Ellen Strunk, PT, MS, GCS, CEEAA, CHC, discusses the switch from RUGs payment system to the PDPM and the opportunities and challenges this presents for Skilled Nursing Facilities.
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The Resident Assessment Instrument (RAI) manual does not indicate who can or cannot complete the BIMS. You should refer to your facility, federal and state policies, and procedures on who can complete an assessment.
PDPM payments are calculated using the unadjusted CMI for each component, the variable per diem payment adjustment schedule, the unadjusted urban and rural federal per diem rates, the labor-related share, and the geographic wage indexes.
CMS has not yet announced if they will hold any face-to-face trainings. Please check with your facility and state nursing home associations.
The assessment schedule for completing the five-day MDS is not changing. Providers can choose any day between day 1-8 as the Assessment Reference Date for the five-day MDS.
The CMI under PDPM relative to the CMI under RUG-IV for the nursing components are projected to increase.
The Final Rule does not include any information relating to the role of a Rehab Technician.
There is no mention in the Fiscal Year 2019 Final Rule for SNFs that co-treatment has been revised.
This early on, it is hard to tell. I recommend you stay in communication with your managed care vendors and monitor their websites.
The number of MDS coordinators on staff will continue to be driven by the number of skilled short-term patients and long-term patients. The number of scheduled and unscheduled assessments will decrease for skilled, short-term patients, but the MDS will still be required at admission and discharge. The MDS schedule for long-term patients is not changing.
The PDPM model will apply to Medicare, fee-for-service, Part A patients. Medicare-managed care products will determine whether to use PDPM for their contracts. Each state’s Medicaid program will also have to determine whether to use PDPM or to stay with their current reimbursement methodology.
The specific instructions for coding comorbidities under PDPM have not been written yet. In the Final Rule, The Center for Medicare & Medicaid Services (CMS) stated: “a resident’s total comorbidity score, which would be the sum of the points associated with all of a resident’s comorbidities and services, would be used to classify the resident into an NTA case-mix group.” (CMS-1696-F, pg 192). The information to classify the resident into an NTA case-mix group would come from the MDS. Currently, the instructions for including a comorbidity in Section I: Active Diagnoses in the Last 7 Days states: “The items in this section are intended to code diseases that have a direct relationship to the resident’s current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death.” (CMS’s RAI Version 3.0 Manual, Page I-1).
Therapy services will continue to be an integral part of the interdisciplinary care provided to beneficiaries in a skilled nursing facility (SNF). Even though the mechanism of paying nursing facilities for therapy services provided to Part A patients is changing, it doesn’t mean that patients will no longer need (and benefit from) skilled therapy services. However, with less emphasis on the volume of services provided, therapy contractors have to find other methods for therapy delivery compensation.
The SNF benefit is based on the premise of a patient that requires these skilled services on a daily basis. The term “daily” is defined as seven days a week for nursing services and 5-7 days a week for rehabilitation services. If these criteria are met, the patient is skilled.
CMS did not change the qualifying criteria for an SNF stay. The same criteria has to be met for a patient to remain skilled under PDPM as it exists today. The Medicare Benefit Policy Manual (100-2), Coverage of Extended Care (SNF) Services Under Hospital Insurance (Chapter 8), Section 30 states:
“Care in an SNF is covered if all of the following four factors are met:
The term “daily” is defined as seven days a week for nursing services and 5-7 days a week for rehabilitation services.
Ellen R. Strunk, PT, MS, GCS, CEEAA, CHC has worked in various roles and settings as both clinician and manager/director. Presently, Ellen is owner of Rehab Resources & Consulting, Inc. (RRC). RRC specializes in helping customers understand the CMS prospective payment systems in the skilled nursing facility and home health settings, as well as outpatient therapy billing. Ms. Strunk’s experience includes utilizing medical record reviews and data systems to help therapy providers meet regulatory guidelines.