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.

  • 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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  • 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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  • CMS May 7 and 8, 2019, SNF QRP Post-Training Videos and Slide Sets Available (7/19)

    By CMS - July 29, 2019

    Videos and post-training materials (includes answers to knowledge checks and interactive sessions) from the May 2019 Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Provider Training held in Kansas City, MO, on May 7 and 8, 2019, are now available.

    Please note: Post-training materials include answers to knowledge checks and interactive sessions. Additionally, Section GG presentation has been updated to include links to videos shown during the training.

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  • PDPM Admission Checklist Tool

    By AAPACN - July 23, 2019
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  • Beta PDPM Grouper DLL Released (7/19)

    By CMS - July 04, 2019

    A BETA version of the PDPM Grouper DLL has been posted, along with its source code.  Please read the READ ME FIRST.PDF within the ZIP file before attempting to use the grouper software.  Note that testing of the DLL is ongoing.  Please report any issues found to PDPM@cms.hhs.gov.

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  • PDPM Training and Technical Resources, Including Grouper Logic & ICD-10 Mappings (7/19)

    By CMS - July 02, 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.

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  • April Five-Star Changes: Impacts and Action Steps

    By Caralyn Davis, Staff Writer - May 30, 2019

    On April 24, the Centers for Medicare & Medicaid Services (CMS) made a series of changes to the Five-Star Quality Rating System on Nursing Home Compare. Now that directors of nursing services (DNSs) have that update under their belt, they can take the following steps to get a handle on the biggest surprises:

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  • Utilizing Restorative Nursing Programs to Optimize Outcomes and Balance Costs Under PDPM

    By Pam Truscott, MSN, RN, QCP, DNS-CT - May 30, 2019

    With the implementation of the Patient-Driven Payment Model (PDPM) just a few short months away, you may be asking yourself what benefits restorative nursing programs will have under the new system. PDPM will focus less on the volume of therapy minutes and more on the resident’s characteristics and diagnoses. However, SNF leadership must balance the costs of the services provided while achieving successful resident outcomes. Facility leaders may want to consider how a comprehensive restorative nursing program can help them reach these goals, given that such a program can maintain or improve a resident’s function, improve quality outcomes, and reduce costly complications such as wounds.

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  • Preliminary RAI Manual v1.17 Released (5/19)

    By CMS - May 20, 2019

    The PDF file labeled “MDS 3.0 RAI Manual v1.17 October 1, 2019” is now available.

    Please note this early release is being provided in response to stakeholder feedback. The MDS 3.0 RAI Manual v1.17 contains many updates including information related to the Patient Driven Payment Model. Please check back prior to October 1, 2019 for a final posting which may contain additional updates.

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  • ODF News: CMS Tackles SNF VBP, Other FY 2020 Proposals

    By Caralyn Davis, Staff Writer - May 07, 2019

    Not surprisingly, the April 19 release of the fiscal year (FY) 2020 Skilled Nursing Facility Prospective Payment System (SNF PPS) Proposed Rule (CMS-1718-P) was the primary focus of officials with the Centers for Medicare & Medicaid Services (CMS) during the April 23 Skilled Nursing Facility/Long-term Care Open Door Forum (ODF). Highlights include the following:

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  • 7 Important Steps to Shore Up Documentation Under PDPM

    By AADNS - April 25, 2019

    With the implementation of the Patient-Driven Payment Model (PDPM) on October 1, 2019, facility staff are feeling the pressure to start scrutinizing the completeness of clinical documentation in support of MDS items that will determine reimbursement for Medicare Part A residents.

    “Documentation under PDPM is going to be more critical than ever,” states Lynn A. Milligan, MSN/ED, RN, DNS-CT, RAC-CT. Jessie McGill, RN, RAC-MTA, RAC-MT, agrees: “We are moving from the RUG-IV payment model, which primarily uses therapy minutes and ADLs to determine payment, to a model which uses a multitude of clinical items.” Below are some important steps a director of nursing should take to ensure that proper documentation is captured and complete, which will result in accurate reimbursement for the facility and more positive outcomes for residents.

     

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  • FY 2020 SNF PPS Proposed Rule (4/19)

    By CMS - April 19, 2019

    Proposed Fiscal Year 2020 Payment and Policy Changes for Medicare Skilled Nursing Facilities (CMS-1718-P)

    On April 19, 2019, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule [CMS-1718-P] for Fiscal Year (FY) 2020 that updates the Medicare payment rates and the quality programs for skilled nursing facilities (SNFs). This proposed rule is part of our 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.  Additionally, effective October 1, 2019, CMS will begin using a new case-mix model, the Patient Driven Payment Model (PDPM), which focuses on the patient’s condition and resulting care needs rather than on the amount of care provided in order to determine Medicare payment.

    This fact sheet discusses three major provisions of the proposed rule: the proposed changes to SNF payment policy under the SNF Prospective Payment System (PPS), the SNF Value-Based Purchasing Program (VBP), and the SNF Quality Reporting Program (QRP).  This proposed rule includes policies that would continue a commitment to shift Medicare payments from volume to value, with the continued implementation of the PDPM, SNF VBP, and SNF QRP to improve program interoperability, operational quality and safety.

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  • 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.
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  • 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.

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