Definitions
What does CMI stand for?
Case Mix Index
How many NTA points is an opportunistic Infection?
2
How many case mix components are there?
Bonus available 100
6
If your GG score is 5, are you more independent or dependent?
Dependent
A resident with a positive Covid test on 4/20, with documented strict isolation started on 4/20. They are in a private room on 4/20 and 4/21 until noon when a roommate was moved in who is also Covid Positive. The next mds ARD is set for 5/3, can you capture Isolation on the mds?
Yes
If a resident has a BIMS score of 10, what is their cognitive level?
Mild Cognitive Impairment
Case mix rate
Bonus: Can you name them?
PT, OT, SLP, Nursing, NTA, Non-case mix
What does PDPM stand for?
Patient Driven Payment Model
After day 20 the PT and OT Case Mix Components rate drop by how many % each week?
2% a week
If PT Case Mix Group and OT Case Mix Group are both TK will the rate for each component be the same?
No, the acuity scores are different for each discipline therefore, the rate is different.
How many questions on the MDS affect reimbursement?
161
Resident admitted to facility on 3/24/24 with primary diagnosis of hip fracture. MDS coordinator set a 5 day with an ARD of 3/29/24. Resident has a history of CVA from 1 year ago and is receiving a mechanical soft diet due to dysphagia. Has a diagnosis of cognitive communication deficit per provider documentation. Speech therapy is in and resident showed loss of liquids from mouth when working with speech. This is documented on 3/27/24. Social Services completed a BIMS on 3/30/24 that resulted in a score of 7. Which speech case mix group will this resident fall into?
Bonus question for 200
SF 2.82
If a resident rejects care for 5 days, has wandering behavior for 2 days, has a BIMS of 7 and a nursing function (GG) score of 10 what clinical category would they classify into?
Behavior Symptoms/Cognition
*Bonus: If BIMS was completed on or before the ARD, what would the difference in CMI be?
*Bonus - SI 3.34
What does NA, not acceptable primary diagnosis mean?
Does not map to a clinical diagnosis category
Where does HIV diagnosis have to be coded in order to get the 8 NTA points?
Has to be on the UB-04.
Diagnosis code B20
Isolation w/ GG score 15 is what nursing category and case mix group?
Clinically Complex
CA1
Within the PDPM clinical category hierarchy what is higher - acute neurologic or pulmonary?
acute neurologic
If a resident has physical or verbal behavior 4 or more days, BIMS less than 9 and two restorative programs what Nursing Category would this be?
Behavior – BAB2
A resident with aphasia, COPD, dysphagia R13, diabetes, seizure disorder, and CVA. Which of these are speech comorbidities?
Aphasia, CVA
BONUS general 500
What is coded in GG?
usual performance of ADLs
True or False: PDPM is used for reimbursement only for Medicare A residents.
False
HIPPS code of KDEF1 would calculate to how much daily reimbursement, for days 4-20 with urban daily base rate?
$635.60
Which PDPM component/groups apply to Medicaid Case Mix?
Nursing Group Only
For a new admit, 5 day assessment, what days can the GG be done/used?
days 1-3
What Nursing Group would a resident with Diabetes, two or more insulin order changes and a GG score of 14 fall into?
Special Care High
A resident’s nursing case mix group is BAB1 and a PHQ2-9 was completed after a suicidal ideation with a score of 11. Nothing else changed. Would your nursing case mix increase?
BONUS available for 400
yes
BONUS Scenario 400
What would your nursing case mix increase to?
BABA2
Is Sitting to Lying one of the ADL’s (functional performance) scores for acuity?
Yes
If these are the current case mix index’s: PT:1.58 OT:1.55 SLP:2.21 Nsg:1.76 NTA:1.26
What is the HIPPS code?
Bonus available 500
GEGD1
Which groups have a variable per diem?
NTA, PT, OT
Where does the supportive documentation to code section GG come from?
BONUS available 300
Nursing, Therapy and CNA
A resident is admitted with an acute infection, what PT/OT clinical category will they fall into?
Medical Management
Two residents are admitting, Resident #1 has a Hip fracture and Resident #2 has a new CVA which resident will map to a higher diagnosis category?
Resident #1
BONUS HIPPS codes 500
What is the daily rate from days 4-20?
$602.32
Is it important to have accurate information for section GG (A resident’s usual performance)? If so what does it affect?
- Yes – Affects reimbursement and multiple Quality Measures.
This also can affect adl care, requirements for sig. Change and care planning
What is HIPPS code comprised of (5 characters) in order ?
PT/OT, SLP, Nursing Case Mix, NTA, assessment code indicator
What is the PHQ2-9 score required to qualify for the depression end-split?
equal to or greater than 10
(but not 99)
Business office gets a Diagnosis Mismatch error when trying print/pull the UB-04. What does this mean and what should be looked at?
Primary diagnosis on UB-04 (diagnosis sheet) doesn’t match primary diagnosis on MDS in I0020B
If a resident has dialysis and a nursing function score of 10 what category would they classify in?
Special Care Low
If you have a GG score of 15, what is the highest nursing category can a resident be classified in?
Clinically Complex
Bonus scenario2 800
*What clinical category do they fall into?
clinical category - CA1
What is the benefit of the Mini nutritional risk assessment?
Determination of Malnutrition or Risk of malnutrition
If these are the Case mix index’s: PT:1.40 OT:1.42 SLP:2.70 Nsg:1.39 NTA:0.91
What is the HIPPS code?
Bonus question available 700
NHUE1
What is the payment difference with special care high with and without the depression end split for a resident with a function score of 10?
With depression (HBC2) $259.64
Without depression (HBC1) $215.55
With a Nursing Function Score of 16 is the resident Dependent or Ind
Independent
A Resident with open lesion or surgical wound with treatments, PHQ2-9 of 11, Function score of 11 would fall under what category, HIPPS Code and CMI ?
Clinically Complex, CBC2, 1.47
Med A resident is only receiving PT and OT. Which case mix groups are calculated for the reimbursement rate?
PT, OT, SLP, Nursing, NTA, base rate
HIPPS Codes 700
what is the daily rate from days 4-20?
$516.36
What is the Four Criteria for coding isolation?
Room by themselves
Diagnosed highly transmissible disease
All services brought to resident
Precautions above and beyond standard precautions
Resident has a PDPM HIPPS code of KDKF ($570.69) on the 5-day MDS assessment. Resident becomes dehydrated and IV fluids are started. Should an IPA be completed?
Bonus available 800
Should an IPA be completed? yes
Nursing function score is comprised of what 7 items?
Eating, Toilet Hygiene, Sit to Lying, Lying to Sitting on Side of Bed, Sit to Stand, Chair/Bed to Chair Transfer, Toilet Transfer
What is the PDPM clinical category hierarchy (10)?
Major Joint replacement/spinal surgery, Orthopedic surgery, Non-orthopedic surgery, Non-surgical orthopedic surgery/Musculoskeletal, Acute Neurological, Acute Infection, Cancer, Cardiovascular/coagulations, Pulmonary, Medical Management
A resident with COPD, a diabetic foot ulcer and malnutrition what are the NTA points and what is the category?
NC *6 points
COPD 2 pts, DM 2 pts, Diabetic foot ulcer 1pt, malnutrition 1pt
if the wound is infected add 2pts for total of 8 points
A resident has a diagnosis of COPD with SOB lying flat, Diabetes, IV fluids during 7 day lookback while not a resident, PHQ2-9 score of 4, eating set up, toilet hygiene set up, sit to lying supervision touch, Lying to sitting in bed supervision touch, chair to bed transfer set up, toilet transfer set up set up. *What is their GG score? * Do they fall into the depression category?
BONUS available 600
GG score - 15
depression category - No
HIPPS codes 800
If so, what would you anticipate the new HIPPS code to be (if everything else stays the same) What would the new rate be?
new HIPPS code to be (if everything else stays the same) KDGD
new rate - $674.50