Integrated Coding & PDPM Case Study


»» Hello everyone. Good afternoon. Good afternoon, Jen. I heard you all. The roar was amazing. Fabulous. All right. I hope you enjoyed your lunch. Welcome to this Integrated Coding and PDPM
Case Study. This is going to take us for the next two
hours. And it is my pleasure to be able to co-present
this session with my friend and colleague John Kane who is a tough act to follow right
after watching him all morning. Again thanks to CMS, my colleagues at CMS
and Econometrica for having me present. You will use several handouts today. They should be in the left-side of your folder,
or no, right-side of your folder today, right. The handouts that you’re going to need include
the PDPM Case Study Narrative, the Integrated Coding and PDPM Case Study Coding Sheet, the
PDPM Factsheet and SNF Classification Walk Through and the Integrated Coding and PDPM
Case Study HIPPS Information Sheet. As in all of our sessions we have a group
of acronyms, again they’re presented here. Again I won’t read this slide or the next
to you, but I do want to remind you that you have that nice comprehensive acronym list
in your folder. Here’s our objectives. This session is your opportunity to apply
all of the knowledge that you’ve acquired during this two-day training and likely lots
of other trainings and reading, and all of that that you’ve done before and use that
knowledge to accurately code a clinical resident scenario and you’ll be able to calculate the
appropriate Health Insurance Prospective Payment System or HIPPS code under PDPM. Meet Mrs. S, she probably looks a lot like
some other residents you’ve seen in these two days. She’s a 78 year-old female. She was admitted to the acute care hospital
on November 3 with respiratory distress and right hip pain following a fall. Her admission diagnoses were right proximal
femoral fracture and exacerbation of congestive heart failure or CHF. On the Case Study Narrative you’ll see a bunch
more information about her. I’ll share just a few more details about her
with you. Her past medical history includes hypertension,
CHF, COPD and depression. She underwent a total hip arthroplasty on
November 4th to repair her femoral fracture. She required post op diuresis and supplemental
oxygen due to her CHF. During her hospitalization she developed a
Stage 4 pressure ulcer on her coccyx. Her postop status stabilized but given her
medical conditions about her continued need for pressure ulcer care, as well as OT and
PT, she was transferred to your skilled nursing facility on December 1. So as I mentioned, there is additional information
in the Case Study Narrative that you have in your folder. We’d like you now to work together. And I’m going to give you a little more info
on this. But ultimately you’re going to be using those
four documents that I mentioned that are listed on this slide and then use the Case Study
to code a subset of the admission and discharge items on the Coding Sheet and ultimately complete
the PDPM Calculation Worksheet. You will also find information on your tables
that you can share as a group. There’s some additional resources. These are the items you’re going to code for
the 5-day. Again I’m not going to read them to you. You can see them on the sheet itself. Then you’ll also code the Self-Care and Mobility
items on the Part A PPS discharge. When you look at the coding sheet you’ll find
some sections of the MDS already populated. And these are sections that you need in order
to complete your Calculation Worksheet. But it’s not necessarily info that’s in your
Case Study. The other thing I want to mention to you is
you can assume that this resident as I was looking at this, I thought, oh, there’s one
more piece of information I’m not sure if we gave you. But she had therapy, one discipline, on the
first Saturday she was there. Otherwise she only had Monday through Friday
therapy the next three weeks, okay, for the rest of her stay. So you’re going to need that piece of info
to do some coding. Yep. She had therapy. I think it was OT, on the first Saturday she
was there. Then her therapy was scheduled Monday through
Friday for both therapies, okay. So here’s your charge for about the next half
hour. Use the documents that I mentioned in the
Case Study to go ahead and code that. John and I will — actually I’ll see you in
about a half hour. We have planned 25-30 minutes. At the May training folks needed a little
more time to get through this. So I’m going to kind of check in with you
around 25 or 30. I hope that the folks that are also participating
remotely will take this opportunity to participate in this Case Study and come back. Plan on being back to debrief with us in a
half hour. But know that we may give you a few more minutes
at that time. So by my watch, it’s 12:52 so somebody help
keep me honest. I’ll see you about 1:22. We’re around if we can help. Then after you guys complete this I’ll come
back and debrief the coding with you before turning it over to John to walk through the
calculations with you. Okay. So go forth and do. Holler if you have questions. And thanks again for sticking with us. You guys are doing great. All right. So let’s start with Section A from our admission,
our first assessment there. And how did you code this A0300 Optional State
Assessment? No, right. Correct. And the rationale, again this is our SNF PPS
Assessment. How did you code A0310B? Did you code that as a 1, indicating a 5-day. Not much new here except there’s a whole lot
less choices, right, which is a good thing. And how did you code A0310E, is this the first
assessment since most recent admission, entry or reentry? Yes. Again that is first coded as 1. But in practice again we have just our PPS
Assessment here, pretty likely in practice you’re going to be combining it with your
OBRA assessment as well, right. And is this an SNF interrupted stay? No. And we heard about the interrupted stay. Just to review, that is when the resident
is in a Part A stay, they’re discharged from the SNF or discharged from Medicare Part A
covered care or stay, they subsequently resume for that within that interruption window. And when is that interruption window? How many days? 3 days. You’ve got it. And our gender is what? Female, sure. And how did you code A2400 Medicare stay? 1, excellent. And the start of Medicare? You’re entering 12/01. Super. This end of Medicare, do you agree it’s dashes? So I have a trivia question for you. We know that a dash is a standard no information
code, but it also means that a date has not yet occurred. So in addition to this item we use the dash
for date has not yet occurred in what other items? Therapy end dates. Woo! You guys are good. GG0100, Prior Functioning. Let’s go on to this. Let’s begin by looking at GG0100, Prior Functioning
Everyday Activities. How did you code Self-Care, A? 3, sure. She lives with her son. She’s in that two-level home and prior to
acute hospitalization she was independent. And that’s what that says. And how about indoor mobility? I have a 3 as well. Again we know she used that rolling walker
but she was independent with that. C for stairs. How did she do? I have a 2, that she needed some help. Great. And how about functional cognition? Oops, no — yes, functional cognition. I gave you the answer, 2. I’m clicker happy up here. She did need some help with grocery shopping,
paying the bills, doing things like that, her medication management. Then we go on to prior device use. And prior device use captures the devices
and aids that she used immediately prior to her illness. And how did you code this? A and D, great. Again she used both of those. The rationale is there. All right. Next let’s go on to GG0130 or Self-Care with
her Admission Performance and Discharge Goal. Remember that the coding is going to reflect
the three days of her Part A stay. The idea really is to capture the baseline
before the resident has benefited from any physical therapy, or occupational therapy,
or any therapy. So how did you code eating? 05 and a 06 it sounds like. Again here’s the rationale for that. She does need some help with setup, opening
containers and cutting her food. But it’s expected she’ll be independent prior
to her discharge. Then we have oral hygiene. 05 and 06 excellent. The CNA sets up her supplies but the team
expects she’ll be independent with that. Then we have C, toileting hygiene? 04 on here. Again, in her OT evaluation — oops, that’s
oral hygiene. In her OT evaluation we read that she needed
some steadying assistance from her helper while she adjusts her underwear and slacks. So again she is needing a little more help
with the supervision or touching assistance. And then we expect she’ll be independent. Shower or bathe self? We have a 02 on this one, so needing much
more help for this one. Again substantial/maximal help here. She is requiring more assistance. The helper helps her by wheeling in and provides
her really with more than half the effort. She is going to be coded a 02 there. Again OT expects her to be independent, but
perhaps with some adaptive equipment. Does that impact how we code her in this? Nope, adaptive equipment is fine. Next we have upper body dressing. Do you guys agree? Remember the upper body dressing can’t be
coded based on just a hospital gown. My guess is nobody wears a hospital gown in
most of your nursing homes or facilities. Do they? I want my jammies when I come to your nursing
home please, not a hospital gown. I don’t want to be showing my back end to
everybody walking by. She does need that setup or clean-up assistance. The CNA helps with her blouse and her bra,
with getting those for her. And then she’ll expect that she’ll be independent. And then lower body dressing. How did you do here? 03 and a 06. Great. In OT we have quite a bit of information about
the help. We noticed that in the OT evaluation that
she needed one helper. And she also did less than half the effort. Again once we’re seeing 02 we’re coding different
if someone needed two helpers, probably not with lower body dressing but perhaps. And then again she does half of the effort
there. We expect that she will be able to dress independently
by her discharge. And then finally we have for here putting
on/taking off footwear. How did you guys decide on that? 01, right now. That’s correct. Dependent for admission, 06 for Discharge
Goal. And there’s our rationale. One helper does this for her, puts on her
socks and shoes for her. But we do expect that she’ll be independent. All right. Let’s go on to GG0170. Here we’re looking at Mobility Admission Performance
and Discharge. And like the section we just looked at, this
is a 3-day assessment window hopefully capturing the status prior to the benefit of any therapy. (alarm going off) Now, there’s an alarm again. What is with you guys and alarms when I am
speaking? (Laughter) Do you need that to stay awake? What is it? Is it this? (Laughter) All right, anyway. So first we come to GG0170A, Roll Left and
Right. For coding on this we looked to our PT notes
in our Case Study. And what did you find out here? Coded as a 02, excellent. We hope that she’ll be a 06 on discharge. Here’s her rationale. The therapist provided more than half the
effort but expects that by discharge she’ll be independent with bed mobility including
left to right. And then sit to lying, again we have a 02. And the PT again notes that she only contributed
a small amount. So the resident only contributed a small amount. So again we have a code of 02. And as I mentioned, here’s our rationale. Again therapy provided more than half the
effort but the therapist expects she’ll be independent. So next we have lying to sitting on side of
the bed. Before we look at the coding for this item,
I think that it’s important to note that there are coding tips for the items that we just
reviewed, just a couple of them. However there’s five tips for this item. And why do I mention that? Because so often it’s the coding tips that
really guide the assessors. And often it’s the tips that provide the answers
to the questions that get submitted to the RAI coordinator, or to the CMS help desk. So I just encourage you when you’re reviewing
the RAI Manual and as you’re training folks on the manual that you apply those coding
tips, to various scenarios. Most of the time coding tips are added in
response to multiple questions about a particular thing. So they really are a very, very important
part of the instructions. So let’s take a look at how we coded this. We have a 02 and a 06. Do you agree? Great. Again quite a bit of information to support
coding. Her admission performance as 02. We note that she can bring her left leg off
the bed, assist with pushing up and then needs assistance to bring that other leg off the
side of the bed and is fully supported to come to that sitting position. And I think we would agree on that, that it’s
more than half the effort based on that. But we expect she’ll be independent when she
goes. Then we have Sit to Stand or GG0170D. I hear again a 02. And again, our Case Study indicates that she
does require maximal assistance. But PT therapist uses a gait belt. Mrs. S can steady herself. PT expects that she’ll be independent with
her rolling walker when she leaves. Then chair/bed-to-chair transfer. Like the other items here we’ve coded that
a 02 and a 06. Again our therapist noted that she required
that maximal assist to pivot transfer to a wheelchair. The therapist provides more than half the
effort. And the therapist expects that she’ll conduct
that independently when she leaves with her walker. Then we have toilet transfer. Here we change it up a little bit. We have a 03 and a 06. Do you guys agree? So partial or moderate, that is our staff
member, our helper is doing less than half. So we go back to OT’s notes to code here. And in those notes we see she required the
assistance of one helper to slowly lower her with trunk support onto her bedside and provides
contact-guard when she gets off the commode. And again the helper provides less than half
the effort. And then car transfer 88 and a 04. Great. Keep in mind we have those four activity did
not occur codes. We have they could refuse. It’s not applicable because it wasn’t attempted
and the individual didn’t perform that prior to their current illness, exacerbation or
injury. A 10, if it was environmental limitations,
or not attempted due to medical condition or safety concerns, which is the case for
our resident. And again our rationale, this just was not
tried on admission, but they expect with a contact-guard and her walker, she’ll be able
to do this activity prior to her discharge. Let’s look at walk. How did you code walk 10 feet? 03, 04. Great, you guys are good. Let’s look at the rationale. There she does walk 10 feet with a walker
and assistance of one helper. She needs steadying help. And she really needs some of her weight to
be supported in the last three of those ten feet. And by discharge it’s expected that she’ll
be able to do this using her walker with supervision or touching. Walk 50 feet with two turns? I have 88, I agree, and then 04. Again let’s look at the rationale. This was not attempted due to her fatigue
and decreased endurance. Any distance beyond 15 feet for her requires
that manual wheelchair. But they do expect that she’ll be able to
do this with contact guard when she leaves the facility using her rollator walker. How did you code walk 50 feet? 09, 09, great. Again, she wasn’t doing this before. It’s not expected she’ll do this after her
SNF stay. Walking 10 feet on uneven surfaces, how did
she do with that? I have 88 but it’s expected to be that she’ll
by discharge be able the do this with one helper or supervision or touching. Due to her medical condition it wasn’t tried,
but we expect she’ll be able to do that with her walker and the help. Then a curb? I have 88. Then what happens when we code 88? What do we do then? So we code 88, not attempted due to medical
condition. And then what happens? A skip pattern, right. We skip all the way to what? GG0170P. So we know if we can’t attempt one, we can’t
attempt the rest of them, right? Here again picking up the object is not attempted
due to the medical condition. But we expect that she’ll be able to do this
with setup when she leaves. Do you agree? Great. And she will again require adaptive equipment,
right. She can’t bend at the hip. Is that okay? Can she use a reacher or whatever? Sure. Next we get to does she use a wheelchair or
scooter. How did you code this one? This is one of those clicker questions to
make sure you’re awake. So if you would please go ahead and use Slido. Take just a moment to pick yes or no to indicate
whether she uses a wheelchair or scooter. We’ll give just another minute for our folks
online as well as those in the room who are just waking Slido up. Okay. It looks like we’re almost all yes. Let’s see what the right answer is. Yes, it is. Anything more than 15 feet, know she needs
a wheelchair. How did she do with wheeling 50 feet with
two turns? We have a 02 and a 06. Do you guys agree? For her admission performance the rationale
is once she is seated in her wheelchair she could complete those two turns. But she can only propel about 20 feet and
someone needs to help her for the last 30 feet because of her poor endurance. And remember with that they expect she’ll
be able to do that without any help at discharge. Remember those two turns can be the same way,
different directions. And they have to be how many degrees? 90-degrees, right. And then indicate the type of wheelchair or
scooter. Again you go to Slido for this. Was it manual or was it motorized? So you indicate the type of the wheelchair. A, for manual and B, for motorized. We’ll give just a moment for that. Okay. Let’s see what we came up with. And again it is manual. She used a manual wheelchair. And then we have wheel 150 feet. Okay. We have 02, 02. Great. And again on admission she becomes fatigued
after only about 20 feet. The therapist needs to help her. And they believe that she’ll probably only
go about 60 feet when she reaches her maximum potential and that someone will need to help
her with the rest. Remember she did only go about 70 feet prior
to her injury. All right. And there’s our rationale for that. Again we’re going to return to polling to
indicate what type of wheelchair we used for her. So going that longer distance did she use
a manual wheelchair or a motorized wheelchair? Okay. Looks like almost everybody said manual, and
that is correct. And here’s our last screenshot of Section
GG that shows — I’m sorry, GG0170. And we’re going to move on to I0020, the resident’s
primary medical condition. So here’s a screenshot of I0020. Remember in this item the assessor documents
the resident’s primary medical condition category that best describes the primary reason for
the Part A stay. And I want to give you all a secret. All of you that send the questions to say,
what is the primary reason for their medical stay,>we are not at the bedside. Who knows that information? The caregivers. Who can help them if they can’t figure it
out? John? The physician, right, who’s admitted them
and saying why they need medical care. Okay. We do not know the primary. Everybody hear that? Tell your friends. Shout it from the lighthouse. We do not know the primary reason for their
medical care. You all got that? Excellent. Okay. John, how many questions do you have after
we say that? (Laughter)
But really, guys. Think about clinical judgment, all of what
you know about your resident. We can’t tell that from a thousand miles away. You guys are at that bedside caring for the
people. You know what’s going on with those individuals. Does that make sense? And sometimes it might be — you can’t say
well that patient came in with this, they have this issue. And this guy has the same issue. They must have the same condition. It’s all about using the guidance in the manual,
asking the physician, getting that information. So with that, what is Mrs. S’ primary medical
condition category? Is it hip and knee fracture? Fractures and other multiple trauma? Debility or cardiorespiratory conditions? Or medically complex conditions? And go ahead and just take a couple of minutes
and vote on that. You guys have been great with participating
in the Case Studies and the pollings and all of that. We hope it keeps you awake and moving ahead
with us. So thanks for doing that. All right. I think we’re almost up about 300 or so. Let’s look at what the right answer is. It is fractures and other multiple trauma. Remember, if a resident’s primary medical
condition is fractures or other multiple trauma, it includes hip fractures, pelvic fractures,
other fractures as well. Okay. All right. And there’s our rationale. And what we have here is why we wouldn’t code
them. So we’re not coding the replacement because
even though she had that it was secondary to her fracture. And she also does have CHF and COPD but that’s
not the primary reason she’s in your facility. Again she has a pressure ulcer that may be
considered a medically complex condition but that’s not what prompted her to come to your
SNF. Does that make sense? Great. And here’s the ICD-9 code again. So we’re coding that for a 10. And there’s your ICD-9 code again. This is you guys go back to the physician
to say what is going on here? What are we coding? And then looking up, finding those codes. And then also in this, we are going to — so
the code she has here again is the fracture of an unspecified part of the neck or the
right femur, a subsequent encounter with a closed fracture with routine healing. So that’s the level of detail here with the
ICD-10. You would also check I3900 for this as well
for her diagnosis. And that’s right there. Great. Prior surgery. You all ready? Did she have prior surgery? Yes. So remember we’re talking about major surgery
in the last 100 days prior to her admission. Remember that major surgery for this item
for J2000 refers to a procedure, generally refers to a procedure that meets the following
criteria: The resident was an inpatient in acute care for at least one day in the 100
days prior to admission to the SNF, and the surgery carried some degree of risk. So remember we’re talking about major surgery
in the last 100 days prior to her admission. Remember that major surgery for this item
for J2000 refers to a procedure, generally refers to a procedure that meets the following
criteria: The resident was an inpatient in acute care for at least one day in the 100
days prior to admission to the SNF, and the surgery carried some degree risk to the resident’s
life and potentially severe disability. If you’re not sure of that who can help you? The provider, absolutely, the physicians. Get some input if you’re not not sure and
confident to make that decision. Again one case from one resident may be very
different from another. Then recent surgery requiring active SNF? Yes. And again she had that major — that hip surgery
following her fracture and then ends up in your SNF. Then if we look at the surgical procedures
this is just kind of a snapshot, a subset of those items. And here the assessor codes surgeries that
have happened within the last 30 days and during the inpatient stay immediately preceding
that SNF Part A admission, and that have a direct relationship to that SNF diagnosis
that’s coded in I0020B. So what did you check here? Hip replacement. And we know that she had that hip replacement
in the last 30-days right before she came to the SNF. And that is a direct relationship. Remember you’re not going to code conditions
here that have been resolved, that do not affect the current status, or do not drive
that resident’s plan of care as these would be considered surgeries that do not require
active care in the skilled nursing facility. And that does it for the 5-day assessment. Let’s move on to the Discharge Assessment. I’m sorry, there’s our rationale again with
the surgery. So Self-Care Discharge Performance. I assure you this part’s going to go pretty
quick. Then we’ll get John up here. So we have eating, 06. Everybody agree, independent? Yep. So she could do all her own setup. She used her utensils and she could use the
glass or cup to feed herself and to drink her liquids. Oral hygiene, we have 06 as well. Again she could do some of her hygiene tasks,
brushing her teeth without any help. And toileting hygiene, 06. Yep. She was independent with her perineal hygiene
and her clothing adjustment, didn’t need any help with that. And shower/bathe self? Also 06. With this she was independent when she used
her chair and other adaptive equipment and that’s just fine that she used that. And then upper body dressing, again a 06. She’s independent there. And lower body dressing? 06 as well, still independent there. And how about her footwear? 06 as well. Great. Again she could do her socks and shoes independently,
use some adaptive equipment and that’s just fine for Section GG. And then we go to her mobility performance
at discharge. Rolling left to right, 06. Again she could do that side to side, back
onto her back without any help. With her sitting to lying, again independent
with that, to go from sitting to supine and from lying to sitting on the edge of the bed
she was also independent. She really could move around from sitting
to lying and moving around the bed without any trouble. Then we have sit to stand? 06 as well. She could go from a seated to a standing position
using her walker but not requiring any help. And then chair/bed-to-chair transfer, again
a 06. She could use her walker but could do that
independently. Her toilet transfer again a 06. She could get on and off that toilet without
any help. She used a raised toilet seat. But that’s just fine. And then the car transfer, how did she do
with that? 04, excellent. Again, at discharge she performs those with
just contact-guard. What if someone just had to supervise her? How would she be coded then? 04, right. Remember contact-guard or touching assistance,
04. Good. And then walk 10 feet we had 04 as well. And again there she’s using — that is that
scenario. She’s using just supervision, having just
supervision. How about walk 50 feet with the two turns? 04 as well. Again she could do that with her walker and
that contact-guard help. Then walk 150 feet, 09. She wasn’t doing that before. She’s still not doing that. Great. All right. Then we go to walking on uneven surfaces. I have a 04 and I heard some 04s from the
audience. That’s great. Again she needed contact-guard with that. How about steps? Could she do 1 step? She needed — I hear a 04. She needed some contact guard, do you agree? Yeah, one helper. Excuse me. How about 4 steps? Also a 04, great. Again contact-guard with one helper. How about 12 steps? 04 again. And you guys are right on with that again,
contact-guard. She lived on the second floor, I believe so
I’m glad we got her going 12 steps. And then how about picking up an object? 05, great. And our rationale for that? She needed setup of her adaptive equipment
but after that she was just fine to do that. And does she use a wheelchair or scooter? Right back to that Slido. So does she use a wheelchair or a scooter? Select A for no, and B for yes. We’ll give just a couple of moments for you
to get your answers in. Okay. Let’s see how we did. Excellent. We have yes, she used a manual wheelchair. And so could she wheel 50 feet with two turns? Yes. Do you agree with a 06 on that one? Great. So she was able to go about 60 feet with two
turns without any help. And how about wheel 150 feet? I’m sorry, we need to indicate what type of
wheelchair, sorry. Again back to Slido to indicate manual or
motorized. And we’ll give you just a moment to do that. You guys are still participating pretty robustly. You stuck with us for two long days. Great job. All right. Let’s see how we came out for an answer. Manual is correct. She used her manual wheelchair. And how about — we’ve got our wheeling 150
feet? I have 02. And she could go about 60 feet but the helper
needs to help her with that remaining 90 feet. Great. And again, indicate the type of wheelchair
that was used. And you’ll pick A for manual and B for motorized. We’ll give you just another moment there. All right. Let’s see how we did. Great, manual. Again, she did use a manual wheelchair. So that does it for GG. There was our last screenshot of GG. Let’s move on to look at O0425 Part A, Therapies. I’m just going to really quickly review this
because the slides are — the coding is already populated here. So on this she didn’t receive any speech. So we are skipping those. She did have 16 OT sessions and that totaled
908 minutes. And she had 72 individual — 70 concurrent,
106 group and 47 co-treatment sessions. And then for physical therapy, again she had
a total of 635 minutes of individual, a total of 825 all together, 635 individual, 40 concurrent,
100 group and 63 co-treatment for 15 days. And when we look at distinct calendar days,
this is the last item I’ll debrief with you, how many distinct days did she have? Remember I gave you a little hint on that
one? She did have 16 days when she received at
least 15 minutes of therapy. She had OT on that first Saturday but then
the rest of her therapy was Monday through Friday. And at this point I’m going to turn this presentation
over to John. And thank you guys for your time and attention
this afternoon. I appreciate it. (Applause)
»» Okay. So I have Jen’s phone number for all of you
to just call her with questions, just so you know. Unless you’re building is in Hawaii, in which
case I would be happy to fly out there, meet with you personally. It’s no problem. With all the information that Jen just went
through we’re now going to walk through how this patient would actually get classified
under PDPM given all the information that we just did. So the first step we have is in terms of the
calculation of the PDPM cognitive level, which is relevant in terms of the SLP component
under PDPM. This is where we could derive from the BIMS
or staff assessment. Now there is something on this slide that
is incorrect. And I will apologize for that, this is something
I should have caught. The second bullet here where it says “if neither
the BIMS nor staff assessment is completed then it cannot be assigned therefore a PDPM
case-mix group cannot be determined” this is no longer the case. We have heard you very loud and clear about
the problems associated with this. So we actually were able the make a change
in the Grouper for this where if neither the BIMS nor the staff assessment is completed
then the patient will simply be characterized as being cognitively intact. So what that ultimately means for you is that
if the person, let’s just say you were going through the SLP — sorry? Okay. So let’s say we were going through the SLP
component and you get to that first criteria where it was presence of an acute neurologic
condition SLP-related comorbidity or cognitive impairment, it would mean that for that third
one cognitive impairment you just wouldn’t be able to get credit for that if the BIMS
or staff assessment weren’t completed. But if the person had an acute neurologic
condition and a speech-related comorbidity and the BIMS and the staff assessment weren’t
done you could still get the NE2 from that one. So that is a pretty significant change from
what is listed in the second bullet, which will hopefully allay some concerns around
that. So the first step is in terms of determining
the BIMS score. Step one we determine the BIMS score as recorded
in MDS item C0500. And the BIMS summary score here was 14. Hopefully everyone has that. Determine the resident’s PDPM cognitive level
based on that BIMS score. So the person had a score of 14 and so that
would put them in the 13-15 bin. Therefore they are identified as being cognitive
intact. Step two if the BIMS score is blank or has
a dash value you can go to the staff assessment. Here that was not necessary because we did
have a BIMS score. That score was a 14 which again was cognitively
intact. The next step is in terms of the PT component. Where we start is with the clinical category. And that starts with the primary diagnosis
that is coded in I002B. Here Jen already went through this in terms
of the code which was 10 and then the actual ICD code which is the S72.001D code. That code maps to the major joint replacement
or spinal surgery group if you look at our ICD-10 mapping that’s available on the PDPM
website. We have that again maps to this clinical category. The default clinical category here again is
the major joint replacement or spinal injury group based on that ICD-10 code. Go to Step 1A which is determine if they received
a major joint replacement or spinal injury as coded in Section J, specifically J2100. And here the answer is yes, they did. So you would code 1. Step 1B and 1C speak to the resident would
be eligible for the surgical clinical category and received orthopedic surgery except MJR
or spinal surgery. 1C is that they’re eligible for the surgical
clinical category and received a significant non-orthopedic procedure. This is where we talk about the interplay
between Section J surgery check offs and the clinical category. Because there are some say orthopedic conditions
where they have a surgical procedure that may be done as well as a nonsurgical intervention. And here you might get the default nonsurgical
category but if we see that surgery is checked off in Section J, you get the surgery category
associated with that. Here however there was a major joint replacement
that was done, therefore neither 1B nor 1C applies here. So both of the responses here is no. If any of the procedures in J2300 through
J2420 was performed during the prior inpatient stay then the resident is categorized into
the MJR or spinal surgery group. We did have one. Which one was it? J2310, hip replacement. So based on the responses in J2100 and J2310
is Mrs. S eligible for the surgical clinical category and received major joint replacement
or spinal surgery? We will now move to… there we go. That’s probably my fault it didn’t come up. So lots of yeses. Two noes. Come on, noes you can do it. Lots of yeses. Lots of yeses. One more no. Or one no got away. (Laughter) One’s holding out. Come on! All right. Despite the underdog, I apologize for the
one person who said no. We’ll go back to the question and find the
answer. And the answer was, yes. Kind of wish it was no just because that one
person stood out and would laugh at everyone. But the answer is, yes. They did have the prior surgery, the major
joint replacement which is checked off in J2310 as we just saw in the prior slide. Next up in terms of determining the resident’s
primary diagnosis and clinical category is that as you saw earlier in my presentation
there was those collapsed clinical categories. So we had the default clinical categories
of which there were ten. Those collapsed down into four clinical categories
of which MJR or spinal surgery is one of them. Therefore they would fall into that as the
primary diagnosis clinical category for their PT component. So Step 1D, finalize the assignment. If they’re not eligible for a different clinical
category from default you select the one that they fell into. Here that was the major joint replacement
spinal surgery group. Therefore that is the patient’s primary diagnosis
clinical category. Step 2, we’re now into Step 2. It took us a long time to get here. So Step 2 we look at this. The mapping again, in terms of collapsing
the clinical categories together, MJR actually translates directly back over into the major
joint replacement spinal surgery group. So because they were in the major joint replacement
spinal surgery group as the default category their PT clinical category is also the same
MJR group. Next step, now that we’re beyond the clinical
category is to actually look at their functional score. Here again Jen did a great job of walking
through all the Section GG coding. Here all we’re going to do is say that based
on that coding here’s what their functional score would be. So this is the same slide you saw earlier
as far as what scores they received for their admission performance. And this is just going to show the translation
from that admission performance score over to what they’re actual scores would be under
Section GG. So here as you can see if they had a 05 or
06 that translates to a 4, 04 on the admission performance translates to a 3, so on and so
forth. So here again, you can see for the mobility
admission performance for GG0170 again you can see the scores that were provided for
each of those and then the mapping is to the right that shows what those scores translate
to in terms of their functional score. So now we can see how each of those translates
over and we can start to see what the patient’s total functional score would be. So for eating it was 05 that therefore that
translates to 04. Oral hygiene was an 05 translates to a 4,
so on and so forth for each one of these. This is just taking the performance score
and mapping it to it’s correlated functional score. The next step is to average the function scores
for the two bed mobility items, the three transfer items and the two walking items. For the bed mobility you would take the sum
of the function scores from sit to lying and lying to sitting on the bed, divide that sum
by 2. So each of those had a 1. You have 1 plus 1 equals 2. Divide that by 2, you get back to a bed mobility
functional score of the average of 1. Average transfer, taking the sum again of
these three which is sit to stand, chair/bed-to-chair and toilet transfer. So each of those was a 1, a 1 and a 2 respectively. That adds up to a 4. You divide that by 4 to get the average. The average is 1.3. We’re going to leave it as 1.3 for the moment. Same for walking. Again taking the average of the walking 50
feet with two turns as well as the walking 150 feet. Add those together. They were both 0. 0 divided by 2, you’re left with 0. You now calculate the sum of all of those
listed here, the eating, the oral hygiene, toileting hygiene and then the averages from
the three that we just did. Take all of those together get to 13.3. Again, keep that decimal through to this point. Then once you get to the end round to the
nearest whole number. Once you round to the whole number that’s
13. PT functional score is 13. Everyone get 13? Anyone have — questions about that? We’ll take that later. PT case-mix group. So now that we have their PT clinical category
as well as their functional score we can actually now figure out what group they fall into. They had a major joint replacement spinal
surgery clinical category. Theirfunctional score was a 13. And so based on steps 1 and 2 in terms of
where this person fell, they would then fall into the group TC. So the MJR, the functional score puts them
in the 10-23 bin. That translates to a case-mix group of TC. OT, really simple. If they’re in PT group, TC group, there are
OT group TC. Super simple, that’s pretty much it. Moving on to SLP. For SLP, a very different classification methodology
than we saw for PT and OT. So it starts off though in the same way, which
is to look at the clinical category. Again the clinical category was the major
joint replacement or spinal surgery group. In terms of the mapping, the collapsed mapping
from the clinical category to the component-specific clinical category, here we see that major
joint replacement maps to the non-neurologic category, which really just means they don’t
have an acute neurologic issue. It’s not acute neurologic, they go into the
non-neurologic group. The next step is to determine if there are
any SLP-related comorbidities. Mrs. S does not have any of these comorbidities
that would be coded in Section I or O on the 5-day assessment and so we leave this one
behind. The next was determine the presence of a cognitive
impairment. We’ve done that with the BIMS score earlier,
the score of 14 which identified Mrs. S as being cognitively intact. And therefore that means there’s no presence
of a cognitive impairment. Step 5, determine how many of the following
conditions are present. There were the three criteria that I mentioned
earlier, acute neurological condition, SLP-related comorbidity or cognitive impairment. Mrs. S did not have any of these on the 5-day
therefore the number of conditions present is equal to 0. So then we move on to the next set of criteria
which were swallowing disorder and mechanically altered diet. The first one in terms of a swallowing disorder
we used K0100. We see that Mrs. S did not have any signs
or symptoms of a possible swallowing disorder. Step 7 we look to see whether or not Mrs.
S was on a mechanically altered diet. And as we see here it’s checked off in K0510C
that Mrs. S was on a mechanically altered diet. So now we go to Step 8 which is to look at
those two criteria in concert with each other to determine whether or not neither of them
were present, either of them was present, or if they were both present. Here we see that even though Mrs. S does not
have a swallowing disorder she was on a mechanically altered diet. Therefore she would qualify for either. We go on to Step 9 which is to take those
two sets of criteria together. For the first one it was that there was to
presence of an acute neurologic condition, comorbidity, or cognitive impairment. Then there was a mechanically altered diet
so she went into either. So ultimately Mrs. S goes into group SB. So we’ve now gotten through the therapy components
for Mrs. S’ classification. Next one we’re going to move on to is the
non-therapy ancillary component. Here as I mentioned earlier, today there’s
the NTA comorbidity score. That’s how we identify a person’s NTA component
rate. So here we look to see if the patient qualified
for any of the various NTA comorbidities that we have listed. Here we found that there was actually one
condition for which Mrs. S had that qualified for the NTA component and that was the presence
of a Stage 4 pressure ulcer which was coded in M0300D1. That ulcer counts for 1 point. Therefore Mrs. S’ comorbidity score is a score
of 1. So the COPD was listed as something that was
in her history, but not listed as being active. Therefore it was — (audience comment) Right. But unless the active diagnoses is coded on
the MDS, which in this Case Study it was not, then the patient wouldn’t classify for that,
therefore it wouldn’t count towards their NTA comorbidity score. All of it depends on if that item is checked
off on the MDS as being an active diagnosis. I can’t remember which item it is, I think
it’s I6200 or something like that. (audience comment) Whether it was a coding
error I will leave aside and probably turn to the table over there. But in so much as it is not coded on the MDS
then the Grouper wouldn’t give credit for it. Therefore it’s a score of 1. So determine the resident’s NTA group based
on their classification. Here they had a score of 1, and therefore they
fit into the group of 1-2. If COPD were coded, just to throw that out
there, I think COPD counts for 2 points. That would give them a total score of 3 which
would put them into the ND group. So if you happen to have coded that, that’s
the group they would have been in with the COPD. But here we’re going to say they’re in group
NE. Last step in terms of overall components is
the calculation of the PDPM nursing function score or the nursing component. So first we begin with the nursing function
score which is distinct from the therapy score. So just be aware that the things that we use
for calculating the nursing function score are different than those than we use for the
therapy score. So the mapping is basically the same in terms
of the score within the admission or interim performance versus what it codes out to in
terms of the function score. So here again we’re going to see just the
same GG coding that we saw earlier that Jen already went over. It just shows what is that score — and the
ones that are relevant are highlighted in yellow or green, I’m colorblind so I don’t
know, but some color that’s there — and it maps over to a function score. Same for the mobility items. Again those are highlighted in that color
and then maps over. So here we actually have listed out all of
the various ones that we use for the nursing function score and what they translate to
in terms of the admission score versus the function score that we use for the calculation
of their group. Next step is to average the two bed mobility
items and the three transfer items same as we did earlier here. Here bed mobility, again it was 1 and a 1,
sums to 2. 2 divided by 2 you get an average score of
1. Same for transfer, same exact calculation
we did earlier. 1, plus 1 plus 2 to 4. 4 divided by 3, you get to 1.3. Maintain the decimal at this point. You now calculate the sum of adding those
averages that we just calculated back to the eating and toileting hygiene which were 4
and 3. You get a total score of 9.3 then rounded
it off to the nearest whole number which is 9. And your PDPM nursing function score is a
9. Next is to determine the resident’s nursing
case-mix group, which as I mentioned earlier is basically the same as how you would do
it currently. It’s the exact same steps that we get to in
order to identify their nursing group as we do under RUG-IV. So first determine which of these six categories
they’re going to fall into, the extensive services through their reduced physical function. And the assigned classification is the first
group for which the resident is qualified. So the first one we’ll look at is extensive
services. So determine whether or not any of these extensive
services were coded while a resident. And for Mrs. S, none of those services were
received while a resident. So therefore not extensive services. Next step is special care high. We see whether or not any of those treatments
and services that were identify under special care high were received. None of those were received while she was
a resident and therefore not special care high. We move to special care low. Determine whether or not any of these conditions
or services that were listed were checked off. If not, skip to clinically complex. Mrs. S does have one of the listed conditions
that was from the selected treatments and that was the Stage 4, M0300D1 pressure ulcer,
two or more skin treatments. And so therefore she would qualify for special
care low. Step 2, if at least one of the special care
conditions is coded and the resident as a total PDPM function score of 14 or less, which
she does having a function score of 9, she qualifies for special care low. So here based on the coding on the MDS we
see that Mrs. S qualifies for special care low. We do not need to consider the clinically
complex or reduced physical function. We have her nursing category at this point. The next step is that this category happens
to come with a end-split for depression. So we evaluate the patient for the presence
of depression. And we look to see whether or not the total
severity score that’s listed in item D0300 is equal to 10 or greater, but not 99. We look here and the total severity score
for Mrs. S was a 2 as listed in D0300, therefore Mrs. S does not qualify for the depression
end-split for this category. Step 4, pulling all these various factors
together, we have a special care low classification function score of 9 and the absence of depression. Therefore putting all of those things together
Mrs. S would qualify for LBC1. Now the HIPPS code, now that we have all of
this information, we have all the various case-mix components done. The only thing left that we’ll talk about
is the AI indicator. But in order to build the HIPPS code, if you
remember before it basically gets built on each of those individual components. So for the first one, Mrs. S was classified
into group TC. Basically just carve off the T. The first
character in the HIPPS code is a C. Second character is the SLP component. Based on all the various criteria, Mrs. S
qualified for group SB. Again, carve off the first letter of the character
for the HIPPS code is a B. Nursing component, again special care low and function score
of 9 with no symptoms of depression, qualified for group LBC1. This is where you actually do have to look
at the mapping to see how it translates over. And here LBC1 translates to a K for the character
within the HIPPS code. Fourth component, which is the NTA component
has again a NTA score of 1, or 3, depending on how you coded it. We’ll go with 1 for now. So if it was a 1, the group was NE. Again carve off the N. You get the E. The
E is the character you use in the HIPPS code. If it was C, you would use a C. Last part
of it is the assessment indicator. There are only two as compared to all the
ones we have under RUG-IV. We only have the two. It’s either a 5-day or it’s an Interim Payment
Assessment. Here we’re talking about a 5-day PPS Assessment. Therefore the fifth HIPPS character which
is the assessment indicator would be a 1. Put all of those five things together you
get to this HIPPS code which could be CBKE1 or C1 depending on the COPD. But here we have CBKE1 as the HIPPS code for
this person. So we’ve done the Case Study, and if you have
any questions about that please submit them to Slido we’ll go over them and thank you
all for participating in this. »»So we have like 12 minutes left apparently. I don’t have anything else to do so why not
take some live Q&A. So if you guys have some questions you want
to throw them out there. We’re just going to ad hoc it a little bit. We have some Slido questions. I’ll take a couple of these while you guys
think of questions. So the first one was, how come there are therapy
items on the 5-day NP item set if therapy day and minutes will not go into calculating
the PDPM code? And how come if they are needed on the 5-day
set they’re not needed for the IPA item set? That second question is actually a really,
really good question. I’ll have to think about more why we didn’t
put it on the IPA. The reason that we wanted to maintain the
therapy items on the 5-day assessment was because we wanted to be able to see in that
first week what was happening in terms of their therapy, particularly for data monitoring
purposes. We wanted to see what is happening in that
first week currently under RUG-IV and then what is happening on the 5-day in that first
week under PDPM. So a lot of that was just for us to be able
to monitor what was going on during that first week. As far as why we didn’t include it on the
IPA item set, that’s a really good question. I probably would have personally preferred
to have it on there just to see what’s happening at that point. That’s something we can potentially look at. Oh, questions are changing all over the place. Is just therapy documentation enough to code
Section GG? That I cannot answer. I’ll have the turn to one of my colleagues
to answer that one. Jen, I don’t know if you want to throw out
an answer on that? »» No, I do not. »» Fair enough. Does the primary diagnosis of I0200B have
to match the primary diagnosis that’s billed on the UB04. This is a great question. And the answer is no. The technical answer is, no, they don’t need
to match. However, my question back to that would be,
why don’t they? And so, do they have to match in order for
you to actually get paid? No. You will get paid based on the HIPPS code
that is reported on the claim not based on the primary diagnosis that is listed on the
claim. However, that would be something that I would
look at and say, I wonder why these two things are not matching. And the last one that’s here is, working through
the Case Study is interesting. All information is therapy-based when this
is to be collaborative between therapy and nursing as per the RAI Manual guidance. »» You want to take some from the crowd? »» Not sure that that one’s true. »» Where is my person where is my person
that was running after me? »» One question. »» Well it’s just a quick question. On your slides you had the AIDS add-on for
the nursing component still at 18% but in the Final Rule it had 12.8%. Is that a typo? »» It did? »» Yeah. »» I’d have to look at that. That’s odd. »» I know because it says 128 goes to 12.8. So I went back into the Final Rule and double
checked myself. »» I’ll take a look at that. If it is that’s definitely a typo. The current adjustment is 128% on the entire
per diem, and under PDPM it’s an 18% add-on for nursing and then there’s the NTA component
of it. So yeah I’ll take a look at that. That’s weird. Thank you. »» I just have a question about the transition
of the IPA. What’s the start date in A2400 for Medicare? Would it be the date from September? »» It would be the date that they started
the Medicare stay, correct. Oh, sorry. I apologize. The question was, on the transitional IPA’s,
what date should be coded into A2400 for the Medicare start date. And the answer was that it should be when
they started on the Medicare stay, sorry I apologize. »» Who’s next? »» No other questions, really? We do have questions. »» (Audience question)
»» I’m going to have this gal ask her question. We’ll get over to you. »» Sorry. »» I have a question in regard to the calculation
you just took us through. When you brought up the crosswalk for the
ICD-10 code when it got to that clinical category on your slide it said the major joint replacement
but on the actual crosswalk it says nonsurgical for that diagnosis. »» It does? »» So I’m totally thrown off on how you
got to major joint using the crosswalk. And I know the surgery that says may be eligible
based on the surgery, but I just pulled it up off the website. »» Okay. That might be a typo on the slide. But because of the check off in the MJR in
Section J you’re going to end up in the MJR regardless. »» You’ll get there regardless just because
I said they had — because when I get to the surgeries then I wouldn’t mark that they actually
had a fracture repair. I would still say hip replacement even though
it was related to the fall not a planned hip replacement? »» No. As long as they had a hip replacement that’s
documented then you can code the hip replacement. Then that would put them into the MJR group. »» Okay. »» Hello. This is a follow-up to the primary diagnosis
question that’s on the screen. Correct ICD-10 coding, for example the sepsis
case that we had earlier in the slides, the patient had a procedure complication infection
that led to the sepsis which is a T-code in ICD-10 and then a secondary code would have
been the A-code that you listed as the code that would go into the I0020B. Are you indicating that that particular box
is not meant to be always the same as what the principal diagnosis would be on the UB
because we would focus on the infection itself? Like the staph infection itself, rather than
the fact that the staph infection was from a complication? So the complication code would not be the
reason for the admission but it would be the principal diagnosis on our UB. »» Okay. I mean, part of this could be my misapprehension
of what the principal diagnosis on the UB is intended to reflect. In so much as — so I002B is intended to reflect
the primary reason that they’re admitted for the SNF stay. So personally I would think of that as being
the principal diagnosis. But to the extent that that box on the UB
is being used for a different purpose, then again I could see why they wouldn’t match. But the main thing I would want to indicate
to folks is that regardless of any mismatch they’re still going to receive payment based
on the HIPPS code that is presented on the claim regardless of discordance between the
two diagnoses. »» Because some codes do require that there
be a code listed before it. Whenever we’re coding we have sequencing guidelines. So if our sequencing guidelines according
to the ICD-10 CM guidelines and conventions say that we would code the complication first,
and we would code the staph infection second, your example has the staph infection listed
in the I002B space. But the UB, if it’s coded and sequenced correctly,
would have the complication code listed first and the infection code listed second. »» Got it. Okay. That makes sense. »» So is that why — is that an example
of when the primary wouldn’t be the same as the principal? »» Following your example, which I am in
no means an ICD-10 coding expert as I’m sure you all know by now with all the discussions
that we’ve had, following all of what you just said, then yes, that could be potentially
an example of why there would be discordance. But again, the main thing that I just want
to make sure is clear is that regardless of that discordance the payment will be driven
by the code that is present on the MDS which will then feed into the clinical category,
which will then feed into the HIPPS code. »» … Where they might choose the one that’s
going to have — if one over the other would have a better reimbursement attached to it,
then I can see where they might could. »» I’ll leave that last part aside. I won’t comment on the reimbursement enhancement
part of it. »» I’m just saying that I go could pick
or choose which one of those two when you have two required to sum up the principal. »» Right. »» Can we get a mic over to this gentlemen
by the way. »» We have one I have one right here. »» Can you just briefly repeat what you
said. You had a slide that had a second bullet that
has since been updated about the BIMS and how that affected? »» Yes, absolutely. So the question was can I repeat what clarification
I made with regard to one of the slides where there was a piece of information that was
inaccurate. The piece of information that was inaccurate
was in relation to the BIMS and the staff assessment. It was the second bullet on that slide. It stated that if neither the BIMS nor the
staff assessment were completed that ultimately the patient’s PDPM classification could not
be determined. That is no longer the case. So what is the case is that if neither the
BIMS nor the staff assessment are completed then the patient is basically deemed as being
cognitively intact for the purposes of classification. So even if they had a cognitive impairment,
the Grouper wouldn’t identify that. They wouldn’t get credit for that in terms
of their classification. »» A patient is admitted to the hospital
because of an acute fracture and while in the hospital the patient develops an acute
CVA. Then when the patient is transferred to the
nursing home what is the primary diagnosis? What is the category? Because both are equally important, you know,
the rehabilitation for the acute fracture, also the rehabilitation for the CVA. »» So I’m going to echo something that Jen
said earlier, which is that not being at the bedside I am not going to say what is the
primary diagnosis. The primary coded in I0020B is intended to
reflect is what the primary or main reason that a person is admitted to your SNF. That is a question that based on all of the
information plus a lot more information that I’m sure is in that question, that information
would have to drive that answer of what is the primary diagnosis. »» And the other question is what makes
a condition an acute condition? Because many patients come to nursing homes
with ten, twenty, different medical problems. And most of those problems might be active. The patient is diabetic and basically we’re
trying to bring the blood sugar down. The patient has a hip fracture that needs
rehabilitation. The patient also had an acute CVA while in
the hospital. And the patient has COPD that is being treated
with bronchodilator and corticosteroids. Many times it’s like, six, seven, eight things
going on at the same time. How do we know what we should code it as an
active diagnoses? »» Well you would be coding all of them
as active diagnoses. All of those things should be captured at
some point on the MDS and certainly captured in your documentation. But I think underlying that question. And to repeat the question, it’s that you
could have a lot of different things going on with a patient and so what would you — correct
me if I’m wrong, the question is fundamentally, with all these things that could be going
on with a particular patient how do you identify the primary diagnosis or the one thing you’re
going to code into I0020B is a fair rephrase or restatement. The answer again is going to lie at the discretion
and the considerations of the provider. You’re going to have to look at that patient
and decide what is the main reason the person is here? What is the best thing can I put into this? To sort of cite back to the old SAT guidance
that we would get, if you had multiple answers that were the right one, pick the best one. Here if you have multiple diagnoses that you
can select from but you feel like one is — there’s a lot of things going on but it’s really not
the CVA that’s driving the care plan, it’s really not the diabetes that’s driving the
care plan, it’s really the fracture or it’s really the what have you, that’s the thing
that should be coded as the primary diagnosis. That’s something that I don’t think we can
answer for any particular patient. I think that’s something we have to rely on
you guys to answer based on your interactions with the patient and your understanding of
their condition. »» Okay, John, we have time for one more
question. »» Hello. A little bit long, sorry. So scenario would be, resident has surgery
in a prior hospital stay before the Part A stay. So then after discharge from the hospital
the patient would then get admitted to say the SNF next door. From that SNF patient stays in for a few days,
starts to develop pneumonia, gets sent back out to the hospital being treated for the
pneumonia. After being discharged from the hospital comes
to my SNF and so now the question is going to be, are we able to code that prior surgery? It occurred in the last 30 days. It’s documented. It occurred during the preceding hospital
stay prior to the Part A. But it wasn’t the — it was for the SNF that the patient went
to next door. Would I be able to code it in my SNF if it’s
still an active diagnoses? »» I have to try to restate this. So the question was — no, you’re good. I think I got this. So the question was, if a person had a condition
for which they — for a surgery that they received during the prior hospital stay, admitted
to a SNF. They then were discharged from the SNF, gone
to a different SNF, and went back to the hospital, came back to a new SNF, can the new SNF code
the surgery that occurred during the preceding hospital stay or during the initial hospital
day. Is that it? Okay, good. The answer is, yes. So if that surgery is affecting their care
planning and it’s something that occurred during — especially their qualifying hospital
stay, then yes. It is something that can be coded by the subsequent
SNF.

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