Patient-Driven Payment Model (PDPM)

The Patient-Drive Payment Model (PDPM) is here, and AANAC will continue to help you through the transition. Visit this page frequently for new tools, education, and resources for ongoing success under PDPM.

  • FY 2022 SNF PPS Proposed Rule Puts the Spotlight on Quality Measures

    By Caralyn Davis, Staff Writer - April 17, 2021

    On April 8, the Centers for Medicare & Medicaid Services (CMS) released for public inspection the Fiscal Year (FY) 2022 Proposed Rule for the Skilled Nursing Facility Prospective Payment System (SNF PPS) and Consolidated Billing, and Updates to the Quality Reporting Program and Value-Based Purchasing Program (CMS-1746-P) as required by law. The agency will accept comments, which may be made electronically, through June 7.

    The FY 2022 SNF PPS proposed rule is a sweeping document that discusses specific proposals for FY 2022 and beyond, as well as new ideas that CMS is still beginning to formulate—with a heavy emphasis on future quality reporting.

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  • OIG to Look at SNF PDPM Reimbursement (4/21)

    By OIG - April 16, 2021

    The OIG will determine whether Medicare payments to SNFs under PDPM complied with Medicare requirements.

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  • Beta Test: JAVA PDPM Grouper (4/21)

    By CMS - April 16, 2021
    A beta test version of the Java PDPM Grouper has been posted. This version is to allow users to familiarize themselves with the Java program.  The Fiscal Year 2022 PDPM Grouper, v.2.0, will be distributed only in a Java version.
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  • FY 2022 SNF PPS Proposed Rule Considers PDPM Parity Adjustment and Other Changes (4/21)

    By CMS - April 08, 2021

    Fiscal Year (FY) 2022 Skilled Nursing Facility Prospective Payment System Proposed Rule (CMS 1746-P) Fact Sheet

    CMS issued a proposed rule that would update Medicare payment policies and rates for skilled nursing facilities under the Skilled Nursing Facility (SNF) prospective payment system (PPS) for fiscal year (FY) 2022. In addition, the proposed rule includes proposals for the SNF Quality Reporting Program (QRP), and the SNF Value-Based Program (VBP) for FY 2022. CMS is publishing this proposed rule consistent with the legal requirements to update Medicare payment policies for SNFs on an annual basis. The major provisions of the proposed rule include the following:

    • FY 2022 Proposed Updates to the SNF Payment Rates  
    • Methodology for Recalibrating the PDPM Parity Adjustment
    • Rebase and Revise the SNF Market Basket
    • Section 134 of the Consolidated Appropriations Act, 2021  – New Blood Clotting Factor Exclusion from SNF Consolidated Billing 
    • Proposed changes in PDPM ICD-10 Code Mappings 
    • Skilled Nursing Facility Quality Reporting Program (SNF QRP) update
    • Closing the Health Equity Gap – RFI
    • Skilled Nursing Facility (SNF) Healthcare-Associated Infections (HAI) Requiring Hospitalization Measure
    • COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) Measure
    • Transfer of Health (TOH) Information to the Patient-PAC Quality Measure
    • Public Reporting of Quality Measures with Fewer than Standard Numbers of Quarters Due to COVID-19 Public Health Emergency (PHE) Exemptions
    • Fast Healthcare Interoperability Resources (FHIR) in support of Digital Quality Measurement in Quality Reporting Programs – RFI
    • Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program
    • Proposal to suppress the SNF readmission measure in the SNF VBP Program
    • Expanded SNF VBP Program
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  • The Big Dig and PDPM Gold

    By Jessie McGill, RN, RAC-MT, RAC-MTA - March 16, 2021

    The Patient-Driven Payment Model (PDPM) uses 161 MDS items to establish the five case-mix adjusted components. Some of these 161 items will have supporting documentation easily found in the medical record, but other items may require some digging. From burrowing through hospital records and querying the physician to probing staff for additional clarification, thoroughly mining the medical record can yield a substantial impact on both the accuracy of the assessment and PDPM billing codes.

    Read this article for tips on how to dig into the detailed information NACs need for calculating PDPM.

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  • Final PDPM Grouper DLL V1.0009 (Supporting Info Updated) Effective Oct. 1, 2020

    By CMS - February 04, 2021

    February 4, 2021

    An update to the PDPM Grouper DLL package was posted.  This is NOT a change to the previously posted DLL file itself, just supporting information.  The documentation file was updated, as there were NTA mapping changes not previously documented.  Also, one file in the source code zip from the previous package, mdsgrouper,h, was not the latest version.  The correct version is included in this updated package.  NOTE: the DLL was compiled with the latest version of mdsgrouper.h in the previous package.  Therefore, there is no change to the DLL file itself.

    An updated errata (V3.00.7) was posted for the FINAL version (v3.00.1) of the MDS 3.0 Data Specifications, currently in production.  The resolution to issue 17 in the previous errata was flawed, as the addition of edit -3963d prevented submission of IPA inactivations.  Therefore, edit -3963d has been suspended for now, and will be revised in a future release.

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

    By AANAC - January 26, 2021
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  • Q&A: Do parenteral or IV fluids count under Special Care High for while a resident and while not a resident?

    By Jennifer LaBay, RN, RAC-MT, RAC-MTA, CRC - January 26, 2021
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  • TIP: CMS Releases Update to PDPM Grouper

    By AANAC - January 12, 2021
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  • jRAVEN 1.7.7 Free MDS Submission Software Updated (1/21)

    By QTSO - January 11, 2021

    The Resident Assessment Validation and Entry System (jRAVEN) was developed by the Centers for Medicare & Medicaid Services (CMS). jRAVEN is a free Java based software application which provides an option for facilities to collect and maintain MDS Assessment data for subsequent submission to the appropriate state and/or national data repository. jRAVEN displays the MDS Item Sets similar to the paper version of the forms. Please consult the jRAVEN Installation and User Guides for additional information.

    jRAVEN v1.7.7 is now available for download under the Downloads section at the bottom of this webpage. Users do not need a previous version of jRAVEN to download, install or use jRAVEN v1.7.7.

    jRAVEN v1.7.7 includes the following enhancements:

    • The new MDS VUT, v3.5.0, updated to support Issue #17 in Errata v3.00.6 and the new ICD Code files that are in effect as of 1/1/2021
    • The new PDPM Grouper, v1.0009, updated to include the ICD codes that are effective 01/01/202
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  • FY 2021 ICD-10 Code Lookup File for MDS Item I0020B (1/21)

    By CMS - January 11, 2021

    The lookup files containing the allowable ICD codes for item I0020B for FY2021 have been updated to contain the following ICD-10 codes , as well as remove M35.8:

    The new ICD-10 codes  may be used for assessments with target date on or after January 1, 2021: Z11.52, Z20.822, Z86.16, M35.81, M35.89 and J12.82. (Note that codes M35.81 and M35.89 replace code M35.8, which should no longer be used on assessments with target date on or after January 1, 2021.)

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  • FY 2021 PDPM ICD-10 Mappings (1/21)

    By CMS - January 11, 2021

    The Mappings file contains: 

    • Mapping of the ICD-10-CM Recorded in Item I0020B of the MDS Assessment to PDPM Clinical Categories 
    • Mapping of Comorbidities Included in the PDPM SLP Component to ICD-10-CM Codes
    • Mapping of Comorbidities Included in the PDPM NTA Component to ICD-10-CM Codes

    These are the codes added in the January 2021 update:

    Z11.52 — Encounter for screening for COVID-19

    Z20.822 — Contact with and (suspected) exposure to COVID-19

    Z86.16 — Personal history of COVID-19

    M35.81 — Multisystem inflammatory syndrome (MIS)

    M35.89 — Other specified systemic involvement of connective tissue

    J12.82 — Pneumonia due to coronavirus disease 2019

    (Note that codes M35.81 and M35.89 replace code M35.8, which should no longer be used on assessments with target date on or after January 1, 2021.)

    This is the seventh release (sixth production release, since 1.0005 was a beta release).

    This release also adds six ICD-10 codes that were inadvertently excluded from the NTA calculation in V1.0006:

    • T8484XA

    • T8389XA

    • T8321XA

    • T82399A

    • T82392A

     • T83021A 

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  • MDS 3.0 Provider User's Guide Updated, Including Validation Rpt Error Messages (1/21)

    By QTSO - January 08, 2021
    Key information about how to submit MDS files and how to obtain and understand error messages on initial and final validation reports. 
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  • The NTA Component of PDPM: Best Practices for Accurate Scoring

    By Caralyn Davis, Staff Writer - December 15, 2020

    Skilled nursing facilities now have more than a year of experience with the Patient-Driven Payment Model (PDPM), the updated case-mix classification system used in the Medicare Part A Skilled Nursing Facility Prospective Payment System (SNF PPS) that includes five case-mix-adjusted payment components: physical therapy (PT), occupational therapy (OT), speech-language pathology (SLP), nursing, and non-therapy ancillaries (NTA). The NTA component uses a weighted comorbidity score (i.e., high-cost conditions or extensive services count for more points) to assign a SNF resident to an NTA case-mix group.

     

    A resident’s NTA score is the sum of the points associated with each comorbidity that they have. For example, a resident with IV medications (5 points) coded in MDS item O0100H2, diabetes mellitus (2 points) coded in I2099, isolation (1 point) coded in O0100M2, and wound infection (2 points) coded in I2500 would have a total NTA comorbidity score of 10. The NTA case-mix groups are based on NTA score ranges: 0 (NF), 1 – 2 (NE), 3 – 5 (ND), 6 – 8 (NC), 9 – 11 (NB), or 12+ (NA), according to table 17, “NTA Case-Mix Groups,” in chapter 6 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual. Therefore, a resident with an NTA comorbidity score of 10 would qualify for the NB NTA case-mix group.

     

    The bottom line is that accurate payment in the NTA component depends on coding each and every NTA comorbidity the resident qualifies for according to the coding instructions in the RAI User’s Manual. Taking the following steps can help nurse assessment coordinators (NACs) capture the optimal NTA comorbidity score:

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  • BIMS MDS Coding Video Tutorial (10/20)

    By CMS - October 29, 2020
    The Centers for Medicare & Medicaid Services (CMS) is releasing a video tutorial to assist providers in Inpatient Rehabilitation Facilities and Skilled Nursing Facilities with standardized data assessment guidance and assessment strategies for the cognitive assessment known as the Brief Interview for Mental Status (BIMS). This video tutorial is approximately 22 minutes in length and is designed to provide targeted guidance for accurate coding using live-action patient/resident scenarios.
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