Patient-Driven Payment Model (PDPM)

The Patient-Drive Payment Model (PDPM) is here, and AADNS will continue to help you through the transition. Visit this page frequently to get new information to help you lead your team and ensure that your facility thrives under PDPM.

  • Dec. 12 SNF ODF Agenda and Call-in Information

    By CMS - December 11, 2019

    The next CMS Skilled Nursing Facilities (SNF)/Long Term Care (LTC) Open Door Forum scheduled for:  

    Date:  Thursday, December 12, 2019

    Start Time:  2:00 PM – 3:00 PM Eastern Time (ET);

    Please dial-in at least 15 minutes before call start time.

    Conference Leaders: Todd Smith & Jill Darling

    **This Agenda is Subject to Change**

    I.  Opening Remarks

    Chair – Todd Smith (Center for Medicare)

    Moderator – Jill Darling (Office of Communications)

    II.   Announcements & Updates

    *PDPM Update

    *Fiscal Year 2020 SNF VBP Facility-Level Dataset and SNF VBP Aggregate Performance

    III. Open Q&A

    **DATE IS SUBJECT TO CHANGE**

    Next ODF: TBD

    Mailbox: SNF_LTCODF-L@cms.hhs.gov

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  • Q&A: I was inquiring on how others’ buildings are composing their PDPM meeting?

    By Ellie Barton, Director of Nursing, Potomac Valley Rehabilitation and Healthcare Center - December 04, 2019
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  • jRAVEN 1.7.2 Free MDS Submission Software Updated (12/19)

    By CMS - December 04, 2019

    jRAVEN (version 1.7.2) is now available for download which contains the following updates:  

    • A defect has been corrected that was causing the HIPPS score that is calculated in jRAVEN to not match the score calculated by the Submission System
    • Changes in support of the MDS Data Specifications Errata V3.00.3
    • The new MDS VUT, version 3.2.0, also updated in support of the Errata V3.00.3
    • All enhancements included with jRAVEN V1.7.0 & V1.7.1:
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  • CMS Implements SNF Claims Hold (11/19)

    By CMS - November 06, 2019

    As CMS has undertaken the implementation of the Patient Driven Payment Model (PDPM), we are holding a limited number of Skilled Nursing Facility (SNF) claims while we make further refinements to our claims processing system.

     

    PDPM is a historic reform of the SNF prospective payment system. PDPM focuses on the patient’s condition and resulting care needs rather than on the amount of care provided in order to determine Medicare payment. PDPM was effective on October 1, 2019.

     

    Specifically, CMS is holding claims with:

    • Dates of service October 1, 2019 or later and
    • Type of Bill (TOB) inpatient services (21X) and swing bed services (18X) subject to SNF Patient Driven Payment Model (PDPM) and
    • Multiple line items, Health Insurance Prospective Payment System (HIPPS) codes, with different rate codes (revenue code 0022).

     

    Typically, SNFs bill these claims on monthly cycles. Claims with single HIPPS codes were previously being held but are now being released for processing. We anticipate releasing the remaining held claims in late November, once CMS completes systems testing to ensure accurate and timely payment. As of November 1, less than 50 claims are being held.

     

    In addition, we underpaid some SNF inpatient services (21X) and swing bed services (18X) claims for dates of service in October 2019 with a single line item, single HIPPS code. We are automatically reprocessing those claims; no provider action is needed.

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  • Medicare Part A: 5 Key Requirements That Haven’t Changed Under PDPM

    By Caralyn Davis, Staff Writer - October 22, 2019

    Directors of nursing services (DNSs) often take a largely hands-off approach to Medicare Part A coverage issues, says Suzy Harvey, RN-BC, RAC-CT, managing consultant at BKD in Springfield, MO. “In many facilities, DNSs more or less delegate the entire Medicare program to the MDS coordinator or the Medicare consultant. This ability to delegate is important because DNSs have such a demanding job. However, DNSs ultimately are responsible for all aspects of resident care. The MDS is a part of that, as are Part A skilled services.”

     

    Consequently, DNSs still need to provide oversight—to be a member of the Medicare Part A team and to be aware of how well facility systems work by either auditing medical records or reviewing the results of delegated audits, suggests Harvey. “A DNS who just says, ‘The MDS coordinator handles that,’ could run into unexpected problems during medical review.”

     

    “The implementation of the Patient-Driven Payment Model (PDPM) changed the payment system used for traditional Part A residents,” notes Harvey. “It did not change the coverage policies for skilled services.”

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  • Q&A: What sections of the MDS allow us to include hospital look-back?

    By Frosini Rubertino, BSN, RN, RAC-CT and AADNS - October 08, 2019
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  • CMS Updates Medicare Benefit Policy Manual, Claims Processing Manual for PDPM (10/19)

    By CMS - October 08, 2019

    CMS has revised SNF-focused chapters in the following manuals in the online manual system to account for the Patient-Driven Payment Model (PDPM):

    • Medicare Benefit Policy Manual;
    • Medicare Claims Processing Manual; and
    • Medicare General Information, Eligibility, and Entitlement Manual.



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  • PDPM Grouper DLL Package Revised Again--Make Sure Your Software Is Updated (10/19)

    By CMS - October 07, 2019
    A revision to the PDPM DLL Package (V1.0003 FINAL) was posted, and the previous version (V1.0002 FINAL) was removed.  This version corrects four bugs that were identified after the V1.0002 release. The package contains updated test files and documentation.
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  • 5 Ways to Benefit From Skilled Therapy Under PDPM

    By Caralyn Davis, Staff Writer - September 25, 2019

    Therapy utilization will no longer be a payment driver under the Patient-Driven Payment Model (PDPM) in the Skilled Nursing Facility Prospective Payment System (SNF PPS), but skilled therapy services still have a key role to play. Liz Barlow, RN, CRRN, RAC-CT, DNS-CT, senior director of quality for RehabCare in Louisville, KY, offers five ways that directors of nursing services (DNSs) can work with the interdisciplinary team to get the most bang for their buck with therapy:

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  • PDPM Game Plan Tool

    By AAPACN - September 25, 2019
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  • CMS Makes Direct Link Between Outcomes and Medical Review

    By Caralyn Davis, Staff Writer - September 11, 2019

    Under the Patient-Driven Payment Model (PDPM), resident outcomes will be key to avoiding medical review, said officials with the Centers for Medicare & Medicaid Services (CMS) during the August 14 Skilled Nursing Facility Quality Reporting Program (SNF QRP) training session, Patient-Driven Payment Model: What Is Changing (and What Is Not). Note: Find the session slides here.

     

    The goal of PDPM is for SNFs to provide value-driven care, said officials. “Fundamentally, it comes down to a balance. A high-value and efficient provider is one that is able to achieve high-quality outcomes at low cost.”

     

    CMS measures SNF quality of care in three main ways:

    • The SNF QRP;

    • The Skilled Nursing Facility Value-Based Purchasing (SNF VBP) program; and

    • The Five-Star Quality Reporting System on Nursing Home Compare.

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  • FY 2020 PDPM ICD-10 Mapping Tool and MDS Item I0020B ICD-10 Code Lookup Tool (9/19)

    By CMS - September 03, 2019

    CMS has released the PDPM ICD-10 Mappings File for FY 2020 as well as the I0020B Code Lookup File. 

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  • PDPM FAQs and Fact Sheets_Revised (9/19)

    By CMS - September 03, 2019

    Fact Sheets

    This section includes fact sheets on a variety of PDPM related topics.

    • Administrative Level of Care Presumption under the PDPM
    • PDPM Payments for SNF Patients with HIV/AIDS
    • Concurrent and Group Therapy Limit
    • PDPM Functional and Cognitive Scoring
    • Interrupted Stay Policy
    • MDS Changes
    • NTA Comorbidity Score
    • PDPM Patient Classification
    • Variable Per Diem Adjustment

    PDPM Frequently Asked Questions

    This section contains frequently asked questions (FAQs) related to PDPM policy and implementation.

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  • Prep Your Restorative Nursing Program for PDPM

    By Caralyn Davis, Staff Writer - August 21, 2019

    Under the Patient-Driven Payment Model (PDPM) that goes into effect this October 1 for the Skilled Nursing Facility Prospective Payment System (SNF PPS), restorative nursing plays two key roles, just as it did under RUG-IV:

    1.  It is a qualifier for two payment classification categories in the nursing component of PDPM:

    a. Behavioral Symptoms and Cognitive Performance, and

    b. Reduced Physical Function.

    Note: See the chart at the end of this article for an overview of restorative nursing’s role in the nursing component of PDPM.

    2.  It also can serve as the daily skilled service required to meet a skilled level of care for Medicare Part A patients (e.g., upon admission when skilled therapy isn’t medically necessary, in conjunction with skilled therapy that doesn’t meet the daily requirement, or after the patient is discharged from skilled therapy). Section 30.6, Daily Skilled Services Defined, in Chapter 8, “Coverage of Extended Care (SNF) Services Under Hospital Insurance,” of the Medicare Benefit Policy Manual offers insights into its role as a daily skilled service:

    “In instances when a patient requires a skilled restorative nursing program to positively affect his functional well-being, the expectation is that the program be rendered at least 6 days a week. (Note that when a patient’s skilled status is based on a restorative program, medical evidence must be documented to justify the services. In most instances, it is expected that a skilled restorative program will be, at most, only a few weeks in duration.)”

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  • 2020 ICD-10-CM Diagnosis Code Files and Coding Guidelines (8/19)

    By CMS - August 12, 2019
    The 2020 ICD-10-CM files  contain information on the ICD-10-CM updates for FY 2020. These 2020 ICD-10-CM codes are to be used for discharges occurring from October 1, 2019 through September 30, 2020 and for patient encounters occurring from October 1, 2019 through September 30, 2020. This also contains the official ICD-10 Coding Guidelines.
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