Under the Patient-Driven Payment Model (PDPM), the Centers for Medicare & Medicaid Services (CMS) will implement an interrupted-stay policy for the first time in the Skilled Nursing Facility Prospective Payment System (SNF PPS). The agency is already ironing out some potential bumps in the implementation process. Following the release of the draft v1.17 Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, CMS has clarified the new policy to account for the difference in how the day of discharge is treated for Part A residents who physically discharge from the SNF vs. those who discharge from Part A and remain in the building (e.g., as a Medicaid resident).

CMS officials reviewed key aspects of the interrupted-stay policy, including this new clarification that impacts the count of noncovered days, during two sessions at the August 14 Skilled Nursing Facility Quality Reporting Program (SNF QRP) training event: Section A, I, J, and O Updates and Patient-Driven Payment Model: What Is Changing (and What Is Not). 

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.

When the Patient-Driven Payment Model (PDPM) implements this October 1 in the fee-for-service Medicare Part A Skilled Nursing Facility Prospective Payment System (SNF PPS), concurrent therapy, group therapy, and even restorative nursing will once again take on a renewed importance as tools for achieving a resident’s clinical goals, says Joel VanEaton, BSN, RN, RAC-MT, vice president of compliance and regulatory affairs for Broad River Rehab in Asheville, NC.

“However, you may run into trouble if SNFs or therapists simply dictate, ‘We will do X amount of concurrent and group therapy,’” suggests VanEaton. “PDPM is intended to be a reimbursement system that elevates the resident’s voice by ensuring that resident care decisions appropriately reflect each resident’s actual care needs.”

Nurse assessment coordinators (NACs) won’t be able to take much of a breather following the October 1, 2019, implementation of the new Patient-Driven Payment Model (PDPM) case-mix classification system for the fee-for-service Medicare Part A Skilled Nursing Facility Prospective Payment System (SNF PPS). NACs will have exactly one year to get comfortable with PDPM before their interdisciplinary team has to begin submitting data for 59.5 new Standardized Patient Assessment Data Elements (SPADEs) across the PPS admission and PPS discharge assessments that will be required under the data submission threshold requirement for the Skilled Nursing Facility Quality Reporting Program (SNF QRP). This includes four SPADEs that will be used to calculate and check the logic of two new MDS-based SNF QRP quality measures (QMs) involving the Transfer of Health Information IMPACT Act domain.

One of the few breaks NACs received in the Fiscal Year (FY) 2020 SNF PPS Final Rule is that CMS has put off plans to expand the SNF QRP to all SNF residents regardless of payer source. Here are the highlights NACs need to know about.

The Significant Change in Status Assessment (SCSA) may be considered an “old dog” in the assessment world, but we will need to learn new tricks under the Patient-Driven Payment Model (PDPM). While the SCSA is an OBRA assessment, historically it could count as a PPS assessment, and could therefore affect payment when completed during a resident’s Medicare stay. Under PDPM, that is no longer the case. The newly-introduced Interim Payment Assessment (IPA) will be the only assessment, beyond the 5-day, that will be able change a resident’s Medicare rate. While this assessment seems to have similarities to the SCSA, nurse assessment coordinators (NACs) must understand the key differences for criteria, scheduling, timing, and payment and survey implications to ensure success under PDPM.  

In the current RUG-IV case-mix classification system used in the Medicare Part A Skilled Nursing Facility Prospective Payment System (SNF PPS), the activities-of-daily living (ADL) score derived from MDS section G (Functional Status) factors into the calculation of every case-mix group. Effective October 1, that all changes. While section G will still be important for care planning and some quality measures (QMs), section GG (Functional Abilities and Goals) will take over on the payment front, providing functional scores that will be used in case-mix classification for three of the five case-mix-adjusted payment components under the new Patient-Driven Payment Model (PDPM): physical therapy (PT), occupational therapy (OT), and nursing.