Patient-Driven Payment Model (PDPM)

The new Medicare payment system is coming! Will you be ready! This new Patient-Drive Payment System (PDPM) is scheduled to begin Oct. 1, 2019, and AADNS is here to help! As a busy DNS, you need breaking PDPM information, and you need it fast! AADNS will provide you with articles, tools, education, and in-depth analysis of how the PDPM will change facility payment and care delivery. Visiting this page frequently to get new information to help you lead your team readiness.

  • April Five-Star Changes: Impacts and Action Steps

    By Caralyn Davis, Staff Writer - May 30, 2019

    On April 24, the Centers for Medicare & Medicaid Services (CMS) made a series of changes to the Five-Star Quality Rating System on Nursing Home Compare. Now that directors of nursing services (DNSs) have that update under their belt, they can take the following steps to get a handle on the biggest surprises:

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  • Utilizing Restorative Nursing Programs to Optimize Outcomes and Balance Costs Under PDPM

    By Pam Truscott, MSN, RN, QCP, DNS-CT - May 30, 2019

    With the implementation of the Patient-Driven Payment Model (PDPM) just a few short months away, you may be asking yourself what benefits restorative nursing programs will have under the new system. PDPM will focus less on the volume of therapy minutes and more on the resident’s characteristics and diagnoses. However, SNF leadership must balance the costs of the services provided while achieving successful resident outcomes. Facility leaders may want to consider how a comprehensive restorative nursing program can help them reach these goals, given that such a program can maintain or improve a resident’s function, improve quality outcomes, and reduce costly complications such as wounds.

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  • Preliminary RAI Manual v1.17 Released (5/19)

    By CMS - May 20, 2019

    The PDF file labeled “MDS 3.0 RAI Manual v1.17 October 1, 2019” is now available.

    Please note this early release is being provided in response to stakeholder feedback. The MDS 3.0 RAI Manual v1.17 contains many updates including information related to the Patient Driven Payment Model. Please check back prior to October 1, 2019 for a final posting which may contain additional updates.

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  • ODF News: CMS Tackles SNF VBP, Other FY 2020 Proposals

    By Caralyn Davis, Staff Writer - May 07, 2019

    Not surprisingly, the April 19 release of the fiscal year (FY) 2020 Skilled Nursing Facility Prospective Payment System (SNF PPS) Proposed Rule (CMS-1718-P) was the primary focus of officials with the Centers for Medicare & Medicaid Services (CMS) during the April 23 Skilled Nursing Facility/Long-term Care Open Door Forum (ODF). Highlights include the following:

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  • 7 Important Steps to Shore Up Documentation Under PDPM

    By AADNS - April 25, 2019

    With the implementation of the Patient-Driven Payment Model (PDPM) on October 1, 2019, facility staff are feeling the pressure to start scrutinizing the completeness of clinical documentation in support of MDS items that will determine reimbursement for Medicare Part A residents.

    “Documentation under PDPM is going to be more critical than ever,” states Lynn A. Milligan, MSN/ED, RN, DNS-CT, RAC-CT. Jessie McGill, RN, RAC-MTA, RAC-MT, agrees: “We are moving from the RUG-IV payment model, which primarily uses therapy minutes and ADLs to determine payment, to a model which uses a multitude of clinical items.” Below are some important steps a director of nursing should take to ensure that proper documentation is captured and complete, which will result in accurate reimbursement for the facility and more positive outcomes for residents.

     

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  • FY 2020 SNF PPS Proposed Rule (4/19)

    By CMS - April 19, 2019

    Proposed Fiscal Year 2020 Payment and Policy Changes for Medicare Skilled Nursing Facilities (CMS-1718-P)

    On April 19, 2019, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule [CMS-1718-P] for Fiscal Year (FY) 2020 that updates the Medicare payment rates and the quality programs for skilled nursing facilities (SNFs). This proposed rule is part of our continuing efforts to strengthen the Medicare program by better aligning payment rates for these facilities with the costs of providing care and increasing transparency so that patients are able to make informed choices.  Additionally, effective October 1, 2019, CMS will begin using a new case-mix model, the Patient Driven Payment Model (PDPM), which focuses on the patient’s condition and resulting care needs rather than on the amount of care provided in order to determine Medicare payment.

    This fact sheet discusses three major provisions of the proposed rule: the proposed changes to SNF payment policy under the SNF Prospective Payment System (PPS), the SNF Value-Based Purchasing Program (VBP), and the SNF Quality Reporting Program (QRP).  This proposed rule includes policies that would continue a commitment to shift Medicare payments from volume to value, with the continued implementation of the PDPM, SNF VBP, and SNF QRP to improve program interoperability, operational quality and safety.

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  • FInal v1.17.1 MDS Item Sets for Oct. 1, 2019 Implementation (4/19)

    By CMS - April 12, 2019
    A new final version of the 2019 MDS item sets (v1.17.1) has been posted. This version is scheduled to become effective October 1, 2019. The draft item sets include the new IPA and OSA.
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  • PDPM FAQs and Fact Sheets_Revised (4/19)

    By CMS - April 12, 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. The PDPM FAQs were updated on 4-4 and then again on 4-11.

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  • Section GG Under PDPM: Issues to Discuss With Your NAC

    By Caralyn Davis, Staff Writer - April 10, 2019

    To date, the accuracy of section GG (functional abilities and goals) hasn’t mattered from a payment perspective. Section GG doesn’t affect payment under the RUG-IV case-mix classification system, and the Skilled Nursing Facility Quality Reporting Program (SNF QRP) only penalizes providers financially for failing to meet the data submission threshold for required MDS data elements, including section GG items. In other words, completeness—not accuracy—is what allows providers to avoid the SNF QRP’s 2% payment cut every fiscal year.

     

    As a result, many SNFs have relied exclusively on therapy to complete section GG, says Robin Hillier, CPA, STNA, LNHA, RAC-MT, president of RLH Consulting in Westerville, OH. “However, CMS always intended section GG to be a collaboration that includes both nursing’s perspective and therapy’s perspective. PDPM will require providers to make good on CMS’s intent because section GG will affect three of the five case-mix-adjusted PDPM payment components: nursing, physical therapy (PT), and occupational therapy (OT).”

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  • PDPM Training and Technical Resources, Including Grouper Logic & ICD-10 Crosswalks (4/19)

    By CMS - April 05, 2019

    PDPM Training Presentation

    This section includes a training presentation which can be used to educate providers and other stakeholders on PDPM policy and implementation.

    PDPM Resources

    This section includes additional resources relevant to PDPM implementation, including various coding crosswalks and classification logic.

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  • Errata for DRAFT MDS Data Specs for Oct. 1, 2019 Show More Item Set Changes Are Coming (4/19)

    By CMS - April 05, 2019

    April 5 update: An errata (V3.00.1) was posted for the DRAFT version (v3.00.1) of the MDS 3.0 Data Specifications, which will go into effect on October 1, 2019. Twenty-one issues were identified. One new item (X0570A) was added. Five existing items were added to additional item sets. Nine new edits were added, and eight existing edits were revised.

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    A new version (V3.00.0) of the MDS 3.0 Data Specifications was posted.  This version is scheduled to become effective October 1, 2019.  Note that there are many significant changes, including the removal of eight item sets (NS, NSD, NO, NOD, SS, SSD, SO, SOD), the addition of two new item sets (IPA and OSA), and item additions in Sections A, GG, I, J, O and Z. These specs accommodate the utilization of the PDPM grouper, which also begins on October 1, 2019.

    In addition, a new version (V1.04.0) of the MDS 3.0 CAT Specifications was posted. This version is also scheduled to become effective October 1, 2019. The specification for CAT 12 (Nutritional Status) has been updated in accordance with the changes in V3.00.0 of the MDS 3.0 Data Specifications.

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  • NACs Under PDPM: What Should They Do With Their ‘Free’ Time?

    By Caralyn Davis, Staff Writer - March 27, 2019

    The MDS assessment schedule for the Skilled Nursing Facility Prospective Payment System (SNF PPS) will be radically simplified under the Patient-Driven Payment Model (PDPM), effective October 1. In the Fiscal Year (FY) 2019 SNF PPS Final Rule, the Centers for Medicare & Medicaid Services (CMS) estimated that the switch to only two required PPS assessments (i.e., the 5-day PPS MDS and the Part A PPS Discharge assessment) would result in each skilled nursing facility (SNF) saving approximately 188 administrative hours per year based on a single PPS assessment taking 51 minutes to complete. Note: CMS didn’t include the optional provider-driven Interim Payment Assessment (IPA) in these calculations.

     

    “However, there is a lot of debate about how much time the changes to the PPS assessment schedule actually will free up once providers move from theory to practice,” says Robin Hillier, CPA, STNA, LNHA, RAC-MT, president of RLH Consulting in Westerville, OH.

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  • New Payment Models for Therapy Contracts

    By Mark McDavid, OTR, RAC-CT, CHC - March 27, 2019

    October 1 will be here before we know it. And with that comes Medicare’s new Patient-Driven Payment Model (PDPM) for beneficiaries accessing their SNF Part A benefit. It seems like every day there is a new webinar being advertised to help you understand all of the ins and outs of PDPM. It is definitely a more complex system than the RUG-IV system we operate under currently. As we analyze data collected in our facilities, trying to understand where we stand in a PDPM world, there is one other thing to consider: your therapy contract.

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  • CMS Transmittal and MLN Connects Article on PDPM Implementation REVISED (3/19)

    By CMS - March 13, 2019

    CR 11152 effectuates changes to the SNF Prospective Payment System (PPS) that are required for the PDPM. These changes were finalized in the FY 2019 SNF PPS Final Rule (83 FR 39162). SNFs billing on Type of Bill (TOB) 21X and hospital swing bed providers billing on TOB 18X, (subject to SNF PPS) will be subject to these requirements. Make sure your billing staff is aware of these changes.

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  • MDS 3.0 Quality Measures (QM) Manual Now Available

    By Caralyn Davis, Staff Writer - February 19, 2019

    On Feb. 1, the QIES Technical Support Office (QTSO) announced changes to the MDS 3.0 Quality Measure Reports in the CASPER Reporting application, including calculation updates/changes to the short-stay pressure ulcer measure, the long-stay pressure ulcer measure, and the long-stay weight loss measure. As a result, providers have been expecting the Centers for Medicare & Medicaid Services (CMS) to quickly release version 12 of the MDS 3.0 Quality Measures (QM) User’s Manual. Although CMS mentioned that there would be a delay of the release of the MDS 3.0 QM User's Manual during the SNF LTC Open Door Forum on Feb. 14, the new version was posted on Feb. 21, 2019 and is now available. 

     

    In other manual news, providers also won’t get the draft version of the next update to the RAI User’s Manual for the MDS 3.0 quite as early as most hoped to help them prepare for the Oct. 1, 2019, implementation of the Patient-Driven Payment Model (PDPM) under the Skilled Nursing Facility Prospective Payment System (SNF PPS).

     

    “We historically publish that manual more toward August,” said officials. “We do understand the need to be able to review [it for] the PDPM, so our goal is to have that published in May sometime this year.”

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