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.

  • RAI Manual v1.17.1 Posted for Oct. 1 Implementation (9/19)

    By CMS - September 18, 2019

    This page contains the MDS 3.0 RAI Manual v1.17.1 and MDS forms, effective October 1, 2019. This version of the MDS 3.0 RAI Manual incorporates clarifications to existing coding and transmission policy; it also addresses clarifications and scenarios concerning complex areas. 

    Since the preliminary release of the manual on May 20, 2019, changes have been made to clarify which assessments swing bed providers must complete; the definition of the “interruption window” for interrupted Part A-covered stays; the coding of item I0200B; and changes related to group therapy policies, as well as other corrections. Please see the document titled “MDS 3.0 RAI Manual v1.17.1 Replacement Manual Pages and Change Tables_October 2019."

    Read more
  • 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

    Read more
  • 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.

    Read more
  • TIP: PDPM Resources Updated

    By AANAC - September 11, 2019
    Read more
  • Q&A: What is the primary ICD-10-CM code to use when a resident has weakness related to sepsis, but the sepsis is resolved prior to SNF admission?

    By Carol Maher, RN-BC, CPC, RAC-MT - September 11, 2019
    Read more
  • 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
    Read more
  • Final PDPM Grouper DLL Released Plus Errata (9/19)

    By CMS - September 09, 2019

    The FINAL version of the PDPM Grouper DLL has been posted, along with its source code, plus an errata.  Note that the DLL interface has not changed since the beta version. Documentation and test files will be provided in a separate posting – coming soon. Please report any issues found to PDPM@cms.hhs.gov.

    Read more
  • 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). 

    Read more
  • FY 2020 PDPM ICD-10 Mapping Tool and MDS Item I0020B ICD-10 Code Lookup Tool (9/19)

    By CMS - September 03, 2019

    CMS has released the PDPM ICD-10 Mappings File for FY 2020 as well as the I0020B Code Lookup File. 

    Read more
  • 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.

    Read more
  • Final MDS 3.0 Data Specs for Oct. 1, 2019 Implementation (8/19)

    By CMS - August 21, 2019

    The FINAL version (V3.00.1) of the MDS 3.0 Data Specifications was posted.  This version is scheduled to become effective October 1, 2019.  Note that there have been additional revisions since the errata – they can be identified by looking for “post-errata” in the version notes for the items and edits.

    In addition,  V1.04.0 of the MDS 3.0 CAT Specifications  is also scheduled to become effective October 1, 2019. The specification for CAT 12 (Nutritional Status) has been updated in accordance with the changes in V3.00.0 of the MDS 3.0 Data Specifications.
    Read more
  • Under PDPM, Group/Concurrent Therapy Will Need NAC Case Management

    By Caralyn Davis, Staff Writer - August 13, 2019

    When the Patient-Driven Payment Model (PDPM) implements this October 1 in the fee-for-service Medicare Part A Skilled Nursing Facility Prospective Payment System (SNF PPS), concurrent therapy, group therapy, and even restorative nursing will once again take on a renewed importance as tools for achieving a resident’s clinical goals, says Joel VanEaton, BSN, RN, RAC-MT, vice president of compliance and regulatory affairs for Broad River Rehab in Asheville, NC.

     

    “However, you may run into trouble if SNFs or therapists simply dictate, ‘We will do X amount of concurrent and group therapy,’” suggests VanEaton. “PDPM is intended to be a reimbursement system that elevates the resident’s voice by ensuring that resident care decisions appropriately reflect each resident’s actual care needs.”

    Read more
  • Interrupted Stay Tracker Tool

    By AANAC - August 13, 2019
    Read more
  • TIP: Aug. 13 CMS SNF QRP Training Provides Clarification

    By AANAC - August 13, 2019
    Read more
  • Q&A: For residents admitted during the last week of September, how would we schedule the admission and 5-day assessments?

    By Scott Heichel RN, RAC-MT, DNS-CT, QCP, CIC - August 13, 2019
    Read more
1 of 7 Next