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.

  • FY 2020 PDPM ICD-10 Mapping Tool and MDS Item I0020B ICD-10 Code Lookup Tool UPDATED (4/20)

    By CMS - April 01, 2020

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

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  • PDPM Grouper DLL Package Revised Again--Make Sure Your Software Is Updated (3/20)

    By CMS - March 31, 2020
    A revision to the PDPM DLL Package (V1.0004 FINAL) was posted, and the previous version (V1.0003 FINAL) was removed.  This version adds support for the new ICD-10-CM code for Coronavirus, U07.1. Note that this code is ONLY in effect for assessments with target date 04-01-2020 and later.  The package contains updated test files and documentation.
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  • jRAVEN 1.7.3 Free MDS Submission Software Updated (3/20)

    By CMS - March 30, 2020

    jRAVEN (version 1.7.3) is now available for download which contains the following updates:  

    • The new COVID-19 ICD code has been added, effective 4/1/2020. In support of that this new release of jRAVEN has the following updates:

     

    MDS Validation Utility Tool (VUT) V3.3.0

    The MDS Validation Utility Tool (VUT) v3.3.0 is now available. This release is effective on April 1, 2020, and supports the addition of the new COVID-19 ICD Code. For additional information please review the associated MDS VUT ReadMe text file.

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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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  • 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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  • 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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