Patient-Driven Payment Model (PDPM): At-a-Glance
Patient-Driven Payment Model (PDPM): At-a-GlanceThe proposed PDPM establishes a rate on the 5-day MDS for the entire stay by combiningfive different case-mix components (PT, OT, SLP, Nursing, and Non-Therapy Ancillary) withthe non-case-mix component. The rate may be changed during the Medicare Part A stay bycompleting the Interim Payment Assessment (IPA) for substantial changes.Use the following at-a-glance tools to identify the case-mix group for each component andimprove your understanding of the proposed Patient-Driven Payment E: This document is intended to aid members in their review of the Patient-Driven Payment Model.Resources: FY 2019 SNF PPS Proposed Rulemaking and CMS draft PDPM Calculation Worksheet forSNFs. All information regarding PDPM is subject to change pending final rulemaking. AANAC has madeevery attempt to ensure the accuracy and reliability of the information provided. AANAC does notaccept any responsibility or liability for the accuracy, content, and completeness of the information.Copyright 2018, American Association of Post-Acute Care Nursing, d/b/a American Association of Nurse Assessment Coordination. All Rights Reserved. AANAC.org1
Proposed Patient-Driven Payment Model: At-a-GlancePT Component and OT Component*ClinicalCategoryMajor JointReplacement orSpinal dicSurgery andAcute NeurologicGG FunctionScorePT and OTCase-Mix Group0–5TA6–9TB10–23TC01, 07,09, 8824TD0–5TEGG0130A1 Self-care: ty: Lying to sitting onGG0170C1side of bed0–5TIGG0170D1 Mobility: Sit to stand6–9TJGG0170E1Mobility: Chair/bed-tochair transfer10–23TKGG0170F1Mobility: Toilet transfer24TLGG0170J1Mobility: Walk 50 feet with2 turns0–5TMGG0170K1 Mobility: Walk 150 feet6–9TN10–23TO24TPScoring Response for Section GG Items05, 06ScoreSet-up assistance, independent404Supervision or touching assistance303Partial/moderate assistance202Substantial/maximal assistance1Dependent, refused, not attempted0Section GG itemsSelf-care: Oral hygieneGG0130C1 Self-care: Toileting hygieneGG0170B1Mobility: Sit to lyingScore0–40–4(avg. of 2 bedmobility items)0–4(avg. of 3transfer items)0–4(avg. of 2walking items)PT Component and OT Component:PT and OT components will always result in thesame case-mix group; however, the PT and OTcase-mix indices/payment levels differ.NOTE: This document is intended to aid members in their review of the Patient-Driven Payment Model.Resources: FY 2019 SNF PPS Proposed Rulemaking and CMS draft PDPM Calculation Worksheet for SNFs. Allinformation regarding PDPM is subject to change pending final rulemaking. AANAC has made every attempt toensure the accuracy and reliability of the information provided. AANAC does not accept any responsibility orliability for the accuracy, content, and completeness of the information.Copyright 2018, American Association of Post-Acute Care Nursing, d/b/a American Association of Nurse Assessment Coordination. All Rights Reserved. AANAC.org2
Proposed Patient-Driven Payment Model: At-a-GlanceSLP ComponentPresence of Acute Neurologic Condition,SLP-Related Comorbidity*,or Cognitive Impairment**NoneAny oneAny twoAll threePresence of:Swallowing Disorder (K0100A–D) ORMechanically Altered Diet (K0510C2)SLP othSLSLP-Related Comorbidities:Aphasia (I4300); CVA, TIA, or Stroke (I4500);Hemiplegia or Hemiparesis (I4900); TBI(I5500); Tracheostomy (O0100E2); Ventilator(I0100F2); Laryngeal Cancer, Apraxia,Dysphagia, ALS, Oral Cancers, Speech andLanguage Deficits (I8000)Cognitive Impairment:The PDPM cognitive level is based on theBrief Interview for Mental Status (BIMS) orstaff assessment. See the PDPM calculationworksheet provided by CMS for details.NOTE: This document is intended to aid members in their review of the Patient-Driven Payment Model.Resources: FY 2019 SNF PPS Proposed Rulemaking and CMS draft PDPM Calculation Worksheet for SNFs. Allinformation regarding PDPM is subject to change pending final rulemaking. AANAC has made every attempt toensure the accuracy and reliability of the information provided. AANAC does not accept any responsibility orliability for the accuracy, content, and completeness of the information.Copyright 2018, American Association of Post-Acute Care Nursing, d/b/a American Association of Nurse Assessment Coordination. All Rights Reserved. AANAC.org3
Proposed Patient-Driven Payment Model: At-a-GlanceNOTE: This document is intended to aid members in their review of the Patient-DrivenPayment Model. Resources: FY 2019 SNF PPS Proposed Rulemaking and CMS draftPDPM Calculation Worksheet for SNFs. All information regarding PDPM is subjectto change pending final rulemaking. AANAC has made every attempt to ensure theaccuracy and reliability of the information provided. AANAC does not accept anyresponsibility or liability for the accuracy, content, and completeness of the information.Nursing Component*RESIDENTGG-basedFunction ScoreEXTENSIVESERVICESYESES33 TRACHEOSTOMY & VENTILATOR 0-142 TRACHEOSTOMY OR VENTILATOR 0-141 INFECTION ISOLATION0-14ES2ES1NOSPECIALCARE 160-56-1415-16CDE22 NURSING REHAB 2 11-16BAB21 NURSING REHAB 0-111-16BAB10-56-1415-160-56-1415-16PDE2ADL2 DEPRESSEDYES1 NOTDEPRESSEDADL2 DEPRESSEDADLHDE1HBC2HBC1NOSPECIALCARE LOWYES1 NOTDEPRESSEDADL2 DEPRESSEDADLLDE1LBC2LBC1NOCLINICALLYCOMPLEXYES1 NOTDEPRESSEDADLCBC2CDE1CA2CBC1CA1NOBEHAVIOR SXCOGNITIONYESNOREDUCEDPHYSICALFUNCTION2 NURSINGREHAB 2 YES1 NURSINGREHAB 0-1Scoring Response for Section GG Items05, 06ADLADLScorePDE1PBC2PA2PBC1PA1Section GG itemsScoreSet-up assistance, independent4GG0130A1 Self-care: Eating0–404Supervision or touching assistance3GG0130C1 Self-care: Toileting hygiene0–403Partial/moderate assistance2GG0170B102Substantial/maximal assistance1Dependent, refused, not attempted0Mobility: Lying to sitting onGG0170C1side of bed01, 07,09, 88Nursing Component:See the CMS PDPM calculation worksheet forinclusion criteria for each nursing classification.Mobility: Sit to lyingGG0170D1 Mobility: Sit to standGG0170E1Mobility: Chair/bed-tochair transferGG0170F1Mobility: Toilet transfer0–4(avg. of 2 bedmobility items)0–4(avg. of 3transfer items)Copyright 2018, American Association of Post-Acute Care Nursing, d/b/a American Association of Nurse Assessment Coordination. All Rights Reserved. AANAC.org4
Proposed Patient-Driven Payment Model: At-a-GlanceNon-Therapy Ancillary (NTA) ComponentCondition/Extensive ServiceHIV/AIDSSourcePointsSNF Claim8MDS Item K0510A2, K0710A27Special Treatments/Programs: Intravenous Medication Post-admit CodeMDS Item O0100H25Special Treatments/Programs: Ventilator or Respirator Post-admit CodeMDS Item O0100F24Parenteral IV Feeding: Level LowMDS Item K0510A2,K0710A2, K0710B23Parenteral IV Feeding: Level HighLung Transplant StatusMDS Item I80003MDS Item O0100I22Major Organ Transplant Status, Except LungMDS Item I80002Active Diagnoses: Multiple Sclerosis CodeMDS Item I52002Opportunistic InfectionsMDS Item I80002Active Diagnoses: Asthma COPD Chronic Lung Disease CodeMDS Item I62002Bone/Joint/Muscle Infections/Necrosis—Except Aseptic Necrosis of BoneMDS Item I80002Chronic Myeloid LeukemiaMDS Item I80002Wound Infection CodeMDS Item I25002Active Diagnoses: Diabetes Mellitus (DM) CodeMDS Item I29002EndocarditisMDS Item I80001Immune DisordersMDS Item I80001End-Stage Liver DiseaseMDS Item I80001Special Treatments/Programs: Transfusion Post-admit CodeOther Foot Skin Problems: Diabetic Foot Ulcer CodeMDS Item M1040B1Narcolepsy and CataplexyMDS Item I80001Cystic FibrosisMDS Item I80001MDS Item O0100E21MDS Item I17001Special Treatments/Programs: Tracheostomy Care Post-admit CodeActive Diagnoses: Multi-Drug Resistant Organism (MDRO) CodeSpecial Treatments/Programs: Isolation Post-admit CodeMDS Item O0100M21Specified Hereditary Metabolic/Immune DisordersMDS Item I80001Morbid ObesityMDS Item I80001ContinuedNTA Score RangeNTA Case-Mix Group12 NA9–11NB6–8NC3–5ND1–2NE0NF** High level: K0710A2 3. 51% or more (while a resident)** Low level: K0710A2 2. 26–50% (while a resident) andK0710B2 2. 501cc/day or more (while a resident)NOTE: This document is intended to aid members in their review of the Patient-Driven Payment Model.Resources: FY 2019 SNF PPS Proposed Rulemaking and CMS draft PDPM Calculation Worksheet for SNFs. Allinformation regarding PDPM is subject to change pending final rulemaking. AANAC has made every attempt toensure the accuracy and reliability of the information provided. AANAC does not accept any responsibility orliability for the accuracy, content, and completeness of the information.Copyright 2018, American Association of Post-Acute Care Nursing, d/b/a American Association of Nurse Assessment Coordination. All Rights Reserved. AANAC.org5
Proposed Patient-Driven Payment Model: At-a-GlanceNon-Therapy Ancillary (NTA) Component (Continued)Condition/Extensive ServiceSourcePointsSpecial Treatments/Programs: Radiation Post-admit CodeMDS Item O0100B21Highest Stage of Unhealed Pressure Ulcer—Stage 4MDS Item M0300D11Psoriatic Arthropathy and Systemic SclerosisMDS Item I80001Chronic PancreatitisMDS Item I80001Proliferative Diabetic Retinopathy and Vitreous HemorrhageMDS Item I80001MDS Item M1040A,M1040C1MDS Item I80001MDS Item H0100D1MDS Item I80001Other Foot Skin Problems: Foot Infection Code, Other Open Lesion on FootCode, Except Diabetic Foot Ulcer Code (M1040B)Complications of Specified Implanted Device or GraftBladder and Bowel Appliances: Intermittent CatheterizationInflammatory Bowel DiseaseAseptic Necrosis of BoneMDS Item I80001MDS Item O0100D21Cardio-Respiratory Failure and ShockMDS Item I80001Myelodysplastic Syndromes and MyelofibrosisMDS Item I80001Systemic Lupus Erythematosus, Other Connective Tissue Disorders, andInflammatory SpondylopathiesMDS Item I80001Diabetic Retinopathy—Except Proliferative Diabetic Retinopathy andVitreous HemorrhageMDS Item I80001MDS Item K0510B21Severe Skin Burn or ConditionMDS Item I80001Intractable EpilepsyMDS Item I80001Active Diagnoses: Malnutrition CodeMDS Item I56001Disorders of Immunity—Except: RxCC97: Immune DisordersMDS Item I80001Cirrhosis of LiverMDS Item I80001MDS Item H0100C1Respiratory ArrestMDS Item I80001Pulmonary Fibrosis and Other Chronic Lung DisordersMDS Item I80001Special Treatments/Programs: Suctioning Post-admit CodeNutritional Approaches While a Resident: Feeding TubeBladder and Bowel Appliances: OstomyNTA Score RangeNTA Case-Mix Group12 NA9–11NB6–8NC3–5ND1–2NE0NFNOTE: This document is intended to aid members in their review of the Patient-Driven Payment Model.Resources: FY 2019 SNF PPS Proposed Rulemaking and CMS draft PDPM Calculation Worksheet for SNFs. Allinformation regarding PDPM is subject to change pending final rulemaking. AANAC has made every attempt toensure the accuracy and reliability of the information provided. AANAC does not accept any responsibility orliability for the accuracy, content, and completeness of the information.Copyright 2018, American Association of Post-Acute Care Nursing, d/b/a American Association of Nurse Assessment Coordination. All Rights Reserved. AANAC.org6
!INITIAL REVIEWOF THE PROPOSED PATIENT DRIVEN PAYMENT MODELPrepared by: Mark McDavid, OTR, RAC-CTModel’s Release Date: April 27, 2018 Initial Review Release Date: April 30, 2018Payment Model Background and Purpose of this Initial ReviewAs you may be aware, the Center for Medicare and Medicaid Services (CMS) publishedthe 266-page Prospective Payment System and Consolidated Billing for Skilled NursingFacilities (SNF) Proposed Rule for FY 2019 on Friday, April 27th. Included in the Ruleis the annual payment update for SNF PPS rates, updates to the SNF Value-BasedPurchasing Program and the SNF Quality Reporting Program, and the introduction ofthe Patient Driven Payment Model (PDPM). This document (the Proposed Rule) will bereferred to as CMS-1696-P. You can find the full version of the Proposed Rule ralregister.gov/2018-09015.pdf?utm campaign pi%20subscription%20mailing%20list&utm source federalregister.gov&utm medium email.In 2017, CMS published the Advanced Notice of Proposed Rule Making (ANPRM)which introduced the Resident Classification System – Version I (RCS-I) to theindustry. The RCS-I was developed as a result of the combined efforts of Acumen, aconsulting group hired by CMS, and an interdisciplinary technical expert panel.Following publication, CMS began accepting comments. RCS-I would fundamentallychange the way long-term care providers are reimbursed for the Part A post-acutecare skilled services. For that reason, many different entities had varying opinions onRCS-I. As recently as the February 2018 SNF Open Door Forum (ODF), CMS wascontinuing to solicit comments on RCS-I even though the comment period was closed.This signaled to many of us that CMS was not happy with RCS-I in its proposedpublished form. In that ODF, John Kane, SNF Team Lead at CMS, said that there wasno timeline for RCS-I. This, it turns out, foreshadowed RCS-I’s fate, which is that it hasbeen scrapped (at least in part) for a new model by a different name. Seagrove Rehab Partners, Initial Review PDPM 2018.Page 1 of 21
!This new proposed model, PDPM, was introduced Friday afternoon as part of thisyear’s SNF PPS Proposed Rule. This Initial Review was created after spending the lastseveral days reading through and studying this release. The purpose of this InitialReview document is to discuss the important components of the new PDPM in orderto educate readers on how SNFs will be reimbursed for Part A service if/when thisnew model goes from proposed to final rule.The New StructureOver the years, Medicare, MedPac, Congress, and various other stakeholders havebeen pushing to move the payment system away from counting therapy minutes toinstead reimbursing SNFs based on patient characteristics and/or patient outcomes.The new PDPM will pay for SNF PPS-care based on patient characteristics and not avolume of services provided. The current RUGs-IV system is a case-mix indexmaximizing system. In this system, as patients qualify for various RUGs (of the 66RUGs available), then the system automatically assigns the highest paying RUG foreach patient’s reimbursement. This is almost always a Rehab RUG (over 90 percent ofSNF PPS days were reimbursed via one of the Rehab RUGs per CMS-1696-P). In thenew PDPM, case-mix indexing will still play a role, but there are several differentcomponents that will contribute to the reimbursement that will ultimately equal thepatient’s daily rate, or per diem. They are: PT component, OT component, SLPcomponent, Nursing component, Non-Therapy Ancillary component, and the NonCase-Mix component. The first five of which will be case-mix adjusted based onpatient characteristics, and the last will be a flat rate.Components 1 and 2: Physical and Occupational Therapy Case-mixClassificationWhile Physical Therapy (PT) and Occupational Therapy (OT) will be separatecomponents, their case-mix adjustment will be calculated together. There will be twopatient characteristics used to determine the PT and OT case-mix classification. Theyare Clinical Category and Function Score. This process starts by using the clinicalreason for the patient’s skilled stay to then place that patient into one of ten clinicalcategories. PDPM outlines 10 clinical categories based on ICD-10-CM diagnoses codedat I8000 on the MDS. Table 14 from CMS-1696-P outlines those 10 categories: Seagrove Rehab Partners, Initial Review PDPM 2018.Page 2 of 21
!In the ANPRM document that outlined RCS-I last year, this was decreased to 5categories for figuring the PT/OT component. However, based on comments to lastyear’s publication, CMS has now further pared down the PT and OT components to 4categories in Table 15 of CMS-1696-P. These will be the 4 Clinical Categories drivingthe PT and OT case-mix classification:This clinical category would be determined by the ICD-10-CM code reported on thefirst item of I8000 from the MDS 3.0. A review of ICD-10-CM mapping to clinicalcategories vice-Payment/ Seagrove Rehab Partners, Initial Review PDPM 2018.Page 3 of 21
!SNFPPS/therapyresearch.html) will show that in some cases one ICD-10-CM will mapto more than one clinical category. The multiple categories are due, in part, to the factthat resident needs will differ depending on whether or not the resident receivedsurgical intervention while in the hospital immediately preceding this SNF stay.Typically, patients who have had surgery in the immediately preceding hospital staywill require extensive post-surgical nursing or rehabilitation care in the SNF. If thepatient did not receive a surgical procedure in the immediately preceding hospitalstay, then the resulting clinical category will be a non-surgical one. Here is theexample given in CMS-1696-P (pages 81-82):For example, certain wedge compression fractures that were treated with aninvasive surgical procedure such as a fusion during the prior inpatient staywould be categorized as Major Joint Replacement or Spinal Surgery, but if thesecases were not treated with a surgical procedure they would be categorized asNon-Surgical Orthopedic/Musculoskeletal. For residents who received a relatedsurgical procedure during the prior inpatient stay, a provider would need toindicate the type of surgical procedure performed for the resident to beappropriately classified under PDPM.In order to capture the inpatient surgical procedure, CMS is requiring providers touse an ICD-10-PCS code corresponding to the surgical procedure in the second line onI8000. If this proposal is finalized, then CMS will provide an ICD-10-PCS map ofprocedures to PDPM clinical categories.The next step in determining the PT and OT component case-mix score is todetermine the patient’s Function Score. Currently in the RUGs system (and previouslyproposed in RCS-I), CMS uses Section G: Functional Status (or the ADL score section ofthe MDS) to determine the patient’s functional score. In the new PDPM, CMS isproposing to use Section GG: Functional Abilities and Goals data to determine theFunction Score. Thus, the Functional Score will be determined by four late loss ADLsand two early loss ADLs. Specifically, that includes two bed mobility items, threetransfer items, one eating item, one toileting item, one oral hygiene item, and twowalking items. These were chosen as they are highly predictive of PT and OT costs Seagrove Rehab Partners, Initial Review PDPM 2018.Page 4 of 21
!per day. Tables 16, 17, and 18 of CMS-1696-P graphically show how these items willhelp produce the Function Score:The scores for each of the Section GG items above will be added together to get aTotal Function Score. This score will be used in Table 21 to further place the patientinto the appropriate Case-mix Classification Group. Seagrove Rehab Partners, Initial Review PDPM 2018.Page 5 of 21
!As you may recall, the RCS-I proposal included cognitive status as a determinant forthe PT/OT case-mix classification. Due to comments in response to ANPRM, CMS hassince removed cognitive status as a determinant of the PT and OT case-mixclassification. CMS uses a Classification and Regression Trees (CART) algorithm tohelp determine the resident groups and cognition was included as an independentvariable in the CART analysis. For more information on the CART analysis refer topage 93 of the CMS-1696-P document.Taking 1) Primary clinical reason for SNF stay and 2) Function Score into account, wecan now classify a patient into a PT and OT Case-Mix Classification Group. Table 21graphically shows the breakdown of each
Bladder and Bowel Appliances: Intermittent Catheterization MDS Item H0100D 1 Inflammatory Bowel Disease MDS Item I8000 1 Aseptic Necrosis of Bone MDS Item I8000 1 Special Treatments/Programs: Suctioning Post-admit Code MDS Item O0100D2 1 Cardio-Respiratory Failure and Shock MDS Item I8000 1 Myelodysplastic Syndromes and Myelofibrosis MDS Item .
AHCA PDPM Academy MDS Core Items Mock Up_Template With Circles . o. AHCA PDPM Resident Classification Worksheet_Template (4/15/19 Update) o. AHCA PDPM Component Variable Per-Diem and RUG-IV Rate Reference Tables (4/15/19 Update) AHCA PDPM Hospital Discharge Toolkit . o.
The purpose of this Patient-Driven Payment Model (PDPM) calculation worksheet is to illustrate how a resident is classified for payment purposes and how per diem payment is calculated under PDPM. This document is a draft worksheet that is intended to aid stakeholders
Skilled Nursing Facility FY 2020 PDPM Overview Implementation Date: October 1, 2019 MHTNF_PDPMTRNDECK_0919. Patient-Driven Payment Model (PDPM) Overview Effective October 1, 2019, CMS will be using a new case-mix . Medicare Claims Processing Manual (100-04), Chapter 6:
The Super Heroes of PDPM Melissa Keiter, RN, RAC-CT, DNS-CT, DON & Melissa Sabo, OTR/L, CSRS, CDP . Although we do not often see MDS Coordinators working in our nursing communities wearing capes, they are going to be the secret superheroes of each community under PDPM. PDPM, or the Patient Driven Payment Model, is the new
PDPM Calculation Worksheet for SNFs 1 . In the PDPM, there are five case-mix adjusted components: PT, OT, SLP, NTA, and Nursing. Each patient is to be classified into one and only one group for each of the five case-mix
Sinclair School of Nursing QIPMO PDPM PT OT SLP Nursing NTA Non-Case Mix Total PDPM Rate. 9/20/2019 2 RUG-IV Classifies residents into a therapy RUG based on therapy minutes and days. Non-therapy RUGs were based on certain resident characteristics. The resident’s RUG was either a t
4 payment options available to sars clients 5 4.1 payment option 1 - using efiling to make your payment 5 4.2 payment option 2 - payment at a sars branch 7 4.3 payment option 3 - using the internet to make electronic payment 9 4.4 payment option 4 - bank payments (at one of the relevant banking institutions) 10 4.5 foreign payments 11
8/28/2019 1 SECTION C, D I, J, O AND Z C0100. SHOULD BRIEF INTERVIEW FOR MENTAL STATUS BE CONDUCTED? PDPM cognitive level is utilized in the speech language pathology (SLP) payment component of PDPM. Only in the case of PPS assessments, staff may complete the Staff Assessment for Mental Status for an interviewable resident when the resident is unexpectedly discharged from a
