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.

  • Casper QM Reports / Data Specs Will Remain Out of Sync for Now

    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.

     

    However, CMS doesn’t share that sense of urgency, planning to release version 12 “in the next couple of months,” said officials during the Feb. 14 Skilled Nursing Facility/Long-term Care Open Door Forum (ODF). The methodology for those updated QMs “is not used in the public domain yet,” they explained to justify the agency’s delay in releasing new technical specifications.

     

    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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  • PDPM FAQs and Fact Sheets_Revised (2/19)

    By CMS - February 15, 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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  • PDPM Training and Technical Resources, Including Grouper Logic & ICD-10 Crosswalks (2/19)

    By CMS - February 15, 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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  • CMS Transmittal and MLN Connects Article on PDPM Implementation (2/19)

    By CMS - February 14, 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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  • 7 Ways the DNS Can Lead the Charge for PDPM

    By Caralyn Davis, Staff Writer - February 12, 2019

    Many directors of nursing services (DNSs) have a hands-off approach when it comes to fee-for-service Medicare Part A and the MDS process, says Suzy Harvey, RN-BC, RAC-CT, managing consultant at BKD in Springfield, MO. “DNSs attend morning meetings and sometimes attend Medicare meetings, but they don’t really get involved because they count on their MDS staff to handle those processes.”

     

    That approach works for the RUG-IV case-mix classification system, but when the Skilled Nursing Facility Prospective Payment System (SNF PPS) switches to the Patient-Driven Payment Model (PDPM) on Oct. 1, rehabilitation therapy will no longer drive Part A skilled care, says Harvey. “With PDPM focused on patient characteristics and skilled nursing services instead of therapy volume, nursing will become key to facility success in this new system, and as the supervisor of the nursing staff, the DNS will need to help lead the way.”

     

    It’s important to note that working on PDPM isn’t just another task to add to the DNS’s plate, adds Harvey. “Getting paid appropriately is the focus of PDPM, but it ties back into quality of care. Much of what you will need to work on for PDPM will also benefit you on survey and your quality measures as well.”

     

    Here are seven key steps a DNS can take to get out in front of PDPM:

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  • DRAFT MDS Data Specs and CAT Specs for Oct. 1, 2019

    By CMS - February 05, 2019

    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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  • PDPM Prep and Skilled Nursing: Secure Skilled Coverage Starting Day One

    By Caralyn Davis, Staff Writer - January 16, 2019

    When the Patient-Driven Payment Model (PDPM) replaces RUG-IV as the case-mix classification system for the Skilled Nursing Facility Prospective Payment System (SNF PPS) effective Oct. 1, 2019, some SNFs may see their Part A length of stay temporarily increase, says Maureen McCarthy, BS, RN, RAC-MT, QCP-MT, DNS-MT, RAC-CTA, president/CEO of Celtic Consulting in Torrington, CT.

     

    “The skilled coverage rules for Medicare won’t change just because we are changing payment systems. However, 95 percent of SNF days are in rehab categories, and many providers have been so focused on obtaining the best rehab RUG score that they have lost sight of what the skilled coverage is,” notes McCarthy. “So length of stay may go up for a period of time as SNFs re-learn how to skill patients for nursing services and become comfortable with understanding when the need for skilled care ends if rehab is not involved.”

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  • AADNS's Pathway to PDPM Readiness Tool

    By AADNS - January 16, 2019
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  • DRAFT v1.17.0 MDS Item Sets for Oct. 1, 2019 Implementation (1/19)

    By CMS - January 04, 2019
    A new DRAFT version of the 2019 MDS item sets (v1.17.0) 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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  • Dec. 11, 2018 SNF PPS: PDPM National Provider Call Transcript, Recording, Slides (1/19)

    By CMS - January 03, 2019

    On October 1, 2019, the new Patient Driven Payment Model (PDPM) is replacing Resource Utilization Group, Version IV (RUG-IV) for the Skilled Nursing Facility (SNF) Prospective Payment System (PPS).

    Topics:

    • Overview of PDPM, a new case-mix classification system for SNF Part A beneficiaries
    • Changeover from RUG-IV to PDPM
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  • CMS Warns Against Payment-Driven Therapy Under PDPM

    By Caralyn Davis, Staff Writer - December 18, 2018
    The fundamental reason that the new Patient-Driven Payment Model (PDPM) will replace RUG-IV as the case-mix classification system for traditional Medicare Part A residents under the Skilled Nursing Facility Prospective Payment System (SNF PPS) on Oct. 1, 2019, is that “therapy payments under the SNF PPS are based almost entirely on merely the amount of therapy the patient receives,” said officials with the Centers for Medicare & Medicaid Services (CMS) during the Dec. 11 SNF PPS: PDPM National Provider Call. Note: Access the call slides, as well as a transcript and recording when available, here.
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  • CMS Addresses Medicaid RUG-III & RUG-IV Case Mix Effective Oct. 1, 2019

    By CMS - December 07, 2018

    Summary: States will have access to an optional assessment to support RUG-III and RUG-IV from October 1, 2019 through September 30, 2020. Effective, Oct. 1, 2020, states that continue to use RUG-III or RUG-IV after October 1, 2020 will need to implement a new process to gather the needed data because many of the corresponding MDS items will no longer be present on the MDS.

    Memo:

    On October 1, 2020 CMS will no longer support RUG-III and RUG-IV case-mix methodologies via the Minimum Data Set (MDS). PDPM utilizes a streamlined assessment schedule compared to RUG-III and RUG-IV by eliminating all current scheduled assessments, except the 5-day, and all unscheduled assessments (i.e., Other Medicare-Required Assessments). For States that rely on these assessments for calculating their case-mix group, CMS has created an optional assessment so that Medicaid payment is not adversely impacted when PDPM is implemented on October 1, 2019. States will have some flexibility in crafting policies associated with this assessment. The optional assessment will be effective from October 1, 2019 through September 30, 2020.

    Finally, in an effort to reduce provider burden, improve quality of care, and standardize data elements across provider settings, CMS will be removing several MDS data elements over the next few years. Many MDS data elements used in RUG-III and RUG-IV are no longer required for Federal purposes. With the removal of data elements, RUG-III and RUG-IV will no longer be functional. States that continue to use RUG-III or RUG-IV after October 1, 2020 will need to implement a new process to gather the needed data.

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  • SNF/LTC ODF: CMS Talks Quality and Payment

    By Caralyn Davis, Staff Writer - December 04, 2018

    Change is the one constant nursing homes face these days as the Centers for Medicare & Medicaid Services (CMS) pushes providers to transform from an institutional, service-driven approach to a patient-focused, clinical-need approach that highlights quality of care and quality of life. While this drive began on the survey side with the implementation of the revised Medicare/Medicaid conditions of participation, it now also is taking root on the payment side via several quality programs impacting the fee-for-service Medicare Part A program.

     

    During the Nov. 29 Skilled Nursing Facility/Long-term Care Open Door Forum, CMS officials addressed programs on both sides of the aisle, including:

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  • CMS PDPM Website (11/18)

    By MX - November 26, 2018

    In July 2018, CMS finalized a new case-mix classification model, the Patient Driven Payment Model (PDPM), that, effective beginning October 1, 2019, will be used under the Skilled Nursing Facility (SNF) Prospective Payment System (PPS) for classifying SNF patients in a covered Part A stay. This site includes a variety of educational and training resources to assist stakeholders in preparing for PDPM implementation.


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  • Side-by-Side View: The Big Changes From RUG-IV to PDPM

    By AADNS - November 26, 2018
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