Patient-Driven Payment Model (PDPM)

The Patient-Drive Payment Model (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 PDPM.  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 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.

  • Get MDS Section C Ready For PDPM

    By Caralyn Davis, Staff Writer - June 05, 2019

    Under the Patient-Driven Payment Model (PDPM) that implements on October 1 for the Skilled Nursing Facility Prospective Payment System (SNF PPS), “there has to be a cognitive score in order to calculate the speech-language pathology (SLP) case-mix component and obtain a HIPPS code for billing,” points out Carol Maher, RN-BC, RAC-MT, CPC, director of education for Hansen, Hunter & Co. PC in Vancouver, WA.

    The PDPM cognitive performance level (aka cognitive score) is calculated from MDS section C, “Cognitive Patterns” based on the following:

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  • Preliminary RAI Manual v1.17 Released (5/19)

    By CMS - May 20, 2019

    The PDF file labeled “MDS 3.0 RAI Manual v1.17 October 1, 2019” is now available.

    Please note this early release is being provided in response to stakeholder feedback. The MDS 3.0 RAI Manual v1.17 contains many updates including information related to the Patient Driven Payment Model. Please check back prior to October 1, 2019 for a final posting which may contain additional updates.

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  • The Evolution of the Nurse Assessment Coordinator (NAC) Under PDPM

    By Jane Belt, MS, RN, RAC-MT, RAC-MTA, QCP and Jessie McGill, RN, RAC-MT, RAC-MTA - May 16, 2019

    The October 1, 2019, deadline for implementation of PDPM is looming. Nursing home administrators should use caution if they are thinking that fewer NAC hours will be needed just because the number of PPS assessments will decrease. The MDS is still the primary data source under PDPM, and MDS accuracy and completeness are paramount to accurate reimbursement. The preparation needed to get the NAC ready for their new role under PDPM cannot wait until October! We must start now, especially since we all know how the calendar seems to speed up when the summer months are upon us.

     

    Let’s take a look at some of the NAC’s current tasks and how they will change under PDPM:

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  • PDPM to SPADEs: How to Navigate the Waves of Change

    By Caralyn Davis, Staff Writer - May 16, 2019

    October 1, 2019 will mark the launch of what could be a sustained period of considerable change for the Skilled Nursing Facility Prospective Payment System (SNF PPS), the Skilled Nursing Facility Quality Reporting Program (SNF QRP), the MDS itself—and the role of the nurse assessment coordinator (NAC), suggests Jessie McGill, RN, RAC-MT, RAC-MTA, curriculum development specialist at AANAC.

    The changes start this October 1 with the implementation of the Patient-Driven Payment Model (PDPM) for the fee-for-service Medicare Part A SNF PPS. “This is a distinctly different payment model than RUG-IV, and it will drive a complete shift in the NAC’s focus. Instead of concentrating on therapy minutes and the activities of daily living (ADLs), the NAC will have to pay attention to a whole array of clinical services that need to be captured by the 5-day MDS’s assessment reference date (ARD),” says McGill. “This will mean spending a lot of time looking for documentation, not only from the nursing staff but also from the physicians to support ICD-10-CM codes.”

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  • Going From Skip Days to Interrupted Stays

    By Jessie McGill, RN, RAC-MT, RAC-MTA - May 01, 2019

    Mr. Jones admitted to Happy Acres Nursing Home on Original Medicare a couple of weeks ago, but an acute exacerbation of his COPD has resulted in an emergency room visit and an overnight stay for observation. The nurse assessment coordinator is closely watching the clock to see if Mr. Jones will return within 24 hours from discharge to meet the “midnight rule.” As another hour passes and more than 24 hours has elapsed, the NAC knows she must complete both an OBRA and a Part A PPS Discharge assessment. And for now—until October—her thinking is correct. Once the Patient-Driven Payment Model (PDPM) is implemented though, all of this will change with the “interrupted stay” policy.

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  • The OSA May Be Active Long-Term for Medicaid Case-Mix

    By Caralyn Davis, Staff Writer - April 24, 2019

    Revisions in the April 11 update of Patient-Driven Payment Model: Frequently Asked Questions (FAQs) suggest that the Optional State Assessment (OSA) is no longer a temporary assessment, meaning that it may remain active—and its use may actually expand—in some states for longer than the one fiscal-year (FY) transition period originally set by the Centers for Medicare & Medicaid Services (CMS). Therefore, it’s more vital than ever for nurse assessment coordinators (NACs) in Medicaid case-mix states to understand the OSA and how the October 1 transition of the Medicare Part A Skilled Nursing Facility Prospective Payment System (SNF PPS) to the Patient-Driven Payment Model (PDPM) case-mix classification system from the RUG-IV system can impact their Medicaid nursing facility (NF) payments.

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  • PDPM At-a-Glance Tool

    By AANAC - April 24, 2019
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  • Q&A: If my patient is only receiving PT services, will I still receive a payment rate for the OT and SLP components under PDPM?

    By CMS, PDPM FAQ 4.11.19 - April 24, 2019
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  • Q&A: If I have a resident who was treated for dehydration which was resolved during his or her hospital stay, but needed therapy for muscle weakness, can I assign an ICD-10 code for dehydration?

    By Carol Maher, RN-BC, CPC, RAC-MT - April 24, 2019
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  • Q&A: Under PDPM, if we complete an IPA, and more points are achieved in the NTA component, will the first 3 payment days of the IPA have the adjustment factor of 3.0 like it will at the start of the Medicare stay?

    By Jessie McGill, RN, RAC-MTA, RAC-MT - April 24, 2019
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  • SNF QRP and SPADEs are Center-Stage in FY 2020 SNF PPS Proposed Rule

    By Caralyn Davis, Staff Writer - April 23, 2019

    On April 19, the Centers for Medicare & Medicaid Services (CMS) publicly posted the fiscal year (FY) 2020 Skilled Nursing Facility Prospective Payment System (SNF PPS) Proposed Rule (CMS-1718-P). While the proposed rule updates the Medicare Part A federal per-diem payment rates, those changes are somewhat overshadowed by multiple proposed policy changes focusing on these key areas:

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  • FY 2020 SNF PPS Proposed Rule (4/19)

    By CMS - April 19, 2019

    Proposed Fiscal Year 2020 Payment and Policy Changes for Medicare Skilled Nursing Facilities (CMS-1718-P)

    On April 19, 2019, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule [CMS-1718-P] for Fiscal Year (FY) 2020 that updates the Medicare payment rates and the quality programs for skilled nursing facilities (SNFs). This proposed rule is part of our continuing efforts to strengthen the Medicare program by better aligning payment rates for these facilities with the costs of providing care and increasing transparency so that patients are able to make informed choices.  Additionally, effective October 1, 2019, CMS will begin using a new case-mix model, the Patient Driven Payment Model (PDPM), which focuses on the patient’s condition and resulting care needs rather than on the amount of care provided in order to determine Medicare payment.

    This fact sheet discusses three major provisions of the proposed rule: the proposed changes to SNF payment policy under the SNF Prospective Payment System (PPS), the SNF Value-Based Purchasing Program (VBP), and the SNF Quality Reporting Program (QRP).  This proposed rule includes policies that would continue a commitment to shift Medicare payments from volume to value, with the continued implementation of the PDPM, SNF VBP, and SNF QRP to improve program interoperability, operational quality and safety.

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  • FInal v1.17.1 MDS Item Sets for Oct. 1, 2019 Implementation (4/19)

    By CMS - April 12, 2019
    A new final version of the 2019 MDS item sets (v1.17.1) has been posted. This version is scheduled to become effective October 1, 2019. The draft item sets include the new IPA and OSA.
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  • PDPM FAQs and Fact Sheets_Revised (4/19)

    By CMS - April 12, 2019

    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. The PDPM FAQs were updated on 4-4 and then again on 4-11.

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  • PDPM HIPPS Codes: How They Will Be Determined

    By Caralyn Davis, Staff Writer - April 10, 2019

    When the Patient-Driven Payment Model (PDPM) implements as the case-mix classification system for the skilled nursing facility prospective payment system (SNF PPS) on Oct. 1, 2019, SNFs will have to code a new set of health insurance prospective payment system (HIPPS) codes in MDS item Z0100A (Medicare Part A HIPPS code) and on the Part A claim to identify a SNF resident’s payment classification, pointed out officials with the Centers for Medicare & Medicaid Services (CMS) during the Dec. 11 SNF PPS: PDPM National Provider Call. 

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