PDPM (Patient Driven Payment Model) Preparation: Q & A

If you are working in a Skilled Nursing Facility, odds are you have often been hearing about PDPM. The number of changes can leave you feeling overwhelmed and under-informed. We sat down with LeaderStat’s Director of Clinical Reimbursement, Scott Heichel, to answer some of the most frequently asked questions about the Patient Driven Payment Model. Here is what he had to say:

When will PDPM go into effect and how will the transition happen?

PDPM goes into effect on October 1st, 2019 for traditional Medicare residents. There is not necessarily a transition as RUG IV will end on Septembet 30th, 2019. PDPM goes live the very next day.

Who will be affected by the changes?

All Skilled Nursing Facilities that receive traditional Medicare residents.

Will staff members need additional training?

Absolutely! This is the first total revamp of the Medicare payment system in 20 years. Training should begin now and continue up through and beyond 10-01-2019.

How does PDPM differ from the current RUG-IV model?

Instead of focusing on therapy delivery and section G ADL coding to drive 90+% of all RUG scores billed to Medicare, the Patient Driven Payment Model focuses on patient characteristics to set the reimbursement. There will be 5 components that will vary resident to resident (PT, OT, ST, Nursing, and NTA Non-Therapy Ancillary). Also, the PPS MDS schedule will be dramatically different from RUG IV as the only required MDSs for Medicare will be the 5 day and the End of Medicare Stay assessment.

How will therapy minutes and ratios be effected?

While therapy minutes will no longer be utilized to set reimbursement, providers have been reminded that residents should be evaluated and treated based on their clinical needs. The residents that you will be treating under RUG IV on 09-30-19 will be the same residents you are treating under PDPM on 10-01-19.

What do facilities need to do to prepare for the changes?

Evaluate your systems, beginning with the admission process and receiving the appropriate medical record documentation. How does the facility/physician currently evaluate and choose the primary medical condition to show why the resident needs to come to your SNF for continued care? Who, in your facility, is responsible for the ICD-10 coding? How confident are you that section GG (Functional Abilities) is being collected and assessed accurately? The IPA (Interim Payment Assessment) MDS will require constant monitoring of resident conditions and evaluating for opportunities to set the ARD (Assessment Reference Date), which will change the payment level for a resident.

Is there a suggested implementation plan for facilities?

While this may vary facility to facility, the areas you will want to consider include the following: PDPM training to your IDT, ICD-10 coding competency, section GG accuracy and timeliness, quality of the supportive documentation that nursing provides which will show the characteristics of the residents.

In summary, the most important thing you need to do to prepare your team for PDPM is create an action plan. The time is now. Your plan will likely include training for your staff so you are ready to roll on October 1, 2019, so there is no time to waste!

If you have additional questions or need assistance preparing for this transition, please contact LeaderStat’s consulting division. We are here to help.

Scott Heichel, RN, RAC-MT, DNS-CT, CIC, QCP, and Director of Clinical Reimbursement for LeaderStat and is a member of AANAC’s (American Association of Nurse Assessment Coordination) Expert Advisory Panel, recognized as a Master Teacher through AANAC for their RAC-CT MDS certification courses, and sits on the board as the Vice President of OANAC (Ohio Association of Nurse Assessment Coordinators).