Harmony Healthcare Blog

Resident Classification System RCS-I (Part 2)

Posted by The Harmony Team on Wed, Jul 05, 2017


Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency

bigchangesahead.jpgCMS extended the comment period for the recent ANRP the Advanced Notice of Proposed Rulemaking to August 25th, 2017 at 5:00 p.m. This seems to be a good thing seeing the concepts are a little difficult to assimilate. The logic may be sound via data analysis, but is it applicable? 

The below bullets provide added insight into the rationale for said proposed changes, but it appears our gut instincts evoke a certain tinge of uncertainty. 

Occupational and Physical Therapy Category 

For example, one of the four categories combine Occupational and Physical Therapy. This is because the data shows a direct correlation between OT and PT services. Meaning, when OT is involved, so is PT.  By the same token, the data shows that when OT and PT are involved, Speech Therapy is absent. 

Two Comments: 

  • Maybe Speech Therapy is simply not available?
  • If you pose these finding to a direct care therapist, watch their reaction. They might adamantly disagree.  

ADL Coding (Functional Score) 

The Resident Characteristics for Occupational and Physical Therapy include: 

  • Clinical Categories
  • Functional Score
  • Cognitive Score 

ADL Scoring (Functional Scoring) is another example of data versus reality. The below table depicts the points associated with assistance.

ADL Coding

This table shows: 

  1. The resident who receives Extensive Assistance will be assigned a lower number of points, or 5 points.

    • Is this a true reflection of the highest PT/OT costs, or a product of nationwide under coding of ADLs?
    • The importance of accurate ADL Coding is highlighted in the statistical research based on data from our current payment model. The current RUA RUG Level represents a high PT/OT cost per day resident coded as a Limited Assistance. 
  2. ADL Scoring for resident acuity classification will change in this new payment model. A Functional Measure Score (FMS) will be attained based upon Self-Performance alone, and using only 3 of the 4 Late Loss ADLs.

    • Bed Mobility will be eliminated from scoring based on research that suggest that the measure impacted by environmental factors such as characteristics of the bed and not truly reflecting an underlying resident condition. This seems too risky seeing that bed mobility is a game changer when it comes to providing assistance. Advanced Notice of Proposed Rulemaking
  1. Points were derived by these three selected ADL Self-Performance items based on the observed cost patterns. Statistical evidence revealed that transfer and toileting items for residents who received Limited Assistance had the highest PT/OT costs per day and therefore assigned the highest number of points, or 6 points

    • This seems a little counterintuitive. A patient with maximum assistance may require equal to if not more therapy than a patient with CTG assistance? Could the data be a misleading? In other words, what if the MDS coding is inaccurate? 
  1. Further investigation and research of statistical data revealed that therapy costs first increase and then decrease with increased dependence in Self-Performance in the areas of transfer and toileting. 
  1. It further found that costs consistently decreased with greater dependence in Self-Performance in eating.

    • The importance of providing Clinically Appropriate Therapeutic Interventions is highlighted in the statistical research based on data from our current payment model. The more dependent or lower functioning resident  may be represented as a lower PT/OT of SLP cost per day resident coded as a Totally Dependent. Is this a true reflection of the lowest PT/OT or SLP costs, or a product of providing limited Therapy Services?
    • The coding of an activity that occurred only once or twice, (7) yields one point while the coding of an activity that did not occur during the observation period, (8) yields 0 points in the Functional Measure Score. 

The above information reinforces the ongoing importance of ADL Point of Care Documentation.   The advent of technology in healthcare brings positives and negatives. Theoretically, documenting becomes easier and more precise.  However, this is not always the case.  Either way, it is apparent that there is opportunity nationwide in accurately collecting and reporting the amount of assistance rendered to the resident. 

In closing, the point of this blog post is to open our eyes to the proposed changes in the payment system.  An intense amount of time, research and thought went into the new system.  The burning question is: 

Given the inconsistency and interrater reliability deficit of the current system, how would one develop an entire new system based upon on this historical data?

Harmony Healthcare International (HHI) is available to assist with any questions or concerns that you may have regarding regulatory changes.  You can contact us by clicking here.  Looking to train your staff?  Join us in person at one of our our upcoming Competency/Certification Courses.  Click here to see the dates and locations. 

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Topics: proposed rule, Payment Reform, RCS-I

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