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Patient Driven Payment Model – PDPM Training

 

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.
 
Background
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
Screen Shot 2018-08-15 at 11.27.00 AM.png

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

Component Patient
Characteristics
Per Diem
Structure
# of Case Mix
Groups
PT – Primary reason for SNF Care ICD-10
– Functional Status – MDS Section GG Early and Late Loss
Payment Decreases
After Day 20
16
OT – Primary reason for SNF Care ICD-10
– Functional Status – MDS Section GG Early and Late Loss
Payment Decreases
After Day 20
16
SLP – Primary Reason for SNF care  ICD-10
– Cognitive Status
– Presence of swallowing disorder or mechanically altered diet
– Other SLP related comorbidities
Average Daily Payment
No Variable Payment
12
Nursing – Clinical information from SNF Stay
– Functional Status – MDS Section GG Early and Late Loss
– Extensive Services Received
– Presence of depression
– Restorative nursing services received
Average Daily Payment
No Variable Payment
25
NTAS – Comorbidities present
– Extensive services used
Payment Decreases
After Day 3
6

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

Screen Shot 2018-08-15 at 11.38.13 AM.png

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 TrainingOctober 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)

The ICD-10-CM Expert for SNF, IRF and LTCH comes with Optum’s hallmark features and format to help make the challenge of accurate diagnosis coding easier. Use the code book that contains the complete ICD-10-CM code set and the familiar Optum360 coding and reimbursement alerts for SNF and IRF including: color-coding and symbols identifying diagnoses.

Now expanded to include long-term care hospital (LTCH) coding and reimbursement indicators in the tabular as well as appendices specific to LTCH. Coding tips and definitions of commonly treated conditions specific to these PAC settings are also included.

  • New – Optum360 Edge – Coding tips. Tips specific to these PAC settings are now included.
  • New – Optum360 Edge – Complete list of code changes. All 2019 new, revised, and deleted codes listed in the front of the book.
  • Optum360 Edge – Supplementary appendices. Additional coding and reimbursement information covering PPS for SNF and IRF; Medicare coverage; quality initiatives; and long-term care guidelines and coding examples are located in supplementary appendices.
  • Optum360 Edge – Case Mix Quick Pick Cards. These handy 8.5″ x 11″ laminated cards identify diagnoses
  • Optum360 Edge – Snap tabs. Quickly reference index sections, tabular chapters, and appendices.

ICD-10

Section GG  for Reimbursement Training  October 10, 2019 5:30-8pm cst

Fee 199.00

  • Section GG – Facility Supporting Documentation ToolsOrder Here Price: 35.00
    • Section GG – Functional Abilities and Goals/SNF PPS Medicare Part A Admission – 100/pad Revised to the updated MDS 3.0 Section GG version 1.16.1, this form can be used to train staff and develop your internal processes for evaluating Section GG at admission. This form allows staff to document the resident’s status for the revised GG0130 (Self-Care) and GG0170 (Mobility) items for the first three days of the resident’s stay. The information can then be used to determine the resident’s “usual performance” on admission and to establish realistic Discharge Goals.
    • Section GG Admission
  •  Section GG – Daily Documentation for Section GG Functional Abilities – Discharge – 100/padOrder Here Price 35.00
  • Revised to the updated MDS 3.0 Section GG version 1.16.1, this form can be used to train staff and develop your internal processes for evaluating Section GG for a planned Part A discharge.
  • This form allows staff to document shift-by-shift the resident’s status for the revised GG0130 (Self-Care) and GG0170 (Mobility) items three days prior to a resident’s planned Part A discharge. The information can then be used to determine the resident’s “usual performance” at discharge.
  • To document resident’s performance at a planned Part A admissionPDPM Section gg discharge planned

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 info@mdstraininginstitute.com  Responses to questions will be posted in FAQ documents monthly. We will anticipate the need to seek CMS clarification on many questionsT

Click Here to Register/Order Training or Products Above