Patient-Driven Payment Model (PDPM) Resource Center
PDPM will Replace the RUG-IV per-diem SNF PPS Payment System on October 1, 2019
On July 31, 2018, the Centers for Medicare and Medicaid Services (CMS) published the Prospective Payment System (PPS) and Consolidated Billing for Skilled Nursing Facilities (SNF) Final Rule for Fiscal Year (FY) 2019. In this rule, CMS finalized a proposal to replace the current SNF PPS Resource Utilization Group (RUGs) payment model with a new per-diem payment system called the Patient-Driven Payment Model (PDPM) beginning on October 1, 2019.
In the Balanced Budget Act of 1997, Congress established a SNF prospective payment system (PPS) for Medicare Part A fee-for-service (FFS) payment called the Resource Utilization Group (RUGs) system. However, since its inception,
RUGs has been criticized for not truly being a PPS. Specifically, critics note RUGs is utilization driven by therapy minutes and is a per diem. Additionally, the strong tie of payment to therapy minutes is perceived to be a powerful flaw in RUGs which incentives therapy delivery.
Based on feedback on RCS-1, CMS made an array of changes and released a new, and formally proposed, payment system in our fiscal year 2019 (FY19) Notice of Proposed Rulemaking (NPRM). The proposed payment system was called the Patient-Driven Payment Model (PDPM). After a public comment period, and with some modifications based on those public comments, the PDPM payment model was adopted in the July 30, 2018 SNF PPS Final Rule, with an implementation date set for October 1, 2019.Patient-Driven Payment Model (PDPM)
PDPM is a fundamental shift from RUGs IV and will replace RUGs entirely for Medicare Part A FFS payment to SNFs. Payment is based upon an array of patient characteristics, primarily medical information, associated with newly designed direct care components. Therapy minutes no longer drive payment. See Figure 1 for a comparison of RUGs IV and PDPM payment components.
Figure 1. RUGs IV Payment Components Compared to PDPM
Therapy minutes no longer play a role in determining payment. While CMS still will require therapy minute reporting on the Discharge MDS, therapy minutes and related thresholds no longer drive payment. Rather, patients are assigned to a CMG for each component using clinical information entered onto the SNF PPS Admission MDS which differs by component. The only clinical information on the claim that impacts PDPM payments will be related to residents with HIV/AIDS. In the final rule, CMS made no substantive changes to the patient characteristics and related classification. See Figure 2 for a basic overview.
Figure 2. PDPM Component and Patient Characteristics Used for Case-Mix Group (CMG) Assignment
While considerable analysis is needed to understand how SNFs may optimally deliver quality care under PDPM, five key elements of the payment system are critical to understand when considering preparations for the transition from RUGs to PDPM. See Figure 3., below.
Figure 3. PDPM is a New Medicare Part A Fee-For-Service Payment System: Key Elements to Understand
Education and Training
PDPM Update Intensive Training – September 19 & Sept 26, 2019 5:30-7pm cst
Register Here Price 299.00 This interative Training provides an introductory overview of the new Medicare Part A Skilled Nursing Facility Prospective Payment System (SNF PPS) payment model that will be implemented on October, 1, 2019 (Fiscal Year 2020). This training is designed for clinicians newer to SNF reiumburemment & seeking a step by step breakdown of the old reimbursement to make it easier to learn the new system.
This Training is great for all SNF Team members including MDS, DONs, Rehab, Social Service, Admissions, Restorative Nurse,ect
ICD-10 for PDPM Training – October 3, 2019 5:30-8pm cst
Register Here Price 199.00 This interactive training provides an overview of ICD-10 coding for PDPM in the Skilled Nursing Facility Prospective Payment System (SNF PPS) payment model that will be implemented on October, 1, 2019 (Fiscal Year 2020).
ICD-10 Manual for SNFs
Order Here Price: 169.00 (2020 version will be available Sept 2019) View Table of Contents and sample pages (PDF)
Section GG for Reimbursement Training October 10, 2019 5:30-8pm cst
We will also will offer monthly PDPM update WebEx events and provide montly PDPM FAQs. These resources will be posted at this webpage.
Finally, if you have PDPM questions or recommendations for PDPM education, resource development or training, please email us at firstname.lastname@example.org Responses to questions will be posted in FAQ documents monthly. We will anticipate the need to seek CMS clarification on many questionsT