Rajeev Kumar, M.D.

The PDPM (Patient-Driven Payment Model) will be here quicker than the time it takes for a head to settle on a fresh-drawn pint of beer. But many skilled nursing facilities are still working out their orders.

Specifically, they are looking at the kinks in their MDS (Minimum Data Set) process to accurately capture patient characteristics. The transition from RUG IV to PDPM on October 1, 2019 involves a radical redesign of SNFs reimbursement process for Medicare A services.

Instead of therapy minutes driving payment, certain patient characteristics, including ICD-10 diagnoses, frailty (as measured by functional score and cognitive deficits), co-morbidities such as depression, or a need for altered diets, have become more important under PDPM.

Previously unaccounted for and unreimbursed services, such as intravenous infusions, medications, and equipment will be reimbursed under the NTA (Non-Therapy Ancillaries) category.

Capturing all of the above information in MDS, to establish a case mix index and receive accurate and appropriate reimbursement for care provided, becomes crucial to the SNFs’ financial success and survival under PDPM. In stark contrast with the 20 fields that are expected to be filled under RUG IV, now MDS coordinators will be asked to address 161 fields under PDPM, and use precise ICD-10 codes for all of the patients’ diagnoses. (Out of all of 68,000 codes, more than a third are nonspecific, and if used will result in bills being returned to provider!)

The initial MDS assessment (5-day assessment) is the best opportunity for SNFs to report patient characteristics and receive commensurate reimbursement for services rendered. However, patient characteristics change over time, and all the required information to establish CMIs may not be readily available or captured at the initial MDS assessment.

The Interim Payment Assessment (IPA) is an optional MDS assessment performed after the initial assessment, usually after a change in patient’s condition, to capture a change in patient characteristics.

Obviously, SNFs will need to be selective in using this assessment and perform an IPA only when the resident’s care needs have changed, and the per diem reimbursement for the remainder of the care episode is expected to improve due to provision of more intensive services. The following is a brief discussion on the circumstances when an IPA might be helpful and strategies to successfully conduct an IPA.

NTA: As the most notable differentiator, NTA will be a prime driver for IPAs. If a patient has an acute change of condition after the initial MDS assessment — one that requires intravenous infusion treatments and/or new equipment such as wound vacs — it is a no-brainer to do an IPA and receive credit for the additional services.

However, if a patient was admitted with such treatments that were captured in the initial assessment, but then were discontinued due to completion of treatment, an IPA might capture a lower acuity and therefore a lower case mix index for the remainder of the episode of care and lower per diem reimbursement thereafter.

More importantly, IPA does not reset the variable per diem adjustment schedule for therapy and NTA, and therefore any boost in reimbursement is muted when compared with the initial assessment’s impact on reimbursement.

Physical and Occupational Therapy: It is quite natural that PDPM’s reimbursement curve for nursing services is linearly dependent on frailty. The lower the functional score and cognition, the higher the reimbursement. For Physical and Occupational therapies, the relationship is represented by a bell-shaped curve. This ensures that the most frail and the most independent patients on either extremes of the curve receive less reimbursement for therapy than the patients in the middle who have the greatest potential to improve their function.

Therefore, there comes a time in every patient’s care episode when their functional score improves. If captured via an IPA could result in better reimbursement for therapy services- which more than offsets the modest decline in nursing case mix indices. Since the captured information from IPA is used to calculate reimbursement for the remainder of the care episode, it is important to gauge if the relative improvement in therapy and/or nursing case mix indices is not offset by a potential decline in the NTA score, due to expected lower utilization as the patient improves.

Careful monitoring of section GG scores on MDS will help identify the opportunity for a potential IPA.

Speech therapy: Payment for Speech therapy can change by a factor of six (X6) depending on the patient’s diagnoses and comorbidities- from the least complex CMI to the most. Neurological disease, depression, cognitive deficits, dysphagia, tube feeding or need for a mechanically altered diet must be carefully documented on MDS. If these conditions were not initially present or went unrecognized, an IPA will help improve reimbursement for speech therapy once the clinical documentation supports the change.

Nursing: Even as frailty drives nursing reimbursement, extensive services such as trach care, intravenous infusions, isolation for contagious infections, and managing complex medical illnesses, will raise reimbursement levels. An IPA should be considered whenever such services
are newly initiated.
The one and only reason for a SNF to consider an IPA is to receive a better per diem reimbursement for the remainder of the care episode, so as to provide all necessary care and services for the patient. Note that reimbursement for the care provided until IPA is performed is based on the initial MDS assessment.

IPA is not mandatory even if there is a significant change in the patient’s condition, so the only time an IPA should be on order is much like the beer with the same title. A fresh, cold one that hits the spot!

Rajeev Kumar, M.D., is the Chief Medical Officer at Symbria.