Full Answer
What's new in the 2023 Medicare proposed rule for skilled nursing facilities?
The Centers for Medicare & Medicaid Services (CMS) released the 2023 Medicare Proposed Rule for Skilled Nursing Facilities (SNFs). Significant policy changes proposed for next year focus on payment rates, quality reporting, and the Patient Driven Payment Model (PDPM) code mapping.
What does the Medicare rate change mean for primary care physicians?
The rate change includes the first substantial payment boost to Medicare’s evaluation and management (E/M) codes — extensively utilized by various types of primary care physicians — since the early 1990s, according to CMS.
Will Medicare payments to physicians decrease in 2022?
Medicare payments to physicians will decrease by almost 10% in 2022 in the absence of congressional action. The 2022 rule for physician payments provides a transition period to mitigate the impact of scheduled changes to clinical labor rates.
What is in the proposed annual update to the SNF rule?
The rule’s proposed annual update would increase net payments to SNFs by 3.9% in FY 2023 relative to FY 2022. This includes a 2.8% market-basket update offset by a statutorily-mandated cut of 0.4 percentage point for productivity. The update also includes a 1.5 percentage point increase to counter the agency’s market basket error in FY 2021.
When did PDPM start in Medicare?
January 1, 2020CMS finalized a new case-mix classification model, the Patient-Driven Groupings Model (PDGM), effective January 1, 2020.
What year did PDPM start?
1, 2019In 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.
When did Medicare adopt a physician fee schedule?
1992Background on the Physician Fee Schedule Since 1992, Medicare payment has been made under the PFS for the services of physicians and other billing professionals.
What was before PDPM?
What is PDPM? Patient-Driven Payment Model. The Patient-Driven Payment Model (PDPM) is the proposed new Medicare payment rule for skilled nursing facilities. It is intended to replace the current RUG-IV system with a completely new way of calculating reimbursement.
What did PDPM replace?
The PDPM replaces the Resource Utilization Groups (RUG) system, which had been used since 1998 and which many believe created perverse incentives that contributed to rapid growth and unwarranted variation in Medicare spending on postacute care.
What is PDPM and PDGM?
The intent behind these administrative changes, commonly known as the Patient-Driven Payments Model (PDPM) for skilled nursing facilities (SNFs) and the Patient-Driven Groupings Model (PDGM) for home health care, is to improve the quality of patient care, promote the overall health and wellbeing of the Medicare ...
Did Medicare reimbursement go down in 2022?
Notably, the 2022 Medicare conversion factor will be reduced by approximately 3.85% from 34.8931 (2021) to 33.5983 (2022). This is due in part to the expiration of the 3.75% payment increase provided by the Consolidated Appropriations Act of 2021.
What is the Medicare Final Rule?
The final rule adds Star Ratings (2.5 or lower), bankruptcy or bankruptcy filings, and exceeding a CMS designated threshold for compliance actions as bases for CMS denying a new application or a service area expansion application.
Has Medicare released the 2022 fee schedule?
In addition, the Centers for Medicare and Medicaid Services (CMS) has released the new 2022 physician fee schedule conversion factor of $34.6062 and Anesthesia conversion factor of $21.5623.
What are the 6 components of PDPM?
In the PDPM, there are five case-mix adjusted components: Physical Therapy (PT), Occupational Therapy (OT), Speech-Language Pathology (SLP), Non-Therapy Ancillary (NTA), and Nursing. Each resident is to be classified into one and only one group for each of the five case-mix adjusted components.
How has PDPM changed the way in which long term care facilities are reimbursed?
PDPM reimbursement, which was put into effect on October 1, 2019, shifted the emphasis from the number of visits or services and therapies provided to the particular situations and needs of patients and residents.
Why was PDPM created?
The Medicare Patient-Driven Payment Model (PDPM) is a major overhaul to the current skilled nursing facility (SNF) prospective payment system (PPS). It is designed to address concerns that a payment system based on the volume of services provided creates inappropriate financial incentives.
What is the final rule CMS?
Additionally, in the final rule CMS clarifies definitions and provisions related to the investigation of complaints and team composition and aligns regulatory provisions for the investigation of complaints with sections 1819 and 1919 of the Act. CMS has finalized this clarification.
When was CMS 1679-F issued?
On July 31, 2017, the Centers for Medicare & Medicaid Services (CMS) issued a final rule [CMS-1679-F] outlining Fiscal Year (FY) 2018 Medicare payment rates and quality programs for skilled nursing facilities (SNFs). Policies in the final rule continue to build on CMS’ commitment to shift Medicare payments from volume to value, ...
Clinical labor rates
A scheduled update to clinical labor rates will be implemented over a four-year period, culminating with the new rates taking full effect in 2025, according to a provision in the final rule. That’s a change from the proposed rule, which indicated the full change would be in 2022.
Telehealth
A number of telehealth services will continue to be covered by Medicare through 2023 as CMS evaluates whether they should be covered permanently. The services were scheduled to lose eligibility for coverage at the conclusion of the public health emergency.
Evaluation and management visits
The new rule establishes a definition for split E/M visits as visits provided in the facility setting by a physician and nonphysician practitioner in the same group. The visit should be billed by the clinician who provides “the substantive portion of the visit.”
Vaccine administration
Payment in 2022 will be $30 for influenza, pneumococcal and hepatitis B vaccines and will remain $40 for the COVID-19 vaccine, with the latter rate in effect through the end of the year in which the public health emergency ends. Payment will be $75.50 if administration of the COVID-19 vaccine takes place in a beneficiary’s home.
Reasons for Medicare Reimbursement Model Change
The Centers for Medicare & Medicaid Services (CMS) decision to switch from the current case-mix model (Resource Utilization Groups, Version IV, or RUG-IV) to PDPM was fueled by a number of issues, most notably a reimbursement schedule based on the amount of therapy provided to a patient regardless of unique characteristics, needs or goals.
Components and Patient Classification
To achieve the goals listed above, PDPM will provide a per diem payment based on six components, five of which are case-mix adjusted and determined by patient characteristics.
Determining Medicare Payment Rate under PDPM
Under PDPM, the per diem rate for each of the five case-mix components and the non-case-mix component is tallied. CMS will make adjustments to the Physical Therapy, Occupational Therapy and Non-Therapy Ancillary components over a stay to capture changes in resource utilization.
How and When to Change from RUG-IV to PDPM
Since running both systems at the same time is not feasible for providers and CMS, there will be no transition period between the current and future systems. RUG-IV billing will end September 30, 2019, and PDPM billing will start October 1, 2019.
PDPM Preparation Tips
The impact of the change to PDPM cannot be understated. SNFs should prepare as early as possible and gain a thorough understanding of how this will impact their clinical operations and billing procedures. Here is a quick reminder of action items to prepare for PDPM:
Who will get the biggest Medicare cut?
Anesthesiologists, critical care and emergency medicine providers, respiratory specialists, radiologists and lab pathologists will be among the practitioners facing the biggest Medicare payment cuts under the policy, according to the American Hospital Association (AHA).
What is CMS 2020?
For performance year 2020, CMS will provide automatic full credit for CAHPS patient-experience-of-care surveys.
When will the ACOs have to renew their agreement?
Revising the methodology for calculation of repayment mechanism amounts. Allowing eligible ACOs that renewed their agreement periods beginning on July 1, 2019, or Jan. 1 , 2020, to decrease their repayment mechanism amounts under certain circumstances.
Does Medicare shift payments to primary care physicians?
Medicare shifts payments toward primary care physicians in PFS final rule. Many specialty physicians — and the hospitals that employ them — will see big Medicare payment cuts in January under a newly finalized payment rule.