On October 1, 2019, CMS will implement the new SNF Medicare Part A reimbursement system, the Patient Driven Payment Model, or PDPM. This change in reimbursement will significantly change the way the daily SNF PPS rate is determined. 

The shift from the RUG-IV case-mix model to PDPM is marked by goals to:

  • Improve payment accuracy and ensure appropriate treatment by focusing on the individual patient, rather than volume of services provided
  • Reduce administrative burden on providers
  • Improve SNF payments without increasing total Medicare payments

While RUG-IV categorizes patients into a single, volume-driven case-mix group, PDPM will focus on the clinical characteristics and individualized needs of each resident.

Change is never easy, especially in the heavily regulated healthcare industry. In addition, new regulations often engender a host of questions, creating uneasiness and sometimes leading to a fear of change. But with the right information and the appropriate planning, healthcare organizations can be ready for PDPM.

In my role with Relias, I recently hosted a webinar series focused on PDPM. From the more than 11,000 healthcare professionals who registered, here some of the most frequently asked questions regarding PDPM:

Laying the foundation

Q: We provide trach and vent care in Skilled Nursing Facilities. Most of our patients are Medicaid. How might this impact us?

A:  This would be a state specific question and depends on your specific state’s reimbursement system and what plans once PDPM is implemented. Medicaid specific questions will need to be addressed directly to the respective state.

There may be no immediate impact as CMS will continue to support the RUG III/RUG-IV systems until further notice. Also, an Optional State Assessment (OSA) will be implemented with the PDPM for states that require additional assessments.

Q: How would a resident qualify for PT, OT or SLP if they aren’t receiving it?

A:  The PDPM will determine the appropriate case mix group (CMG) for PT, OT and SLP based on clinical characteristics such as diagnosis, functional score, co-morbidities, surgical procedures, etc. as identified on the MDS. All residents will be classified into on PT, OT, and SLP regardless of the amount of therapy they receive or if they don’t receive any at all.

Therapy case mix groups

Q: It is my understanding that an Interim Payment Assessment (IPA) has to be done if the resident is discharged and out of the facility for MORE than 3 days. Is this correct?

A: No, this is not correct. If a resident is gone for more than 3 days, then a new 5-day assessment is required to be completed. If the resident is gone less than 3 days, then a new 5-day assessment would NOT be completed. This is known as the “Interrupted Stay Policy”.  Interim Payment Assessments are totally OPTIONAL assessments.

PDPM’s nursing case mix groups

Q: If resident was discharged from therapy, is this considered a significant change that we need to complete an Optional State Assessment (OSA)?

A: Under PDPM, there is no requirement to complete an OSA if all therapies are discontinued.  An OSA is an “Optional State Assessment” so would have to inquire with the State on what, if any requirements, they would have related to this assessment.

Also, OBRA regulations related to completion of a SCSA still apply, so it may be possible that the person may qualify for a SCSA due to an improvement.

Non-therapy ancillaries case mix groups

Q: Can you please clarify what kinds of IV fluid we can code? Is it only IV medications or any fluid?

A: There is no change to the coding of these items on the MDS. IV fluids (Section K) that meet the coding requirements for K0510 and K0710 would be counted in the NTA as long as they were provided while a resident. The administration of IV fluids may qualify for the Parenteral/IV Feeding – High or Parenteral/IV Feeding – low NTA points. Refer to the PDPM Calculation Worksheet for more information. IV fluids (Section K) can also qualify for the Special Care High nursing case mix category, regardless where provided.

IV medications (Section O) provided as a resident would also qualify for NTA points as well as the Clinically Complex nursing case mix category.

PDPM’s assessment requirements

Q: How has the regulation changed for late 5-day assessment? Primarily concerned with late notification of change of payor such as managed care.

A: Based on the Draft RAI 3.0 Manual v 1.17 (effective 10/1/19) the policy appears to have been changed in which default would have to be billed if there is no 5-day assessment or the 5-day assessment is late. This appears to be a significant change to current policy in which there is the option for the provider to use the HIPPS code from the OBRA Admission assessment, if completed. These instructions are no longer included in the Draft manual. This may be due to the fact that Section GG does not appear on an Admission assessment so therefore no PDPM HIPPS code would be calculated.

It is expected that further changes to the Draft RAI manual will be forthcoming. We are also waiting for updates to the Medicare Claims Processing Manual for further guidance on billing under PDPM.

Interrupted stay policy

Q: For the ‘no interrupted stay’ we wouldn’t do a new admission, correct?

A: The decision to complete a “New” OBRA Admission assessment is based on the type of OBRA Discharge assessment you completed and/or the length of time the resident was gone. Assuming an initial OBRA Admission assessment had already been completed, then a new OBRA Admission assessment would be required if they were Discharged Return Not Anticipated (DCRNA) OR if they were Discharged Return Anticipated (DCRA)and did not return within 30 days.

The rules related to OBRA Admission assessments are not changing due to the implementation of PDPM.

Putting it all together

Q: If the BIMS was not completed in the lookback period, and is dashed on the MDS, how will a SLP score be generated?

A: Per a recent CMS training, the PDPM grouper is being changed to reflect that a resident would be considered cognitively intact if the BIMS resident interview or if the staff assessment was not completed. This could potentially have an impact on the calculation of the SLP case mix group. This is a change in policy from what is currently in the DRAFT RAI Manual.

It is anticipated that the DRAFT RAI manual will be updated to reflect this change.

PDPM is without a doubt a paradigm shift for Skilled Nursing Facilities. Hopefully, everyone will feel empowered to embrace this change by understanding the changes coming into effect. You can find additional questions, and answers, regarding PDPM in our six-part PDPM Q&A series.

Ronald Orth, RN, CMAC, CHC, is the the Post-Acute Care Curriculum Designer for Relias. He is certified in Healthcare Compliance through the Compliance Certification Board (CCB).