disorder SLP Case- Mix Group SLP Case- Mix Index None Neither SA 0.68 None Either SB 1.82 None Both SC 2.66 Any One Neither SD 1.46 Any One Either SE 2.33 Any One Both SF 2.97 Any Two Neither SG 2.04 Any Two Either SH 2.85 Any Two Both SI 3.51 All Three Neither SJ 2.98 All Three Either SK 3.69 All Three Both SL 4.19 Primary Diagnosis Clinical Category Major Joint Replacement or Spinal Surgery Orthopedic Surgery (Except Major Joint Replacement or Spinal Surgery) Non-Orthopedic Surgery Acute Infections Cardiovascular and Coagulations Pulmonary Non-Surgical Orthopedic/Musculoskeletal Acute Neurologic Cancer Medical Management SLP Clinical Category Non-Neurologic Non-Neurologic Non-Neurologic Non-Neurologic Non-Neurologic Non-Neurologic Non-Neurologic Acute Neurologic Non-Neurologic Non-Neurologic Resources: FY 2019 SNF PPS Final Rulemaking and CMS Draft PDPM Calculation Worksheet for SNFs. FH49 - Developed by Polaris Group Page 109 of 119

111 Special Treatments, Procedures and Programs O0100 Section I: Active Diagnoses Other: I8000 Additional Active Diagnoses See ICD-10 Codes below Speech-Language Pathology Component Patient-Driven Payment Model (PDPM) Co-morbidity O0100E2 Tracheostomy Care I0100F2 Ventilator or Respirator I4300 Aphasia (R47.01, F80.2, F80., I69., G31.01) I4900 Hemiplegia or Hemiparesis (G81., G83., I69. ) I4500 CVA, TIA, or Stroke (I69. ) I5500 TBI (S06. ) Laryngeal Cancer Apraxia Dysphagia ALS Oral Cancers Speech and Language Deficits SLP-Related Co-morbidity ICD-10- CM Code Description ALS G12.21 Amyotrophic lateral sclerosis Apraxia I Apraxia following unspecified cerebrovascular disease Dysphagia I Dysphagia following unspecified cerebrovascular disease Laryngeal Cancer C32.0 Malignant neoplasm of glottis Laryngeal Cancer C32.1 Malignant neoplasm of supraglottis Laryngeal Cancer C32.2 Malignant neoplasm of subglottis Laryngeal Cancer C32.3 Malignant neoplasm of laryngeal cartilage Laryngeal Cancer C32.8 Malignant neoplasm of other specified sites of larynx Laryngeal Cancer C32.9 Malignant neoplasm of larynx, unspecified Oral Cancer C00.0 Malignant neoplasm of external upper lip Oral Cancer C00.1 Malignant neoplasm of external lower lip Oral Cancer C00.3 Malignant neoplasm of upper lip, inner aspect Oral Cancer C00.4 Malignant neoplasm of lower lip, inner aspect Oral Cancer C00.5 Malignant neoplasm of lip, unspecified, inner aspect Oral Cancer C00.6 Malignant neoplasm of commissure of lip, unspecified Oral Cancer C00.8 Malignant neoplasm of overlapping sites of lip Oral Cancer C00.2 Malignant neoplasm of external lip, unspecified Oral Cancer C00.9 Malignant neoplasm of lip, unspecified Oral Cancer C01 Malignant neoplasm of base of tongue Oral Cancer C02.0 Malignant neoplasm of dorsal surface of tongue Oral Cancer C02.1 Malignant neoplasm of border of tongue Oral Cancer C02.2 Malignant neoplasm of ventral surface of tongue Oral Cancer C02.3 Malignant neoplasm of anterior two-thirds of tongue, part unspecified Oral Cancer C02.8 Malignant neoplasm of overlapping sites of tongue Oral Cancer C02.4 Malignant neoplasm of lingual tonsil Resources: FY 2019 SNF PPS Final Rulemaking and CMS Draft PDPM Calculation Worksheet for SNFs. FH49 - Developed by Polaris Group Page 110 of 119

112 Speech-Language Pathology Component Patient-Driven Payment Model (PDPM) SLP-Related Co-morbidity ICD-10- CM Code Description Oral Cancer C02.9 Malignant neoplasm of tongue, unspecified Oral Cancer C03.0 Malignant neoplasm of upper gum Oral Cancer C03.1 Malignant neoplasm of lower gum Oral Cancer C03.9 Malignant neoplasm of gum, unspecified Oral Cancer C04.0 Malignant neoplasm of anterior floor of mouth Oral Cancer C04.1 Malignant neoplasm of lateral floor of mouth Oral Cancer C04.8 Malignant neoplasm of overlapping sites of floor of mouth Oral Cancer C04.9 Malignant neoplasm of floor of mouth, unspecified Oral Cancer C09.9 Malignant neoplasm of tonsil, unspecified Oral Cancer C09.8 Malignant neoplasm of overlapping sites of tonsil Oral Cancer C09.0 Malignant neoplasm of tonsillar fossa Oral Cancer C09.1 Malignant neoplasm of tonsillar pillar (anterior)(posterior) Oral Cancer C10.0 Malignant neoplasm of vallecular Oral Cancer C10.1 Malignant neoplasm of anterior surface of epiglottis Oral Cancer C10.8 Malignant neoplasm of overlapping sites oropharynx Oral Cancer C10.2 Malignant neoplasm of lateral wall of oropharynx Oral Cancer C10.3 Malignant neoplasm of posterior wall of oropharynx Oral Cancer C10.4 Malignant neoplasm of branchial cleft Oral Cancer C10.8 Malignant neoplasm of overlapping sites of oropharynx Oral Cancer C10.9 Malignant neoplasm of oropharynx, unspecified Oral Cancer C14.0 Malignant neoplasm of pharynx, unspecified Oral Cancer C14.2 Malignant neoplasm of waldeyer s ring Oral Cancer C14.8 Malignant neoplasm of overlapping sites of lip, oral cavity and pharynx Oral Cancer C06.0 Malignant neoplasm of cheek mucosa Oral Cancer C06.1 Malignant neoplasm of vestibule of mouth Oral Cancer C05.0 Malignant neoplasm of hard palate Oral Cancer C05.1 Malignant neoplasm of soft palate Oral Cancer C05.2 Malignant neoplasm of uvula Oral Cancer C05.9 Malignant neoplasm of palate, unspecified Oral Cancer C05.8 Malignant neoplasm of overlapping sites of palate Oral Cancer C06.2 Malignant neoplasm of retromolar area Oral Cancer C06.89 Malignant neoplasm of overlapping sites of other parts of mouth Oral Cancer C06.80 Malignant neoplasm of overlapping sites of unspecified parts of mouth Oral Cancer C06.9 Malignant neoplasm of mouth, unspecified Speech and Language Deficits I Other speech and language deficits following unspecified cerebrovascular disease Speech and Language I Aphasia following unspecified cerebrovascular disease Deficits Speech and Language Deficits I Dysphasia following unspecified cerebrovascular disease Resources: FY 2019 SNF PPS Final Rulemaking and CMS Draft PDPM Calculation Worksheet for SNFs. FH49 - Developed by Polaris Group Page 111 of 119

113 Speech-Language Pathology Component Patient-Driven Payment Model (PDPM) SLP-Related Co-morbidity Speech and Language Deficits Speech and Language Deficits Speech and Language Deficits ICD-10- CM Code Description I Dysarthria following unspecified cerebrovascular disease I Fluency disorder following unspecified cerebrovascular disease I Other speech and language deficits following unspecified cerebrovascular disease Cognitive Impairment PDPM Cognitive Level BIMS Score Staff Assessment Score 1-Cognitively Intact Mildly Impaired Moderately Impaired Severely Impaired Mild to Severe Cognitive Impairment BIMS Interview Summary Score 0-15 PDPM Cognitive Level BIMS Score Cognitively Intact To qualify as Cognitively Impaired must be Mildly Impaired 8-12 Mild, Moderate or Severely Impaired Moderately Impaired 0-7 Severely Impaired - If BIMS Interview Summary Score is 99 or - Use Staff Assessment for PDPM Cognitive Level per Calculation Worksheet Resources: FY 2019 SNF PPS Final Rulemaking and CMS Draft PDPM Calculation Worksheet for SNFs. FH49 - Developed by Polaris Group Page 112 of 119

114 Non-Therapy Ancillary (NTA) Component Patient-Driven Payment Model (PDPM) Condition/Extensive Service Source Points HIV/AIDS SNF Claim 8 Parenteral IV Feeding: Level High MDS Items K0510A2 & 7 K0710A2=3 Special Treatments/Programs: Intravenous Medication Post-admit Code MDS Item O0100H2 5 Special Treatments/Programs: Ventilator or Respirator Post-admit Code MDS Item O0100F2 4 Parenteral IV Feeding: Level Low MDS Items K0510A2 & 3 K0710A2=2 & K0710B2=2 Lung Transplant Status MDS Item I Special Treatments/Programs: Transfusion Post-admit Code MDS Item O0100I2 2 Major Organ Transplant Status, Except Lung MDS Item I Active Diagnoses: Multiple Sclerosis Code MDS Item I Opportunistic Infections MDS Item I Active Diagnoses: Asthma COPD Chronic Lung Disease Code MDS Item I Bone/Joint/Muscle Infections/Necrosis Except Aseptic Necrosis of Bone MDS Item I Chronic Myeloid Leukemia MDS Item I Wound Infection Code MDS Item I Active Diagnoses: Diabetes Mellitus (DM) Code MDS Item I Endocarditis MDS Item I Immune Disorders MDS Item I End-Stage Liver Disease MDS Item I Other Foot Skin Problems: Diabetic Foot Ulcer Code MDS Item M1040B 1 Narcolepsy and Cataplexy MDS Item I Cystic Fibrosis MDS Item I Special Treatments/Programs: Tracheostomy Care Post-admit Code MDS Item O0100E2 1 Active Diagnoses: Multi-Drug Resistant Organism (MDRO) Code MDS Item I Special Treatments/Programs: Isolation Post-admit Code MDS Item O0100M2 1 Specified Hereditary Metabolic/Immune Disorders MDS Item I Morbid Obesity MDS Item I Special Treatments/Programs: Radiation Post-admit Code MDS Item O0100B2 1 Highest Stage of Unhealed Pressure Ulcer Stage 4 MDS Item M0300D1 1 Psoriatic Arthropathy and Systemic Sclerosis MDS Item I Chronic Pancreatitis MDS Item I Proliferative Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I Other Foot Skin Problems: Foot Infection Code, Other Open Lesion on MDS Item M1040A& M1040C 1 Foot Code, Except Diabetic Foot Ulcer Code (M1040B) Complications of Specified Implanted Device or Graft MDS Item I Bladder and Bowel Appliances: Intermittent Catheterization MDS Item H0100D 1 Inflammatory Bowel Disease MDS Item I Aseptic Necrosis Bone MDS Item I Special Treatments/Programs: Suctioning Post-admit Code MDS Item O0100D2 1 Cardio-Respiratory Failure and Shock MDS Item I Myelodysplastic Syndromes and Myelofibrosis MDS Item I Systemic Lupus Erythematosus, Other Connective Tissue Disorders, and Inflammatory Spondylopathies MDS Item I Resources: FY 2019 SNF PPS Final Rulemaking and CMS Draft PDPM Calculation Worksheet for SNFs. FH49 - Developed by Polaris Group Page 113 of 119

115 Non-Therapy Ancillary (NTA) Component Patient-Driven Payment Model (PDPM) Condition/Extensive Service Source Points Diabetic Retinopathy Except Proliferative Diabetic Retinopathy and MDS Item I Vitreous Hemorrhage Nutritional Approaches While a Resident: Feeding Tube MDS Item K0510B2 1 Severe Skin Burn or Condition MDS Item I Intractable Epilepsy MDS Item I Active Diagnoses: Malnutrition Code MDS Item I Disorders of Immunity Except: RxCC97: Immune Disorders MDS Item I Cirrhosis of Liver MDS Item I Bladder and Bowel Appliances: Ostomy MDS Item H0100C 1 Respiratory Arrest MDS Item I Pulmonary Fibrosis and Other Chronic Lung Disorders MDS Items I NTA Score Range NTA Case-Mix Group CMI 12+ NA NB NC ND NE NF 0.72 Medicare Payment Days Adjustment Factor Resources: FY 2019 SNF PPS Final Rulemaking and CMS Draft PDPM Calculation Worksheet for SNFs. FH49 - Developed by Polaris Group Page 114 of 119

116 Steps for ICD-10 to PDPM NTA Comorbidity Mapping You can search by ICD-10 code, ICD-10 code description, or Comorbidity description. Use drop down boxes to enter information or you can sort A to Z, or Z to A. Do not use decimal when searching by ICD-10 code. Make sure you are using the most up-to-date version of the NTA Comorbidity Mappings. 1. Determine if the ICD-10 code is listed in the NTA Comorbidity Mappings. 2. Is the ICD-10 code listed as an NTA Comorbidity Qualifier? YES 4. Use column B to determine the NTA Comorbidity Qualifying Category. NO Then the ICD-10 code is not an NTA I8000 Comorbidity Qualifier STOP (Keep in mind resident may still qualify for other MDS item NTA Comorbidity Qualifiers unrelated to ICD-10 I8000.) FH49 - Developed by Polaris Group Page 115 of 119

117 PDPM Payments Slope and Create Incentives for Shorter LOS Costs Payments Total Per Diem Payment is the Sum of Payments for Each Component NTA, OT, and PT taper or decrease over stay. Nursing, SLP, and Non-Case Mix Group remain constant. NTA Triple rate first 3 days; normal rate for rest of stay unless complete an Interim Payment Assessment which may change the rate for this component but does not reset to Day One of stay. OT and PT rates taper 2% every 7 days starting on day 21. Payments Can be Adjusted Using the Interim Payment Assessment (IPA) but the IPA does not reset to Day One for tapering Components Rate Component Per Diem Amount FY 2019 PDPM Unadjusted Federal Rate Per Diem - Urban Nursing NTA PT OT SLP Non-Case- Mix $ $78.05 $59.33 $55.23 $22.15 $92.63 FY 2019 PDPM Unadjusted Federal Rate Per Diem - Rural Rate Component Nursing NTA PT OT SLP Per Diem Amount Non-Case- Mix $98.83 $74.56 $67.63 $62.11 $27.90 $94.34 FH49 - Developed by Polaris Group Page 116 of 119

118 Section GG Nursing Function Score 0-16 GG0130A1 Self-care: Eating PDPM Function Score Work Sheet Coding Function Score Function Score GG0130C1 Self-care: Toileting Hygiene GG0170B1 Mobility: Sit to lying (average of Two) GG0170C1 Mobility: Lying to sitting on side of bed GG0170D1 Mobility: Sit to stand (average of Three) GG0170E1 GG0170F1 Mobility: Chair/bed-to-chair transfer Mobility: Toilet transfer TOTAL Section GG PT/OT Function Score 0-24 Coding Function Score GG0130A1 Self-care: Eating Function Score GG0130B1 GG0130C1 Self-Care: Oral Hygiene Self-care: Toileting Hygiene GG0170B1 Mobility: Sit to lying (average of Two GG0170C1 Mobility: Lying to sitting on side of bed GG0170D1 Mobility: Sit to stand (average of Three) GG0170E1 Mobility: Chair/bed-to-chair transfer GG0170F1 GG0170J1 GG0170K1 Mobility: Toilet transfer Mobility: Walk 50 feet two turns two turns Mobility: Walk 150 Feet (average of two) TOTAL Performance Code 5 day Function Score 05, , 07, 09, 10, 88 0 Total Nursing Function Score: Add up Score for Eating & Toileting with average score for each of the two Mobility groups. Total PT/OT Function Score: Add up Score for Eating, Oral Hygiene, & Toileting with average score for each of the two different Mobility groups. Created by Polaris Group FH49 - Developed by Polaris Group Page 117 of 119