Virginia Case Mix

The new CMS clarifications on ADL scoring and quadriplegia will, all things being equal, lower facility averages, and therefore the state average.  This is happening when we can expect the state average to lower due to recent Part B therapy restrictions as well.  When we see our state CMI fall significantly,  the financial folks are going to go ballistic, because the Medicaid check will be noticeably lower.  

The winners will be:

1.  Those who dig for the third occurrence of extensive assistance by interview, education, and bedside assessment.

2. Those who capture respiratory therapy

3.  Those who can capture 3x week therapy with 2 qualifying restorative 

4.  Those who capture 5x week therapy

5.  Those who get ADL score of 7 and capture IV fluid/meds

6.  Those who realize that a scheduled PPS assessment will be a target record if it is the last one in the quarter.

This means being willing to do extra quarterlies as these events (1-5)   occur.  We are going to have to work harder and focus more on State case mix now.  It won't "just happen" without careful, intense management.    While a lot of us make payroll with the Medicare check, we make budget with the Medicaid check.    We are lucky that the VHCA has been so successful in fending off some of the cuts that other states have taken, but the ADL change at the same time as the Part B therapy change  will  lower our state CMI now.  

Rule on quadriplegia that CMS says will be in May RAI Manual:  Only code 'primary' quadriplegia.  If the quadriplegia is a result of any other process, then code the primary process/disease and not quadriplegia.  For example:  

Quadriplegia due to spinal cord injury:  ok.  

Spastic quadriplegia due to TBI:  not ok per Virginia RAI Manager

Quadriplegia due to CP:  not ok

This raises lots of questions that we will have to ask the State RAI Manager or wait and read the May RAI manual.