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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.
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.
Online user’s guide
Functionality features include:
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.
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?
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:
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.
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.
CMS has revised SNF-focused chapters in the following manuals in the online manual system to account for the Patient-Driven Payment Model (PDPM):
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.
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).