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.

  • 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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  • PDPM FAQs and Fact Sheets_Revised (9/19)

    By CMS - September 03, 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.

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  • First Comes PDPM, Then Comes a SNF QRP Tsunami

    By Caralyn Davis, Staff Writer - August 02, 2019

    Nurse assessment coordinators (NACs) won’t be able to take much of a breather following the October 1, 2019, implementation of the new Patient-Driven Payment Model (PDPM) case-mix classification system for the fee-for-service Medicare Part A Skilled Nursing Facility Prospective Payment System (SNF PPS). NACs will have exactly one year to get comfortable with PDPM before their interdisciplinary team has to begin submitting data for 59.5 new Standardized Patient Assessment Data Elements (SPADEs) across the PPS admission and PPS discharge assessments that will be required under the data submission threshold requirement for the Skilled Nursing Facility Quality Reporting Program (SNF QRP). This includes four SPADEs that will be used to calculate and check the logic of two new MDS-based SNF QRP quality measures (QMs) involving the Transfer of Health Information IMPACT Act domain.

    One of the few breaks NACs received in the Fiscal Year (FY) 2020 SNF PPS Final Rule is that CMS has put off plans to expand the SNF QRP to all SNF residents regardless of payer source. Here are the highlights NACs need to know about.

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  • Spelling Out the Differences Between the IPA and SCSA

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

    The Significant Change in Status Assessment (SCSA) may be considered an “old dog” in the assessment world, but we will need to learn new tricks under the Patient-Driven Payment Model (PDPM). While the SCSA is an OBRA assessment, historically it could count as a PPS assessment, and could therefore affect payment when completed during a resident’s Medicare stay. Under PDPM, that is no longer the case. The newly-introduced Interim Payment Assessment (IPA) will be the only assessment, beyond the 5-day, that will be able change a resident’s Medicare rate. While this assessment seems to have similarities to the SCSA, nurse assessment coordinators (NACs) must understand the key differences for criteria, scheduling, timing, and payment and survey implications to ensure success under PDPM.  

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  • PDPM Training and Technical Resources, Including Grouper Logic & ICD-10 Mappings (7/19)

    By CMS - July 02, 2019

    PDPM Training Presentation

    This section includes a training presentation which can be used to educate providers and other stakeholders on PDPM policy and implementation.

    PDPM Resources

    This section includes additional resources relevant to PDPM implementation, including various coding crosswalks and classification logic.

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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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  • 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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  • 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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  • 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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  • 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 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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  • IPA Prep Starts With 5-Day MDS, Strong Communication System

    By Caralyn Davis, Staff Writer - March 19, 2019

    Under the Patient-Driven Payment Model (PDPM) in the Skilled Nursing Facility Prospective Payment System (SNF PPS), the Interim Payment Assessment (IPA, A0310B = 08) will be the only tool providers have to increase the per-diem rate once it’s set by the 5-day PPS MDS, says Scott Heichel, RN, RAC-MT, DNS-CT, QCP, CIC, director of clinical reimbursement for LeaderStat in Powell, Ohio.

     

    “The optional IPA can be used any time in between the 5-day PPS assessment and the Part A PPS Discharge assessment to capture payment increases when the characteristics of the resident change to a level that it actually affects the PDPM calculation in one or more of the five case-mix-adjusted payment categories: physical therapy (PT), occupational therapy (OT), speech-language pathology (SLP), nursing, or nontherapy ancillaries (NTA),” explains Heichel.

     

    To prepare to make optimal use of the IPA, nurse assessment coordinators (NACs) should consider taking the following steps:

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  • Oct. 1, 2019 PDPM Hard Switch Rules Follow-Up (1/19)

    By CMS - January 07, 2019

    Due to some inconsistencies in the language used by CMS officials during the Dec. 11, 2018 SNF PPS: PDPM National Provider Call, AANAC staff followed up via the CMS press office to confirm how the upcoming PDPM hard switch will work. Like previous transitions, the Oct. 1, 2019, transition to PDPM will be ARD-based.

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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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  • PDPM Switch Could be a Rough Road for Some SNFs

    By Caralyn Davis, Staff Writer - December 20, 2018

    On Oct. 1, 2019, the new Patient-Driven Payment Model (PDPM) will replace RUG-IV as the case-mix classification system for Part A beneficiaries under the Skilled Nursing Facility Prospective Payment System (SNF PPS). “There is no transition period between RUG-IV and PDPM, but rather a hard switch from one system to the other,” said officials with the Centers for Medicare & Medicaid Services (CMS) during the Dec. 11 SNF PPS: PDPM National Provider Call. “This is due to the immense potential for significant administrative burden, and the confusion that would arise from trying to run the RUG-IV and PDPM systems concurrently.” Note: Access the call slides, as well as a transcript and recording when available, here.

     

    The two most critical points that nurse assessment coordinators (NACs) need to know about this hard switch are:

     

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