Should I submit the 5-day PDPM assessment to CMS?
PPS assessments (5-day) completed under PDPM for non-Medicare beneficiaries should not be submitted unless otherwise directed in the future by CMS. It is advised to continue to separate the 5-day from the OBRA Admission assessment unless otherwise instructed. The 2% reduction in therapy - is it designed to keep stays short?
Does your PDPM plan support your diagnosis coding?
This means that providers will have to ensure that the documentation in the medical record supports the diagnosis coding which in turn is used to support the reimbursement. If there is a change in the diagnosis coding, then there should be a change in the PDPM plan.
When to change the PDPM plan for a patient?
If there is a change in the diagnosis coding, then there should be a change in the PDPM plan. CMS has provided two options. The first is a discharge assessment. When the patient no longer meets the skilled criteria for a Part A Medicare stay, the patient should be discharged from Part A.
How can we maximize PDPM reimbursement?
Experts have noted that in order to maximize PDPM reimbursement rates with these changes, facilities needed to shift the emphasis on therapy volume to more comprehensive care that includes therapy, nursing, and non-therapy ancillaries.
Which MDS assessments are required under PDPM?
Under PDPM (effective October 1, 2019), there are 3 SNF PPS assessments: the 5-day Assessment, the Interim Payment Assessment (IPA) and the PPS Discharge Assessment. The 5- day assessment and the PPS Discharge Assessment are required.
When should you do an IPA assessment?
The IPA Assessment must be completed (item Z0500B) within 14 days after the ARD (ARD + 14 days) and must be submitted electronically and accepted into the QIES ASAP system within 14 days after completion (item Z0500B) (completion + 14 days).
When completing an admission assessment which date on the MDS determines whether the entire assessment process was completed by day 14 of the resident's stay?
For example, an Admission assessment must be completed within 14 days of admission. This means that both the MDS and the RAPs (R2b and VB2 dates) must be completed by day 14. The MDS Completion Date (R2b) may be earlier than or the same as the RAPs Completion Date (VB2), and neither can be later than day 14.
When completing a Medicare 5-day PPS assessment with an OBRA admission assessment CAAs must be completed no later than which day?
14 daysA: Per CMS long standing policy, the ARD of the PPS Discharge assessment can be set anytime during the completion period. A SNF PPS Discharge assessment is required to be completed no later than 14 days after the date at A2400C (End Date of Most Recent Medicare Stay).
What is an IPA assessment?
The Integrated Performance Assessment (IPA) is a cluster assessment featuring three tasks, each of which reflects one of the three modes of communication--Interpretive, Interpersonal and Presentational.
What is IPA under PDPM?
Another CMS option under PDPM is to implement the Interim Payment Assessment (IPA). The IPA may be completed by providers in order to report a change in the patient's PDPM classification, rather than discharge the patient from receiving Part A services. CMS has made it clear that the IPA is an optional assessment.
What is the assessment reference date for MDS?
Assessment Reference Date: The Assessment Reference Date (ARD) is the date that signifies the end of the look back period. This date is used to base responses to all MDS coding items. Ø Intent: To establish a common temporal reference point for all staff participating in the resident's assessment.
What is a comprehensive MDS assessment?
The Minimum Data Set (MDS) is part of a federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process entails a comprehensive, standardized assessment of each resident's functional capabilities and health needs.
What is the MDS assessment?
Description: The Long Term Care Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status which forms the foundation of the comprehensive assessment for all residents of long-term care facilities certified to participate in Medicare or Medicaid.
What is an OBRA admission assessment?
The OBRA Admission Assessment is a comprehensive assessment for new residents and, under some circumstances, returning residents. Requirements include: Completed (with CAAs) Completed by the end of day 14, counting the date of admission to the nursing home as day 1.
Can you combine 5 day and discharge assessment?
Answer to question 2: The 5-day assessment, the OBRA admission assessment, and the discharge assessment can be combined when the ARD of the discharge assessment is also compatible with the ARD of the 5-day and OBRA admission assessment.
What is a scheduled PPS assessment?
The SNF PPS establishes a Medicare-Required PPS Assessment schedule. Each required assessment supports reimbursement for a range of days of a Medicare Part A covered stay. The schedule includes assessments performed about Days 5, 14, 30, 60, and 90 of the stay.
Will managed care assessment be done as a 5-day separate assessment that is not transmitted and we do Admission only on those?
At this time CMS has not issued any change in policy related to submission of PPS assessments. PPS assessments (5-day) completed under PDPM for non...
The 2% reduction in therapy - is it designed to keep stays short?
CMS analysis indicates that therapy services decreases during a Medicare stay. The 2% reduction is implemented to correspond with this reduction of...
We provide trach and vent care in Skilled Nursing Facilities. Most of our patients are Medicaid. How might this impact us?
This would be a state specific question and depends on your specific state’s reimbursement system and what plans once PDPM is implemented. Medicaid...
Will therapy still need to track and report co-treatment minutes on the MDS?
Yes, the MDS will still have separate entries for individual, group, concurrent, and co-treatments.
We often receive transfers from other LTC facilities wishing to admit to our facility. We would be doing a 5 day for our facility. The other facility already received the variable per diem rate adjustment. Does that preclude us from receiving the base rate adjustment? Or would we still be able to utilize the base rate adjustment?
The variable rate adjustments are based on Medicare stays. Since the resident would be new to your facility, this is considered a new Medicare Part...
Are MD certs required for 5-14-30-60-90 still or just for the 5 day?
SNF Physician certification and recertification regulatory requirements are independent of the current RUG payment system and the upcoming PDPM. Ph...
How many days does Medicare require a late assessment?
CMS Pays default rate for the 15 days the 14-day assessment would have covered (Days 15–30) In this example, you must complete the 30-day Medicare-required assessment within Days 27–33, which includes grace days, because a late assessment cannot replace a different Medicare-required assessment.
How long does it take for a Medicare Part A resident to return?
The Part A resident returns more than 30 days after a discharge assessment when return was anticipated. The resident leaves a Medicare Advantage (MA) Plan and becomes covered by Medicare Part A (the Medicare PPS schedule starts over as the resident now begins a Medicare Part A stay)
What is the PPS assessment schedule?
The Medicare-required PPS assessment schedule includes 5-day, 14-day, 30-day, 60-day, and 90-day scheduled assessments.
Where to send MDS 3.0 data?
You must transmit MDS 3.0 data to a Federal data repository, the QIES ASAP system. You must submit MDS 3.0 assessments and tracking records mandated under the OBRA and the SNF PPS. Do not submit assessments completed for purposes other than OBRA and SNF PPS requirements (for example, private insurance, including MA Plans). For more information on transmitting MDS 3.0 data to the QIES ASAP system, visit the MDS 3.0 Technical Information webpage and refer to Chapter 5 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual.
When do you have to complete the OBRA discharge assessment?
If the End Date of the Most Recent Medicare Stay (A2400C) occurs on the day of or one day before the Discharge Date ( A2000), you must complete the OBRA Discharge Assessment and the Part A PPS Discharge Assessment, and you may combine them.
What is MDS 3.0?
The MDS 3.0 contains items that reflect the acuteness of the resident’s condition, including diagnoses, treatments, and functional status. MDS 3.0 assessment data is personal information SNFs must collect and keep confidential by Federal law.
What happens if you conduct an assessment earlier than the schedule indicates?
If you conduct an assessment earlier than the schedule indicates (that is, the ARD is not in the assessment window), you will receive the default rate for the number of days the assessment was out of compliance.
Overview
In July 2018, CMS finalized a new case-mix classification model, the Patient Driven Payment Model (PDPM), that, effective beginning October 1, 2019, will be used under the Skilled Nursing Facility (SNF) Prospective Payment System (PPS) for classifying SNF patients in a covered Part A stay.
Fact Sheets
This section includes fact sheets on a variety of PDPM related topics.
PDPM Frequently Asked Questions
This section contains frequently asked questions (FAQs) related to PDPM policy and implementation.
PDPM Training Presentation
This section includes a training presentation which can be used to educate providers and other stakeholders on PDPM policy and implementation.
PDPM Resources
This section includes additional resources relevant to PDPM implementation, including various coding crosswalks and classification logic.
When did CMS start PDPM?
On October 1, 2019, CMS implemented the new SNF Medicare Part A reimbursement, the Patient Driven Payment Model, or PDPM for short. These medicare reimbursement changes have significantly affected the way the daily SNF PPS, or Skilled Nursing Facility Prospective Payment Systems, rates are determined.
What is phase 3 of the PDPM?
The three phases that have been rolled out over the past few years are the first time the ROP has been updated since 1991, and they have caused some major shockwaves. The third phase places an emphasis on trauma-informed care, infection prevention programs, competency development and more. If you’re still worried about Phase 3 of the ROP, here is a collection of resources to help you get prepared.
Does MDS have separate entry for individual treatment?
Yes, the MDS will still have separate entries for individual, group, concurrent, and co-treatments. We often receive transfers from other LTC facilities wishing to admit to our facility. We would be doing a 5 day for our facility. The other facility already received the variable per diem rate adjustment.
When is day 1 of PDPM?
October 1, 2019 will be considered Day 1 of the variable per diem schedule under PDPM, even if the patient began their stay prior to October 1, 2019. The HIPPS code derived from the transitional IPA should be used to bill for dates of service beginning October 1, 2019. Any transitional IPAs with an ARD after October 7, ...
When will IPA transition to PDPM?
It is important that facilities remember that a mandatory IPA will be required to transition from RUG-IV to PDPM on October 1, 2019. The transition between RUG-IV and PDPM will be a “hard” transition, meaning that the two systems will not run concurrently at any point. RUG-IV billing will end on September 30, 2019 and PDPM billing will begin on ...
What is IPA in CMS?
Another CMS option under PDPM is to implement the Interim Payment Assessment (IPA). The IPA may be completed by providers in order to report a change in the patient’s PDPM classification, rather than discharge the patient from receiving Part A services. CMS has made it clear that the IPA is an optional assessment.
When does an ARD need to be set?
If a resident is admitted at the end of September 2019, an ARD would need to be set at the end of September to support payment under RUGs IV PPS for the days in September. For example, a resident admitted on September 28, 2019 would require an ARD in September to support payment for September 28, 29, and 30.
When a patient no longer meets the skilled criteria for a Part A Medicare stay, should the patient be discharged
When the patient no longer meets the skilled criteria for a Part A Medicare stay, the patient should be discharged from Part A. This requires monitoring of the documentation to ensure that it meets the four requirements for Part A found in the Medicare Benefit Policy Manual, Chapter 8, §30.
When will ARD be set for IPA?
An ARD will also be set for the transitional IPA from October 1, 2019 to October 7, 2019 to remain in compliance of starting PDPM process for October 1, 2019.
Are Interim Payment Assessments Mandatory?
As of now, completing an IPA is optional and entirely up to the discretion of the provider. Outlined in Chapter 2 of the RAI User Manual, the assessment is clearly listed as optional. 1 If an IPA is not completed, the reimbursement determined during the intake assessment will carry through the entire duration of the stay.
When Should We Complete an Interim Payment Assessment?
CMS lays out the vision for how they see the IPA being used and the roles it should play.
What If There is No Expected Change in Reimbursement?
If the IPA is optional and the change in the patient’s condition doesn’t result in a positive or negative change in reimbursement, should we still conduct an IPA? The answer to this question is addressed by CMS.
Clarify Your Compliance Questions with an EHR Solution Tailored for Skilled Nursing & Senior Living
Learn how Optima Skilled Nursing & Senior Living can empower your staff to keep up with regulatory challenges such as PDPM, PPS, MDS 3.0, RUGs, PBJ reporting, Section GG, case mix, and CMS Medicare RAC audits.
What is the function score for PDPM?
The function score for patient classification under PDPM is now calculated using data from Section GG of the MDS 3.0 (Functional Abilities and Goals) rather than Section G items.
When will PDPM bill?
Providers would bill for services under PDPM using the Health Insurance Prospective Payment System (HIPPS) code that is generated from a 5-day PPS assessment and Interim Payment Assessment (IPA) with an ARD on or after October 1, 2019.
How long is a PPS assessment?
PDPM utilizes a streamlined assessment schedule, which requires only the 5-day scheduled PPS assessment as the basis for payment under the SNF PPS, as opposed to the current SNF PPS assessment schedule, which requires various scheduled assessments (i.e., 5-day, 14-day, 30-day, 60-day, 90-day), as well as unscheduled assessments, typically referred to as Other Medicare-Required Assessments (OMRAs) (i.e., Start of Therapy OMRA (SOT), End of Therapy OMRA (EOT), Change of Therapy OMRA (COT)). It should be noted that PDPM implementation has no impact on assessments completed as a result of the Omnibus Budget Reconciliation Act of 1987 (i.e., OBRA assessments).
How long is the SNF benefit period?
Under section 1812(a)(2)(A) of the Act, Medicare Part A covers a maximum of 100 days of SNF services per spell of illness, or “benefit period.” SNF coverage also requires a prior qualifying, inpatient hospital stay of at least 3 consecutive days’ duration (counting the day of inpatient admission but not the day of discharge). (See section 1861(i) of the Act; §409.30(a)(1)). Once the 100 available days of SNF benefits are used, the current benefit period must end before a beneficiary can renew SNF benefits under a new benefit period. For the current benefit period to end so a new benefit period can begin, a period of 60 consecutive days must elapse throughout which the beneficiary is neither an inpatient of a hospital nor receiving skilled care in a SNF. (See section 1861(a) of the Act; §409.60). Once a benefit period ends, the beneficiary must have another qualifying 3-day inpatient hospital stay and meet the other applicable requirements before Medicare Part A coverage of SNF care can resume. (See section 1861(i); §409.30)
How many characters are in a PDPM?
The HIPPS code under PDPM is still a five character code, as under RUG-IV. However, under RUG-IV, the first three characters represent the patient’s RUG classification and the last two characters are an assessment indicator (AI) code, to represent the assessment used to generate the patient classification.
When will CMS report RUG IV?
CMS will continue to report the RUG-III and RUG-IV Health Insurance Prospective Payment System (HIPPS) codes, as requested by the state, until September 30, 2020 on the 5-day PPS, OBRA comprehensive and OBRA quarterly assessment types. If a State requires the calculation of RUG-III or RUG-IV more frequently, the State may require its providers to submit the OSA at time points determined by the State. Beginning October 1, 2020, states must use the OSA as the basis for calculating RUG-III and RUG-IV HIPPS codes.
When is PDPM HIPPS code?
To receive a PDPM HIPPS code that can be used for billing beginning October 1, 2019, all providers will be required to complete an IPA with an ARD no later than October 7, 2019 for all SNF Part A patients. October 1, 2019 will be considered Day 1 of the variable per diem schedule under PDPM, even if the patient began their stay prior to October 1, 2019.
What is PDPM in SLPs?
Although PDPM is meant to alleviate pressures to provide as much therapy as possible, it does not address industry-developed pressures such as productivity requirements. It also creates potential new challenges for SLPs. For example, the additional payment for patients on mechanically altered diets may create unintended payment incentives to place patients on mechanically altered diets unnecessarily or keep patients on them longer than clinically warranted.
Is PT and OT reimbursement for comorbidities?
PT and OT are not reimbursed for comorbidities. Another key distinction is that PT and OT payments decrease as the episode goes on (known as a variable per diem payment) while speech-language pathology payment is consistent across the episode.
Can SLPs change their diagnosis?
It is not appropriate for the MDS or SNFs to require SLPs to change their secondary medical and/or treating diagnosis to a different diagnosis that will trigger a speech-language pathology and/or comorbidity payment.
When is a Medicare Part A discharge MDS required?
In other words, the Medicare Part A Discharge MDS is required any time a Medicare Part A stays ends with the only exception being when a patient expires during a Part A stay. Note that section GG is not required and will not appear on the MDS for any unplanned discharges (e.g. unexpected acute care hospital discharges).
When is Medicare Part A PPS discharge completed?
The Medicare Part A PPS Discharge MDS is completed when a patient’s Medicare Part A stay ends: When the Medicare Part A stay ends and the patient remains in the facility. When the Medicare Part A stay ends and the patient is physically discharged from the facility (the Part A PPS and OBRA Discharge assessments may be combined in this situation) ...
What is a PPS discharge assessment?
Effective October 1st, Medicare requires a Medicare Part A PPS Discharge Assessment. This MDS contains the required data elements used to calculate current and future Skilled Nursing Facility Quality Reporting Program (SNF QRP) quality measures under the IMPACT Act. The IMPACT Act directs the Secretary to specify quality measures on which post-acute care (PAC) providers (which includes SNFs) are required to submit standardized patient assessment data. Section 1899B (2) (b) (1) (A) (B) of the Act delineates that patient assessment data must be submitted with respect to a resident’s admission to and discharge from a Medicare Part A Assessment.
Is A2400C equal to ARD?
The ARD must be equal to the date recorded in section A2400C. The only exception is when the End Date of the Most Recent Medicare Stay (A2400C) occurs on the day of or day before the Discharge Date (A2000). In this situation the OBRA Discharge assessment and Part A PPS Discharge assessment are both required and may be combined with an ARD equal ...