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.

  • Balancing Sections G and GG Requirements

    By Jessie McGill, RN, RAC-MT, RAC-MTA - July 10, 2019

    With the enormous focus on the transition from RUG-IV to PDPM, some may consider abandoning their section G Activities of Daily Living (ADLs) training materials, audits, and tools— but wait just a moment! Although section GG is stepping into the Medicare reimbursement spotlight, section G still plays a big role in other types of reimbursement and Quality Measures. To ensure success, the nurse assessment coordinator (NAC) must have a full understanding of the coding instructions, documentation requirements, impact on Quality Measures, and reimbursement for both section G and GG. Here are four key differences between the two sections and tips for successfully managing both.

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  • PDPM Lessons Learned From the Nursing RUGs

    By Caralyn Davis, Staff Writer - July 10, 2019

    On October 1 2019, the nursing case-mix groups used in the RUG-IV case-mix classification system will be streamlined and consolidated to form the nursing component of the Patient-Driven Payment Model (PDPM). By decreasing distinctions based on function for certain groups, the PDPM nursing component will use only 25 case-mix groups (ES3 – PA1) compared to the 43 RUG-IV nursing case-mix groups. For example, the RUG-IV groups HE2 and HD2 will be collapsed into the modified PDPM nursing case-mix group HDE2.

     

    However, the core process for assigning residents to a nursing case-mix group will remain basically the same, taking into account the use of extensive services, the presence of certain clinical conditions, the presence of depression, the provision of restorative nursing services, and the resident’s functional score (using section GG instead of section G). Consequently, nurse assessment coordinators (NACs) and other interdisciplinary team (IDT) members can learn some lessons about historically undercoded MDS items that could impact their ability to achieve the most accurate case-mix group for the PDPM nursing component, says Robin Hillier, CPA, STNA, LNHA, RAC-MT, president of RLH Consulting in Westerville, OH.

     

    Here are four items or sections worth revisiting:

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  • Cognitive Impairment Score Tool

    By AANAC - July 10, 2019
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  • Q&A: How will the 30-day window rule work under PDPM with the new Interrupted Stay Policy?

    By Carol Maher, RN-BC, CPC, RAC-MT - July 10, 2019
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  • Q&A: Resident admitted status post lumbar laminectomy due to lumbar spinal stenosis with neurogenic claudication, what would the primary diagnosis be?

    By Jennifer LaBay RN, RAC-MT, RAC-MTA - July 10, 2019
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  • Challenge Question: Under PDPM, what assessment is required if there is a 3-day break in therapy services?

    By AANAC - June 19, 2019

    Question: Under PDPM, what assessment is required if there is a 3-day break in therapy services?

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  • PDPM Case-Mix Group Conversion to HIPPS Characters Tool

    By AANAC - June 19, 2019
    Getting ready for PDPM? Check out AANAC's new PDPM Case-Mix Group Conversion to HIPPS Characters tool.
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  • Variable Per-Diem Adjustments Will Spotlight Skilling Decisions

    By Caralyn Davis, Staff Writer - June 18, 2019

    This October 1, the Patient-Driven Payment Model (PDPM) will introduce variable per-diem payment adjustments to providers paid under the Skilled Nursing Facility Prospective Payment System (SNF PPS). PDPM has five case-mix-adjusted components that each have an associated payment based on the case-mix group classification: physical therapy (PT), occupational therapy (OT), speech-language pathology services (SLP), nursing, and nontherapy ancillaries (NTA). For the PT, OT, and NTA components, case-mix group payments will decrease over the course of a Part A patient’s stay according to the predetermined schedules and adjustment factors found in Table 20, PT and OT Variable Per Diem Adjustment Factors, and Table 21, NTA Variable Per Diem Adjustment Factors, on page 6-48 of the draft version 1.17 Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual.

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  • Q&A: I have noticed that there are many ICD-10-CM diagnosis codes that result in “return to provider" on the PDPM ICD-10 Mappings. Is it true that we cannot use these codes?

    By Jennifer LaBay, RN, RAC-MT, RAC-MTA - June 18, 2019
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  • 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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  • 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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