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.

  • J2100: How Do Interim Hospital Stays Impact Coding?

    By Caralyn Davis, Staff Writer - December 19, 2019

    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.

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  • PDPM Cognitive Level Still Confuses Some SNFs

    By Caralyn Davis, Staff Writer - December 18, 2019

    PDPM Cognitive Level Still Confuses Some SNFs

    The Patient-Driven Payment Model (PDPM) cognitive level plays a key role in determining a Medicare Part A resident’s speech-language pathology (SLP) case-mix component. The Brief Interview for Mental Status (BIMS), coded in MDS items C0200 – C0500, is its primary driver. If the BIMS cannot be completed, the items C0700 (Short-term Memory OK) and C1000 (Cognitive Skills for Daily Decision-Making) from the Staff Assessment for Mental Status combine with items B0100 (Comatose) and B0700 (Makes Self Understood) to determine the PDPM cognitive level. So it’s no surprise that questions about the PDPM cognitive level came fast and furious at the December 12 Skilled Nursing Facility Long-term Care Open Door Forum (ODF).

     

    Here are the primary issues raised by callers:

     

    If neither the BIMS nor the Staff Assessment is completed, what happens with regard to obtaining a PDPM cognitive level?

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  • J2100: How Do Interim Hospital Stays Impact Coding?

    By Caralyn Davis, Staff Writer - December 18, 2019

    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.

    Read more
  • J2100: How Do Interim Hospital Stays Impact Coding?

    By Caralyn Davis, Staff Writer - December 17, 2019

    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.

    Read more
  • SNF QRP QMs: NACs Should Review ‘The Report Card’ for PDPM

    By Caralyn Davis, Staff Writer - December 04, 2019

    The Patient-Driven Payment Model (PDPM) under the Skilled Nursing Facility Prospective Payment System (SNF PPS) pushes providers to implement value-driven care, which gives added significance to the Skilled Nursing Facility Quality Reporting Program (SNF QRP) quality measures (QMs), says Maureen McCarthy, BS, RN, RAC-MTA, RAC-MT, DNS-MT, QCP-MT, president/CEO of Celtic Consulting in Torrington, CT.

     

    “The SNF QRP QMs are now the report card for PDPM,” she explains. “The Centers for Medicare & Medicaid Services (CMS) has made it clear that the agency will be watching quality of care throughout PDPM implementation. If your care model changes and your quality goes down, you are likely to be audited. Nurse assessment coordinators (NACs) and any other interdisciplinary team (IDT) members who complete the MDS need to be mindful as to how that MDS data will impact not only payment but also quality, especially as more QMs continue to be added to the program.”

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  • NACs Need to Know: 5 Key Medicare Part A Requirements That Haven’t Changed Under PDPM

    By Caralyn Davis, Staff Writer - December 04, 2019

    The nurse assessment coordinator (NAC) often handles the entire Medicare program in the facility, from managing the PPS schedule to leading the skilled coverage decision. With PDPM in full swing, a lot seems to have changed, but some things have not.

     

    “The implementation of the Patient-Driven Payment Model (PDPM) changed the payment system used for traditional Part A residents,” says Suzy Harvey, RN-BC, RAC-CT, managing consultant at BKD in Springfield, MO. “It did not change the coverage policies for skilled services.”

    Key requirements that remain in place—and that NACs need to know about—include the following:

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  • Q&A: Is there a simple way to know which ICD-10 codes should be used to qualify for immune disorders in the NTA component?

    By Jennifer LaBay, RN, RAC-MT, RAC-MTA, CRC - December 04, 2019
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  • MDS 3.0 Provider User's Guide Updated, Including Validation Rpt Error Messages (12/19)

    By QTSO - December 04, 2019
    Key information about how to submit MDS files and how to obtain and understand error messages on initial and final validation reports. 
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  • Q&A: Why is our coding for “IV feeding – While a Resident” not reflected in our NTA score?

    By Jessie McGill, RN, RAC-MT, RAC-MTA - November 25, 2019
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  • Q&A: How should diagnoses be listed on the UB-04 claim?

    By Jennifer LaBay, RN, RAC-MT, RAC-MTA, CRC - November 25, 2019
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  • 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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