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.

  • 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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  • CMS Updates Medicare Benefit Policy Manual, Claims Processing Manual for PDPM (10/19)

    By CMS - October 08, 2019

    CMS has revised SNF-focused chapters in the following manuals in the online manual system to account for the Patient-Driven Payment Model (PDPM):

    • Medicare Benefit Policy Manual;
    • Medicare Claims Processing Manual; and
    • Medicare General Information, Eligibility, and Entitlement Manual.



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  • PDPM Grouper DLL Package Revised Again--Make Sure Your Software Is Updated (10/19)

    By CMS - October 07, 2019
    A revision to the PDPM DLL Package (V1.0003 FINAL) was posted, and the previous version (V1.0002 FINAL) was removed.  This version corrects four bugs that were identified after the V1.0002 release. The package contains updated test files and documentation.
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  • jRAVEN 1.7.1 Free MDS Submission Software Updated (10/19)

    By CMS - October 07, 2019

    jRAVEN (version 1.7.1) is now available for download which contains the following updates:  

    1. The Final PDPM Grouper, version 1.0003

    2)         All enhancements included with jRAVEN v1.7.0:

    3)            MDS Item Set Version V1.17

    4)            MDS Data Specification Version V3.00

    5)            VUT Version V3.1.0

    6)            The initial PDPM Grouper (replaced with the new version, v1.0003)

    7)            Supports the Correction Policy update to not allow corrections if it causes the target date to cross over the 10/1/2019 date

    8)            Supports the updated submission timeframe change from 3 years to 2 years

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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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  • FY 2020 PDPM ICD-10 Mapping Tool and MDS Item I0020B ICD-10 Code Lookup Tool (9/19)

    By CMS - September 03, 2019

    CMS has released the PDPM ICD-10 Mappings File for FY 2020 as well as the I0020B Code Lookup File. 

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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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  • Final MDS 3.0 Data Specs for Oct. 1, 2019 Implementation (8/19)

    By CMS - August 21, 2019

    The FINAL version (V3.00.1) of the MDS 3.0 Data Specifications was posted.  This version is scheduled to become effective October 1, 2019.  Note that there have been additional revisions since the errata – they can be identified by looking for “post-errata” in the version notes for the items and edits.

    In addition,  V1.04.0 of the MDS 3.0 CAT Specifications  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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  • 2020 ICD-10-CM Diagnosis Code Files and Coding Guidelines (8/19)

    By CMS - August 12, 2019
    The 2020 ICD-10-CM files  contain information on the ICD-10-CM updates for FY 2020. These 2020 ICD-10-CM codes are to be used for discharges occurring from October 1, 2019 through September 30, 2020 and for patient encounters occurring from October 1, 2019 through September 30, 2020. This also contains the official ICD-10 Coding Guidelines.
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  • PDPM At-a-Glance Tool

    By AANAC - August 07, 2019
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  • SNF QRP Takes Center-Stage in FY 2020 SNF PPS Final Rule

    By Caralyn Davis, Staff Writer - August 02, 2019

    The Fiscal Year (FY) 2020 Skilled Nursing Facility Prospective Payment System (SNF PPS) Final Rule updates the fee-for-service Medicare Part A payment rates using the new Patient-Driven Payment Model (PDPM) case-mix classification system effective October 1, 2019. On the payment side, the Centers for Medicare & Medicaid Services (CMS) made multiple small corrections, ranging from adjusting the market basket update to correcting the wage-index file. 

    However, the biggest changes that CMS finalized involve new MDS data submission requirements for Standardized Patient Assessment Data Elements (SPADEs) under the Skilled Nursing Facility Quality Reporting Program (SNF QRP) that will go into effect on October 1, 2020—just one year after PDPM implementation. But the changes don’t stop there. Directors of nursing services (DNSs) also need to prepare for a few PDPM policy revisions and updates to the Skilled Nursing Facility Value-Based Purchasing (SNF VBP) program. 

    Here are the highlights of the FY 2020 SNF PPS Final Rule that DNSs need to know about.

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  • FY 2020 SNF PPS Final Rule Link and Fact Sheet (7/19)

    By CMS - July 30, 2019

    The Centers for Medicare & Medicaid Services (CMS) issued a final rule [CMS-1718-F] for Fiscal Year (FY) 2020 Medicare payment rates and quality programs for skilled nursing facilities (SNFs). This final rule is part of the agency’s 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. The final rule [CMS-1718-F] can be downloaded from the Federal Register at: https://www.federalregister.gov/documents/2019/08/07/2019-16485/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities.

    OVERVIEW

    This fact sheet discusses three major provisions of the final rule:

    ·        SNF payment policy under the SNF Prospective Payment System (PPS)

    ·        SNF Value-Based Purchasing Program (VBP)

    ·        SNF Quality Reporting Program (QRP). 

    This final rule includes policies that continue to move forward agency commitments to shift Medicare payments from volume to value, with the continued implementation of the SNF VBP and SNF QRP to improve program interoperability, operational quality and safety.

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