Patient-Driven Payment Model (PDPM)

The new Medicare payment system is coming! Will you be ready! This new Patient-Drive Payment System (PDPM) is scheduled to begin Oct. 1, 2019, and AADNS is here to help! As a busy DNS, you need breaking PDPM information, and you need it fast! AADNS will provide you with articles, tools, education, and in-depth analysis of how the PDPM will change facility payment and care delivery. Visiting this page frequently to get new information to help you lead your team readiness.

  • FInal v1.17.1 MDS Item Sets for Oct. 1, 2019 Implementation (4/19)

    By CMS - April 12, 2019
    A new final version of the 2019 MDS item sets (v1.17.1) has been posted. This version is scheduled to become effective October 1, 2019. The draft item sets include the new IPA and OSA.
    Read more
  • PDPM FAQs and Fact Sheets_Revised (4/19)

    By CMS - April 12, 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. The PDPM FAQs were updated on 4-4 and then again on 4-11.

    Read more
  • Section GG Under PDPM: Issues to Discuss With Your NAC

    By Caralyn Davis, Staff Writer - April 10, 2019

    To date, the accuracy of section GG (functional abilities and goals) hasn’t mattered from a payment perspective. Section GG doesn’t affect payment under the RUG-IV case-mix classification system, and the Skilled Nursing Facility Quality Reporting Program (SNF QRP) only penalizes providers financially for failing to meet the data submission threshold for required MDS data elements, including section GG items. In other words, completeness—not accuracy—is what allows providers to avoid the SNF QRP’s 2% payment cut every fiscal year.

     

    As a result, many SNFs have relied exclusively on therapy to complete section GG, says Robin Hillier, CPA, STNA, LNHA, RAC-MT, president of RLH Consulting in Westerville, OH. “However, CMS always intended section GG to be a collaboration that includes both nursing’s perspective and therapy’s perspective. PDPM will require providers to make good on CMS’s intent because section GG will affect three of the five case-mix-adjusted PDPM payment components: nursing, physical therapy (PT), and occupational therapy (OT).”

    Read more
  • PDPM Training and Technical Resources, Including Grouper Logic & ICD-10 Crosswalks (4/19)

    By CMS - April 05, 2019

    PDPM Training Presentation

    This section includes a training presentation which can be used to educate providers and other stakeholders on PDPM policy and implementation.

    PDPM Resources

    This section includes additional resources relevant to PDPM implementation, including various coding crosswalks and classification logic.

    Read more
  • Errata for DRAFT MDS Data Specs for Oct. 1, 2019 Show More Item Set Changes Are Coming (4/19)

    By CMS - April 05, 2019

    April 5 update: An errata (V3.00.1) was posted for the DRAFT version (v3.00.1) of the MDS 3.0 Data Specifications, which will go into effect on October 1, 2019. Twenty-one issues were identified. One new item (X0570A) was added. Five existing items were added to additional item sets. Nine new edits were added, and eight existing edits were revised.

    ------------------------------------

     

    A new version (V3.00.0) of the MDS 3.0 Data Specifications was posted.  This version is scheduled to become effective October 1, 2019.  Note that there are many significant changes, including the removal of eight item sets (NS, NSD, NO, NOD, SS, SSD, SO, SOD), the addition of two new item sets (IPA and OSA), and item additions in Sections A, GG, I, J, O and Z. These specs accommodate the utilization of the PDPM grouper, which also begins on October 1, 2019.

    In addition, a new version (V1.04.0) of the MDS 3.0 CAT Specifications was posted. This version 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.

    Read more
  • NACs Under PDPM: What Should They Do With Their ‘Free’ Time?

    By Caralyn Davis, Staff Writer - March 27, 2019

    The MDS assessment schedule for the Skilled Nursing Facility Prospective Payment System (SNF PPS) will be radically simplified under the Patient-Driven Payment Model (PDPM), effective October 1. In the Fiscal Year (FY) 2019 SNF PPS Final Rule, the Centers for Medicare & Medicaid Services (CMS) estimated that the switch to only two required PPS assessments (i.e., the 5-day PPS MDS and the Part A PPS Discharge assessment) would result in each skilled nursing facility (SNF) saving approximately 188 administrative hours per year based on a single PPS assessment taking 51 minutes to complete. Note: CMS didn’t include the optional provider-driven Interim Payment Assessment (IPA) in these calculations.

     

    “However, there is a lot of debate about how much time the changes to the PPS assessment schedule actually will free up once providers move from theory to practice,” says Robin Hillier, CPA, STNA, LNHA, RAC-MT, president of RLH Consulting in Westerville, OH.

    Read more
  • New Payment Models for Therapy Contracts

    By Mark McDavid, OTR, RAC-CT, CHC - March 27, 2019

    October 1 will be here before we know it. And with that comes Medicare’s new Patient-Driven Payment Model (PDPM) for beneficiaries accessing their SNF Part A benefit. It seems like every day there is a new webinar being advertised to help you understand all of the ins and outs of PDPM. It is definitely a more complex system than the RUG-IV system we operate under currently. As we analyze data collected in our facilities, trying to understand where we stand in a PDPM world, there is one other thing to consider: your therapy contract.

    Read more
  • May 7 - 8 SNF QRP CMS Training: Register for In-Person or Online Attendance (3/19)

    By CMS - March 21, 2019

    REGISTRATION OPEN – SNF QRP Provider In-Person Training Event, May 7 and 8, 2019

    The Centers for Medicare & Medicaid Services (CMS) will be hosting a 2-day Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) in-person ‘Train the Trainer’ event for providers on May 7 and 8, 2019, at the Sheraton Kansas City Hotel at Crown Center, 2345 McGee Street, Kansas City, MO 64108. This event will be open to all SNF providers, associations, and organizations.

    The primary focus of this 'Train-the-Trainer’ event will be to provide those responsible for training staff at SNFs with information about:

    §  The transition to the Patient Driven Payment Model (PDPM) which becomes effective on October 1, 2019.

    §  A review of SNF QRP changes and updates to the Minimum Data Set (MDS) 3.0 Version 1.17.0, which will become effective on October 1, 2019.

    §  An overview of the eleven SNF QRP Quality Measures.

    §  An interactive session on the use of reports to identify opportunities for process improvement and utilize information contained in reports available via the Certification And Survey Provider Enhanced Reports (CASPER) system to develop quality improvement plans.

    Read more
  • CMS Transmittal and MLN Connects Article on PDPM Implementation REVISED (3/19)

    By CMS - March 13, 2019

    CR 11152 effectuates changes to the SNF Prospective Payment System (PPS) that are required for the PDPM. These changes were finalized in the FY 2019 SNF PPS Final Rule (83 FR 39162). SNFs billing on Type of Bill (TOB) 21X and hospital swing bed providers billing on TOB 18X, (subject to SNF PPS) will be subject to these requirements. Make sure your billing staff is aware of these changes.

    Read more
  • MDS 3.0 Quality Measures (QM) Manual Now Available

    By Caralyn Davis, Staff Writer - February 19, 2019

    On Feb. 1, the QIES Technical Support Office (QTSO) announced changes to the MDS 3.0 Quality Measure Reports in the CASPER Reporting application, including calculation updates/changes to the short-stay pressure ulcer measure, the long-stay pressure ulcer measure, and the long-stay weight loss measure. As a result, providers have been expecting the Centers for Medicare & Medicaid Services (CMS) to quickly release version 12 of the MDS 3.0 Quality Measures (QM) User’s Manual. Although CMS mentioned that there would be a delay of the release of the MDS 3.0 QM User's Manual during the SNF LTC Open Door Forum on Feb. 14, the new version was posted on Feb. 21, 2019 and is now available. 

     

    In other manual news, providers also won’t get the draft version of the next update to the RAI User’s Manual for the MDS 3.0 quite as early as most hoped to help them prepare for the Oct. 1, 2019, implementation of the Patient-Driven Payment Model (PDPM) under the Skilled Nursing Facility Prospective Payment System (SNF PPS).

     

    “We historically publish that manual more toward August,” said officials. “We do understand the need to be able to review [it for] the PDPM, so our goal is to have that published in May sometime this year.”

    Read more
  • 7 Ways the DNS Can Lead the Charge for PDPM

    By Caralyn Davis, Staff Writer - February 12, 2019

    Many directors of nursing services (DNSs) have a hands-off approach when it comes to fee-for-service Medicare Part A and the MDS process, says Suzy Harvey, RN-BC, RAC-CT, managing consultant at BKD in Springfield, MO. “DNSs attend morning meetings and sometimes attend Medicare meetings, but they don’t really get involved because they count on their MDS staff to handle those processes.”

     

    That approach works for the RUG-IV case-mix classification system, but when the Skilled Nursing Facility Prospective Payment System (SNF PPS) switches to the Patient-Driven Payment Model (PDPM) on Oct. 1, rehabilitation therapy will no longer drive Part A skilled care, says Harvey. “With PDPM focused on patient characteristics and skilled nursing services instead of therapy volume, nursing will become key to facility success in this new system, and as the supervisor of the nursing staff, the DNS will need to help lead the way.”

     

    It’s important to note that working on PDPM isn’t just another task to add to the DNS’s plate, adds Harvey. “Getting paid appropriately is the focus of PDPM, but it ties back into quality of care. Much of what you will need to work on for PDPM will also benefit you on survey and your quality measures as well.”

     

    Here are seven key steps a DNS can take to get out in front of PDPM:

    Read more
  • PDPM Prep and Skilled Nursing: Secure Skilled Coverage Starting Day One

    By Caralyn Davis, Staff Writer - January 16, 2019

    When the Patient-Driven Payment Model (PDPM) replaces RUG-IV as the case-mix classification system for the Skilled Nursing Facility Prospective Payment System (SNF PPS) effective Oct. 1, 2019, some SNFs may see their Part A length of stay temporarily increase, says Maureen McCarthy, BS, RN, RAC-MT, QCP-MT, DNS-MT, RAC-CTA, president/CEO of Celtic Consulting in Torrington, CT.

     

    “The skilled coverage rules for Medicare won’t change just because we are changing payment systems. However, 95 percent of SNF days are in rehab categories, and many providers have been so focused on obtaining the best rehab RUG score that they have lost sight of what the skilled coverage is,” notes McCarthy. “So length of stay may go up for a period of time as SNFs re-learn how to skill patients for nursing services and become comfortable with understanding when the need for skilled care ends if rehab is not involved.”

    Read more
  • AADNS's Pathway to PDPM Readiness Tool

    By AADNS - January 16, 2019
    Read more
  • Dec. 11, 2018 SNF PPS: PDPM National Provider Call Transcript, Recording, Slides (1/19)

    By CMS - January 03, 2019

    On October 1, 2019, the new Patient Driven Payment Model (PDPM) is replacing Resource Utilization Group, Version IV (RUG-IV) for the Skilled Nursing Facility (SNF) Prospective Payment System (PPS).

    Topics:

    • Overview of PDPM, a new case-mix classification system for SNF Part A beneficiaries
    • Changeover from RUG-IV to PDPM
    Read more
  • CMS Warns Against Payment-Driven Therapy Under PDPM

    By Caralyn Davis, Staff Writer - December 18, 2018
    The fundamental reason that the new Patient-Driven Payment Model (PDPM) will replace RUG-IV as the case-mix classification system for traditional Medicare Part A residents under the Skilled Nursing Facility Prospective Payment System (SNF PPS) on Oct. 1, 2019, is that “therapy payments under the SNF PPS are based almost entirely on merely the amount of therapy the patient receives,” said officials with the Centers for Medicare & Medicaid Services (CMS) during the Dec. 11 SNF PPS: PDPM National Provider Call. Note: Access the call slides, as well as a transcript and recording when available, here.
    Read more
1 of 2 Next