Care complex measures score

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The Nursing Complex Measures Score (PKMS) is an instrument developed by the German Nursing Council in order to record “high-cost care” in the hospital within professional health and nursing care and to be able to bill it as part of the remuneration. The PKMS is encrypted using the operation and procedure key (OPS) as part of the DRG calculation . If the expenditure points recorded in the PKMS are reached, the OPS 9-20ff can be coded. This triggers the billing of an additional fee (ZE 130), which is billed in addition to the flat rate per case.

backgrounds

In April 2009, at the second nursing summit , to which the Federal Ministry of Health invited representatives from nursing associations and other groups relevant in the health sector, the “nursing funding program” was adopted. The aim of the funding program is to develop around 17,000 nursing staff positions within three years. The reason for this is the increasing quality deficiencies in nursing care as a result of massive job cuts in recent years. The central objectives of the Hospital Financing Reform Act of 2009 were to improve the economic situation of the hospitals , create new positions in the nursing area and provide targeted G-DRG remuneration for those areas in hospitals that have an increased nursing effort.

In the Hospital Remuneration Act Section 4 (10), it says: “[…] The contracting parties at federal level according to Section 9 instruct their DRG institute to develop criteria according to which, from 2012, these additional funds within the framework of the DRG remuneration system are targeted to the areas are assigned, which have an increased nursing effort. "

The OPS 9-20 and the PKMS are a development of the German Care Council on behalf of InEK GmbH and the self-administration partners (health insurance companies and hospital society ) for the implementation of the Hospital Financing Act (Section 4, Paragraph 10 of the KHEntgG).

In order to implement the legal text of the Hospital Remuneration Act , a group of experts, consisting of self-administration partners and experts in nursing, worked out appropriate recommendations for action and adopted them at the second nursing summit. These stipulated that indicators for depicting “high-cost care” were either included in the OPS catalog or as ICD-10 indicators in the G-DRG system. In addition, a “tightening” of the PPR ( nursing staff regulation ) for cost calculation was agreed.

Development of the OPS 9-20, PKMS and PPR-A4

The working group of the now valid PKMS consisted of 12 people from nursing science and nursing management , a medical IT specialist and a representative from GKind (Society for Children's Hospitals and Children's Wards in Germany). According to them, the following were important factors in the development of OPS 9-20 and PKMS:

  • Clear distinction between the patients who were previously classified in PPR-A3 and the "highly complex" patients
  • Consideration of cost-accounting dimensions. The OPS 9-20 in connection with the PKMS in the G-DRG system is supposed to map the patients who generate around 300 to 500 € more care expenditure on the part of the cost calculation.
  • Clear criteria to avoid inflationary coding.

Development of the OPS 9-20

The exact development ideas of the working group on OPS 9-20 are unclear. It can be assumed, however, that these were based on the specifications and structure of other complex codes. It should be noted that the OPS 9-20 of the structure and construction to many parallels to the intensive care complex treatment of ICPM has.

Development of the PKMS

According to the developers, the development of the indicators that are formulated in the PKMS was on the one hand inductive. For this purpose, nurses in various specialist units and clinics were asked what, in their opinion, are the reasons and nursing measures that are considered to be “highly costly” and explain a high expenditure of time. “Highly costly” was defined from an accounting perspective. On the other hand, time measurement studies and real-time surveys of nursing measures from two clinics were used as a basis. Exact evidence of the calculation bases on which the instrument is based are not presented in the book publication.

Development of the PPR-A4

In order to ensure that the OPS 9-20 can also become relevant to revenue in the 2012 data year, it must be ensured from an accounting perspective that the calculation data of the patients with OPS 9-20, which the InEK receives annually from the calculation houses, also show higher case costs. Otherwise a G-DRG grouping of patients would not generate a cost split and patients with OPS 9-20 would not fall into a higher expense group.

The PPR has nine effort groups and a patient can receive a maximum care minute value of 215 minutes in the cost calculation. Against this background, a new calculation basis had to be created for the "highly complex" patient. The PPR-A4 was developed for this. The PKMS daily effort point value triggers the PPR-A4. At the moment, the patient receives 100 minutes more care time for the cost calculation with six expenditure points . This ensures that patients with OPS 9-20 are also visible in the DRG system in terms of costs. During the development of the PPR-A4, the services for “high-cost maintenance” of the PPR-A4 effort group were assigned to the indicators of the PKMS and calculated on the basis of measured values.

Further development

Version 1.0 of the PKMS is currently specified in the OPS catalog as the legal basis for verifying OPS 9-20. Every year, requests for changes can be submitted to the German Institute for Medical Documentation and Information (DIMDI) by specialist committees and clinics . The German Care Council has submitted a proposal to improve the first version of the PKMS. As with the other OPS codes, further development is carried out by professional associations. The German Care Council reported on the extensive user test of the revised PKMS Version 2.0 on its website.

Introduction of the OPS 9-20 and PKMS

Since 2010, hospitals in Germany have been required to encode the OPS key 9-20 when services in connection with "high-cost care" have been provided to a patient. From 2012 this OPS code will be relevant to revenue. The InEK writes about this in the final report for the data year 2010:

“For the data year 2010, data from the OPS code introduced on 01.01.2010 for highly complex patient care (care complex measures score - PKMS) is available for the first time. The documented services are intended to serve as a basis for implementing the legal mandate for the targeted allocation of funds to areas with increased nursing effort (cf. § 4 Paragraph 10 KHEntgG) for 2012. "

- Final report of the InEK

This means that the care services provided for “highly complex patients” will in future have an impact on the calculation according to diagnosis-related case groups (DRG) .

The introduction of the OPS 9-20 is discussed differently in the committees. Since it is about the future distribution of the funding from the funding program, opinions on the OPS 9-20 also differ in the clinics. Since an unequal distribution of patients with “high-cost care” can be assumed, the clinics will benefit to different degrees from the funding of the funding program.

In principle, the introduction of OPS 9-20 is intended to ensure adequate long-term care for patients with high nursing resources. This has to do , among other things, with the calculation instrument for nursing staff regulation (PPR), which is used to calculate the cost of nursing services in the DRG calculation in Germany. The main point of criticism of the instrument is that only a maximum minute value of approx. 215 minutes per day can be taken into account in terms of costs, but there are definitely patients in the hospital who, for B. need four times the nursing time. This leads to compression effects in the calculation system. This means that patients who are “expensive” in terms of nursing are not taken into account in the remuneration, and, conversely, too much is taken into account for patients who require little nursing effort. A central goal of the development of the OPS 9-20 with PKMS was to ensure adequate funding for "high-cost patients" in the future. This happened against the background of an assumed unequal distribution of patient cases in the clinics, which are considered to be “highly costly” in terms of the use of nursing resources.

Hospitals in Germany are under great economic pressure and nursing staff has been viewed from this perspective as a "cost factor". With the introduction of the OPS 9-20, this perspective could change. In the future, care services can have an impact on the revenue situation, as can medical services. In 2011 it can be observed that clinics are increasingly concerned with the implementation of expert standards and the use of nursing concepts such as activating therapeutic care, which are required in the PKMS. The first positive effects were reported in a lecture at the symposium of the German Care Council on May 27, 2011 in Berlin.

OPS 9-20, version 2011

The OPS 9-20 "highly complex care" is one of the so-called complex treatments. In 2010 the OPS 9-20 was added to the catalog of operations and procedure keys.

definition

A procedure key for case grouping within the G-DRG calculation (German-DRG = adaptation in Germany). The following is the wording of the OPS 9-200 from the OPS catalog 2011 (DIMDI):

9-200 elaborate adult care

Excl .: : High Complex Care of Children and Adolescents (PKMS J) (9-201) : High Elaborate care of small children (PKMS K) (9-202)

Note: A code from this area must be entered for patients over the age of 19.

Minimum features:

  • A code from this area must be entered if the conditions of the care complex measures score for adults [PKMS-E] are met in one or more service areas.
  • The resulting expense points are added up daily. The total number of effort points is calculated from the sum of the points determined daily from the PKMS-E over the length of the patient's stay.
  • Expenses that arise on the day of admission and / or discharge are also taken into account.
  • The nursing services are provided by qualified health and nursing staff or under their responsibility.
  • The parameters of the PKMS-E to be used and further usage instructions can be found in the appendix to the OPS.
-9-200.0 43 to 71 effort points
-9-200.1 72 to 100 effort points
-9-200.2 101 to 128 effort points
-9-200.3 129 to 157 effort points
-9-200.4 158 and more effort points

There is a separate OPS for each of the age groups children and young people.

PKMS, version 2011

For the coding of the OPS 9-20, the PKMS is recorded as evidence of the "high-cost maintenance" performed. This is a list of reasons and care measures that can explain the high consumption of care resources in the case of “highly costly patients”. Effort points are stored in the indicators, which are used accordingly to trigger both the OPS 9-20 and the PPR-A4. The PKMS thus takes on the same function of proof of services provided in the hospital as it does for other complex codes, e.g. B. 8-980 intensive medical complex treatment (basic procedure) , is also the case.

definition

The following is the wording from the DIMDI OPS catalog 2011:

The PKMS is an instrument developed by the expert group of the DPR (Deutscher Pflegerat) to map the care of high-cost patients in the hospital on "normal wards". This highly complex care goes well beyond the normal full takeover of care activities in at least one of the 8 service areas of personal care, nutrition, elimination, moving / storage / mobilization / safety, circulation, wound management and breathing and / or in the area of ​​communication / employment there is a significantly higher level Need than the average patient with special services (see PPR (nursing staff regulation) level A3 of the corresponding age group). Three different PKMS were developed because the high-cost care is operationalized differently in the different age groups:
  • for adults (PKMS-E): from the beginning of the 19th year
  • for children and adolescents (PKMS-J): from the beginning of the 7th year to the end of the 18th year
  • for small children (PKMS-K): from the beginning of the 2nd year of life to the end of the 6th year of life
The structure and logic of the three scores are the same and the following should always be observed when using them. The point values ​​express the minimum nursing effort required for a highly costly patient. The reasons for high-cost care are one-off and must be recorded in the event of changes in the patient's condition, and the care interventions must be evidenced by daily (calendar day) performance documentation.
In order for a performance feature to apply, one of the reasons for high-cost care must be present in the relevant service area and a correspondingly listed care intervention profile must be made ...

Scope of the PKMS 2011

No exclusions are currently formulated in OPS 9-20. Therefore, at the moment only the restrictions formulated in the PKMS have to be observed. It is important that the PKMS may only be encoded on "normal station". All wards in a clinic that are not stroke units and intensive care units are rated as “normal wards” . See the FAQs.

The PKMS has been allowed to be encoded on the IMC (Intermediate Care) since 2012 .

Structure and functionality of the PKMS 2011

Each PKMS (E, J, K) formulates in the service areas

  • personal hygiene
  • nutrition
  • excretion
  • Move / camp / mobilize / security
  • Communicate / engage
  • Cycle
  • Wound management
  • breathing

Reasons and maintenance measures that are typical for "high-cost maintenance".

PKMS reasons and maintenance measures

The PKMS-E (adults) has defined 35 different reasons for “high-cost care”. The reasons are patient conditions, behavior or nursing problems, such as B. G10 from the performance area moving / positioning / mobilizing / safety, high pressure ulcer risk or G1 in the performance area personal care, defense behavior / resistance in personal care. The reason G1 defense behavior / resistance could e.g. B. apply to a patient with dementia , if this shows the corresponding indicators formulated in the PKMS. A total of 25 packages of measures were formulated in the PKMS-E. The reasons and the maintenance measures are linked. This means that for certain reasons only certain maintenance measures in the sense of the PKMS lead to expenditure points. The “measure packages” A1 or A3 were assigned to reason G1 in the example. Depending on the patient's situation, the caregiver decides which care measures are to be provided. The following graphics show the permissible maintenance measures for G1.

Extract: PKMS Reasons for the Body Care Service Area (2011)
G1 Defense behavior / resistance in personal hygiene

Characteristic: Resists (mobilization) measures in body care: screams, strikes, insults the nursing staff when washing the whole body, verbally / non-verbally rejects body care
OR
the patient is not familiar with the body care process.
Characteristic: Inability to take care of body care independently and in a structured manner to be carried out: Articles of daily use for personal hygiene cannot be used adequately, lack of initiative to carry out personal hygiene

In the case of a patient who, for example, shows defensive behavior in personal hygiene as a result of dementia, reason G1 is present.

Extract: PKMS maintenance measures for G1 (2011)
G1
G5 		A1 Measures to learn / regain / to motivate independent personal hygiene

Explanation: (hair care, oral care, body washing and / or skin care) in the presence of difficult factors (reasons for PKMS-E). In the care documentation, the individual care objectives of the measures must be shown, as well as the procedure tailored to the patient.

G1
G4
G10 		A3 Therapeutic full body care based on the following concepts:

[List of nursing concepts, e.g. B.]

  • calming / invigorating / basal stimulating GKW

As a maintenance measure z. B. a therapeutically soothing body wash can be carried out. If this was provided by a caregiver, the expenditure points for the body care service area can be counted.

If both the reason exist and the maintenance measure has been carried out, the PKMS expenditure points of the respective service area may be counted. The implementation of the PKMS documentation can be designed individually by the clinics. The PKMS documentation can be integrated into the daily care documentation or recorded on a separate questionnaire. Recording with software is also permitted.

Effort points of the PKMS

The effort points are added daily and collected over the entire duration of the stay. The effort points trigger the OPS 9-20 and the PPR-A4. According to the developer, the cost points are based on the calculated maintenance time. One point of effort corresponds to approx. 30 minutes of care time. There are different point values ​​for the performance areas.

Billing relevance

Since 2012, the additional fee of ZE 130 can be billed when a threshold of 43 expense points is reached. Alternatively, a corresponding additional fee (ZE 131) can be charged for children and adolescents or infants. From 2013, an additional split of the additional fees will result in a higher remuneration from 130 expense points.

Criticism of the PKMS

Additional documentation is required for the hospitals. Various sources state that it takes around 10 minutes per day and patient. Furthermore, every nurse who is to code according to PKMS must be trained accordingly. Institutions report this takes up to four hours. The test quality of the PKMS is discussed critically, and concerns are expressed as to whether the PKMS has the ability in the DRG system to influence the calculation in such a way that the funding from the special care program is distributed in full. In this context, the low number of patients receiving an OPS 9-20 is discussed. The dependence of the score on the length of time the patient has been in the hospital is also discussed. A discussion at item level focuses on the prescribed milliliter values ​​for fluid intake, which patients often cannot achieve. Some clinics seem to have introduced the PKMS documentation separately from the regular documentation. This leads to double documentation, as is the case for B. can be found in the experience report of a facility. This increases the daily documentation effort to approx. 15 minutes, spread over three shifts .

Web links

Individual evidence

  1. ↑ Further and advanced training program - details - BBDK - Berufsbildungswerk Deutscher Hospitals e. V. In: www.bbdk.de. Retrieved October 25, 2016 .
  2. ↑ afp message. In: Deutsches Ärzteblatt. 2009, accessed July 7, 2011 .
  3. ↑ Careum Foundation Zurich on April 10, 2009: Second Nursing Summit: Measures for better care in hospitals adopted ( Memento from July 29, 2012 in the web archive archive.today )
  4. ↑ Act on the regulatory framework for hospital financing from 2009 (Hospital Financing Reform Act - KHRG)
  5. ↑ PKMS. (PDF) DIMDI, accessed on November 13, 2018 .
  6. ↑ Recommendations for action for a more precise mapping of highly costly nursing cases in the G-DRG system. (PDF; 23 kB) (No longer available online.) Federal Ministry of Health, April 2009, archived from the original on May 5, 2014 ; Retrieved July 7, 2011 . Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / www.bmg.bund.de
  7. ↑ a b c d Pia Wieteck (Ed.): Handbuch 2011 for PKMS and PPR-A4 and OPS 9-20 . RECOM-Verlag, Kassel 2011, ISBN 978-3-89752-124-7 .
  8. ↑ complex treatment. DIMDI, accessed July 7, 2011 .
  9. ↑ PKMS-E 2.0 passes an extensive user test. ( Memento from July 10, 2012 in the Internet Archive ) Press release from the German Nursing Council from March 11, 2011.
  10. ^ Final report of the InEK. (PDF; 714 kB) (No longer available online.) Archived from the original on May 5, 2014 ; Retrieved April 17, 2013 . Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / www.g-drg.de
  11. ↑ Lisa Schröder, Pia Wieteck: Maintenance in the DRG system - billing with PKMS relevant to revenue. In: Heilberufe , 4/2010. Melanie Ermert, Kornelia Cordes: A paradigm shift in hospital financing for care makes your actions more transparent and, for the first time, billable. The introduction of the Care Complex Measures Score (PKMS) in a hospital with three entrances. In: Practice Maintaining. The project is a supplement to the magazine. Vol. 2, 2010, pp. 10-15 .; Sabine Bartholomeyczik: Hospital repairs, DRGs and their effects from the nursing perspective. 2007.
  12. ↑ a b Sabine Bartholomeyczik: Hospital repairs DRGs and their effects from the nursing perspective. (PDF; 40 kB) (No longer available online.) In: Dr.-med-Mabuse No. 166. Archived from the original on October 28, 2012 ; Retrieved July 7, 2011 . Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / mabuse-downloads.de
  13. ^ RECOM: Report on the symposium "Nursing and DRG". On May 26 and 27, 2011 Berlin Wannsee Academy ( Memento from May 5, 2014 in the Internet Archive ) (PDF; 156 kB)
  14. ↑ Wolfgang Fiori, Holger Bunzemeier, Norbert Roeder: Blessing and curse of the illustration of the specialization over OPS complex treatments. In: The hospital. (11), 2009, pp. 1065-1075.
  15. ↑ Pia Wieteck, Nicola Lutterbüse, Peter Dirschedl, Hans-Ulrich Euler: Questions and answers on OPS 9-20, PKMS-E, K, J and PPR A4 as of January 2011. (PDF; 138 kB) Retrieved on July 7, 2011 .
  16. ↑ dimdi.de ( Memento of the original from November 7th, 2012 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / www.dimdi.de
  17. ↑ InEK: DRG remuneration catalog 2012 , page 131, accessed on July 11, 2020
  18. ↑ DRG-Entgeltkatalog 2013 , p. 161, accessed on July 11, 2020
  19. ^ G-DRG discussion forum PKMS mydrg.de Information platform on the health industry
  20. ↑ B. Schanz, J. Leonteva: Finally a fair remuneration system? What the introduction of the comprehensive care measures score (PKMS) did and what did not. In: KU Health Management. Vol. 4, 2012, pp. 58-61.
  21. ↑ Erwin Horndasch: OPS 9-20 and PKMS - challenges in documentation. In: Forum of Medicine, Documentation and Medicine, Computer Science. Vol. 4, 2010, pp. 132-136.
  22. ^ Renate Plenge, Michael von Eicken: Experience report of the Catholic Clinic Bochum gGmbH. In: Pia Wieteck (Ed.): Handbuch 2011 for PKMS and PPR-A4 and OPS 9-20 . RECOM-Verlag, Kassel 2011, ISBN 978-3-89752-124-7 .
  23. ↑ B. Schanz: Over the target. In: Station24-Bibliomed. October 13, 2015
  24. ↑ a b c Markus Mai, Aloys Adler, Ester Ehrenstein, Sascha Krames, Sigrid Krause, Stefan Uhl, Oliver Wetzorke: Curse or blessing for care? The Nursing Complex Action Score (PKMS) poses a number of problems . In: KU Health Management . Volume 80, No. 5 , 2011, p. 46-50 .
  25. ↑ B. Schanz, S. Schmitz: Bureaucratic and expensive. In: f & w Bibliomed Verlagsgesellschaft, Melsungen. Vol. 05, 2014, pp. 466–469.
  26. ^ Ricardo Richter, Ulrike von Juterzenka: Experience report of the Wartburg district. In: Pia Wieteck (Ed.): Handbuch 2011 for PKMS and PPR-A4 and OPS 9-20 . RECOM-Verlag, Kassel 2011, ISBN 978-3-89752-124-7 .