In 1775, the chant of the day was “The Redcoats are coming! The Redcoats are coming!” Fast-forward to 2019 and in the realm of skilled nursing providers, the popular refrain is “PDPM is coming! PDPM is coming!”
The Patent Driven Payment Model (PDPM) will be effective October 1, 2019 and will be a fundamental change to the reimbursement for Medicare A services. Of the many changes in PDPM, one of the key changes is the role of functional score. Understanding the functional score will be a vital part of your organization’s PDPM success.
Previously under RUGs IV, the ADL score was calculated based on four “late loss” ADLs (bed mobility, transfer, toilet use, and eating). The score ranged from zero to sixteen with zero being the most independent, and 16 being the most dependent. The ADL score was also used as an end split for many categories, and higher ADL scores would result in higher reimbursement. Therefore, correctly coding MDS section G had a major impact on a provider’s reimbursement under RUGs IV. The ADL score from MDS section G will no longer have an impact on reimbursement with PDPM. Section G coding accuracy will remain important even after the implementation of PDPM in order to calculate Quality Measures, develop resident care plans and identify resident ADL improvements or declines.
The functional score for PT and OT is calculated using 10 questions from MDS section GG:
The functional score for nursing is calculated using seven questions from MDS section GG:
The functional score for nursing does not utilize the walking items or oral hygiene item.
Each functional score item is assigned a score of zero to four points. It is important to remember that the scoring for section GG is the reverse of Section G. Section G scoring states that the higher the score, the more dependent the resident is. Section GG scoring states that the higher the score, the more independent the resident is. Additionally in section GG, several items are combined to determine an average score. Those items are: the two-bed mobility, two walking and three transfer items, which are averaged when calculating the PT and OT functional score, and the three transfer items and two-bed mobility items, which are averaged when calculating nursing functional score. Missing answers (Dependent, Refused, Not Applicable, Not Attempted due to Environmental Limitations, Not Attempted Due to Medical Condition or Safety Concerns) in section GG, all receive zero points for the PDPM functional scores.
The direct relationship between increasing dependence and increased payment under RUGs IV will no longer exist with PDPM. PDPM factors in many resident characteristics such as: diagnosis, functional score, comorbidities, age, cognition, depression, restorative, and recent surgeries to calculate therapy needs and therapy potential specific to the resident. Accurate coding of MDS section GG is already being used for outcome-driven Quality Measures and will be even more important after October 1, 2019. Skilled nursing providers should be reviewing how section GG data is gathered by your staff and reviewing the coding instructions for MDS section GG in the Resident Assessment Instrument (RAI). The RAI states the data for section GG must come from more than one person and from more than one day. Additionally, an interdisciplinary approach should be used. PDPM does not change how MDS section GG is coded, but it does change the importance of the accuracy of the coding.
Jacklyn Brown, RN, is a Clinical Consultant for Richter.
Interested in learning more about how PDPM will affect your facility? Join us for our Nine Steps to PDPM Webinar Series. Click here to learn more.
Do you have questions about functional score under PDPM, or other clinical challenges? Call Richter’s clinical education consultants at 866-806-0799 to schedule a free consultation.