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.

  • ICD-10 Code Lookup Tool / National Center for Health Statistics (2/20)

    By MX - February 04, 2020

    What is the ICD-10-CM Browser Tool [ Beta Version]

    The National Center for Health Statistics ICD-10-CM Browser tool is a user-friendly web-based query application allows users to search for codes from the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) and provides instructional information needed to understand the usage of ICD-10-CM codes. The application provides access to multiple fiscal year version sets that are available with real-time comprehensive results via the search capabilities.

    The National Center for Health Statistics updates ICD-10-CM on an annual basis.  In addition to the new browser tool, ICD-10-CM and all approved updates to the classification are still available on this webpage for public use.

    Features include:

    Online user’s guide


    • The Official ICD–10–CM Coding Guidelines
    • ICD–10–CM Tabular List of Diseases and Injuries
    • ICD–10–CM Index to Diseases and Injuries
    • ICD–10–CM External Cause of Injuries Index
    • ICD–10–CM Table of Neoplasms
    • ICD–10–CM Table of Drugs and Chemicals

    Functionality features include:

    • Search Index for main term or subterms
    • Search by ICD–10–CM code
    • Pop-up instructional notes
    • Ability to toggle from the Index to the Tabular list.
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  • Get Back to Nursing Basics to Determine Skilled Services

    By Caralyn Davis, Staff Writer - February 04, 2020

    With the rush to understand the Patient-Driven Payment Model (PDPM) under the Skilled Nursing Facility Prospective Payment System (SNF PPS), it’s easy to get caught up in meeting the technical criteria for payment—and not pay enough attention to the clinical criteria for meeting a Medicare skilled level of care, says Jennifer LaBay, RN, RAC-MT, RAC-MTA, CRC, an MDS/policy consultant for Triad Health Care LLC in Providence, RI.


    “PDPM puts the focus on the primary medical condition that is coded in MDS item I0020B using an ICD-10-CM diagnosis code,” explains LaBay. “However, there is a general misunderstanding about what the ICD-10 code in I0020B means. Some nurse assessment coordinators (NACs) look at an ICD-10 code and ask, ‘Is this a skilled diagnosis?’ That’s the wrong question, and you need to avoid falling into the trap of thinking that an ICD-10 code in I0020B that does not return to provider (RTP) means you have a skilled service.”


    The primary medical diagnosis in I0020B only sets the payment. “Specifically, it determines a resident’s default clinical category for PDPM’s physical therapy (PT), occupational therapy (OT), and a portion of the speech-language pathology (SLP) payment components,” she notes.

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  • Q&A: Could I set the ARD of an IPA for a previous calendar day if our facility determined that day would be the most beneficial?

    By Scott Heichel, RN, RAC-MT, RAC-CTA, DNS-CT, QCP, CIC - February 04, 2020
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  • SNF PPS Fact Sheet From Medicare Learning Network - Revised (1/20)

    By CMS - February 03, 2020
    The basics of SNF PPS and consolidated billing.
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  • PDPM Cognitive Level Still Confuses Some SNFs

    By Caralyn Davis, Staff Writer - December 18, 2019

    PDPM Cognitive Level Still Confuses Some SNFs

    The Patient-Driven Payment Model (PDPM) cognitive level plays a key role in determining a Medicare Part A resident’s speech-language pathology (SLP) case-mix component. The Brief Interview for Mental Status (BIMS), coded in MDS items C0200 – C0500, is its primary driver. If the BIMS cannot be completed, the items C0700 (Short-term Memory OK) and C1000 (Cognitive Skills for Daily Decision-Making) from the Staff Assessment for Mental Status combine with items B0100 (Comatose) and B0700 (Makes Self Understood) to determine the PDPM cognitive level. So it’s no surprise that questions about the PDPM cognitive level came fast and furious at the December 12 Skilled Nursing Facility Long-term Care Open Door Forum (ODF).


    Here are the primary issues raised by callers:


    If neither the BIMS nor the Staff Assessment is completed, what happens with regard to obtaining a PDPM cognitive level?

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  • NACs Need to Know: 5 Key Medicare Part A Requirements That Haven’t Changed Under PDPM

    By Caralyn Davis, Staff Writer - December 04, 2019

    The nurse assessment coordinator (NAC) often handles the entire Medicare program in the facility, from managing the PPS schedule to leading the skilled coverage decision. With PDPM in full swing, a lot seems to have changed, but some things have not.


    “The implementation of the Patient-Driven Payment Model (PDPM) changed the payment system used for traditional Part A residents,” says Suzy Harvey, RN-BC, RAC-CT, managing consultant at BKD in Springfield, MO. “It did not change the coverage policies for skilled services.”

    Key requirements that remain in place—and that NACs need to know about—include the following:

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  • MDS 3.0 Provider User's Guide Updated, Including Validation Rpt Error Messages (12/19)

    By QTSO - December 04, 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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  • 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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  • Q&A: Is there still a requirement for a five times a week therapy frequency for Medicare?

    By Jennifer LaBay RN, RAC-MT, RAC-MTA, CRC - November 13, 2019
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  • CMS Updates SNF Medical Review Process for PDPM )11/19)

    By CMS - November 11, 2019

    SUBJECT: Updates to the Medical Review Instructions Related to Skilled Nursing Facilities (SNF)

    I. SUMMARY OF CHANGES: The purpose of this Change Request (CR) is to ensure the medical review instructions in Publication (Pub.) 100-08 align with the regulatory updates issued in final rule CMS-1696-F that created the Patient Driven Payment Model (PDPM), which replaces the prior Resource Utilization Group (RUG) classification system, effective October 1, 2019.

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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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  • 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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  • Q&A: Will the Medicare Physician Certification process will be changing as of October 1?

    By Jennifer LaBay, RN, RAC-MT, RAC-MTA - September 11, 2019
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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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