Last July, The Centers for Medicare and Medicaid (CMS) announced a new case-mix classification model, the Patient Driven Payment Model (PDPM). PDPM will take effect beginning October 1, which will be used under the Skilled Nursing Facility (SNF) Prospective Payment System (PPS) for classifying SNF patients in a covered Part A stay.

How will PDPM work?

The PDPM system will effectively overhaul the Resource Utilization Group (RUG-IV) system. While the RUG-IV compensation was driven by volume, PDPM will be based on patients’ care needs. PDPM will utilize six payment components to determine payment:

  • Physical Therapy
  • Occupational Therapy
  • Speech-Language Pathology
  • Non-therapy Ancillary
  • Nursing
  • Non-Case Mix

Patients will be assigned to a Case-Mix Group (CMGs) for each component. For more information on the calculation of reimbursement, you can visit CMS’s PDPM FAQ page.

What will be different?

Payment will now be determined by clinically relevant patient characteristics rather than volume-based measurements, like therapy hours. So rather than relying hevily on therapists to drive reimbursements and, in turn, the patient’s overall care plan, the responsibility will be more in the hands of the nurses, who, as you know, are the front lines of patient care.

This will make payments more specific to the patient – which will more accurately reimburse you for the care you provide to each patient.

What does this mean for my facility?

Your facility will need to do some heavy lifting so that you can benefit from this new system, as the accurate capturing of information will be crucial to your SNF’s success.

Under the RUG-IV, only 20 fields were expected to be filled, but now Minimum Data Set (MDS) coordinators will be asked to fill 161 fields using precise ICD-10 codes for patient diagnoses.

Even if you have already participated in an initial 5-day MDS assessment, patient characteristics can change over time. Experts suggest that an Interim Payment Assessment (IPA), which is performed after an initial assessment, can be the best way to capture a change in patient characteristics when a patient’s condition has changed so that you can maximize your reimbursement potential.

Some instances where an IPA may be helpful:

  •  Non-Therapy Ancillary (NTA)
  • Physical Therapy
  • Occupational Therapy
  • Speech Therapy
  • Nursing

Here is a helpful article that summarizes the strategies for implementing an IPA.

PDPM is swiftly approaching. What to remember as you prepare for October 1.

Coding will be a key skill moving forward. CMS has not specified a required coding program, but facilities should consider taking steps to ensure providers have some ICD-10 code expertise, and perhaps even offer incentive to providers to earn some professional coding credentials. Experts suggest a Certified Inpatient Coder credential through the American Academy of Professional Coders (AAPC.)

Nurses will now quarterback reimbursements. Therapy hours are no longer the key driver of reimbursements, so therapists, in turn, will no longer dictate a resident’s overall care plan. Your nurses may also take on the additional reimbursement paperwork – as an accurate record of resident diagnoses will be vital to accurate Medicare compensation. Make sure you are properly supporting your nursing staff through safe staffing practices.

We are here for you. While CMS’s ultimate goal with this transition from RUG-IV to PDPM is meant to improve patient care, increase the accuracy of reimbursements, and remove some of the administrative burdens on SNF providers, we know that implementing radical changes to your facility’s processes will significantly impact your day-to-day. Remember that you have a resource in us – if you’d like to have a conversation about how we can best suit your needs in light of these changes, let us know.

 

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IntelyCare was created by nurses, for nurses. We’re here to take care of those who take care of everyone else; our staffing solution gives nurses the opportunity for a better, more flexible schedule to help reduce nurse stress. Apply today to join the future of nursing.