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.

  • Sept. 19 SNF/LTC Open Door Forum Agenda and Call-in Info

    By CMS - September 11, 2019

    The next CMS Skilled Nursing Facilities (SNF)/Long Term Care (LTC) Open Door Forum scheduled for:  

    Date:  Thursday, September 19, 2019

    Start Time:  2:00 PM – 3:00 PM Eastern Time (ET);

    Please dial-in at least 15 minutes before call start time.

    Conference Leaders: Todd Smith & Jill Darling

    **This Agenda is Subject to Change**

    I.   Opening Remarks

    Chair – Todd Smith (Center for Medicare)

    Moderator – Jill Darling (Office of Communications)

    II.   Announcements & Updates

    *PDPM Update

    *PBJ Update

    *Policy Questions should be sent to: NHStaffing@cms.hhs.gov

    *Technical Issues/Questions should be sent to: NursingHomePBJTechIssues@cms.hhs.gov

    *PBJ Website: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html

    * CMS-6058-FC Medicare, Medicaid, and Children's Health Insurance Programs; Program Integrity Enhancements to the Provider Enrollment Process

    *SNF QRP resource update

    III. Open Q&A

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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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  • TIP: Aug. 13 CMS SNF QRP Training Provides Clarification

    By AANAC - August 13, 2019
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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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  • 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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  • 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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  • 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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  • FY 2020 SNF PPS Proposed Rule (4/19)

    By CMS - April 19, 2019

    Proposed Fiscal Year 2020 Payment and Policy Changes for Medicare Skilled Nursing Facilities (CMS-1718-P)

    On April 19, 2019, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule [CMS-1718-P] for Fiscal Year (FY) 2020 that updates the Medicare payment rates and the quality programs for skilled nursing facilities (SNFs). This proposed rule is part of our 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.  Additionally, effective October 1, 2019, CMS will begin using a new case-mix model, the Patient Driven Payment Model (PDPM), which focuses on the patient’s condition and resulting care needs rather than on the amount of care provided in order to determine Medicare payment.

    This fact sheet discusses three major provisions of the proposed rule: the proposed changes to SNF payment policy under the SNF Prospective Payment System (PPS), the SNF Value-Based Purchasing Program (VBP), and the SNF Quality Reporting Program (QRP).  This proposed rule includes policies that would continue a commitment to shift Medicare payments from volume to value, with the continued implementation of the PDPM, SNF VBP, and SNF QRP to improve program interoperability, operational quality and safety.

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  • No. 1 Sign of GG Dysfunction? Therapy Runs the Show Alone

    By Caralyn Davis - February 20, 2019

    Providers have been collecting data for MDS section GG (Functional Abilities and Goals) since October 2016, largely to meet the data submission threshold for the Skilled Nursing Facility Quality Reporting Program (SNF QRP). “In many SNFs, nursing has generally abdicated responsibility for section GG to the therapy department because there is no payment attached to section GG under the RUG-IV case-mix classification system,” says Joel VanEaton, BSN, RN, RAC-MT, vice president of compliance and regulatory affairs for Broad River Rehab in Asheville, NC.

     

    “That’s a big mistake when it comes to the Patient-Driven Payment Model (PDPM), which implements on Oct. 1,” says VanEaton. “To correctly define the resident’s functional profile in section GG, you have to figure out how to shift from that therapy-only paradigm to a paradigm of true collaboration, particularly among the MDS department, nursing, and rehab.”

     

    “The most significant problem with section GG is that coding often isn’t interdisciplinary,” agrees Tracy Montag, BSN, RN, RAC-MT, clinical consultant with the Senior Living Services Consulting Group at RKL LLP in York, PA. “There are still a lot of facilities that don’t look at usual performance over three days because coding is so therapy-driven. For example, for the 5-day PPS MDS, they input information directly into section GG from the documentation the therapist completes during the therapy evaluation. Sometimes facilities don’t even have information collected for some components of section GG because therapy is not seeing the resident for those components.”

     

    To improve section GG coding accuracy, nurse assessment coordinators (NACs) should consider the following steps:

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  • CMS Targets May Release for Draft RAI Manual

    By Caralyn Davis, Staff Writer - February 19, 2019

    In preparation for the Oct. 1, 2019, implementation of the Patient-Driven Payment Model (PDPM) under the Skilled Nursing Facility Prospective Payment System (SNF PPS), officials with the Centers for Medicare & Medicaid Services (CMS) had promised an early release of the draft version of the next update to the RAI User’s Manual for the MDS 3.0. However, that release won’t occur quite as early as most providers hoped.

     

    “We historically publish that manual more toward August,” said officials during the Feb. 14 Skilled Nursing Facility/Long-term Care Open Door Forum (ODF). “We do understand the need to be able to review [it for] the PDPM, so our goal is to have that published in May sometime this year.”

     

    In other manual news, CMS also expects to release version 12 of the MDS 3.0 Quality Measures (QM) User’s Manual “in the next couple of months,” said officials. On Feb. 1, the QIES Technical Support Office (QTSO) announced changes to the MDS 3.0 Quality Measure Reports in the CASPER Reporting application, including calculation updates/changes to the short-stay pressure ulcer measure, the long-stay pressure ulcer measure, and the long-stay weight loss measure. The methodology for those updated QMs “is not used in the public domain yet,” said officials to justify the agency’s delay in releasing new technical specifications.

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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: Are the PDPM rates still adjusted by a VBP adjustment factor and in cases where a provider fails to submit data required by the SNF QRP?

    By CMS - January 09, 2019
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  • From SNF PPS Final Rule to Medicare Remit: How Much $ Will You Get?

    By Caralyn Davis, Staff Writer - December 18, 2018

    Due to how payments are calculated in the Medicare Part A Skilled Nursing Facility Prospective Payment System (SNF PPS), there’s always been a slight difference between the federal payment rate tables that are published annually in the SNF PPS rules and the adjusted rates that SNFs actually receive from their Medicare administrative contractors (MACs). The potential difference increased slightly in fiscal year (FY) 2018 with the launch of the Skilled Nursing Facility Quality Reporting Program (SNF QRP). However, financial discrepancies could be larger than ever now that the Skilled Nursing Facility Value-Based Purchasing (SNF VBP) program impacts SNF PPS payment effective with FY 2019, which began on Oct. 1, 2018.

     

    To avoid problems in such key areas as accounts receivable and budget forecasting, nurse assessment coordinators (NACs) and billing staff need to understand the basic rules for how SNF PPS payment rates are created and adjusted, especially now that SNF QRP and SNF VBP are in the mix. The key steps discussed below (and presented graphically in a flow chart at the end of this article) lead from:

     

    (1)   The unadjusted federal payment rates that the Centers for Medicare & Medicaid Services (CMS) publishes in the SNF PPS rules, to

    (2)   The adjusted rates that SNFs bill on Part A claims, to

    (3)   The Medicare remittance advices that MACs use to explain final claim adjudication and payment information.

     

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  • SNF/LTC ODF: CMS Talks Quality and Payment

    By Caralyn Davis, Staff Writer - December 04, 2018

    Change is the one constant nursing homes face these days as the Centers for Medicare & Medicaid Services (CMS) pushes providers to transform from an institutional, service-driven approach to a patient-focused, clinical-need approach that highlights quality of care and quality of life. While this drive began on the survey side with the implementation of the revised Medicare/Medicaid conditions of participation, it now also is taking root on the payment side via several quality programs impacting the fee-for-service Medicare Part A program.

     

    During the Nov. 29 Skilled Nursing Facility/Long-term Care Open Door Forum, CMS officials addressed programs on both sides of the aisle, including:

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

    By AANAC - November 12, 2018
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