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.

  • TIP: CMS Releases Update to PDPM Grouper

    By AANAC - January 12, 2021
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  • jRAVEN 1.7.7 Free MDS Submission Software Updated (1/21)

    By QTSO - January 11, 2021

    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 v1.7.7 is now available for download under the Downloads section at the bottom of this webpage. Users do not need a previous version of jRAVEN to download, install or use jRAVEN v1.7.7.

    jRAVEN v1.7.7 includes the following enhancements:

    • The new MDS VUT, v3.5.0, updated to support Issue #17 in Errata v3.00.6 and the new ICD Code files that are in effect as of 1/1/2021
    • The new PDPM Grouper, v1.0009, updated to include the ICD codes that are effective 01/01/202
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  • FY 2021 ICD-10 Code Lookup File for MDS Item I0020B (1/21)

    By CMS - January 11, 2021

    The lookup files containing the allowable ICD codes for item I0020B for FY2021 have been updated to contain the following ICD-10 codes , as well as remove M35.8:

    The new ICD-10 codes  may be used for assessments with target date on or after January 1, 2021: Z11.52, Z20.822, Z86.16, M35.81, M35.89 and J12.82. (Note that codes M35.81 and M35.89 replace code M35.8, which should no longer be used on assessments with target date on or after January 1, 2021.)

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  • Final PDPM Grouper DLL V1.0009 (REVISED) Effective Oct. 1, 2020

    By CMS - January 11, 2021

     

    An update to the PDPM Grouper DLL has been posted, along with its source code and test cases. This version, V1.0009, adds support for new ICD-10 codes that may be used for assessments with target date on or after January 1, 2021: Z11.52, Z20.822, Z86.16, M35.81, M35.89 and J12.82. (Note that codes M35.81 and M35.89 replace code M35.8, which should no longer be used on assessments with target date on or after January 1, 2021.)
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  • FY 2021 PDPM ICD-10 Mappings (1/21)

    By CMS - January 11, 2021

    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

    These are the codes added in the January 2021 update:

    Z11.52 — Encounter for screening for COVID-19

    Z20.822 — Contact with and (suspected) exposure to COVID-19

    Z86.16 — Personal history of COVID-19

    M35.81 — Multisystem inflammatory syndrome (MIS)

    M35.89 — Other specified systemic involvement of connective tissue

    J12.82 — Pneumonia due to coronavirus disease 2019

    (Note that codes M35.81 and M35.89 replace code M35.8, which should no longer be used on assessments with target date on or after January 1, 2021.)

    This is the seventh release (sixth production release, since 1.0005 was a beta release).

    This release also adds six ICD-10 codes that were inadvertently excluded from the NTA calculation in V1.0006:

    • T8484XA

    • T8389XA

    • T8321XA

    • T82399A

    • T82392A

     • T83021A 

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  • MDS 3.0 Provider User's Guide Updated, Including Validation Rpt Error Messages (1/21)

    By QTSO - January 08, 2021
    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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  • The NTA Component of PDPM: Best Practices for Accurate Scoring

    By Caralyn Davis, Staff Writer - December 15, 2020

    Skilled nursing facilities now have more than a year of experience with the Patient-Driven Payment Model (PDPM), the updated case-mix classification system used in the Medicare Part A Skilled Nursing Facility Prospective Payment System (SNF PPS) that includes five case-mix-adjusted payment components: physical therapy (PT), occupational therapy (OT), speech-language pathology (SLP), nursing, and non-therapy ancillaries (NTA). The NTA component uses a weighted comorbidity score (i.e., high-cost conditions or extensive services count for more points) to assign a SNF resident to an NTA case-mix group.

     

    A resident’s NTA score is the sum of the points associated with each comorbidity that they have. For example, a resident with IV medications (5 points) coded in MDS item O0100H2, diabetes mellitus (2 points) coded in I2099, isolation (1 point) coded in O0100M2, and wound infection (2 points) coded in I2500 would have a total NTA comorbidity score of 10. The NTA case-mix groups are based on NTA score ranges: 0 (NF), 1 – 2 (NE), 3 – 5 (ND), 6 – 8 (NC), 9 – 11 (NB), or 12+ (NA), according to table 17, “NTA Case-Mix Groups,” in chapter 6 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual. Therefore, a resident with an NTA comorbidity score of 10 would qualify for the NB NTA case-mix group.

     

    The bottom line is that accurate payment in the NTA component depends on coding each and every NTA comorbidity the resident qualifies for according to the coding instructions in the RAI User’s Manual. Taking the following steps can help nurse assessment coordinators (NACs) capture the optimal NTA comorbidity score:

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  • BIMS MDS Coding Video Tutorial (10/20)

    By CMS - October 29, 2020
    The Centers for Medicare & Medicaid Services (CMS) is releasing a video tutorial to assist providers in Inpatient Rehabilitation Facilities and Skilled Nursing Facilities with standardized data assessment guidance and assessment strategies for the cognitive assessment known as the Brief Interview for Mental Status (BIMS). This video tutorial is approximately 22 minutes in length and is designed to provide targeted guidance for accurate coding using live-action patient/resident scenarios.
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  • State PDPM Data Collection Map Tool

    By AANAC - October 07, 2020
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  • 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.”

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  • Section GG Data Collection Tool for OBRA Assessments

    By AANAC - October 06, 2020
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  • 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
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  • 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
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  • 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

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  • 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.”

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