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Update Needed for MDS PDPM LTC Algorithm

Last updated on

The Texas Health and Human Services Commission (HHSC) and the Texas Medicaid & Healthcare Partnership (TMHP) have identified an enhanced solution in the nursing component of the Patient Driven Payment Model (PDPM) for Long-Term Care (LTC) Calculation. HHSC and TMHP are working to update the element in the calculation so that users will receive the correct PDPM LTC value on the following assessments:

  • Minimum Data Set (MDS)
  • Medical Necessity and Level of Care (MN/LOC)
  • STAR Kids Screening and Assessment Instrument (SK-SAI)

Background

The PDPM LTC value contains three components:

  • Nursing
  • Non-therapy ancillary
  • Brief Interview for Mental Status (BIMS) for cognitive impairment

The nursing component is determined by comparing the assessment to the criteria for a tier, beginning with Extensive Services. If an assessment meets the criteria for a tier, the nursing evaluation stops, and a value is assigned. The tiers for nursing component, from highest to lowest, are:

  • Extensive Services (E).
  • Special Care High (H).
  • Special Care Low (L).
  • Clinically Complex (C).
  • Behavior/Cognitive (B).
  • Reduced Physical Function (P).

Update Details

The update will add an evaluation of the nursing function score at the beginning of the Behavior/Cognitive tier. Any assessment not already assigned a nursing component score that has a nursing function score of “0” through “5” will receive a nursing component score of “B.” This designation does not mean that the individual has a behavioral or cognitive condition—it is only used to ensure that residents who have higher nursing needs receive a higher nursing value.

TMHP and HHSC will provide additional instructions for affected nursing facilities (NFs) and managed care organizations (MCOs) when the update is implemented. Providers do not need to take any action or call the TMHP LTC Help Desk at this time.