CMS plans to closely monitor “service utilization, payment and quality trends which may change as a result of implementing PDPM. If changes in practice and/or coding patterns arise, then we may take further action…” (e.g., system recalibration, rebasing case-mix weights, case-mix creep adjustments).
CMS will develop a “robust monitoring program” that uses data from assessments, claims, cost reports and more to assess both the impact of implementing PDPM and to identify and provider-level issues related to PDPM payments.
PDPM does not change Medicare’s fundamental requirements for SNF coverage (e.g., 3-day qualifying stay, daily skilled services). Conditions of Participation, OBRA assessments and others all remain in place.
Clinical category assignment is critical as it impacts four of the five case-mix categories.
ICD-10-CM code in I0020B must represent the primary reason for the SNF stay. In the FY 2019 Final Rule (and again on the SNF Open Door Forum held August 2, 2018), CMS clarified that the diagnosis listed [in I0020B] should NOT reflect the reason for the qualifying hospitalization, but the reason for the SNF admission, which may or may not be the same.
Clinical category assignment will be derived from I0020B and information entered into new items (effective October 1, 2019) in J2000
In response to stakeholder comments about the challenge of receiving timely and accurate diagnosis information from the referring hospital, and the fact that many SNFs do not have certified coders on staff, CMS stated during the August 2018 SNF Open Door Forum that PDPM does not require any additional information than what is currently required under RUG-IV.
ICD-10-CM codes listed as Return to Provider (RTP) are not deemed appropriate to enter as the primary reason for SNF care. These codes either lack specificity or the underlying condition cannot be the main reason for SNF care. The FY 2020 Proposed Rule (released April 19, 2019) discusses a subregulatory process for updating code mappings and lists in a timely manner.
There are no “losers” with respect to nursing CMGs. All of these groups have gone up with respect to CMI compared to RUG-IV.
Interdisciplinary collaboration and education about correct coding in Section GG is essential to accurate category assignment for nursing, PT and OT.
The number of therapy minutes does not matter for purposes of payment. However, because of concerns around limiting therapy under PDPM, CMS has added Section O items to the PPS DC assessment so they can track provider behavior. John Kane from CMS said, “If a patient requires 720 minutes on September 30, 2019, we would expect the same patient to require 720 min on October 1.”
Group and concurrent limit of 25 percent reflects unallocated minutes under PDPM; not allocated minutes, as under RUG-IV. This means, the 25 percent limit will be reached sooner under PDPM than (it would have been) under RUG-IV (had providers been delivering group and concurrent).
In the FY 2020 SNF PPS Proposed Rule, CMS proposes to modify the definition of group therapy under PDPM to align with that in the inpatient rehab facility (IRF) setting: 2-6 patients at the same time who are performing the same or similar activities.
Software systems will need to track concurrent and group minutes differently under PDPM.
In response to stakeholder concerns regarding the 25 percent limit, CMS reiterated several times that currently, <1 percent of all therapy minutes are provided in a group or concurrent format, so a limit of 25 percent is “more than enough” to allow some flexibility on the part of providers.
John Kane said, “We understand that the number of group and concurrent minutes will likely increase with PDPM, and we hope it is based on patient needs.”
If the group/concurrent limit is exceeded, providers will receive a “non-fatal” error from the QIES ASAP system. In a revised FAQ document on CMS’s PDPM Resource webpage, CMS states the provider will receive a warning edit on the validation report that will inform them that they have exceeded the 25 percent limit. The edit will state: “The total number of group and/or concurrent minutes for one or more therapy disciplines exceeds the 25 percent limit on concurrent and group therapy. Consistent violation of this limit may result in your facility being flagged for additional medical review.” CMS will also monitor provision and be aware of facilities that exceed the limit and will re-visit the idea of a penalty for exceeding the limit in the future.