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.

  • 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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  • jRAVEN 1.7.6 Free MDS Submission Software Updated (10/20)

    By QTSO - October 16, 2020

    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 v1.7.6 is now available for download. Users do not need a previous version of jRAVEN to download, install or use jRAVEN v1.7.6.

    jRAVEN v1.7.6 includes the following enhancement:

    • The new PDPM Grouper, V1.0008, included in this are the six ICD-10 codes that were added in the 1.0007 version.


    JRAVEN v1.7.6 replaces jRAVEN (version 1.7.5), which contained the following updates:  

    • The new PDPM Grouper, v1.0007, along with its source code and test cases, which was updated to include the 6 ICD-10 codes that were inadvertently excluded from the previous release (1.0006).  This version, V1.0007, adds six ICD-10 codes that were inadvertently excluded from the NTA calculation: 
    • T8484XA, 
    • T8389XA, 
    • T8321XA, 
    • T82399A, 
    • T82392A, and 
    • T83021A. 
    • The OBRA PDPM Grouper Calculation screen (for states requiring PDPM scores on OBRA comprehensive NC & NQ assessments) was updated to allow for entry of an End Date to go up through 12/31/2099
    • The updates included with jRAVEN 1.7.4 (MDS Item Set v1.17.2, Data Specification Errata v3.00.5, the MDS VUT v3.4.0)
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  • FY 2021 PDPM ICD-10 Mappings (8/20)

    By CMS - August 09, 2020

    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
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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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  • CMS Addresses PDPM Claims Issue for Out-of-Sequence Claims, Will Correct in October (2/20)

    By CMS - February 26, 2020

    Colleagues—

    This message will appear in this week’s edition of MLN Connects, but we wanted to give our partners advance notice—please share with your members.

    SNF PDPM Claims Issue

    Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) initial claims that are processed out of sequence are not paying the correct Variable Per Diem (VPD)-adjusted rate. Also all adjustment claims are not processing correctly. Claims need to process in date of service order for each stay for the VPD to calculate correctly. We will correct this issue in October. In the interim:

    • Submit claims in sequence by waiting at least 2 weeks before billing subsequent claims
    • To adjust claims, cancel the initial claim and all subsequent claims in the SNF stay then rebill in sequential order; or, hold adjustments (when allowable) until October when they will process correctly
    • We encourage you to submit a complete bill at the time of entry

    Sincerely,

    Robin Fritter

    Director, Division of Provider Relations & Outreach

    Provider Communications Group
    Centers for Medicare & Medicaid Services

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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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