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.

  • 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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  • TIP: CMS Provides Update on Skilled Nursing Facility (SNF) Claims

    By AANAC - November 13, 2019
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  • Q&A: Can the facility count services that were provided in the ER prior to the resident being admitted inpatient as "while in facility" if they were to complete an IPA upon return?

    By Scott Heichel, RN, CIC, RAC-MT, DNS-CT, QCP - November 13, 2019
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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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  • Final MDS 3.0 Data Specs for Oct. 1, 2019 Implementation Plus Errata (11/19)

    By CMS - November 12, 2019

    The FINAL version (V3.00.1) of the MDS 3.0 Data Specifications is effective October 1, 2019. In November 2019, an updated errata (V3.00.3) was posted for the FINAL version (v3.00.1) of the MDS 3.0 Data Specifications, currently in production. Two issues were identified. One edit, -3941, will be deleted, and one edit, -3965, will be added. These changes will go into production on December 3, 2019. Once in production, these two changes will be retroactive, applying to all assessments with target dates on or after October 1, 2019.

    In addition,  V1.04.0 of the MDS 3.0 CAT Specifications  is effective as of October 1, 2019.
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  • CMS Implements SNF Claims Hold (11/19)

    By CMS - November 06, 2019

    As CMS has undertaken the implementation of the Patient Driven Payment Model (PDPM), we are holding a limited number of Skilled Nursing Facility (SNF) claims while we make further refinements to our claims processing system.

     

    PDPM is a historic reform of the SNF prospective payment system. PDPM focuses on the patient’s condition and resulting care needs rather than on the amount of care provided in order to determine Medicare payment. PDPM was effective on October 1, 2019.

     

    Specifically, CMS is holding claims with:

    • Dates of service October 1, 2019 or later and
    • Type of Bill (TOB) inpatient services (21X) and swing bed services (18X) subject to SNF Patient Driven Payment Model (PDPM) and
    • Multiple line items, Health Insurance Prospective Payment System (HIPPS) codes, with different rate codes (revenue code 0022).

     

    Typically, SNFs bill these claims on monthly cycles. Claims with single HIPPS codes were previously being held but are now being released for processing. We anticipate releasing the remaining held claims in late November, once CMS completes systems testing to ensure accurate and timely payment. As of November 1, less than 50 claims are being held.

     

    In addition, we underpaid some SNF inpatient services (21X) and swing bed services (18X) claims for dates of service in October 2019 with a single line item, single HIPPS code. We are automatically reprocessing those claims; no provider action is needed.

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  • BMI Plays a Key Role From Reimbursement to Care Planning

    By Caralyn Davis, Staff Writer - October 16, 2019

    As a screening tool to identify potential weight problems for adults, body mass index (BMI) has always been important to document, but it gained new importance as a reimbursement factor for Medicare Part A residents under the Patient-Driven Payment Model (PDPM). Here’s what nurse assessment coordinators (NACs) need to know about BMI:

     

    Learn the NTA impact for PDPM

    “Residents who are morbidly obese may require a higher degree of nursing effort and skilled nursing care. Likewise, residents at the other end of the scale who are at risk for malnutrition also require more skilled nursing care,” says Pam Duchene, PhD, APRN-BC, NEA, FACHE, RAC-MT, DNS-CT, QCP, vice president of education and training for Harmony Healthcare International in Topsfield, MA.

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  • IPA Algorithm Tool

    By AANAC - October 16, 2019
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  • Q&A: How do I capture that therapy treatment since the IPA does not ask any skilled therapy questions?

    By Jennifer Labay, RN, RAC-MT, RAC-MTA - October 16, 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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  • jRAVEN 1.7.1 Free MDS Submission Software Updated (10/19)

    By CMS - October 07, 2019

    jRAVEN (version 1.7.1) is now available for download which contains the following updates:  

    1. The Final PDPM Grouper, version 1.0003

    2)         All enhancements included with jRAVEN v1.7.0:

    3)            MDS Item Set Version V1.17

    4)            MDS Data Specification Version V3.00

    5)            VUT Version V3.1.0

    6)            The initial PDPM Grouper (replaced with the new version, v1.0003)

    7)            Supports the Correction Policy update to not allow corrections if it causes the target date to cross over the 10/1/2019 date

    8)            Supports the updated submission timeframe change from 3 years to 2 years

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  • Triple Check Your PDPM Transition

    By Jessie McGill, RN, RAC-MTA - October 02, 2019

    The transition from the RUG-IV to the Patient-Driven Payment Model (PDPM), was a hard transition. SNFs followed RUG-IV PPS scheduling and rules through September 30 and then, on October 1, they began PDPM. However, there is still a transition process that must be followed, and nurse assessment coordinators (NACs) need to fully understand all the requirements. NACs also need to double check all payer types and assessment reference dates (ARDs) and ensure that, by the end of October 7, the facility has completed all steps the process requires. Lastly, NACs may want to consider completing a quick triple check or a billing review to ensure all the conditions of Medicare billing have been met before the end of the transition. While the triple check process is typically reserved for reviewing the previous month’s claims, completing an expedited check by October 7, before the end of the transition, can help reduce the risk of payment penalties. Here are three key steps to a successful transition: 

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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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  • TIP: PDPM HAS ARRIVED

    By AANAC - October 02, 2019
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