Effective October 1, 2019
The Patient-Driven Payment Model (PDPM) will replace the RUG-IV system currently used for skilled nursing facility (SNF) payment. Unless CMS makes any changes in program implementation, we anticipate the effective date of the change to be October 1, 2019. The PDPM proposes to use a person-centered and holistic approach to resident assessment by integrating the scope of clinical complexity with reduction of focus on the quantity of therapy minutes for purposes of categorizing reimbursement groupers.
The PDPM program proposes to simplify the MDS schedule. The following list summarizes key features of the PDPM:
- The PDPM program has six payment components. Five of the six are case-mix adjusted. These components for classification and payment include: Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST), Non-therapy Ancillary (NTA) as well as Nursing. The sixth component incorporates one non-case mix adjusted component, which reflects operational costs such as room and board. Each resident will be assigned to each of these six components regardless of services provided.
- Based upon MDS data, the resident might be assigned to each of the five case mix adjusted components. A resident profile will be some combination of these five categories. The PDPM contains 16 PT groups, 16 OT groups, 12 Speech groups, six NTA groups, as well as 25 nursing groups (which is down from 43 nursing groups).
- Each of the separate case-mix components has its own adjusted index with a corresponding per diem rate.
- Three of the categories (PT, OT and NTA) have adjustable per diem structures that allow for changes in rates related to shifting resources required during the resident’s stay. For example, the PT and OT base rates are reduced by 2% for every successive seven-day period beginning on day 21. Additionally, the NTA component multiplies by a factor of three for the first three days and then reduces to a factor of one beginning on day four and remains constant for the remainder of the stay.
- The total per diem rate is calculated by adding the variable components of PT, OT, and NTA rates to the non-variable Nursing and ST components as well as the non-case mix adjusted component.
- Therapy components might utilize up to 25% of total minutes provided with concurrent or group therapy modalities. If centers exceed 25%, the QIES ASAP Validation reports will reflect this. Administration should consider their method to monitor this.
- The quantity of therapy minutes provided will be based solely on the clinical judgment of the care team. Additionally, the intensity of therapy services will be based on resident need rather than a reimbursement (RUG) category.
- Accurate diagnosis coding on the MDS via ICD-10 codes upon admission will be crucial. There are important complexities, considerations of Primary/Secondary Diagnosis, as well as Principal Diagnosis. This is also important related to medical comorbidities. The Principal Diagnosis is often misunderstood; some consider it the same as the Primary Diagnosis which is, in fact, not so. The Principal Diagnosis code reflects the condition established after study to be chiefly responsible for occasioning the admission of the patient to the facility (in –patient setting). For example, a resident with Alzheimer’s Disease who is on your long-term unit and has a fall and fracture will return with the same Principal Diagnosis as noted on the UB box 69 (reason why the resident was admitted to your facility). The Primary Diagnosis is the reason why the resident requires skilled care. The Secondary Diagnosis is a supportive diagnosis and/or is related to other conditions that affect the resident’s care and/or length of stay.
- The PT and OT components will be assigned to their respective case mix group based on the ICD-10 code (derived from MDS Section I0020B in combination with surgical procedures designated on sections J2100 thru J5000) and cross-walked to one of four major categories as well as a functional score derived from section GG.
- The Nursing component will use similar criteria to the current non-therapy RUG classifications for assignment to its respective case mix group. For example, clinical characteristics that currently place the resident into the Extensive Services, Special Care High and Low, Clinically Complex, Behavioral and Reduced Physical Function RUG categories will be used in PDPM along with the functional score (now derived from section GG rather than section G). These clinical characteristics will continue to use indicators of depression (derived from the PHQ-9 score on section D [Mood]) as well as two restorative nursing programs six times per week to determine the “end-splits” for calculation.
- The NTA category incorporates additional comorbidities such as COPD, morbid obesity and pressure ulcers into the per diem rate. Additionally, the NTA has a modifier for parenteral/IV feeding. There are 50 potential comorbidities that might factor into the NTA with a weighted structure (e.g. some diagnoses assigned more points than others). The NTA then sums the number of comorbidity points (up to 12) to assign its designated case mix group.
- A diagnosis of HIV/ Aids will affect the Nursing component with an 18% add-on. Additionally, this diagnosis will count for one of the comorbidities on the NTA (eight points on the weighted score). The designation or “trigger” for the HIV/ Aids diagnosis will derive from a “B20” code used on the SNF claim (not from the MDS). Please be advised this should be reflected on your diagnosis listing to then be pulled to your UB 04. As a reminder, this is a privacy protected diagnosis. For more information on this please reach out to us or our Director of Health Information, Heather Py, RHIT, CCS, CPHS, RAC-CT, for support.
- The case mix grouper assigned to the ST component will be based on the following five clinical characteristics:
- Acute Neurologic or Non-Neurologic
- SLP-Related Comorbidity
- Cognitive Impairment
- Mechanically Altered Diet
- Swallowing Disorder
These five characteristics will derive from diagnosis coding (cross-walked to acute neurologic, non-neurologic and SLP- related comorbidity), as well as MDS items from Section C (BIMS score) and Section K (mechanically alter diet and swallowing disorder).
- The PDPM will require only two MDS assessments (a 5-day assessment and Discharge assessment). There will also be an optional Interim Payment Assessment (IPA), which facilities might complete if clinical characteristics determine that there would be a change in the case mix groupers (e.g. in at least one of the five case mix adjusted components).
- For residents that initiated their Part A stay prior to October 1, 2019, and continued after October 1, 2019, an IPA assessment will need to be completed for each Part A resident to determine a HIPPS modifier for billing effective October 1, 2019. Facilities will have until October 7, 2019, to complete each of these assessments without incurring penalty.