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.

  • Are Therapy Changes Putting Daily Skilled Services at Risk?

    By Caralyn Davis, Staff Writer - November 13, 2019

    The October 1 implementation of the Patient-Driven Payment Model (PDPM) under the Skilled Nursing Facility Prospective Payment System (SNF PPS) for traditional fee-for-service Medicare Part A residents brought quick changes to therapy provision among some providers. Led by Modern Healthcare, multiple news publications reported nationwide lay-offs of therapists and therapy assistants, as well as corporate mandates to provide group or concurrent therapy or to provide a set number of therapy minutes per SNF resident—without regard for a therapist’s clinical judgment of each resident’s individual needs.

     

    The situation is so alarming to therapists that the American Physical Therapy Association (APTA), the American Speech-Language-Hearing Association (ASLHA), the National Association for the Support of Long-term Care (NASL), and the American Occupational Therapy Association (AOTA) banded together to issue a Compliance Statement to help therapists navigate the process for reporting compliance concerns. These organizations also are working directly with the Centers for Medicare & Medicaid Services (CMS) to identify troubling trends, as evidenced by the AOTA’s October 17 statement, An Important Message About PDPM From AOTA.

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  • Final MDS 3.0 Data Specs for Oct. 1, 2019 Implementation Plus Errata (11/19)

    By CMS - November 12, 2019

    The FINAL version (V3.00.1) of the MDS 3.0 Data Specifications is effective October 1, 2019. In November 2019, an updated errata (V3.00.3) was posted for the FINAL version (v3.00.1) of the MDS 3.0 Data Specifications, currently in production. Two issues were identified. One edit, -3941, will be deleted, and one edit, -3965, will be added. These changes will go into production on December 3, 2019. Once in production, these two changes will be retroactive, applying to all assessments with target dates on or after October 1, 2019.

    In addition,  V1.04.0 of the MDS 3.0 CAT Specifications  is effective as of October 1, 2019.
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  • CMS Implements SNF Claims Hold (11/19)

    By CMS - November 06, 2019

    As CMS has undertaken the implementation of the Patient Driven Payment Model (PDPM), we are holding a limited number of Skilled Nursing Facility (SNF) claims while we make further refinements to our claims processing system.

     

    PDPM is a historic reform of the SNF prospective payment system. PDPM focuses on the patient’s condition and resulting care needs rather than on the amount of care provided in order to determine Medicare payment. PDPM was effective on October 1, 2019.

     

    Specifically, CMS is holding claims with:

    • Dates of service October 1, 2019 or later and
    • Type of Bill (TOB) inpatient services (21X) and swing bed services (18X) subject to SNF Patient Driven Payment Model (PDPM) and
    • Multiple line items, Health Insurance Prospective Payment System (HIPPS) codes, with different rate codes (revenue code 0022).

     

    Typically, SNFs bill these claims on monthly cycles. Claims with single HIPPS codes were previously being held but are now being released for processing. We anticipate releasing the remaining held claims in late November, once CMS completes systems testing to ensure accurate and timely payment. As of November 1, less than 50 claims are being held.

     

    In addition, we underpaid some SNF inpatient services (21X) and swing bed services (18X) claims for dates of service in October 2019 with a single line item, single HIPPS code. We are automatically reprocessing those claims; no provider action is needed.

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  • BMI Plays a Key Role From Reimbursement to Care Planning

    By Caralyn Davis, Staff Writer - October 16, 2019

    As a screening tool to identify potential weight problems for adults, body mass index (BMI) has always been important to document, but it gained new importance as a reimbursement factor for Medicare Part A residents under the Patient-Driven Payment Model (PDPM). Here’s what nurse assessment coordinators (NACs) need to know about BMI:

     

    Learn the NTA impact for PDPM

    “Residents who are morbidly obese may require a higher degree of nursing effort and skilled nursing care. Likewise, residents at the other end of the scale who are at risk for malnutrition also require more skilled nursing care,” says Pam Duchene, PhD, APRN-BC, NEA, FACHE, RAC-MT, DNS-CT, QCP, vice president of education and training for Harmony Healthcare International in Topsfield, MA.

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  • CMS Updates Medicare Benefit Policy Manual, Claims Processing Manual for PDPM (10/19)

    By CMS - October 08, 2019

    CMS has revised SNF-focused chapters in the following manuals in the online manual system to account for the Patient-Driven Payment Model (PDPM):

    • Medicare Benefit Policy Manual;
    • Medicare Claims Processing Manual; and
    • Medicare General Information, Eligibility, and Entitlement Manual.



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  • PDPM Grouper DLL Package Revised Again--Make Sure Your Software Is Updated (10/19)

    By CMS - October 07, 2019
    A revision to the PDPM DLL Package (V1.0003 FINAL) was posted, and the previous version (V1.0002 FINAL) was removed.  This version corrects four bugs that were identified after the V1.0002 release. The package contains updated test files and documentation.
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  • jRAVEN 1.7.1 Free MDS Submission Software Updated (10/19)

    By CMS - October 07, 2019

    jRAVEN (version 1.7.1) is now available for download which contains the following updates:  

    1. The Final PDPM Grouper, version 1.0003

    2)         All enhancements included with jRAVEN v1.7.0:

    3)            MDS Item Set Version V1.17

    4)            MDS Data Specification Version V3.00

    5)            VUT Version V3.1.0

    6)            The initial PDPM Grouper (replaced with the new version, v1.0003)

    7)            Supports the Correction Policy update to not allow corrections if it causes the target date to cross over the 10/1/2019 date

    8)            Supports the updated submission timeframe change from 3 years to 2 years

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  • Triple Check Your PDPM Transition

    By Jessie McGill, RN, RAC-MTA - October 02, 2019

    The transition from the RUG-IV to the Patient-Driven Payment Model (PDPM), was a hard transition. SNFs followed RUG-IV PPS scheduling and rules through September 30 and then, on October 1, they began PDPM. However, there is still a transition process that must be followed, and nurse assessment coordinators (NACs) need to fully understand all the requirements. NACs also need to double check all payer types and assessment reference dates (ARDs) and ensure that, by the end of October 7, the facility has completed all steps the process requires. Lastly, NACs may want to consider completing a quick triple check or a billing review to ensure all the conditions of Medicare billing have been met before the end of the transition. While the triple check process is typically reserved for reviewing the previous month’s claims, completing an expedited check by October 7, before the end of the transition, can help reduce the risk of payment penalties. Here are three key steps to a successful transition: 

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  • RAI Manual v1.17.1 Changes Include New Modification Rule

    By Caralyn Davis, Staff Writer - October 02, 2019

    In addition to updating the coding instructions for MDS item I0020B (ICD Code/Resident’s Primary Medical Condition), the Centers for Medicare & Medicaid Services (CMS) made several other changes to version 1.17.1 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual compared to the draft version 1.17. Most were expected given the updated presentations CMS officials gave at the August 13 – 14 Skilled Nursing Facility Quality Reporting Program (SNF QRP) training event, as well as the finalized requirements in the Fiscal Year (FY) 2020 Skilled Nursing Facility Prospective Payment System (SNF PPS) Final Rule. These included updates to the definition of an interruption window and changes to the group therapy coding instructions. However, there were also some new updates. For example, CMS established a new 10/01/2019 Cross-Over Rule as part of its MDS modification policy.

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  • MDS 3.0 Provider User's Guide Updated, Including Validation Rpt Error Messages (9/19)

    By QTSO - September 30, 2019
    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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  • RAI Manual v1.17.1 Update Raises Acute ICD-10 Code Questions

    By Caralyn Davis, Staff Writer - September 25, 2019

    Last week, the Centers for Medicare & Medicaid Services (CMS) released the long-awaited version 1.17.1 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual. One change from the draft version 1.17 manual highlights some ongoing confusion about how to code ICD-10-CM diagnosis codes in MDS items I0020B (ICD Code/Resident’s Primary Medical Condition) and I8000 (Additional Active Diagnoses) to ensure accurate case-mix classification in the Patient-Driven Payment Model (PDPM).

    The ICD-10 code entered in I0020B determines a Part A resident’s default primary diagnosis clinical category for the physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) payment components under PDPM. In addition, ICD-10 codes entered in I8000 determine whether the resident qualifies for certain comorbidities under the SLP component (identified in Table 14, “SLP-Related Comorbidities,” in the PDPM Calculation Worksheet for SNFs section of chapter 6 in the RAI User’s Manual) or the nontherapy ancillaries (NTA) component (identified in Table 16, “NTA Comorbidity Score Calculation”).

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

    By AANAC - September 25, 2019
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  • Uncomplicating the Interrupted Stay Policy

    By Jessie McGill, RN, RAC-MT, RAC-MTA - September 24, 2019

    SNFs are in the final stage of preparation for Patient-Driven Payment Model (PDPM) implementation, but alongside the payment model’s introduction, new policies are being introduced that add layers of complexity that nurse assessment coordinators (NACs) must master this fall. For example, the new Interrupted Stay Policy adds a whole new critical thinking process to what has been a simplified PPS schedule. However, the Interrupted Stay Policy does not need to cause anxiety—it just needs to be better understood.  Here are seven tips to uncomplicate the Interrupted Stay Policy:

    1.       Understand the two criteria of the Interrupted Stay Policy.

    The Interrupted Stay Policy essentially combines multiple SNF PPS stays that are separated by less than three days into one stay when the resident meets both of the following criteria:

    1.       Resident returns to the same skilled nursing facility (SNF), and

    2.       Returns by 11:59 pm of the third calendar day

    The Interruption Stay Policy also introduces the concept of the “interruption window,” which begins with the calendar day of discharge and includes the two calendar days immediately following. If the resident’s Medicare stay ends, and the resident remains in the facility with benefit days remaining, then the interruption window begins on the first non-covered day and includes the next two calendar days.

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  • CMS Makes Direct Link Between Outcomes and Medical Review

    By Caralyn Davis, Staff Writer - September 11, 2019

    Under the Patient-Driven Payment Model (PDPM), resident outcomes will be key to avoiding medical review, said officials with the Centers for Medicare & Medicaid Services (CMS) during the August 14 Skilled Nursing Facility Quality Reporting Program (SNF QRP) training session, Patient-Driven Payment Model: What Is Changing (and What Is Not). Note: Find the session slides here.

     

    The goal of PDPM is for SNFs to provide value-driven care, said officials. “Fundamentally, it comes down to a balance. A high-value and efficient provider is one that is able to achieve high-quality outcomes at low cost.”

     

    CMS measures SNF quality of care in three main ways:

    • The SNF QRP;

    • The Skilled Nursing Facility Value-Based Purchasing (SNF VBP) program; and

    • The Five-Star Quality Reporting System on Nursing Home Compare.

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  • Interrupted-Stay Policy: CMS Clarifies Noncovered Days

    By Caralyn Davis, Staff Writer - September 04, 2019

    Under the Patient-Driven Payment Model (PDPM), the Centers for Medicare & Medicaid Services (CMS) will implement an interrupted-stay policy for the first time in the Skilled Nursing Facility Prospective Payment System (SNF PPS). The agency is already ironing out some potential bumps in the implementation process. Following the release of the draft v1.17 Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, CMS has clarified the new policy to account for the difference in how the day of discharge is treated for Part A residents who physically discharge from the SNF vs. those who discharge from Part A and remain in the building (e.g., as a Medicaid resident).

     

    CMS officials reviewed key aspects of the interrupted-stay policy, including this new clarification that impacts the count of noncovered days, during two sessions at the August 14 Skilled Nursing Facility Quality Reporting Program (SNF QRP) training event: Section A, I, J, and O Updates and Patient-Driven Payment Model: What Is Changing (and What Is Not). 

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