About PDPM

The transition to the Patient-Driven Payment Model (PDPM) on October 1, 2019, marks the largest reimbursement change to the Skilled Nursing industry in 20 years. As skilled nursing providers and their therapy contract company partners prepare for PDPM implementation, we at Casamba want to help you through this change that’s designed to lead to better, more efficient and more cost-effective patient outcomes.

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Does therapy still matter to reimbursement under Medicare Part A with the transition to PDPM?

While SNF payments will no longer be based on therapy minutes, therapy is still part of Medicare Part A reimbursement. PT, OT and SLP are three of the five case-mix adjusted components of PDPM.

Which section of the Minimum Data Set (MDS) determines PDPM functional levels?

Self-care and mobility information coded in Section GG helps to determine the functional levels for PT, OT and Nursing case-mix groups (CMGs).

What is a the “non-case-mix” component?

The non-case-mix component covers things like room/board, capital costs and overhead. It does not depend on upon resident characteristics.

Has the MDS Assessment schedule changed under PDPM?

The required, or scheduled, MDS assessments have been reduced to an initial 5-day and a PPS Discharge assessment.

Can changes be made to a resident’s PDPM classification after the initial 5-day assessment?

Yes. A new optional assessment called an Interim Payment Assessment (IPA) may be completed at the provider’s discretion.

How should my facility respond to the change from RUG-IV to PDPM?

    • Determine how your facility can ensure accuracy of diagnostic and functional coding and presence of supportive clinical documentation for both therapy and nursing.
    • Review CMS’s Provider-Specific Impact Files and/or PDPM Grouper Tool to start assessing how PDPM can impact your facility.
    • If your EMR vendor has the capability to analyze current MDS data to compare RUG-IV to PDPM, take advantage of that opportunity as well.
    • Discuss PDPM preparation and understanding with your therapy department.
    • Discuss PDPM changes with your EMR, looking at issues such as:
      • Selecting I0020B diagnosis
      • Identifying/tracking of non-therapy ancillary (NTA) conditions
      • Identifying/tracking of cognitive impairments
      • Identifying/tracking of SLP comorbidities
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    • Discuss efficiency and effectiveness of transfer documentation with main referring hospitals.
    • Consider specific processes required to track changes in resident function to decide when an IPA is necessary.
    • Investigate/inquire if other payers (including Medicaid and managed care) are looking to implement changes related to PDPM.

How is reimbursement calculated for PDPM?

PDPM per diem payments are calculated using the unadjusted Federal urban or rural base rate for each component, the case-mix index (CMI), the variable per diem payment (VPD) adjustment factor if applicable (or in the case of the nursing CMG, the AIDS add-on) and the geographic wage indices to adjust the rate for a specific locality. Each component is added together to generate the per diem rate for the resident.

How is reimbursement calculated for PDPM
Source: CMS

Will the initial required PDPM 5-day assessment schedule include grace days?

The 5-day MDS assessment schedule remains unchanged. Providers have the ability to choose any day between days 1-8 as the Assessment Reference Date (ARD) for the 5-day MDS.

How will SNF providers handle the transition from RUG-IV to PDPM on October 1, 2019, from an MDS schedule perspective?

All residents in a Medicare Part A stay who were admitted on or before September 30, 2019, will need to have an IPA completed with an ARD of October 1 – October 7, 2019, to generate reimbursement under PDPM beginning October 1, 2019.

List a few way facilities can best prepare for PDPM?

PDPM requires a lot of preparation. Here are a few ideas that can help:

      • Documentation: Medical records must support both MDS and claim coding. Supporting documents from referring hospitals as well as nursing, restorative, therapy and dietary documentation in the SNF are important to support the case-mix groups in PDPM.
      • Train staff: Make sure staff is properly coding the MDS. Consider ICD-10 coding and Section GG training, as both are important components of the CMGs for PT, OT and nursing.
      • Develop clinical competencies: PDPM requires clinicians to practice at the top of their license, effectively managing complex clinical needs and upstream and downstream transitions of care. Preventing hospital readmissions is critical to SNF success under the Quality Reporting and Value-based Purchasing Programs.

PDPM Links

PDPM Overview From CMS

PDPM Calculation Worksheet For SNFs (From CMS)

Casamba Customers should visit the Casamba Skilled Community for more information about PDPM and how Casamba is ready for your transition.

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