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.

  • jRAVEN 1.7.6 Free MDS Submission Software Updated (10/20)

    By QTSO - October 16, 2020

    The Resident Assessment Validation and Entry System (jRAVEN) was developed by the Centers for Medicare & Medicaid Services (CMS). jRAVEN is a free Java based software application which provides an option for facilities to collect and maintain MDS Assessment data for subsequent submission to the appropriate state and/or national data repository. jRAVEN displays the MDS Item Sets similar to the paper version of the forms. Please consult the jRAVEN Installation and User Guides for additional information.

    jRAVEN v1.7.6 is now available for download. Users do not need a previous version of jRAVEN to download, install or use jRAVEN v1.7.6.

    jRAVEN v1.7.6 includes the following enhancement:

    • The new PDPM Grouper, V1.0008, included in this are the six ICD-10 codes that were added in the 1.0007 version.


    JRAVEN v1.7.6 replaces jRAVEN (version 1.7.5), which contained the following updates:  

    • The new PDPM Grouper, v1.0007, along with its source code and test cases, which was updated to include the 6 ICD-10 codes that were inadvertently excluded from the previous release (1.0006).  This version, V1.0007, adds six ICD-10 codes that were inadvertently excluded from the NTA calculation: 
    • T8484XA, 
    • T8389XA, 
    • T8321XA, 
    • T82399A, 
    • T82392A, and 
    • T83021A. 
    • The OBRA PDPM Grouper Calculation screen (for states requiring PDPM scores on OBRA comprehensive NC & NQ assessments) was updated to allow for entry of an End Date to go up through 12/31/2099
    • The updates included with jRAVEN 1.7.4 (MDS Item Set v1.17.2, Data Specification Errata v3.00.5, the MDS VUT v3.4.0)
    Read more
  • Final PDPM Grouper DLL V1.0008 (REVISED) Effective Oct. 1, 2020

    By CMS - October 12, 2020

    An update to the PDPM Grouper DLL has been posted, along with its source code and test cases.  This version, V1.0008, corrects an issue with a dynamic array that was not consistently reinitialized when processing multiple assessments within a short time frame.  This occasionally caused incorrect PDPM recalculation results when processing pre- and post- 10/01/2020 assessments.

    The FINAL version of the PDPM Grouper supports the calculation of PDPM payment codes on OBRA assessments when not combined with the 5-day SNF PPS assessment, specifically the OBRA comprehensive (NC) and OBRA quarterly (NQ) assessment item sets.  Note that the grouper will return 4-character codes for these OBRAs.

    It is important to include the control item STATE_PDPM_OBRA_CD (as defined in the V3.00.5 errata for the FINAL version (v3.00.1) of the MDS 3.0 Data Specifications) for assessments with target date on or after October 1, 2020.  

    Note that this FINAL version supports the ICD-10 codes that are defined in the data specifications as valid for item I0020B for FY2021.  Also, please note that the grouper expects valid FY2021 ICD-10 codes for I8000A-J when processing assessments with target date on or after October 1, 2020.  

    Read more
  • State PDPM Data Collection Map Tool

    By AANAC - October 07, 2020
    Read more
  • PDPM Internal Audits: How to Be Proactive in a Time Crunch

    By Caralyn Davis, Staff Writer - October 06, 2020

    Navigating the COVID-19 public health emergency can be difficult for skilled nursing facilities (SNFs). However, no matter what the challenges are—staffing shortages, time-consuming infection prevention and control practices, the need to rearrange schedules and duties to preserve personal protective equipment (PPE), residents who need extra time and attention, or the myriad other issues—providers still have to be paid, and that means nurse assessment coordinators (NACs) need to do internal audits so they are ready to back up Patient-Driven Payment Model (PDPM) case-mix classifications for Part A residents if a Medicare auditor comes knocking.

     

    What to do going forward

    “The key to efficient PDPM internal audits during a COVID-19 outbreak or any crisis is focus,” says Robin Hillier, CPA, STNA, LNHA, RAC-MT, president of RLH Consulting in Westerville, OH. “Obviously, the best practice is to audit every MDS item and look for missed coding opportunities, as well as double-checking what you have already coded. However, that may not always be a realistic option, especially during a pandemic when, for example, you may need to work the floor because of a staffing shortage. In addition, a full audit isn’t necessary to be sure you can defend your billing to a Medicare auditor.”

    Read more
  • Section GG Data Collection Tool for OBRA Assessments

    By AANAC - October 06, 2020
    Read more
  • Q&A: Our state is requiring PDPM data on OBRA assessments. Is section GG collected on only Medicaid residents or for all payer types?

    By Jessie McGill, RN, RAC-MT, RAC-MTA - October 06, 2020
    Read more
  • MDS 3.0 Provider User's Guide Updated, Including Validation Rpt Error Messages (9/20)

    By QTSO - September 29, 2020
    Key information about how to submit MDS files and how to obtain and understand error messages on initial and final validation reports. 
    Read more
  • FY 2021 ICD-10 Code Lookup File for MDS Item I0020B

    By CMS - September 17, 2020
    The lookup files containing the allowable ICD codes for item I0020B have been updated for FY2021, and is posted as a ZIP file. 
    Read more
  • Q&A: Under PDPM, do I complete the PPS Discharge Assessment (NPE) when therapy ends or wait until the Medicare stay ends?

    By Jennifer LaBay, RN, RAC-MTA, CRC - September 01, 2020
    Read more
  • Is Your State Considering PDPM Data Collection? Four Steps to Prepare

    By Jessie McGill, RN, RAC-MT, RAC-MTA - August 19, 2020

    The Centers for Medicare and Medicaid Services (CMS) gave states the option to collect Patient-Driven Payment Model (PDPM) billing codes on OBRA assessments when not combined with a Medicare PPS 5-Day assessment, beginning Oct. 1, 2020. While most of the information used to establish these codes is already on the OBRA assessments, the additional data collection will require both time to complete and training to perform correctly. Notably, the addition of completing the admission performance column for section GG (Functional Abilities) will take the most time. A lack of proper training for the staff completing this section has the potential to cause inaccuracies and confusion among direct care staff. However, the stress and workload can be mitigated with a strong preparation plan and ongoing support to direct care staff. Follow these four steps to ensure your team is ready to complete successfully the documentation and data collection for section GG on OBRA assessments:

    1.      Understand how your state is using the information and expected future implications

    Read more
  • FY 2021 PDPM ICD-10 Mappings (8/20)

    By CMS - August 09, 2020

    The Mappings file contains: 


    • Mapping of the ICD-10-CM Recorded in Item I0020B of the MDS Assessment to PDPM Clinical Categories 
    • Mapping of Comorbidities Included in the PDPM SLP Component to ICD-10-CM Codes
    • Mapping of Comorbidities Included in the PDPM NTA Component to ICD-10-CM Codes
    Read more
  • MDS Section J: Learn What ‘Major’ Surgery Means

    By Caralyn Davis, Staff Writer - August 04, 2020

    “Does this surgery count as a major surgery?” is one of the most frequently asked questions that nurse assessment coordinators (NACs) have about MDS items J2100 (Recent Surgery Requiring Active SNF Care) and J2300 – J5000 (Recent Surgeries Requiring Active SNF Care: Surgical Procedures), says Carol Maher, RN-BC, RAC-MTA, RAC-MT, CPC, director of education for Hansen, Hunter & Co. PC in Vancouver, WA.

     

    “It’s an important question because capturing a major surgery in J2100 and J2300 – J5000 can make a difference in the Medicare Part A payment that you receive for the physical therapy (PT) and occupational therapy (OT) components under the Patient-Driven Payment Model (PDPM),” says Maher. “A major surgery can move the resident from their default primary diagnosis clinical category established in I0020B (ICD Code/Primary Medical Condition) into a potentially higher-paying surgical clinical category for PT and OT.”

    Read more
  • FY 2021 SNF PPS Final Rule Released (7/20)

    By CMS - August 02, 2020

    On July 31, 2020, the Centers for Medicare & Medicaid Services (CMS) issued a final rule [CMS-1737-F] for Fiscal Year (FY) 2021 that updates the Medicare payment rates and the value-based purchasing program for skilled nursing facilities (SNFs). CMS is publishing this final rule consistent with the legal requirements to update Medicare payment policies for SNFs on an annual basis. In recognition of the significant impact of the COVID-19 public health emergency, and limited capacity of health care providers to review and provide comment on extensive proposals, CMS has limited annual SNF rulemaking required by statute to essential policies including Medicare payment to SNFs.

    The final rule includes routine technical rate-setting updates to the SNF prospective payment system (PPS) payment rates, and adopts the revised Office of Management and Budget (OMB) statistical area delineations.  In addition, the rule applies a 5 percent cap on wage index decreases from FY 2020 to FY 2021. In response to stakeholder feedback, we are also finalizing changes to the International Classification of Diseases, Version 10 (ICD-10) code mappings, effective October 1, 2020. Finally, this rule includes minor administrative changes related to the SNF Value-Based Purchasing (VBP) Program.

    Read more
  • Hospital Diagnoses: Why You Need to Do a Deeper Dive

    By Caralyn Davis, Staff Writer - July 21, 2020

    Obtaining the most specific medical diagnosis benefits skilled nursing facilities (SNFs) on two fronts: receiving accurate reimbursement under the Patient-Driven Payment Model (PDPM) for Medicare Part A residents and improving the quality of care for all residents, says Carol Maher, RN-BC, RAC-MTA, RAC-MT, CPC, director of education for Hansen, Hunter & Co. PC in Vancouver, WA.

     

    “Often, to get a diagnosis to map from the MDS to a clinical category for the physical therapy (PT), occupational therapy (OT), or speech-language pathology (SLP) payment components under PDPM, you need a more specific diagnosis,” explains Maher. “However, it’s not all about payment. Even without the mapping problem, the resident’s medical record needs to be as accurate and complete as possible, and that includes having accurate diagnoses so that the interdisciplinary team can provide the correct treatment.”

     

    For example, if a resident goes to see an outside provider, the face sheet that the nursing home sends with that resident should be as accurate as possible, she points out. “If the resident had a heart attack, was the myocardial infarction a STEMI (ST-segment elevation myocardial infarction) or a non-STEMI? You don’t want to leave that type of diagnosis unspecified because including the most accurate diagnosis on the nursing home face sheet could affect that outside provider’s treatment decisions and the resident’s overall quality of care.”

    Read more
  • To IPA or NOT To IPA: That Is an Important Question

    By Carol Maher, RN-BC, RAC-MTA, RAC-MT, RAC-CTA, RAC-CT, CPC - May 05, 2020

    Healthcare professionals were relieved when CMS agreed to make the Interim Payment Assessment (IPA) optional instead of a requirement. This meant that skilled nursing facilities (SNFs) could decide when or if they would complete these payment assessments. CMS anticipated that SNFs would perform IPAs during each Medicare Part A stay both to improve Medicare payment during the stays and to monitor patients’ clinical status. However, data shows that few IPAs are being completed.

     

    One likely reason why: the complexity of the new Patient-Driven Payment Model (PDPM) makes it difficult to know when an MDS would improve the final payment. John Kane, CMS’s SNF Payment Team Lead, stated during one of CMS’s train-the-trainer sessions that there could be as many as 1,900 possible payment combinations per PPS MDS.

     

    So how can you know whether an IPA would improve the Medicare payment? First, let’s consider the impact of CMS’s original plan to require the IPAs. CMS proposed that IPAs would be completed when there was a change in one of the first-tier classification criteria in any of the proposed payment components. For example, if the resident had been classified into the Major Joint Replacement category for the PT/OT component and their primary diagnosis changed to Medical Management, the IPA would have been required. Likewise, when a resident’s Nursing component category changed from Extensive Services to Special Care Low, an IPA would have been required. We are grateful that assessments are not mandatory in these circumstances, but they provide a useful starting point for understanding when an IPA could be financially beneficial.

     

    In the SNF PPS Final Rule for FY 2020, CMS included the following table showing the FY 2020 federal unadjusted urban base rates for each of the six PDPM payment components:

    Read more
1 of 8 Next