The Proposed Patient-Driven Payment Model (PDPM): What Does It Mean for Skilled Nursing Facilities?

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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Q & A

If there is a question of cognitive impairment, would an SLP be able to complete the Brief Interview of Mental Status (BIMS) to help get that information into the MDS? Or, does it have to be done by nurse/social worker?

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.

What is the Calculation for PDPM? Base Rate x CMI x Wage Index (then adjustment rates if applicable)?

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.

Will there be face to face trainings that facilities can attend?

CMS has not yet announced if they will hold any face-to-face trainings. Please check with your facility and state nursing home associations.

Will the initial required PDPM have grace days like we have with current PPS scheduling?

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.

We have a faculty that runs 25 vents and rehab is involved for up to 30-35 days. How will PDPM effect this as we typically use all 100 days.

The CMI under PDPM relative to the CMI under RUG-IV for the nursing components are projected to increase.

Is there anything mentioned in Final Rule about rehab technicians’ ability to treat patients within the line of sight of a therapist?

The Final Rule does not include any information relating to the role of a Rehab Technician.

You mentioned the impact on concurrent and group therapy. Is there any impact on co-treatment by PDPM?

There is no mention in the Fiscal Year 2019 Final Rule for SNFs that co-treatment has been revised.

Do you expect managed care to follow these new guidelines as well?

This early on, it is hard to tell. I recommend you stay in communication with your managed care vendors and monitor their websites.

Will facilities reduce the number of MDS Coordinators on staff?

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.

So this applies only to Medicare patients and not to managed care/Medicaid?

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.

What are three ways that facilities can prepare for PDPM?

  1. Train staff—ensure staff is coding the Minimum Data Set (MDS) appropriately and accurately. Consider ICD-10 coding training for those completing the MDS. And, train all staff in the new sections of the MDS, especially Section GG since it will be an important element of case-mix index (CMI).
  2. Develop clinical competencies—staff members that work in nursing facilities need practice at the top of their license. Clinical outcomes, successful discharges, and decreases in rehospitalization will enable nursing facilities to take advantage of other opportunities for reimbursement through the Quality Reporting Program and Value-Based Purchasing Program.
  3. Document, document, document—the medical record must always support the MDS coding and the coding on the claim. Having supportive documentation from the hospital, and notes in nursing, dietary, restorative, and therapy, is important to support the CMIs in the PDPM.

Does one count all comorbidities whether or not they impact the care plan?

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).

How will therapy services remain profitable with the changes in PDPM?

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.

Does the 3-day, no therapy rule apply when residents refuse or are sick?

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.

What are the determinants of someone remaining skilled in PDPM versus needing a cut letter? (PT and OT were frequently the skill and a cut was done after the end of therapy services.)

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 patient requires skilled nursing services or skilled rehabilitation services, i.e., services that must be performed by or under the supervision of professional or technical personnel (see §§30.2 - 30.4); are ordered by a physician and the services are rendered for a condition for which the patient received inpatient hospital services or for a condition that arose while receiving care in a SNF for a condition for which he received inpatient hospital services;
  • The patient requires these skilled services on a daily basis (see §30.6); and
  • As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF. (See §30.7.)
  • The services delivered are reasonable and necessary for the treatment of a patient’s illness or injury, i.e., are consistent with the nature and severity of the individual’s illness or injury, the individual’s particular medical needs, and accepted standards of medical practice. The services must also be reasonable in terms of duration and quantity.”

The term “daily” is defined as seven days a week for nursing services and 5-7 days a week for rehabilitation services.

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Instructor Bio

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.

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