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.

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

    By AANAC - September 25, 2019
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  • FY 2020 PDPM ICD-10 Mapping Tool and MDS Item I0020B ICD-10 Code Lookup Tool (9/19)

    By CMS - September 03, 2019

    CMS has released the PDPM ICD-10 Mappings File for FY 2020 as well as the I0020B Code Lookup File. 

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  • Final MDS 3.0 Data Specs for Oct. 1, 2019 Implementation (8/19)

    By CMS - August 21, 2019

    The FINAL version (V3.00.1) of the MDS 3.0 Data Specifications was posted.  This version is scheduled to become effective October 1, 2019.  Note that there have been additional revisions since the errata – they can be identified by looking for “post-errata” in the version notes for the items and edits.

    In addition,  V1.04.0 of the MDS 3.0 CAT Specifications  is also scheduled to become effective October 1, 2019. The specification for CAT 12 (Nutritional Status) has been updated in accordance with the changes in V3.00.0 of the MDS 3.0 Data Specifications.
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  • 2020 ICD-10-CM Diagnosis Code Files and Coding Guidelines (8/19)

    By CMS - August 12, 2019
    The 2020 ICD-10-CM files  contain information on the ICD-10-CM updates for FY 2020. These 2020 ICD-10-CM codes are to be used for discharges occurring from October 1, 2019 through September 30, 2020 and for patient encounters occurring from October 1, 2019 through September 30, 2020. This also contains the official ICD-10 Coding Guidelines.
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  • FY 2020 SNF PPS Final Rule Link and Fact Sheet (7/19)

    By CMS - July 30, 2019

    The Centers for Medicare & Medicaid Services (CMS) issued a final rule [CMS-1718-F] for Fiscal Year (FY) 2020 Medicare payment rates and quality programs for skilled nursing facilities (SNFs). This final rule is part of the agency’s 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. The final rule [CMS-1718-F] can be downloaded from the Federal Register at: https://www.federalregister.gov/documents/2019/08/07/2019-16485/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities.

    OVERVIEW

    This fact sheet discusses three major provisions of the final rule:

    ·        SNF payment policy under the SNF Prospective Payment System (PPS)

    ·        SNF Value-Based Purchasing Program (VBP)

    ·        SNF Quality Reporting Program (QRP). 

    This final rule includes policies that continue to move forward agency commitments to shift Medicare payments from volume to value, with the continued implementation of the SNF VBP and SNF QRP to improve program interoperability, operational quality and safety.

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  • CMS May 7 and 8, 2019, SNF QRP Post-Training Videos and Slide Sets Available (7/19)

    By CMS - July 29, 2019

    Videos and post-training materials (includes answers to knowledge checks and interactive sessions) from the May 2019 Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Provider Training held in Kansas City, MO, on May 7 and 8, 2019, are now available.

    Please note: Post-training materials include answers to knowledge checks and interactive sessions. Additionally, Section GG presentation has been updated to include links to videos shown during the training.

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  • PDPM and Section K—Three Processes to Shore Up Now

    By AANAC - March 19, 2019

    While no new items in section K of the MDS are expected this October, the Patient-Driven Payment Model (PDPM) is a game changer and some of the existing section K items are going to get a lot more attention. While swallowing and nutritional status have always been important for care areas and care planning, starting October 1, section K steps into the reimbursement spotlight for the speech-language pathology (SLP) component of PDPM. Not to mention, other key MDS items, like parenteral/IV feedings, tube feeding, and intake by artificial route, which currently impact reimbursement, will have even more pull under PDPM.

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  • CMS Section GG Decision Tree Training Document Available (1/19)

    By CMS - January 29, 2019

    A decision tree training document to help with coding Section GG self-care and mobility data elements is now available. This document provides an overview of the 6 codes and coding instructions for admission/discharge.


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  • Q&A: What are some notable differences between G and GG scoring methodologies?

    By CMS - January 09, 2019
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  • Dec. 11, 2018 SNF PPS: PDPM National Provider Call Transcript, Recording, Slides (1/19)

    By CMS - January 03, 2019

    On October 1, 2019, the new Patient Driven Payment Model (PDPM) is replacing Resource Utilization Group, Version IV (RUG-IV) for the Skilled Nursing Facility (SNF) Prospective Payment System (PPS).

    Topics:

    • Overview of PDPM, a new case-mix classification system for SNF Part A beneficiaries
    • Changeover from RUG-IV to PDPM
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  • 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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  • 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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  • SNF PPS: CMS Proposes Big Changes for Oct. 1, 2019

    By Caralyn Davis, Staff Writer - May 01, 2018

    On April 27, 2018, the Centers for Medicare & Medicaid Services (CMS) proposed to launch a revised case-mix classification model called the Patient-Driven Payment Model (PDPM) effective Oct. 1, 2019, (i.e., starting with FY 2020) that could radically re-imagine the job of the nurse assessment coordinator (NAC). The PDPM makes the use of therapy minutes to classify a resident for payment purposes obsolete, significantly alters the PPS assessment schedule, and institutes a variable per-diem payment adjustment schedule for the first time in SNF PPS history, according to the Fiscal Year (FY) 2019 Skilled Nursing Facility Prospective Payment System (SNF PPS) Proposed Rule.

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