You Are Here:Home/Information/Patient-Driven Payment Model (PDPM)
Government sources documents
PDPM Virtual Workshop
PDPM Game Plan
Join AANAC for 24/7 access to resources and education that keep you up-to-date and ahead of changes.
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.
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 (version 1.7.4) is now available for download which contains the following updates:
Beginning October 1, 2020, states will have the option to direct their providers to have the PDPM Grouper score calculated on the standalone OBRA comprehensive and quarterly assessments. In support of this a new State PDPM OBRA flag has been defined that will be used to indicate if and when the provider will be having the PDPM payment score calculated on these standalone OBRA assessments. For more detailed information on how to set the new State PDPM OBRA flag in jRAVEN 1.7.4, please refer to the “Grouper Configuration” section of the jRAVEN User Guide 1.7.4 that is downloaded with the jRAVEN application and also available in the “References & Manuals” QTSO page for Nursing Home/Swing Bed Providers. Providers whose States require these items should follow the RAI User’s Manual coding guidance and refer to State-specific guidance for additional State-specific coding instructions. Please confirm with your State Medicaid Agency if your State will require the calculation of the PDPM payment codes on the OBRA assessments when not combined with a 5-day SNF PPS assessment.
Note that the State PDPM OBRA flag will also be displayed (read-only) on the assessment screen at the bottom of Section Z for assessments with target dates on and after October 1, 2020.
The FINAL version of the PDPM Grouper DLL V1.0006 has been posted, along with its source code and test cases. This version supports the calculation of PDPM payment codes on OBRA assessments when not combined with the 5-day SNF PPS assessment, specifically the OBRA comprehensive (NC) and OBRA quarterly (NQ) assessment item sets. Note that the grouper will return 4-character codes for these OBRAs.
It is important to include the control item STATE_PDPM_OBRA_CD (as defined in the V3.00.5 errata for the FINAL version (v3.00.1) of the MDS 3.0 Data Specifications) for assessments with target date on or after October 1, 2020.
Note that this FINAL version supports the ICD-10 codes that are defined in the data specifications as valid for item I0020B for FY2021. Also, please note that the grouper expects valid FY2021 ICD-10 codes for I8000A-J when processing assessments with target date on or after October 1, 2020.
The Centers for Medicare and Medicaid Services (CMS) gave states the option to collect Patient-Driven Payment Model (PDPM) billing codes on OBRA assessments when not combined with a Medicare PPS 5-Day assessment, beginning Oct. 1, 2020. While most of the information used to establish these codes is already on the OBRA assessments, the additional data collection will require both time to complete and training to perform correctly. Notably, the addition of completing the admission performance column for section GG (Functional Abilities) will take the most time. A lack of proper training for the staff completing this section has the potential to cause inaccuracies and confusion among direct care staff. However, the stress and workload can be mitigated with a strong preparation plan and ongoing support to direct care staff. Follow these four steps to ensure your team is ready to complete successfully the documentation and data collection for section GG on OBRA assessments:
1. Understand how your state is using the information and expected future implications
The Mappings file contains:
“Does this surgery count as a major surgery?” is one of the most frequently asked questions that nurse assessment coordinators (NACs) have about MDS items J2100 (Recent Surgery Requiring Active SNF Care) and J2300 – J5000 (Recent Surgeries Requiring Active SNF Care: Surgical Procedures), says Carol Maher, RN-BC, RAC-MTA, RAC-MT, CPC, director of education for Hansen, Hunter & Co. PC in Vancouver, WA.
“It’s an important question because capturing a major surgery in J2100 and J2300 – J5000 can make a difference in the Medicare Part A payment that you receive for the physical therapy (PT) and occupational therapy (OT) components under the Patient-Driven Payment Model (PDPM),” says Maher. “A major surgery can move the resident from their default primary diagnosis clinical category established in I0020B (ICD Code/Primary Medical Condition) into a potentially higher-paying surgical clinical category for PT and OT.”
On July 31, 2020, the Centers for Medicare & Medicaid Services (CMS) issued a final rule [CMS-1737-F] for Fiscal Year (FY) 2021 that updates the Medicare payment rates and the value-based purchasing program for skilled nursing facilities (SNFs). CMS is publishing this final rule consistent with the legal requirements to update Medicare payment policies for SNFs on an annual basis. In recognition of the significant impact of the COVID-19 public health emergency, and limited capacity of health care providers to review and provide comment on extensive proposals, CMS has limited annual SNF rulemaking required by statute to essential policies including Medicare payment to SNFs.
The final rule includes routine technical rate-setting updates to the SNF prospective payment system (PPS) payment rates, and adopts the revised Office of Management and Budget (OMB) statistical area delineations. In addition, the rule applies a 5 percent cap on wage index decreases from FY 2020 to FY 2021. In response to stakeholder feedback, we are also finalizing changes to the International Classification of Diseases, Version 10 (ICD-10) code mappings, effective October 1, 2020. Finally, this rule includes minor administrative changes related to the SNF Value-Based Purchasing (VBP) Program.
Obtaining the most specific medical diagnosis benefits skilled nursing facilities (SNFs) on two fronts: receiving accurate reimbursement under the Patient-Driven Payment Model (PDPM) for Medicare Part A residents and improving the quality of care for all residents, says Carol Maher, RN-BC, RAC-MTA, RAC-MT, CPC, director of education for Hansen, Hunter & Co. PC in Vancouver, WA.
“Often, to get a diagnosis to map from the MDS to a clinical category for the physical therapy (PT), occupational therapy (OT), or speech-language pathology (SLP) payment components under PDPM, you need a more specific diagnosis,” explains Maher. “However, it’s not all about payment. Even without the mapping problem, the resident’s medical record needs to be as accurate and complete as possible, and that includes having accurate diagnoses so that the interdisciplinary team can provide the correct treatment.”
For example, if a resident goes to see an outside provider, the face sheet that the nursing home sends with that resident should be as accurate as possible, she points out. “If the resident had a heart attack, was the myocardial infarction a STEMI (ST-segment elevation myocardial infarction) or a non-STEMI? You don’t want to leave that type of diagnosis unspecified because including the most accurate diagnosis on the nursing home face sheet could affect that outside provider’s treatment decisions and the resident’s overall quality of care.”
In response to State Medicaid Agency and stakeholder requests, CMS has updated the MDS 3.0 item sets (version 1.17.2) and related technical data specifications. These changes will support the calculation of PDPM payment codes on OBRA assessments when not combined with the 5-day SNF PPS assessment, specifically the OBRA comprehensive (NC) and OBRA quarterly (NQ) assessment item sets, which was not possible with item set version 1.17.1. This will allow State Medicaid Agencies to collect and compare RUG-III/IV payment codes to PDPM ones and thereby inform their future payment models.
The changes to the technical data specifications that support these modifications are contained in the Errata v3.00.4 which can be accessed in the file: MDS 3.0 data specs errata (v3.00.4) Final 04-30-2020 in the Downloads section below. Supporting materials including the 1.17.2 Item Change History report and the revised 1.17.2 Item Sets can be accessed in the file: MDS 3.0 Final Item Sets v1.17.2 for October 1 2020 zip also posted in the Downloads section below.
Please confirm with your State Medicaid Agency if your State will be requiring the calculation of the PDPM payment codes on the OBRA assessments when not combined with a 5-day SNF PPS assessment.
June 25, 2020 update: An updated errata (V3.00.5) was posted for the FINAL version (v3.00.1) of the MDS 3.0 Data Specifications, currently in production. Two issues were identified. These changes will go into production on October 1, 2020. As a result, two edits will be revised. These changes will facilitate calculation of PDPM HIPPS codes on OBRA assessments for states that wish to have this calculation performed.
Healthcare professionals were relieved when CMS agreed to make the Interim Payment Assessment (IPA) optional instead of a requirement. This meant that skilled nursing facilities (SNFs) could decide when or if they would complete these payment assessments. CMS anticipated that SNFs would perform IPAs during each Medicare Part A stay both to improve Medicare payment during the stays and to monitor patients’ clinical status. However, data shows that few IPAs are being completed.
One likely reason why: the complexity of the new Patient-Driven Payment Model (PDPM) makes it difficult to know when an MDS would improve the final payment. John Kane, CMS’s SNF Payment Team Lead, stated during one of CMS’s train-the-trainer sessions that there could be as many as 1,900 possible payment combinations per PPS MDS.
So how can you know whether an IPA would improve the Medicare payment? First, let’s consider the impact of CMS’s original plan to require the IPAs. CMS proposed that IPAs would be completed when there was a change in one of the first-tier classification criteria in any of the proposed payment components. For example, if the resident had been classified into the Major Joint Replacement category for the PT/OT component and their primary diagnosis changed to Medical Management, the IPA would have been required. Likewise, when a resident’s Nursing component category changed from Extensive Services to Special Care Low, an IPA would have been required. We are grateful that assessments are not mandatory in these circumstances, but they provide a useful starting point for understanding when an IPA could be financially beneficial.
In the SNF PPS Final Rule for FY 2020, CMS included the following table showing the FY 2020 federal unadjusted urban base rates for each of the six PDPM payment components:
To bill under traditional fee-for-service Medicare Part A, skilled nursing facilities (SNFs) must obtain appropriate, timely physician certifications and recertifications of posthospital inpatient extended-care services. The physician cert/recert policy did not change with the implementation of the Patient-Driven Payment Model (PDPM) on October 1, 2019.
However, the Centers for Medicare & Medicaid Services (CMS) did adjust the instructions in the Medicare Online Manual System to explain when providers need to obtain a new physician certification vs. when they should continue using the existing cert/recert to account for the interrupted stay policy that was implemented in conjunction with PDPM. This adjustment brought to light the fact that some SNFs may be counting calendar days instead of Medicare days to determine when certs/recerts are due—a practice that is incorrect CMS officials tell the American Association of Nurse Assessment Coordination (AANAC).
“The regulations at 42 CFR 424.20(d) state that the first recertification is required no later than ‘the 14th day of post-hospital SNF care.’ This would have the schedule track with the days of the stay (i.e., covered days) rather than calendar days,” explain officials. Note: Review the physician cert/recert section of the Code of Federal Regulations in the box at the end of this article.
“This also tracks with previous statements we have made comparing the recertification timeline with the variable per-diem schedule, and interrupted stays have similar impacts on both, as noted in response to FAQ 13.21,” say officials. Here is the FAQ excerpted from Patient-Driven Payment Model: Frequently Asked Questions (FAQs):
On April 10, the Centers for Medicare & Medicaid Services (CMS) released for public inspection the Fiscal Year (FY) 2021 Proposed Rule for the Skilled Nursing Facility Prospective Payment System (SNF PPS) and Consolidated Billing (CMS-1737-P) as required by law. In a major break from recent years, CMS offers no proposals for updating the Skilled Nursing Facility Quality Reporting Program (SNF QRP) and only what the agency describes as “minor administrative proposals” related to the SNF Value-Based Purchasing (VBP) program.
However, CMS does propose several other revisions in addition to the required Medicare Part A payment rate update. These include: