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.

  • jRAVEN 1.7.7 Free MDS Submission Software Updated (1/21)

    By QTSO - January 11, 2021

    The Resident Assessment Validation and Entry System (jRAVEN) was developed by the Centers for Medicare & Medicaid Services (CMS). jRAVEN is a free Java based software application which provides an option for facilities to collect and maintain MDS Assessment data for subsequent submission to the appropriate state and/or national data repository. jRAVEN displays the MDS Item Sets similar to the paper version of the forms. Please consult the jRAVEN Installation and User Guides for additional information.

    jRAVEN v1.7.7 is now available for download under the Downloads section at the bottom of this webpage. Users do not need a previous version of jRAVEN to download, install or use jRAVEN v1.7.7.

    jRAVEN v1.7.7 includes the following enhancements:

    • The new MDS VUT, v3.5.0, updated to support Issue #17 in Errata v3.00.6 and the new ICD Code files that are in effect as of 1/1/2021
    • The new PDPM Grouper, v1.0009, updated to include the ICD codes that are effective 01/01/202
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  • FY 2021 PDPM ICD-10 Mappings (1/21)

    By CMS - January 11, 2021

    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 

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  • BIMS MDS Coding Video Tutorial (10/20)

    By CMS - October 29, 2020
    The Centers for Medicare & Medicaid Services (CMS) is releasing a video tutorial to assist providers in Inpatient Rehabilitation Facilities and Skilled Nursing Facilities with standardized data assessment guidance and assessment strategies for the cognitive assessment known as the Brief Interview for Mental Status (BIMS). This video tutorial is approximately 22 minutes in length and is designed to provide targeted guidance for accurate coding using live-action patient/resident scenarios.
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  • FY 2021 SNF PPS Final Rule Released (7/20)

    By CMS - August 02, 2020

    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.

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  • FY 2021 SNF PPS Proposed Rule: CMS Holds Steady on the SNF QRP, SNF VBP

    By Caralyn Davis, Staff Writer - April 13, 2020

    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.

    CMS also is keeping its options open for future adjustments to the PDPM based on its ongoing monitoring efforts. Here are highlights of the FY 2021 proposed rule.

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  • Q&A: Does anyone have an IPA Policy?

    By Maureen McCarthy, BS, RN, RAC-MT, QCP-MT, DNS-MT, RAC-MTA President/CEO Celtic Consulting, LLC - February 19, 2020
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  • SNF PPS Fact Sheet From Medicare Learning Network - Revised (1/20)

    By CMS - February 03, 2020
    The basics of SNF PPS and consolidated billing.
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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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  • 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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  • 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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  • 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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