The October 1, 2019, deadline for implementation of PDPM is looming. Nursing home administrators should use caution if they are thinking that fewer NAC hours will be needed just because the number of PPS assessments will decrease. The MDS is still the primary data source under PDPM, and MDS accuracy and completeness are paramount to accurate reimbursement. The preparation needed to get the NAC ready for their new role under PDPM cannot wait until October! We must start now, especially since we all know how the calendar seems to speed up when the summer months are upon us.

Let’s take a look at some of the NAC’s current tasks and how they will change under PDPM:

October 1, 2019 will mark the launch of what could be a sustained period of considerable change for the Skilled Nursing Facility Prospective Payment System (SNF PPS), the Skilled Nursing Facility Quality Reporting Program (SNF QRP), the MDS itself—and the role of the nurse assessment coordinator (NAC), suggests Jessie McGill, RN, RAC-MT, RAC-MTA, curriculum development specialist at AANAC.

The changes start this October 1 with the implementation of the Patient-Driven Payment Model (PDPM) for the fee-for-service Medicare Part A SNF PPS. “This is a distinctly different payment model than RUG-IV, and it will drive a complete shift in the NAC’s focus. Instead of concentrating on therapy minutes and the activities of daily living (ADLs), the NAC will have to pay attention to a whole array of clinical services that need to be captured by the 5-day MDS’s assessment reference date (ARD),” says McGill. “This will mean spending a lot of time looking for documentation, not only from the nursing staff but also from the physicians to support ICD-10-CM codes.”

Mr. Jones admitted to Happy Acres Nursing Home on Original Medicare a couple of weeks ago, but an acute exacerbation of his COPD has resulted in an emergency room visit and an overnight stay for observation. The nurse assessment coordinator is closely watching the clock to see if Mr. Jones will return within 24 hours from discharge to meet the “midnight rule.” As another hour passes and more than 24 hours has elapsed, the NAC knows she must complete both an OBRA and a Part A PPS Discharge assessment. And for now—until October—her thinking is correct. Once the Patient-Driven Payment Model (PDPM) is implemented though, all of this will change with the “interrupted stay” policy.

Revisions in the April 11 update of Patient-Driven Payment Model: Frequently Asked Questions (FAQs) suggest that the Optional State Assessment (OSA) is no longer a temporary assessment, meaning that it may remain active—and its use may actually expand—in some states for longer than the one fiscal-year (FY) transition period originally set by the Centers for Medicare & Medicaid Services (CMS). Therefore, it’s more vital than ever for nurse assessment coordinators (NACs) in Medicaid case-mix states to understand the OSA and how the October 1 transition of the Medicare Part A Skilled Nursing Facility Prospective Payment System (SNF PPS) to the Patient-Driven Payment Model (PDPM) case-mix classification system from the RUG-IV system can impact their Medicaid nursing facility (NF) payments.

On April 19, the Centers for Medicare & Medicaid Services (CMS) publicly posted the fiscal year (FY) 2020 Skilled Nursing Facility Prospective Payment System (SNF PPS) Proposed Rule (CMS-1718-P). While the proposed rule updates the Medicare Part A federal per-diem payment rates, those changes are somewhat overshadowed by multiple proposed policy changes focusing on these key areas:

Proposed Fiscal Year 2020 Payment and Policy Changes for Medicare Skilled Nursing Facilities (CMS-1718-P)

On April 19, 2019, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule [CMS-1718-P] for Fiscal Year (FY) 2020 that updates the Medicare payment rates and the quality programs for skilled nursing facilities (SNFs). This proposed rule is part of our continuing efforts to strengthen the Medicare program by better aligning payment rates for these facilities with the costs of providing care and increasing transparency so that patients are able to make informed choices.  Additionally, effective October 1, 2019, CMS will begin using a new case-mix model, the Patient Driven Payment Model (PDPM), which focuses on the patient’s condition and resulting care needs rather than on the amount of care provided in order to determine Medicare payment.

This fact sheet discusses three major provisions of the proposed rule: the proposed changes to SNF payment policy under the SNF Prospective Payment System (PPS), the SNF Value-Based Purchasing Program (VBP), and the SNF Quality Reporting Program (QRP).  This proposed rule includes policies that would continue a commitment to shift Medicare payments from volume to value, with the continued implementation of the PDPM, SNF VBP, and SNF QRP to improve program interoperability, operational quality and safety.

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. The PDPM FAQs were updated on 4-4 and then again on 4-11.

When the Patient-Driven Payment Model (PDPM) implements as the case-mix classification system for the skilled nursing facility prospective payment system (SNF PPS) on Oct. 1, 2019, SNFs will have to code a new set of health insurance prospective payment system (HIPPS) codes in MDS item Z0100A (Medicare Part A HIPPS code) and on the Part A claim to identify a SNF resident’s payment classification, pointed out officials with the Centers for Medicare & Medicaid Services (CMS) during the Dec. 11 SNF PPS: PDPM National Provider Call. 

April 5 update: An errata (V3.00.1) was posted for the DRAFT version (v3.00.1) of the MDS 3.0 Data Specifications, which will go into effect on October 1, 2019. Twenty-one issues were identified. One new item (X0570A) was added. Five existing items were added to additional item sets. Nine new edits were added, and eight existing edits were revised.

------------------------------------

A new version (V3.00.0) of the MDS 3.0 Data Specifications was posted.  This version is scheduled to become effective October 1, 2019.  Note that there are many significant changes, including the removal of eight item sets (NS, NSD, NO, NOD, SS, SSD, SO, SOD), the addition of two new item sets (IPA and OSA), and item additions in Sections A, GG, I, J, O and Z. These specs accommodate the utilization of the PDPM grouper, which also begins on October 1, 2019.

In addition, a new version (V1.04.0) of the MDS 3.0 CAT Specifications was posted. This version 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.

Under the Patient-Driven Payment Model (PDPM) in the Skilled Nursing Facility Prospective Payment System (SNF PPS), the Interim Payment Assessment (IPA, A0310B = 08) will be the only tool providers have to increase the per-diem rate once it’s set by the 5-day PPS MDS, says Scott Heichel, RN, RAC-MT, DNS-CT, QCP, CIC, director of clinical reimbursement for LeaderStat in Powell, Ohio.

“The optional IPA can be used any time in between the 5-day PPS assessment and the Part A PPS Discharge assessment to capture payment increases when the characteristics of the resident change to a level that it actually affects the PDPM calculation in one or more of the five case-mix-adjusted payment categories: physical therapy (PT), occupational therapy (OT), speech-language pathology (SLP), nursing, or nontherapy ancillaries (NTA),” explains Heichel.

To prepare to make optimal use of the IPA, nurse assessment coordinators (NACs) should consider taking the following steps: