Amy Stewart

How does an OBRA significant change in status assessment impact Medicare Part A payment under the Patient-Driven Payment Model?

In the past, a significant change in status assessment (SCSA) could impact the payment of a Medicare Part A resident’s stay. Under PDPM, that is not so. 

With PDPM, an SCSA can be combined with a 5-day PPS assessment, if the admission assessment has already been done. An SCSA may also be combined with a PPS discharge assessment. In both cases, the addition of the SCSA does not affect the Medicare payment.

In contrast, an SCSA cannot be combined with the Interim Payment Assessment (IPA), which is the only other PPS assessment that can impact the Medicare Part A payment. The IPA is an optional assessment that can be completed to report a change in a resident’s PDPM classification. The IPA is the only unscheduled PPS assessment, and it is always a stand alone. 

An SCSA is a required assessment when the resident has a major decline or major improvement in their status that will not normally resolve itself, that impacts more than one area of a resident’s health status, and that requires interdisciplinary review and/or revision of the care plan.

It is easy to get confused and think that if a resident meets the requirement for an SCSA, they automatically would quality for an IPA, but that is not the case. The IPA uses an item set that collects data on limited MDS items, those used for case-mix classifications under PDPM. Under PDPM, the 5-day PPS assessment sets the payment for the entire Medicare Part A stay, unless the facility decides to complete the optional IPA. If facility staff have determined that both an IPA and an SCSA are needed, these two assessments must be done separately.