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Case Mix Group Estimator Report

Learn how the Case Mix Group Estimator helps estimate therapy CMGs for Medicare A & Managed Care A patients using diagnosis codes & GG scores.

Melanie Conlon avatar
Written by Melanie Conlon
Updated over 5 months ago

Dashboard Overview

  • Dashboard Name: Case Mix Group Estimator

  • Dashboard Description: This report estimates CMGs based on the diagnosis codes for Part A and Managed A patients, GG scores from PT & OT evaluations, and SLP evaluations.

  • Location: Bottom of the MDS tab, under the “Case Mix Groups & HIPPS” dashboard

  • Available to: Enterprise Portal & DOR users (note: DOR users will not have the "Facility" filter)

  • Rows per Episode of Care: One row per episode of care where the payer type is Medicare A or Managed Care A, using data from the earliest evaluations within that episode of care.

Pre-requisites for PT/OT CMG

For the PT/OT CMG estimate to be valid, the following conditions must be met:

  1. Primary Diagnosis Code: A valid, billable primary medical diagnosis code (ICD-10).

  2. GG Items for PT Eval: The following Mobility Admission GG items from the PT eval are required:

    • GG0170B: Sit to Lying

    • GG0170C: Lying to Sitting on Side of Bed

    • GG0170D: Sit to Stand

    • GG0170E: Chair/Bed-to-Chair Transfer

    • GG0170F: Toilet Transfer

  3. GG Items for OT Eval: The following Self-Care Admission GG items from the OT eval are required:

    • GG0130A: Eating

    • GG0130B: Oral Hygiene

    • GG0130C: Toileting Hygiene

How the PT/OT CMG Estimate is Calculated

  1. Clinical Category:

    • The primary medical ICD-10 code is mapped to a default clinical category.

    • This default clinical category is then mapped to a PDPM PT/OT Clinical Category.

  2. GG Function Score:

    • The GG items from both PT and OT evaluations are scored based on MDS rules.

    • If any GG item is missing, the score defaults to 0, affecting the final estimate.

    • The final function score is calculated by averaging and summing the scores and rounding to the nearest integer.

Important Note: Although the report does not restrict the evaluation dates, for the most accurate CMG estimates, the PT and OT evaluations should occur within 3 days of admission.

The report displays the dates for both the admission and the evaluations so users can ensure the estimates are based on timely data.

Pre-requisites for SLP CMG

For the SLP CMG estimate to be valid, the following conditions must be met:

  1. Primary Diagnosis Code: A valid, billable primary medical diagnosis code (ICD-10).

  2. SLP Evaluation:

    • Cognitive Impairment: If the patient is cognitively impaired, this must be checked in the "Clinical Impressions" section of the SLP eval.

    • Swallowing Disorder: At least one of the following must be selected in the "Clinical Impressions" section:

      • Oral dysphagia

      • Pharyngeal dysphagia

    • Mechanically Altered Diet: To confirm the presence of a mechanically altered diet, ensure:

      • "Dysphagia" is selected on the first page of the SLP eval.

      • An option other than "Regular" or "Thin Liquid" is selected from the "Swallowing Assessment" dropdown in the "Objective Assessment" section.

How the SLP CMG Estimate is Calculated

The SLP CMG estimate is based on the following factors:

  1. Acute Neurologic Condition: If the primary diagnosis code maps to an "Acute Neurologic" category, the patient is considered to have this condition.

  2. SLP-Related Comorbidity: Any ICD-10 codes identified as SLP-related comorbidities per CMS’s PDPM rules.

  3. Cognitive Impairment, Mechanically Altered Diet, and Swallowing Disorder: Any ICD-10 codes identified as SLP-related to Presence of Presence of Cognitive Impairment, Presence of Mechanically Altered Diet, Presence of Swallowing Disorder per CMS’s PDPM rules.

If you have any further questions or need additional assistance, please feel free to reach out to your Customer Success Representative. We're here to help! 😊

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