You Are Here:Home/Information/Patient-Driven Payment Model (PDPM)
Government sources documents
PDPM Virtual Workshop
PDPM Game Plan
Join AANAC for 24/7 access to resources and education that keep you up-to-date and ahead of changes.
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.
To bill under traditional fee-for-service Medicare Part A, skilled nursing facilities (SNFs) must obtain appropriate, timely physician certifications and recertifications of posthospital inpatient extended-care services. The physician cert/recert policy did not change with the implementation of the Patient-Driven Payment Model (PDPM) on October 1, 2019.
However, the Centers for Medicare & Medicaid Services (CMS) did adjust the instructions in the Medicare Online Manual System to explain when providers need to obtain a new physician certification vs. when they should continue using the existing cert/recert to account for the interrupted stay policy that was implemented in conjunction with PDPM. This adjustment brought to light the fact that some SNFs may be counting calendar days instead of Medicare days to determine when certs/recerts are due—a practice that is incorrect CMS officials tell the American Association of Nurse Assessment Coordination (AANAC).
“The regulations at 42 CFR 424.20(d) state that the first recertification is required no later than ‘the 14th day of post-hospital SNF care.’ This would have the schedule track with the days of the stay (i.e., covered days) rather than calendar days,” explain officials. Note: Review the physician cert/recert section of the Code of Federal Regulations in the box at the end of this article.
“This also tracks with previous statements we have made comparing the recertification timeline with the variable per-diem schedule, and interrupted stays have similar impacts on both, as noted in response to FAQ 13.21,” say officials. Here is the FAQ excerpted from Patient-Driven Payment Model: Frequently Asked Questions (FAQs):
On April 10, the Centers for Medicare & Medicaid Services (CMS) released for public inspection the Fiscal Year (FY) 2021 Proposed Rule for the Skilled Nursing Facility Prospective Payment System (SNF PPS) and Consolidated Billing (CMS-1737-P) as required by law. In a major break from recent years, CMS offers no proposals for updating the Skilled Nursing Facility Quality Reporting Program (SNF QRP) and only what the agency describes as “minor administrative proposals” related to the SNF Value-Based Purchasing (VBP) program.
However, CMS does propose several other revisions in addition to the required Medicare Part A payment rate update. These include:
When the nurse assessment coordinator (NAC) prepares to code the MDS, the process starts with data collected during the lookback period. However, one frequently-asked question is, “When can services that occurred prior to admission to the skilled nursing facility (SNF) be captured on the MDS?” There is no simple answer, because it depends on the coding instructions for each MDS item. Let’s take a look at the particulars of coding preadmission data, why it is collected, and how preadmission data is used under PDPM.
Chapter 3 of the RAI User’s Manual contains the coding instructions for each MDS item; however, the overview of chapter 3, pages 3-1 through 3-6, are often overlooked. This brief section discusses coding conventions, which apply to all MDS items, and includes the instructions on preadmission data:
With the exception of certain items (e.g., some items in Sections K and O), the lookback period does not extend into the preadmission period unless the item instructions state otherwise. In the case of reentry, the lookback period does not extend into time prior to the reentry, unless instructions state otherwise.
MDS Item Set 1.17.1 Preadmission Data and Why It Is Collected
Under the Patient-Driven Payment Model (PDPM), MDS item I8000 (Additional Active Diagnoses) is on every nurse assessment coordinator’s (NAC’s) radar thanks to its role as a source of ICD-10-CM diagnosis codes that can influence the speech-language pathology (SLP) or nontherapy ancillaries (NTA) case-mix-adjusted payment components—not to mention its role providing risk-adjustment covariates for the Skilled Nursing Facility Quality Reporting Program (SNF QRP) quality measures (QMs) says Carol Maher, RN-BC, RAC-MTA, RAC-MT, RAC-CTA, RAC-CT, CPC, director of education for Hansen, Hunter & Co. PC in Vancouver, WA.
“Despite this renewed focus on I8000, NACs and other interdisciplinary team (IDT) members are still struggling with diagnosis coding,” says Maher. “There is a lot of confusion in SNFs across the country.”
Here are seven steps the NAC and other IDT members can take to address common problems that may prevent I8000 from being coded accurately:
The Centers for Medicare & Medicaid Services is releasing three short video tutorials to assist providers with coding Section GG. These videos, ranging from 5 to 10 minutes, are designed to provide targeted guidance using simulated patient scenarios. To access the videos, click on the links below:
· GG0130H. Putting on/taking off footwear.
· GG0170L. Walking 10 feet on uneven surfaces.
· GG1070P. Picking up object.
From January 26 through February 16, 2020, a software issue caused Skilled Nursing Facility (SNF) claims to be incorrectly cancelled with a message that there was no three day qualifying hospital stay. This issue is corrected. If your claims were incorrectly cancelled, re-bill them in sequential order to receive payment.
· Claims need to process in date of service order for each stay for the Variable Per Diem (VPD) to calculate correctly
· Submit claims in sequence and wait at least 2 weeks before billing subsequent claims
· Some of the affected claims with older dates of service will require a timely filing exception; enter “Resubmission due to non-qualifying stay” in the remarks field
· This issue was not caused by the recent implementation of the SNF Patient Driven Payment Model
· Contact your MAC to receive the Medicare Beneficiary Identifier (MBI) for deceased beneficiaries
Nurse assessment coordinators (NACs) and other MDS assessors must be ready to code multiple new standardized patient assessment data elements (SPADEs) and other MDS items that will be required to meet the data submission threshold in the Skilled Nursing Facility Quality Reporting Program (SNF QRP), as well as new or revised items that aren’t part of the SNF QRP, effective this October 1.
However, it’s not time for practice coding scenarios just yet. The draft version 1.18.0 MDS item sets and their companion MDS 3.0 Item Set Change History for October 2020 Version 1.18.0 remain in draft format. In addition, the Centers for Medicare & Medicaid Services (CMS) hasn’t announced a timeline for releasing a revised Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, and significant training opportunities from CMS are still months away.
Nevertheless, AANAC master teachers recommend NACs and other interdisciplinary team (IDT) members go ahead and take a bird’s eye look at the following revisions:
This message will appear in this week’s edition of MLN Connects, but we wanted to give our partners advance notice—please share with your members.
SNF PDPM Claims Issue
Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) initial claims that are processed out of sequence are not paying the correct Variable Per Diem (VPD)-adjusted rate. Also all adjustment claims are not processing correctly. Claims need to process in date of service order for each stay for the VPD to calculate correctly. We will correct this issue in October. In the interim:
Director, Division of Provider Relations & Outreach
Provider Communications Group
Centers for Medicare & Medicaid Services
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.
Dysphagia coding plays a key role in the Patient-Driven Payment Model (PDPM) through both section I (Active Diagnoses) and section K (Swallowing/Nutritional Status) of the MDS. Here are the keys to getting it right:
Don’t assume IDT members understand PDPM
Sometimes nurse assessment coordinators (NACs) assume that speech-language pathologists and registered dietitians (RDs) already understand PDPM and the Resident Assessment Instrument (RAI) process when they walk in the door, notes Brenda Richardson, MA, RDN, LD, FAND, a long-term care nutrition expert based in Salem, IN, who is the past chair of the Academy of Nutrition and Dietetics Political Action Committee (ANDPAC) and recipient of the 2019 Academy Lenna Frances Cooper Memorial Lecture Award.
“However, dysphagia’s role in PDPM is complex. Not only do IDT members need to understand each resident’s dysphagia diagnosis, they also need to understand how that diagnosis maps—or doesn’t map—to the ICD-10-CM codes that impact PDPM, as well as how that corresponds to the MDS and the coding instructions for sections I and K,” she points out. “Employers, including contract service employers, often do not prioritize training related to payment models, so taking the time to sit down with speech pathologists and RDs to discuss the rules will only improve your ability to capture dysphagia accurately on the MDS.”
Ten subitems in MDS item O0100 (Special Treatments, Procedures, and Programs) can affect from one to three of the case-mix-adjusted payment components in the Patient-Driven Payment Model (PDPM): speech-language pathology (SLP), nontherapy ancillaries (NTA), and/or nursing. The following chart shows the potential impacts:
Potential PDPM Impact
O0100A2 (Chemotherapy While a Resident)
Nursing Clinically Complex
O0100B2 (Radiation While a Resident)
NTA (1 point), Nursing Special Care Low, Nursing Clinically Complex
O0100C2 (Oxygen Therapy While a Resident)
· Must be in combination with I6300 (Respiratory Failure) to qualify for Nursing Special Care Low
Nursing Special Care Low, Nursing Clinically Complex
O0100D2 (Suctioning While a Resident)
NTA (1 point)
O0100E2 (Tracheostomy Care While a Resident)
SLP, NTA (1 point), Nursing Extensive Services, Nursing Clinically Complex
O0100F2 (Invasive Mechanical Ventilator (ventilator or respirator) While a Resident)
SLP, NTA (4 points), Nursing Extensive Services, Nursing Clinically Complex
O0100H2 (IV Medications While a Resident)
NTA (5 points), Nursing Clinically Complex
O0100I2 (Transfusions While a Resident)
NTA (2 points), Nursing Clinically Complex
O0100J2 (Dialysis While a Resident)
O0100M2 (Isolation or Quarantine for Active Infectious Disease (does not include standard body/fluid precautions) While a Resident)
NTA (1 point), Nursing Extensive Services, Nursing Clinically Complex
Note: When more than one nursing category is listed, the resident may be classified into the lower category depending on other MDS data, e.g., the resident’s nursing function score.
MDS item I0020B (ICD Code/Resident’s Primary Medical Condition) sets a Medicare Part A resident’s default primary diagnosis clinical category for determining case-mix classification in the physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) payment components of the Patient-Driven Payment Model (PDPM). However, a major surgery in the resident’s immediately preceding inpatient hospital stay that is coded in MDS items J2100 – J5000 can push the resident into a surgical category that takes precedence over the default category, resulting in a higher-paying case-mix group.
Item J2100 (Recent Surgery Requiring Active SNF Care) is the lynchpin to achieving a surgical clinical category, serving as the gateway question that determines whether or not a surgery can be captured in J2300 – J5000 (Recent Surgeries Requiring Active SNF Care). Note: See the PDPM Calculation Worksheet for SNFs in chapter 6 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual for details on how items in J2300 – J5000 impact classification.