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New Assessment Documentation Process PDPM Payment Driven Payment Model for October 2019

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New Mandated Patient Driven Payment Model (PDPM)

PDPM is one of the initiatives resulting from the Improving Medicare Post-Acute Care Transformation Act of 2014 (the IMPACT Act). 
 
In July 2018, CMS finalized a new case-mix classification model, the Patient Driven Payment Model (PDPM) which is the proposed new Medicare payment rule for skilled nursing facilities. This model is intended to replace the current Resource Utilization Group (RUG-IV) system with a completely new way of calculating reimbursement and is slated to go into effect beginning October 1, 2019.
 
Under PDPM, therapy minutes are removed as the basis for payment in favor of resident classifications and anticipated resource needs during the course of a resident’s stay. PDPM assigns every resident a case-mix classification that drives the daily reimbursement rate for that individual. The currently utilized Resource Utilization Group, Version IV (RUG-IV) billing will end on September 30, 2019.
 
PDPM will be a significant shift in how SNFs are paid, and facilities need to start preparing for the change. PDPM:
  • Removes therapy minutes as a determinant of payment and creates a new model where payment is linked to differences in clinical characteristics.
  • Creates a separate payment component for Non-Therapy Ancillaries (NTA), using resident characteristics to predict utilization of these services
  • Focuses on clinically relevant factors and ICD-10 diagnosis codes to determine payment
The implementation of PDPM will be one more step towards moving reimbursement for care from volume to value. As payment shifts from therapy focus to clinical characteristics focus, there will need to be more detailed documentation to support the medical condition.

Under currently utilized RUGs, there are approximately 20 items on the MDS which impact reimbursement. Under PDPM, there will be approximately 160 items which impact reimbursement.

MDS Implications - Patients over Paperwork

PDPM emphasizes patients over paperwork, as it eliminates the current (MDS) schedule.
  • MDS assessments will be more streamlined under the PDPM model. Only two required assessments: the five-day assessment and the discharge assessment.
The five-day assessment must be completed between:
  • Days one and eight and will be effective for the entire length of stay unless an optional assessment is performed.
Each facility may need to revise the systems currently in place to make sure that the information critical to reimbursement is recorded accurately on the five-day assessment. Missing an item on the five-day MDS will impact reimbursement for the entire resident stay.
 
Note: Current 14-day, 30-day, 60-day and 90-day assessments will be discontinued.
  • Discharge assessments will not impact reimbursement―however; this is where therapy notes will be reported.
If a resident leaves the facility and is away from the facility for less than three days, then the stay is considered the same admission. If the resident is away for more than three days, the admission is considered a new admission, and the Non-Therapy Ancillaries (NTAs) and therapy payments are returned to day one payment.

HINT: NTA’s are a long list of diagnostic categories and clinical support services needed to care for those patients that may be more medically complex or demonstrate a higher acuity. NTA’s are calculated, upon admission, by assessing a patient’s clinical profile.
  • Facilities will have the option to perform an Interim Payment Assessment (IPA) should the resident’s clinical characteristics change. This assessment must be completed within 14 days of the change in characteristics and can affect reimbursement. This assessment is similar to a significant change and will only be used as such.
Under PDPM, cognitive testing will become more important. Specifically, the Brief Instrument for Mental Status, or (BIMs) which is completed in order to satisfy Section C: Cognitive Patterns on the Minimum Data Set (MDS) to effectively guide care planning for residents with confusion or a cognitive impairment. Knowing whether a resident has a mild-to-severe cognitive impairment will truly impact:
  • Care planning and the interdisciplinary team’s approach, and
  • SNF revenue – by increasing the Case Mix Index related to the SLP component under PDPM. 
    NOTE: A cognitive impairment requires more resources; thus it will pay more in the new system.
The MDS has been an important tool in driving resident care over that last 30 years, and continues to be relied upon for quality data but it has primarily been utilized as an assessment tool to drive the plan of care with little impact to reimbursement.

However, with the implementation of PDPM and the shift from therapy-driven reimbursement to clinical characteristics as the basis for reimbursement; the MDS will become vital data to obtaining proper reimbursement.
The Activity Department
The elimination of 14-day, 30-day, 60-day and 90-day assessments will alleviate some documentation stress and allow all interdisciplinary departments to spend more quality time in resident interactions.
 
However, with this change, the Activity Department will need to spend more time on the daily documentation process. The daily progress notes need to more clearly detail how the resident pursues activity interests and their level of engagement. Surveyors will be looking for more details in this new process, especially with one-to-one documentation.
 
The new PDPM revised reporting is said to fit into a broader push by CMS toward “patient-centered” reimbursement models that more accurately measures and matches payment rates to the residents’ needs. Remember, it is critical for services to be driven by patient need, not administrative or payer mandates.

The Nursing Department

Under the soon-to-be retired Resource Utilization Group (RUG) system, therapists often dictated a resident’s overall care plan, as their services formed the backbone of Medicare reimbursements. But with therapy no longer driving the reimbursement narrative, nurses will once again return to clinical characteristics of the resident’s individual needs.
 
Nurses may also become individual facilities’ point people for handling the new reimbursement paperwork burdens. Accurately recording residents’ diagnoses and specific medical issues will be vital to receiving the proper compensation for the services — and while experts are split over the exact coding expertise needed to get the job done — front-line nurses and Minimum Data Set (MDS) coordinators will need to be perfect when performing initial assessments.

Summary

In short, therapy hours will no longer drive reimbursements. Providers will receive Medicare payments based on their patients’ care needs, bringing the focus back on individual residents and away from meeting volume benchmarks.
 
The same story is playing out across the industry to realign incentives around patient characteristics rather than running up the tab on the volume and intensity of services.
 
Resources:

https://skillednursingnews.com/2019/03/pdpm-101-what-skilled-nursing-providers-need-to-know-now/
 
https://avalere.com/insights/strategic-imperatives-for-skilled-nursing-facilities-preparing-for-new-payment-system
 
https://www.ahcancal.org/facility_operations/medicare/Pages/PDPM-Resource-Center.aspx
 
https://electronichealthreporter.com/what-is-the-patient-driven-payment-model-how-skilled-nursing-providers-can-get-ahead-of-pdpm/

 
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/MLN_CalL_PDPM_Presentation_508.pdf
 
https://www.berrydunn.com/blog/is-your-revenue-cycle-team-ready-for-medicares-patient-driven-payment-model-pdpm

https://www.berrydunn.com/blog/new-patient-driven-payment-model-from-cmswhat-to-expect-and-what-to-do

 

 

 

Have a topic request or question for Celeste?

 

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ENROLL Now

 

 

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Activity Directors Network was founded in 1996 on the idea that we could help create elderly care that dramatically improved the lives of those we all serve. We envision facilities that feel like homes and that celebrate our resident’s individuality and allows them to live with dignity, purpose and joy. We believe the exchange of education and wisdom between the most talented teachers and passionate students is the way to make an impact. Each and every single one of you are the revolution that is changing everything. Thanks for being a part of The Network.

 

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