CMS National Provider Call – SNF PPS: Patient Driven Payment Model

Mary Madison, RN,RAC-CT, CDP 
Clinical Consultant – Briggs Healthcare®

If you did not attend the December 11, 2018 National Provider Call – you missed a good one. This 2-hour call was literally jam-packed with information specific to the replacement of the current RUG-IV PPS reimbursement system with PDPM!   John Kane and Penny Gershman of CMS did a stellar job of covering 90 slides in a bit over 1 hour and answering questions  in the remaining hour.  There was a lotto impart as a presenter and a lot to absorb as a listener.

Here are the key take-aways, from my perspective, at this point in time, just a mere 293 days until October 1, 2019:

  • The new Patient Driven Payment Model website should become your latest bookmarked website.  Check it often!  You will find critical resources to guide your understanding and implementation of the PDPM reimbursement system.  You will find:
    • Numerous Fact Sheets
    • PDPM FAQ documents that CMS will be updating throughout the next year.  CMS noted that the FAQs will be dated so we’ll know which FAQ is the latest.  The current FAQ document posted carries no date.
    • PDPM resources such as crosswalks, grouper logic, classification walk throughs, etc.
    • You can submit PDPM questions to CMS via the hyperlink on the left side of the web page.
    • The November 19, 2018 Background& Finalized Changes to SNF PPS handout slides are currently found beneath the PDPM Training Presentation section. This is a session priorto the December 11, 2018 session.
  • Download a copy of the December 11, 2018 National Provider Call presentation slides and share with other staff/team members that are involved with the SNF PPS activities in your facility.
  • Watch the MLN Events page for notification that the recording and transcript of the December 11th NPC has been posted.  Encourage team members to listen and even listen a second time to capture all of the information that was provided.  The dissemination of this very important information was fast and furious.  Having the slides available for reference (and note-taking) is a great plus.  CMS stated that the audio recording and transcript will be posted in about 2 weeks.
  • There will be more education and training for PDPM in the coming months so stay tuned for those announcements.
  • 90% of skilled coverage days (and reimbursement)are currently allocated to therapy.  This will definitely change with PDPM.  CMS will be watching what happens with provision of therapy after the implementation of PDPM.  CMS has long been concerned, and with good reason, as to the number of therapy minutes reported and the corresponding reimbursement. John Kane noted that the “fundamental problem” with the current RUG-IV system is that therapy payments are based “primarily on the amount of therapy provided to a patient, regardless of the patient’s unique characteristics,needs or goals.”   PDPM focuses on the patient characteristics, needs and goals rather than the volume of services provided.It was stated that CMS expects therapy utilization/services to decrease under PDPM. If CMS sees issues with provision of therapy, there would likely bemeasures instituted including professional education extending into quality measures and consequences.  “The needs of the resident is what counts.”
  • As we’ve heard before, each patient will be classified into a group for each of the 5 case-mix adjusted components with different criteria for each of those 5 for further classification.
  • We received a hint of new items (and new Item Sets) that will comprise the MDS 3.0 v.1.17 Item Sets for October 1, 2019:
    • I0020B – SNF Primary Diagnosis
    • J2100 – J5000 – Patient Surgical History(check boxes similar to active diagnoses check boxes in Section I)
    • O0425A1 – O0425C5 – Report of therapy discipline, mode of therapy and total minutes therapy was provided during the entire PPS stay.  These items will be on the NPE.
    • I13000 – Ulcerative Colitis or Crohn’s Disease of Inflammatory Bowel Disease will be added to the 5-day PPS and Interim Payment Assessments
    • New assessment/item set – IPA or Interim Payment Assessment – There will be a new column “5” in Section GG to capture the interim performance (currently we assess and encode Section GG on skilled,traditional Part A admission and discharge only).  The new column will carry a 3-day look-back before and including the ARD of the IPA (ARD + 2 calendar days before the ARD).
    • Swing bed facilities will see the addition of 4items to the SB Item Set for use in determining payment in the PDPM model:
      • K0100 – Swallowing Disorder
      • I1300 – Ulcerative Colitis or Crohn’s Disease of Inflammatory Bowel Disease
      • I4300 – Active Diagnosis: Aphasia
      • O0100D2 – Special Treatments, Procedures &Programs: Suctioning, While a Resident
  • The SNF PPS Assessment Schedule (A0310B) will be modified to include 3 instead of the current 9:
    • 5-day Scheduled PPS Assessment (ARD of days 1-8)
    • Interim Payment Assessment (IPA) – Optional
    • PPS Discharge Assessment (NPE)
  • There will be an Optional Statement Assessment or OSA that will not be a Part A PPS assessment.  States currently using RUG-III or RUG-IV legacy items can opt to use the OSA as a basis to determine Medicaid payment.  The OSA will be available to states through September 30, 2020.  CMS will not support the OSA (which supports the RUG-III/RUG-IV legacy items)beyond October 1, 2020.
  • There will be an Interrupted Stay Policy that your team will need to become familiar with.
  • PDPM will address Administrative Presumption.  Reference slides #72 and#73 of the December 11th presentation for more information.
  • Add-on reimbursement for care of patients with AIDS will continue with PDPM.  AIDS is not encoded on the MDS Item Sets in most if not all states, but it must be coded on the SNF claim using ICD-10-CM code B20 in order to receive the additional reimbursement.
  • HIPPA coding will change with PDPM.  Reference slides #78 through #81 of the December 11th presentation for that information.
  • Slide #85 speaks to the transition from RUG-IV to PDPM next year.  This bears special attention as the “transition” from one reimbursement system to another will be hard switch!  RUG-IV billing will end at 11:59pm on September 30, 2019 with PDPM billing beginning at midnight on October 1,2019.  Every year we have residents that bridge the October 1st date in our skilled facilities.  Carefully review slide #85 as well as watch for future reference to the transition. It’s not business as usual! 
  • CMS made clear that policies, governing provisions, skilled coverage, documentation of need for therapy and skilled care, etc. will NOT change under PDPM. Certification/recertification of need for skilled care will continue tobe paramount as well medical necessity and everything else we’re doing today. 
  • CMS stated that they are working to release the DRAFT v1.17 MDS 3.0 Item Sets as well asa DRAFT RAI User’s Manual in early2019 – their aim is to release these drafts in January 2019.  Keep an eye out for those.  (Briggs Healthcare® is watching for these items as well and will keep you posted.)
  • Medicare Advantage/Alternative plans currently receive no monies from CMS so they decide how they will pay skilled facilities for care provided.  They may/may not choose to implement PDPM for their plans. Check with any such payers to learn their plan for reimbursement effective October 1, 2019.
  • Check with your EMR software vendor re:programming the PDPM specs for the software you utilize for the MDS.  No doubt all existing vendors are working on this extremely significant change but check to be sure.  CMS does plan to update their free software offering – jRAVEN.

Lastly, keep your eyes and ears open for future opportunities from CMS and other educators to learn more about PDPM. Use the tools provided by CMS to get ahead of this change so you/your team is ready! From a historical perspective, we’ve lived with the RUG-IV SNF PPS reimbursement model since 1998. We can do PDPM as well. Just breathe and keep learning!