Caryn Adams

Now that PDPM is officially underway, what should I be concerned about?

As our clinical team and I have completed trainings for facility staff on the Patient-Driven Payment Model, questions and concerns related to compliance and payment have come forth.

The way skilled nursing facilities will be reimbursed has changed; the Medicare regulations and requirements have not. The requirements for the hospital stay, along with the fact that the skilled stay must be related to the qualifying stay, remain in effect. 

The certification and recertification process also has remained unchanged. The concern from some facilities is that the MDS schedule has changed, and so must have this process. Please remember that the MDS schedule has no bearing whatsoever on the certs and recerts.

A certification must be obtained upon admission, and recertification by day 14 and no more than 30 days from the last signature date. The components for reimbursement have changed and documentation must be present to support those components. Under the RUGs System, the focus had largely been on therapy documentation to support therapy minutes and medical necessity as therapy drove reimbursement.

Under PDPM, skilled documentation must be present to support MDS coding, as well as medical necessity and the diagnosis coding. 

Before the October claims are submitted, it is strongly recommended that a revised triple-check process occurs to ensure all payment items are appropriately supported in the medical record. 

While most facilities have planned and prepared for PDPM, it is hoped that the billing process about to commence goes smoothly.