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.

  • Balancing Sections G and GG Requirements

    By Jessie McGill, RN, RAC-MT, RAC-MTA - July 10, 2019

    With the enormous focus on the transition from RUG-IV to PDPM, some may consider abandoning their section G Activities of Daily Living (ADLs) training materials, audits, and tools— but wait just a moment! Although section GG is stepping into the Medicare reimbursement spotlight, section G still plays a big role in other types of reimbursement and Quality Measures. To ensure success, the nurse assessment coordinator (NAC) must have a full understanding of the coding instructions, documentation requirements, impact on Quality Measures, and reimbursement for both section G and GG. Here are four key differences between the two sections and tips for successfully managing both.

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  • PDPM Lessons Learned From the Nursing RUGs

    By Caralyn Davis, Staff Writer - July 10, 2019

    On October 1 2019, the nursing case-mix groups used in the RUG-IV case-mix classification system will be streamlined and consolidated to form the nursing component of the Patient-Driven Payment Model (PDPM). By decreasing distinctions based on function for certain groups, the PDPM nursing component will use only 25 case-mix groups (ES3 – PA1) compared to the 43 RUG-IV nursing case-mix groups. For example, the RUG-IV groups HE2 and HD2 will be collapsed into the modified PDPM nursing case-mix group HDE2.

     

    However, the core process for assigning residents to a nursing case-mix group will remain basically the same, taking into account the use of extensive services, the presence of certain clinical conditions, the presence of depression, the provision of restorative nursing services, and the resident’s functional score (using section GG instead of section G). Consequently, nurse assessment coordinators (NACs) and other interdisciplinary team (IDT) members can learn some lessons about historically undercoded MDS items that could impact their ability to achieve the most accurate case-mix group for the PDPM nursing component, says Robin Hillier, CPA, STNA, LNHA, RAC-MT, president of RLH Consulting in Westerville, OH.

     

    Here are four items or sections worth revisiting:

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  • Cognitive Impairment Score Tool

    By AANAC - July 10, 2019
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  • Q&A: How will the 30-day window rule work under PDPM with the new Interrupted Stay Policy?

    By Carol Maher, RN-BC, CPC, RAC-MT - July 10, 2019
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  • Q&A: Resident admitted status post lumbar laminectomy due to lumbar spinal stenosis with neurogenic claudication, what would the primary diagnosis be?

    By Jennifer LaBay RN, RAC-MT, RAC-MTA - July 10, 2019
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  • August 13 - 14 CMS SNF QRP Training Event: Register to Attend Online or In-person

    By CMS - July 04, 2019

    REGISTRATION OPEN – SNF QRP Provider In-Person Training Event, August 13 and 14, 2019

    The Centers for Medicare & Medicaid Services (CMS) will be hosting a 2-day Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) in-person ‘Train the Trainer’ event for providers on August 13 and 14, 2019, at the Four Seasons Hotel, 200 International Drive, Baltimore, MD 21202. This event will be open to all SNF providers, associations, and organizations.

    Like the May 2019 SNF QRP Provider Training, the primary focus of this 'Train-the-Trainer’ event will be to provide those responsible for training staff at SNFs with information about:

    ·        The transition to the Patient Driven Payment Model (PDPM) which becomes effective on October 1, 2019.

    ·        A review of SNF QRP changes and updates to the Minimum Data Set (MDS) 3.0 Version 1.16.0, which became effective October 1, 2018.

    ·        An overview of the eleven SNF QRP Quality Measures.

    An interactive session on the use of reports to identify opportunities for process improvement and utilize information contained in reports available via the Certification And Survey Provider Enhanced Reports (CASPER) system to develop quality improvement plans.

    During this event, presenters will incorporate additional information into their presentations based on questions received from participants during the May training.

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  • Beta PDPM Grouper DLL Released (7/19)

    By CMS - July 04, 2019

    A BETA version of the PDPM Grouper DLL has been posted, along with its source code.  Please read the READ ME FIRST.PDF within the ZIP file before attempting to use the grouper software.  Note that testing of the DLL is ongoing.  Please report any issues found to PDPM@cms.hhs.gov.

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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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  • 2020 ICD-10-CM Diagnosis Code Files Available (6/19)

    By CMS - June 25, 2019
    The 2020 ICD-10-CM files  contain information on the ICD-10-CM updates for FY 2020. These 2020 ICD-10-CM codes are to be used for discharges occurring from October 1, 2019 through September 30, 2020 and for patient encounters occurring from October 1, 2019 through September 30, 2020.
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  • Challenge Question: Under PDPM, what assessment is required if there is a 3-day break in therapy services?

    By AANAC - June 19, 2019

    Question: Under PDPM, what assessment is required if there is a 3-day break in therapy services?

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  • PDPM Case-Mix Group Conversion to HIPPS Characters Tool

    By AANAC - June 19, 2019
    Getting ready for PDPM? Check out AANAC's new PDPM Case-Mix Group Conversion to HIPPS Characters tool.
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  • Variable Per-Diem Adjustments Will Spotlight Skilling Decisions

    By Caralyn Davis, Staff Writer - June 18, 2019

    This October 1, the Patient-Driven Payment Model (PDPM) will introduce variable per-diem payment adjustments to providers paid under the Skilled Nursing Facility Prospective Payment System (SNF PPS). PDPM has five case-mix-adjusted components that each have an associated payment based on the case-mix group classification: physical therapy (PT), occupational therapy (OT), speech-language pathology services (SLP), nursing, and nontherapy ancillaries (NTA). For the PT, OT, and NTA components, case-mix group payments will decrease over the course of a Part A patient’s stay according to the predetermined schedules and adjustment factors found in Table 20, PT and OT Variable Per Diem Adjustment Factors, and Table 21, NTA Variable Per Diem Adjustment Factors, on page 6-48 of the draft version 1.17 Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual.

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  • Q&A: I have noticed that there are many ICD-10-CM diagnosis codes that result in “return to provider" on the PDPM ICD-10 Mappings. Is it true that we cannot use these codes?

    By Jennifer LaBay, RN, RAC-MT, RAC-MTA - June 18, 2019
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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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  • Preliminary RAI Manual v1.17 Released (5/19)

    By CMS - May 20, 2019

    The PDF file labeled “MDS 3.0 RAI Manual v1.17 October 1, 2019” is now available.

    Please note this early release is being provided in response to stakeholder feedback. The MDS 3.0 RAI Manual v1.17 contains many updates including information related to the Patient Driven Payment Model. Please check back prior to October 1, 2019 for a final posting which may contain additional updates.

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