It isn’t coming anymore. It’s here.

The Patient Driven Payment Model has finally arrived. And even though we have been talking about getting ready for it since April 2018, there’s still work to be done. 

For providers who started preparing right away, there will be a learning curve as the new rules around coding, billing and care are fully implemented. For providers who haven’t begun preparing for the payment reform, it’s not too late to start, but there are some key steps you should take to successfully transition and focus on what’s next.

The significance of the change

PDPM is turning what we knew with regard to the Resource Utilization Groups on its head.  ICD-10 codes will drive reimbursement more than therapy minutes, and triple checks won’t review just one, but five scores: Nursing, Physical Therapy, Occupational Therapy, Speech Language Pathology and Non-therapy Ancillaries. Length of stay will affect reimbursement with NTA payments adjusting on day four, and PT and OT decreasing by 2% every seven days after day 20. 

One of the biggest changes is the reduction in the number of assessments from five scheduled Prospective Payment System assessments to just one: the five-day assessment. This means providers will need better, more timely and comprehensive information at the beginning of the stay in order to code that one payment in MDS as completely and accurately as possible.

What to focus on first

If you haven’t started preparing for PDPM yet, focus on the transition. Ensure you have all the required information to code the Interim Payment Assessments required to get PDPM rates on Oct. 1. For all residents in the building on Sept. 30 and Oct. 1, you will need a RUG score and a PDPM score. 

The PDPM transition IPAs must have an ARD between Oct. 1 and Oct. 7. But you need to understand the importance of the data required to code those IPAs. The most important information you need is a comprehensive list of the right diagnoses for each resident. This may include auditing records to ensure all comorbidities affecting care are captured, and that the right supportive documentation is present in the chart. Importantly, the primary diagnosis must be linked to a clinical category in order to be used as a primary diagnosis for PDPM.  

It’s important to note that while there are more than 68,000 ICD-10 codes, approximately 24,000 of them are not linked to a clinical category and are flagged as Return to Provider. RTP codes cannot be used as a primary diagnosis because the clinical category is used to calculate an OT or PT case-mix group. Without the clinical category, the score cannot be determined.

ICD-10 codes are also needed to calculate SLP and NTA scores. Comorbidities listed under the NTA category determine the scoring for that case-mix group. Since NTAs pay 300% of the regular rate for days one to three of a Part A stay, and the first three days post-transition, a comprehensive list is the only way to optimize PDPM reimbursement across all case-mix groups.  

Electronic Health Record software will be instrumental during this process. It should reveal if an ICD-10 code is linked to a clinical category, capture the SLP and NTA comorbidities, and enter the codes linked to payment and care into the MDS. If your EHR does not have this capability, then use the resources available at CMS. This includes spreadsheets that list all diagnoses by clinical category and the scoring used for NTA and speech calculations.  

Ensure you have the resources needed to organize and complete the documentation and IPAs required throughout the transition. Providers should take note of any added workload, depending on their Med A census, as well as consider that new residents admitted on and after Oct. 1 will need data collected for PDPM. 

What to Focus on Next

After the transition, providers should assess and redefine any processes impacted by PDPM.  This includes MDS data collection, determination of the right primary diagnosis and resource use, coding of section GG, and how to do triple checks in the new model. This is also an opportunity to begin standardizing care practices for predictable outcomes and lengths of stay, given the variable payment rates. 

Getting the right primary diagnosis is integral to optimal payment and should be decided by the whole care team with the physician. The primary diagnosis needs to accurately reflect care and services in relation to the resources required to meet those needs.  

MDS data collection will be more critical now that there is a single PPS payment assessment.  Since full discharge information may not be available until several weeks after a patient is admitted to a facility, providers must communicate and collaborate with their hospital partners in order to get the information required to support the MDS. Gathering as much information as possible on comorbidities will be essential to appropriate reimbursement.

Section GG also introduces new considerations. Section GG coding is different from Section G.  The legends and scoring are reversed, and the “usual performance” scoring is based on an average, not an algorithm. Unlike section G, this section should be completed by professional staff. Both nursing and therapy is used to calculate the QRP functional performance cross-continuum quality measure.

Triple checks will need to focus on all case-mix group scores independently. While RUGs calculated only one score for payment, PDPM will have five. Again, EHR software will be critical here. Case-mix analyzers should identify how the payment items on the MDS were coded to help verify reimbursement.

Providers should note that there is a period of increased auditing by CMS after every major change to the payment process. With PDPM, CMS has identified they will be looking for material changes in QMs, reimbursement, swallowing disorders, mechanical diets and therapy provision as indicators for audit. In order to pass these audits without financial disruption, providers will need to provide clear documentation to support your MDS coding, or make changes to the types of residents or business practices that could affect payments. This includes clear and concise documentation in resident records of the care provided. 

If you have not yet started preparing, your team does have plenty of work to do. But it’s not insurmountable. While overhauling the system makes for a rocky transition period, with thorough planning and a good understanding of PDPM, you will survive — especially with the help of smart technology solutions.

Jayne Warwick, RN, is PointClickCare’s Director of Market Insight.