Questions About PDPM? We Have The Answers

Even though the Patient Driven Payment Model (PDPM) has been in effect since October 1, 2019, there are still several questions surrounding this new change. Scott Heichel, RN, RAC-MT, RAC-CTA, DNS-CT, CIC, QCP, and Director of Clinical Reimbursement for LeaderStat, shares his thoughts to some of the most frequently asked questions.

A best practice would be relying on an IDT approach of assessing the resident. Per the RAI manual version 1.17.1, CMS expects the assessment of the resident’s functional ability to be based on an IDT approach: Assess the resident’s self-care performance based on direct observation, incorporating resident self-reports and reports from qualified clinicians, care staff, or family documented in the resident’s medical record during the three-day assessment period. CMS anticipates that an interdisciplinary team of qualified clinicians is involved in assessing the resident during the three-day assessment period.

The assessment of the 24 self-care and mobility items are based on very specific and at times multi-step tests. Unless your STNA/CNAs have been specifically trained and can distinguish between standard ADL care and section GG Functional Assessment, use caution when relying on this documentation. Also, have you witnessed the STNA/CNAs actually performing these Functional Assessments or could the STNA/CNA be trying to answer the questions based on the daily care they provide to everyone?

Simply allowing the information from a PT or OT Evaluation to auto populate section GG does not provide an IDT approach to this assessment. Also, this would only be two individuals (PT/OT) opinions to the “usual performance” for the resident in these Functional areas. Depending on which day of stay and what time of day these Evaluations are performed could have a significant impact to the picture obtained of the resident, therefore misrepresenting the “usual performance”.

Answer- If the predicted daily rate from the IPA is higher than the current daily rate. The IPA comes down to some simple questions. If I complete the IPA, will my daily rate increase? Will it increase to a level that is worth completing this MDS? Is the predicted length of stay following the IPA worth completing this MDS? Keep in mind the preceding questions and also the staff time and energy to complete the IPA (GG, BIMS, PHQ-9 also) before the IDT makes the final decision.

If even 1 of the 5 Case Mix adjusted PDPM components changes, should you complete an IPA? Unfortunately, the decision to complete an IPA or not complete an IPA will be a very case by case decision at your facility. As you have 5 separate and distinct Case Mix adjusted PDPM components, having 1 increase in its Case Mix doesn’t mean that the other 4 have also. In fact, you could have 1 increase in its Case Mix, 3 stay the same, and 1 decrease its Case Mix. The overall daily rate may get worse or better in this situation, based on the individual resident acuity that is captured on the MDS.

The optional IPA is not to be confused with the prior EOT MDS that was needed when a resident under a Rehab RUG ends rehab services and continues under a nursing skilled service. Therapy ending services wouldn’t typically be an IPA trigger, but the acuity picture of the resident may warrant an IPA investigation.

The SCSA has very specific criteria for when to complete and not complete, outlined in chapter 2 of the RAI User’s manual. The IPA is a strictly optional assessment for Medicare residents and is to be utilized to capture an increase in the daily PDPM rate. Also, the IPA cannot be combined with any other assessment.

Under PDPM, there is no required MDS to complete for this situation. Under RUGs, the provider was required to complete an EOT (End of Therapy) MDS once the resident ended therapy services and the provider was going to continue to skill the resident for at least 3 billable days after therapy. The purpose of the EOT was to reclassify the RUG score from a Rehab RUG to a nursing based RUG. Under PDPM, the payment rate is not impacted by therapy services. If therapy is seeing the resident and then ends the case, the facility would need to determine if a further daily skilled need is still required, but no additional MDS is needed.