Patient-Driven Payment Model (PDPM)

The Patient-Drive Payment System (PDPM) is scheduled to begin Oct. 1, 2019, and AANAC is here to help!

The Centers for Medicare & Medicaid Services released the Fiscal Year (FY) 2019 Skilled Nursing Facility Prospective Payment System (SNF PPS) final rule, which solidified their plans to implement the PDPM. The PDPM is set to replace the RUG-IV case-mix classification model that has been the hallmark of SNF PPS for years. This new payment system will be unlike anything SNFs have seen before! You and your staff have a lot to do to get ready for the PDPM, and AANAC will be with you the entire way.  Visit this page frequently to get tools, education, and resources to help you lead your team readiness.

  • CMS Addresses Medicaid RUG-III & RUG-IV Case Mix Effective Oct. 1, 2019

    By CMS - December 07, 2018

    Summary: States will have access to an optional assessment to support RUG-III and RUG-IV from October 1, 2019 through September 30, 2020. Effective, Oct. 1, 2020, states that continue to use RUG-III or RUG-IV after October 1, 2020 will need to implement a new process to gather the needed data because many of the corresponding MDS items will no longer be present on the MDS.

    Memo:

    On October 1, 2020 CMS will no longer support RUG-III and RUG-IV case-mix methodologies via the Minimum Data Set (MDS). PDPM utilizes a streamlined assessment schedule compared to RUG-III and RUG-IV by eliminating all current scheduled assessments, except the 5-day, and all unscheduled assessments (i.e., Other Medicare-Required Assessments). For States that rely on these assessments for calculating their case-mix group, CMS has created an optional assessment so that Medicaid payment is not adversely impacted when PDPM is implemented on October 1, 2019. States will have some flexibility in crafting policies associated with this assessment. The optional assessment will be effective from October 1, 2019 through September 30, 2020.

    Finally, in an effort to reduce provider burden, improve quality of care, and standardize data elements across provider settings, CMS will be removing several MDS data elements over the next few years. Many MDS data elements used in RUG-III and RUG-IV are no longer required for Federal purposes. With the removal of data elements, RUG-III and RUG-IV will no longer be functional. States that continue to use RUG-III or RUG-IV after October 1, 2020 will need to implement a new process to gather the needed data.

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  • TIP: Are you ready for PDPM?

    By AANAC - December 03, 2018
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  • CMS PDPM Website (11/18)

    By MX - November 26, 2018

    In July 2018, CMS finalized a new case-mix classification model, the Patient Driven Payment Model (PDPM), that, effective beginning October 1, 2019, will be used under the Skilled Nursing Facility (SNF) Prospective Payment System (PPS) for classifying SNF patients in a covered Part A stay. This site includes a variety of educational and training resources to assist stakeholders in preparing for PDPM implementation.


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  • PDPM FAQs and Fact Sheets (11/18)

    By CMS - November 26, 2018

    Fact Sheets

    This section includes fact sheets on a variety of PDPM related topics.

    • Administrative Level of Care Presumption under the PDPM
    • PDPM Payments for SNF Patients with HIV/AIDS
    • Concurrent and Group Therapy Limit
    • PDPM Functional and Cognitive Scoring
    • Interrupted Stay Policy
    • MDS Changes
    • NTA Comorbidity Score
    • PDPM Patient Classification
    • Variable Per Diem Adjustment

     

    PDPM Frequently Asked Questions

    This section contains frequently asked questions (FAQs) related to PDPM policy and implementation.

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  • PDPM Training and Technical Resources, Including Grouper Logic & ICD-10 Crosswalks (11/18)

    By CMS - November 26, 2018

    PDPM Training Presentation

    This section includes a training presentation which can be used to educate providers and other stakeholders on PDPM policy and implementation.

    PDPM Resources

    This section includes additional resources relevant to PDPM implementation, including various coding crosswalks and classification logic.

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  • MDS Items Impacting Reimbursement for RUG-IV, PDPM, and SNF QRP

    By AANAC - November 12, 2018
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  • Get Serious About Active Diagnoses / ICD-10 to Survive PDPM

    By Caralyn Davis, Staff Writer - October 30, 2018

    Active diagnoses and ICD-10-CM diagnosis codes will be a significant payment driver in the Patient-Driven Payment Model (PDPM) that goes into effect on Oct. 1, 2019, under the skilled nursing facility prospective payment system (SNF PPS) for traditional Medicare Part A residents. Diagnoses will impact all five of the case-mix-adjusted payment categories: physical therapy (PT), occupational therapy (OT), speech-language pathology (SLP), nontherapy ancillary (NTA), and nursing, notes Judy Wilhide Brandt, RN, BA, QCP, CPC, RAC-MT, DNS-CT, principal of Wilhide Consulting in in Virginia Beach, VA.

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  • PDPM and ICD-10-CM Quick Reference Guide

    By AANAC - October 18, 2018
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  • Are You Using the Right FY 2019 Federal RUG Rates?

    By Caralyn Davis - October 16, 2018

    On Oct. 3, CMS published a correction notice for the Fiscal Year (FY) 2019 Skilled Nursing Facility Prospective Payment System (SNF PPS) final rule to address a series of technical errors. “Chief among those” were corrections to the total case-mix-adjusted federal per-diem RUG-IV payment rates that were necessary due to errors in copying values, said officials with the Centers for Medicare & Medicaid Services (CMS) at the Oct. 11 Skilled Nursing Facility/Long-term Care Open Door Forum (ODF).

     

    Specifically, CMS has issued updated versions of both Table 6, “RUG-IV Case-Mix Adjusted Federal Rates and Associated Indexes—Urban,” and Table 7, “RUG-IV Case-Mix Adjusted Federal Rates and Associated Indexes—Rural,” to correct the Total Rate column. For example, those tables in the FY 2019 SNF PPS final rule show federal RUX payment as $832.89 for urban SNFs and $852.10 for rural SNFs. The correction notice changes the federal RUX rate to $832.61 urban and $851.84 rural.

     

    Other FY 2019-specific corrections include the following:

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  • Five Mistakes Often Made Selecting ICD-10-CM Codes in the SNF

    By Jessie McGill, RN, RAC-MT - October 16, 2018
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  • PDPM At-a-Glance Tool

    By AANAC - October 03, 2018
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  • 8 Steps Will Lay The Groundwork For PDPM Success

    By Caralyn Davis, Staff Writer - October 03, 2018

    Effective Oct. 1, 2019, the Patient-Driven Payment Model (PDPM) in the skilled nursing facility prospective payment system (SNF PPS) will revamp how SNFs are paid to care for traditional fee-for-service Medicare Part A residents. “PDPM will look almost entirely different from the RUG models that SNFs have been working with for roughly 20 years,” says Scott Heichel, RN, RAC-MT, DNS-CT, QCP, CIC, director of clinical reimbursement for LeaderStat in Powell, Ohio.

     

    When the Centers for Medicare & Medicaid Services (CMS) released the draft of the PDPM predecessor RCS-I, rumors immediately popped up that the reduction in administrative burden from the streamlined PPS assessment schedule would encourage providers to reduce their nurse assessment coordinator (NAC) staffing. However, aside from how that hot take ignored OBRA and Medicare Advantage assessments, “PDPM actually offers you the chance to make the NAC role even more important than it is under RUG-IV,” says Heichel.

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  • FY 2019 SNF PPS Final Rule PLUS Correction, Updated Wage Index Tables (10/18)

    By CMS - October 01, 2018
    Medicare Program: Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities Final Rule for FY 2019, SNF Value-Based Purchasing Program, and SNF Quality Reporting Program

    This final rule updates the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs) for fiscal year (FY) 2019. This final rule also replaces the existing case-mix classification methodology, the Resource Utilization Groups, Version IV (RUG-IV) model, with a revised case-mix methodology called the Patient-Driven Payment Model (PDPM) beginning on October 1, 2019. The rule finalizes revisions to the regulation text that describes a beneficiary’s SNF “resident” status under the consolidated billing provision and the required content of the SNF level of care certification. The rule also finalizes updates to the SNF Quality Reporting Program (QRP) and the Skilled Nursing Facility ValueBased Purchasing (VBP) Program. 

    Correction Notice SUMMARY: This document corrects technical errors in the final rule that appeared in the August 8, 2018 Federal Register (83 FR 39162) entitled “Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities (SNF) Final Rule for FY 2019, SNF Value-Based Purchasing Program, and SNF Quality Reporting Program.” DATES: The corrections in this document are effective October 1, 2018 .

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  • Get Ready for QRP and PDPM with MDS Hours Calculators

    By AANAC - September 12, 2018
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  • Q&A: Under the Patient-Driven Payment Model (PDPM), which goes into effect October 1, 2019, will therapy minutes still drive payment?

    By Jessie McGill RN, RAC-MT - September 12, 2018
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