The Mappings file contains: 

• Mapping of the ICD-10-CM Recorded in Item I0020B of the MDS Assessment to PDPM Clinical Categories 
• Mapping of Comorbidities Included in the PDPM SLP Component to ICD-10-CM Codes
• Mapping of Comorbidities Included in the PDPM NTA Component to ICD-10-CM Codes

These are the codes added in the January 2021 update:

Z11.52 — Encounter for screening for COVID-19

Z20.822 — Contact with and (suspected) exposure to COVID-19

Z86.16 — Personal history of COVID-19

M35.81 — Multisystem inflammatory syndrome (MIS)

M35.89 — Other specified systemic involvement of connective tissue

J12.82 — Pneumonia due to coronavirus disease 2019

(Note that codes M35.81 and M35.89 replace code M35.8, which should no longer be used on assessments with target date on or after January 1, 2021.)

This is the seventh release (sixth production release, since 1.0005 was a beta release).

This release also adds six ICD-10 codes that were inadvertently excluded from the NTA calculation in V1.0006:

• T8484XA

• T8389XA

• T8321XA

• T82399A

• T82392A

 • T83021A 

On July 31, 2020, the Centers for Medicare & Medicaid Services (CMS) issued a final rule [CMS-1737-F] for Fiscal Year (FY) 2021 that updates the Medicare payment rates and the value-based purchasing program for skilled nursing facilities (SNFs). CMS is publishing this final rule consistent with the legal requirements to update Medicare payment policies for SNFs on an annual basis. In recognition of the significant impact of the COVID-19 public health emergency, and limited capacity of health care providers to review and provide comment on extensive proposals, CMS has limited annual SNF rulemaking required by statute to essential policies including Medicare payment to SNFs.

The final rule includes routine technical rate-setting updates to the SNF prospective payment system (PPS) payment rates, and adopts the revised Office of Management and Budget (OMB) statistical area delineations.  In addition, the rule applies a 5 percent cap on wage index decreases from FY 2020 to FY 2021. In response to stakeholder feedback, we are also finalizing changes to the International Classification of Diseases, Version 10 (ICD-10) code mappings, effective October 1, 2020. Finally, this rule includes minor administrative changes related to the SNF Value-Based Purchasing (VBP) Program.

On April 10, the Centers for Medicare & Medicaid Services (CMS) released for public inspection the Fiscal Year (FY) 2021 Proposed Rule for the Skilled Nursing Facility Prospective Payment System (SNF PPS) and Consolidated Billing (CMS-1737-P) as required by law. In a major break from recent years, CMS offers no proposals for updating the Skilled Nursing Facility Quality Reporting Program (SNF QRP) and only what the agency describes as “minor administrative proposals” related to the SNF Value-Based Purchasing (VBP) program.

However, CMS does propose several other revisions in addition to the required Medicare Part A payment rate update. These include:

• Multiple changes to the ICD-10-CM code mappings used for case-mix classification in the Patient-Driven Payment Model (PDPM);

• Technical changes to the regulatory language in the Code of Federal Regulations, including a proposed change that will clarify the “practical matter” criterion of a Part A skilled level of care by removing an outdated example that referred to the repealed Part B therapy cap provision; and
  

• Changes to how SNFs are identified as rural or urban for wage index classification, as well as a proposal to cap wage index decreases from FY 2020 to FY 2021 as a transition measure.

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.”

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:

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.

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.

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.)”