Definitions
HIPPS Codes
Case Mix/Rate
General
Scenario 1
Scenario 2
BONUS
100

What does CMI stand for?

Case Mix Index

100

How many NTA points is an opportunistic Infection?

2

100

How many case mix components are there?


Bonus available 100

6


100

If your GG score is 5, are you more independent or dependent?

Dependent

100

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  

100

If a resident has a BIMS score of 10, what is their cognitive level?

Mild Cognitive Impairment

100

Case mix rate

Bonus: Can you name them?

PT, OT, SLP, Nursing, NTA, Non-case mix

200

What does PDPM stand for?

Patient Driven Payment Model

200

After day 20 the PT and OT Case Mix Components rate drop by how many % each week?

2% a week

200

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.  

200

How many questions on the MDS affect reimbursement?

161

200

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 

 


200

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

200

 *Bonus: If BIMS was completed on or before the ARD, what would the difference in CMI be?

*Bonus - SI 3.34

300

What does NA, not acceptable primary diagnosis mean?

Does not map to a clinical diagnosis category 

300

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

300

Isolation w/ GG score 15 is what nursing category and case mix group?

Clinically Complex

CA1

300

Within the PDPM clinical category hierarchy what is higher  - acute neurologic or pulmonary?

acute neurologic

300

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

300

A resident with aphasia, COPD, dysphagia R13, diabetes, seizure disorder, and CVA. Which of these are speech comorbidities?

Aphasia, CVA

300

BONUS general 500


What is coded in GG?



usual performance of ADLs


400

True or False:  PDPM is used for reimbursement only for Medicare A residents.

False

400

HIPPS code of KDEF1 would calculate to how much daily reimbursement, for days 4-20 with urban daily base rate?

$635.60

400

Which PDPM component/groups apply to Medicaid Case Mix?

Nursing Group Only

400

For a new admit, 5 day assessment, what days can the GG be done/used?

days 1-3

400

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

400

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

 

400

BONUS Scenario 400

 What would your nursing case mix increase to?


BABA2

500

Is Sitting to Lying one of the ADL’s (functional performance) scores for acuity?

Yes

500

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  

500

Which groups have a variable per diem?  

NTA, PT, OT

500

Where does the supportive documentation to code section GG come from?  


BONUS available 300

  Nursing, Therapy and CNA

500

A resident is admitted with an acute infection, what PT/OT clinical category will they fall into?

Medical Management

500

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  

500

BONUS HIPPS codes 500

What is the daily rate from days 4-20?

   $602.32

600

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 

 

600

 What is HIPPS code comprised of (5 characters) in order ?

PT/OT,    SLP,    Nursing Case Mix,     NTA,  assessment code indicator

600

What is the PHQ2-9 score required to qualify for the depression end-split?

equal to or greater than 10

(but not 99)

600

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

600

If a resident has dialysis and a nursing function score of 10 what category would they classify in?

Special Care Low

600

If you have a GG score of 15, what is the highest nursing category can a resident be classified in?

Clinically Complex

600

Bonus scenario2    800

 *What clinical category do they fall into?

clinical category -  CA1

700

What is the benefit of the Mini nutritional risk assessment?

Determination of Malnutrition or Risk of malnutrition

700

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    


700

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

700

With a Nursing Function Score of 16 is the resident Dependent or Ind

Independent

700

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

700

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

700

HIPPS Codes 700

what is the daily rate from days 4-20?

$516.36

800

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

800

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


800

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

800

 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  

800

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

800

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


800

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