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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.
On April 8, the Centers for Medicare & Medicaid Services (CMS) released for public inspection the Fiscal Year (FY) 2022 Proposed Rule for the Skilled Nursing Facility Prospective Payment System (SNF PPS) and Consolidated Billing, and Updates to the Quality Reporting Program and Value-Based Purchasing Program (CMS-1746-P) as required by law. The agency will accept comments, which may be made electronically, through June 7.
The FY 2022 SNF PPS proposed rule is a sweeping document that discusses specific proposals for FY 2022 and beyond, as well as new ideas that CMS is still beginning to formulate—with a heavy emphasis on future quality reporting.
The OIG will determine whether Medicare payments to SNFs under PDPM complied with Medicare requirements.
Fiscal Year (FY) 2022 Skilled Nursing Facility Prospective Payment System Proposed Rule (CMS 1746-P) Fact Sheet
CMS issued a proposed rule that would update Medicare payment policies and rates for skilled nursing facilities under the Skilled Nursing Facility (SNF) prospective payment system (PPS) for fiscal year (FY) 2022. In addition, the proposed rule includes proposals for the SNF Quality Reporting Program (QRP), and the SNF Value-Based Program (VBP) for FY 2022. CMS is publishing this proposed rule consistent with the legal requirements to update Medicare payment policies for SNFs on an annual basis. The major provisions of the proposed rule include the following:
The Patient-Driven Payment Model (PDPM) uses 161 MDS items to establish the five case-mix adjusted components. Some of these 161 items will have supporting documentation easily found in the medical record, but other items may require some digging. From burrowing through hospital records and querying the physician to probing staff for additional clarification, thoroughly mining the medical record can yield a substantial impact on both the accuracy of the assessment and PDPM billing codes.
Read this article for tips on how to dig into the detailed information NACs need for calculating PDPM.
February 4, 2021
An update to the PDPM Grouper DLL package was posted. This is NOT a change to the previously posted DLL file itself, just supporting information. The documentation file was updated, as there were NTA mapping changes not previously documented. Also, one file in the source code zip from the previous package, mdsgrouper,h, was not the latest version. The correct version is included in this updated package. NOTE: the DLL was compiled with the latest version of mdsgrouper.h in the previous package. Therefore, there is no change to the DLL file itself.
An updated errata (V3.00.7) was posted for the FINAL version (v3.00.1) of the MDS 3.0 Data Specifications, currently in production. The resolution to issue 17 in the previous errata was flawed, as the addition of edit -3963d prevented submission of IPA inactivations. Therefore, edit -3963d has been suspended for now, and will be revised in a future release.
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 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.)
The Mappings file contains:
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:
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: