Patient-Driven Payment Model (PDPM)

The Patient-Drive Payment Model (PDPM) is scheduled to begin Oct. 1, 2019, and AANAC is here to help!

The Centers for Medicare & Medicaid Services released the Fiscal Year (FY) 2019 Skilled Nursing Facility Prospective Payment System (SNF PPS) final rule, which solidified their plans to implement PDPM.  PDPM is set to replace the RUG-IV case-mix classification model that has been the hallmark of SNF PPS for years. This new payment system will be unlike anything SNFs have seen before! You and your staff have a lot to do to get ready for PDPM, and AANAC will be with you the entire way.  Visit this page frequently to get tools, education, and resources to help you lead your team readiness.

  • May 7 - 8 SNF QRP CMS Training: Register for In-Person or Online Attendance (3/19)

    By CMS - March 21, 2019

    REGISTRATION OPEN – SNF QRP Provider In-Person Training Event, May 7 and 8, 2019

    The Centers for Medicare & Medicaid Services (CMS) will be hosting a 2-day Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) in-person ‘Train the Trainer’ event for providers on May 7 and 8, 2019, at the Sheraton Kansas City Hotel at Crown Center, 2345 McGee Street, Kansas City, MO 64108. This event will be open to all SNF providers, associations, and organizations.

    The primary focus of this 'Train-the-Trainer’ event will be to provide those responsible for training staff at SNFs with information about:

    §  The transition to the Patient Driven Payment Model (PDPM) which becomes effective on October 1, 2019.

    §  A review of SNF QRP changes and updates to the Minimum Data Set (MDS) 3.0 Version 1.17.0, which will become effective on October 1, 2019.

    §  An overview of the eleven SNF QRP Quality Measures.

    §  An interactive session on the use of reports to identify opportunities for process improvement and utilize information contained in reports available via the Certification And Survey Provider Enhanced Reports (CASPER) system to develop quality improvement plans.

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  • IPA Prep Starts With 5-Day MDS, Strong Communication System

    By Caralyn Davis, Staff Writer - March 19, 2019

    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:

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  • PDPM and Section K—Three Processes to Shore Up Now

    By AANAC - March 19, 2019

    While no new items in section K of the MDS are expected this October, the Patient-Driven Payment Model (PDPM) is a game changer and some of the existing section K items are going to get a lot more attention. While swallowing and nutritional status have always been important for care areas and care planning, starting October 1, section K steps into the reimbursement spotlight for the speech-language pathology (SLP) component of PDPM. Not to mention, other key MDS items, like parenteral/IV feedings, tube feeding, and intake by artificial route, which currently impact reimbursement, will have even more pull under PDPM.

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  • Interrupted Stay Policy

    By AANAC - March 19, 2019
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  • CMS Transmittal and MLN Connects Article on PDPM Implementation REVISED (3/19)

    By CMS - March 13, 2019

    CR 11152 effectuates changes to the SNF Prospective Payment System (PPS) that are required for the PDPM. These changes were finalized in the FY 2019 SNF PPS Final Rule (83 FR 39162). SNFs billing on Type of Bill (TOB) 21X and hospital swing bed providers billing on TOB 18X, (subject to SNF PPS) will be subject to these requirements. Make sure your billing staff is aware of these changes.

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  • MDS Vendor Call Q&As and Minutes Suggest Early May RAI Manual Release (3/19)

    By CMS - March 08, 2019
    RAI Manual expected early May; PDPM grouper expected mid-to-late May, with a summer update to reflect ICD-10 changes going into effect on 10/01/2019; and other news from the Feb. 26 MDS 3.0 Vendor Call:
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  • IPAs: Basic Rules of the Road

    By Caralyn Davis, Staff Writer - March 06, 2019

    With the next version of the RAI User’s Manual not slated to be released until late spring, there are still some unknowns about the new Interim Payment assessment (IPA), but the Centers for Medicare & Medicaid Services (CMS) has established the basic rules of the road. Here’s a handy summary of the information CMS has provided thus far.

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  • Challenge Question: Truth or Myth of PDPM?

    By AANAC - March 06, 2019

    To achieve a PDPM case-mix group for the SLP component, the resident must be receiving speech therapy on the 5-day MDS.

    A)   Truth

    B)   Myth

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  • No. 1 Sign of GG Dysfunction? Therapy Runs the Show Alone

    By Caralyn Davis - February 20, 2019

    Providers have been collecting data for MDS section GG (Functional Abilities and Goals) since October 2016, largely to meet the data submission threshold for the Skilled Nursing Facility Quality Reporting Program (SNF QRP). “In many SNFs, nursing has generally abdicated responsibility for section GG to the therapy department because there is no payment attached to section GG under the RUG-IV case-mix classification system,” says Joel VanEaton, BSN, RN, RAC-MT, vice president of compliance and regulatory affairs for Broad River Rehab in Asheville, NC.

     

    “That’s a big mistake when it comes to the Patient-Driven Payment Model (PDPM), which implements on Oct. 1,” says VanEaton. “To correctly define the resident’s functional profile in section GG, you have to figure out how to shift from that therapy-only paradigm to a paradigm of true collaboration, particularly among the MDS department, nursing, and rehab.”

     

    “The most significant problem with section GG is that coding often isn’t interdisciplinary,” agrees Tracy Montag, BSN, RN, RAC-MT, clinical consultant with the Senior Living Services Consulting Group at RKL LLP in York, PA. “There are still a lot of facilities that don’t look at usual performance over three days because coding is so therapy-driven. For example, for the 5-day PPS MDS, they input information directly into section GG from the documentation the therapist completes during the therapy evaluation. Sometimes facilities don’t even have information collected for some components of section GG because therapy is not seeing the resident for those components.”

     

    To improve section GG coding accuracy, nurse assessment coordinators (NACs) should consider the following steps:

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  • How Will PDPM Change the Role of the NAC?

    By Jessica Kunkler, MA, Staff Writer - February 20, 2019

    If you are a nurse assessment coordinator (NAC), you’ve probably heard that there will be fewer assessments for Original Medicare residents under the Patient-Driven Payment Model (PDPM). But what does this mean for you, your role, and your job security? Here is what you need to know.

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  • TIP: PDPM Resources Updated

    By AANAC - February 20, 2019
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  • CMS Targets May Release for Draft RAI Manual

    By Caralyn Davis, Staff Writer - February 19, 2019

    In preparation for the Oct. 1, 2019, implementation of the Patient-Driven Payment Model (PDPM) under the Skilled Nursing Facility Prospective Payment System (SNF PPS), officials with the Centers for Medicare & Medicaid Services (CMS) had promised an early release of the draft version of the next update to the RAI User’s Manual for the MDS 3.0. However, that release won’t occur quite as early as most providers hoped.

     

    “We historically publish that manual more toward August,” said officials during the Feb. 14 Skilled Nursing Facility/Long-term Care Open Door Forum (ODF). “We do understand the need to be able to review [it for] the PDPM, so our goal is to have that published in May sometime this year.”

     

    In other manual news, CMS also expects to release version 12 of the MDS 3.0 Quality Measures (QM) User’s Manual “in the next couple of months,” said officials. On Feb. 1, the QIES Technical Support Office (QTSO) announced changes to the MDS 3.0 Quality Measure Reports in the CASPER Reporting application, including calculation updates/changes to the short-stay pressure ulcer measure, the long-stay pressure ulcer measure, and the long-stay weight loss measure. The methodology for those updated QMs “is not used in the public domain yet,” said officials to justify the agency’s delay in releasing new technical specifications.

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  • PDPM FAQs and Fact Sheets_Revised (2/19)

    By CMS - February 15, 2019

    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.

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  • PDPM Training and Technical Resources, Including Grouper Logic & ICD-10 Crosswalks (2/19)

    By CMS - February 15, 2019

    PDPM Training Presentation

    This section includes a training presentation which can be used to educate providers and other stakeholders on PDPM policy and implementation.

    PDPM Resources

    This section includes additional resources relevant to PDPM implementation, including various coding crosswalks and classification logic.

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  • TIP: CMS Releases GG Tool

    By AANAC - February 06, 2019
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