What are the experts saying about PDPM?

Aug 03, 2018
The Bottom Line

If you’ve been paying attention to the progression of CMS’ new payment system to replace RUG-IV, beginning with the advanced notice of proposed rule-making published last April, when it was introduced as the Resident-Classification System, to the proposed rule published this May, when it was revamped and renamed the Patient-Drive Payment Model (PDPM), the good news is that the biggest change is behind us. The SNF PPS final rule released by CMS this week doesn’t deviate too much from the proposed rule, but as experts get a chance to read through the 424-page document, they have a mix of concerns, words of advice, and positive outlooks for change.

“With the 25% cap on group and concurrent therapy, tracking is important,” says Todd J. Selby, Attorney at Hall, Render, Killian, Heath & Lyman, P.C. “I know the provider industry is not happy with this as they feel it is an arbitrary number designed to just reduce therapy.”

While some are worried about PDPM’s move away from therapy minutes, Renee Kinder, MS, CCC-SLP, RAC-CT, Director of Clinical Education at Encore Rehabilitation Services encourages therapists to re-envision their role and look at PDPM as “the ultimate opportunity for full engagement in education, training, and more importantly MDS coding to promote successful and accurate coding for key sections in the MDS. Therapists who are worried about layoffs need to learn to advocate better for their scope now and not just the volume of their services, but sharing the true, clinical benefits that come from their services internally.”

PDPM classifies patients and pays the facility for each of five components each day—nursing, physical therapy, occupational therapy, speech language pathology and need for non-therapy ancillaries.  These five components plus a sixth, non-case mix for facility overhead, comprises the per diem payment, explains Cynthia K. Morton, MPA, Executive Vice President for the National Association for the Support of LTC.

She notes that one change made in the final rule is that the interim payment assessment (IPA) was made optional for providers. “It’s possible that the resident’s condition could change and the criteria to trigger an IPA is confusing. If the facility files an IPA it could place the resident into a different component, possibly changing the reimbursement amount.”

“What providers risk when not completing the IPA is that they are not taking the opportunity to do a clinical assessment, thus risking not being fully aware of patient needs. While completing an IPA will not reset payment, it’s so important to understand root cause when changes occur and bring everyone together to discuss,” says Kinder.

Because the IPA will be optional and providers can determine their own criteria for when an IPA is completed, Kinder says that CMS is revising the assessment reference date (ARD) criteria they proposed to be the date the facility chooses to complete the assessment relative to the triggering event that causes a facility to choose to complete the IPA. Payment based on the IPA will begin the same day as the ARD, she explains.

Although not new from the proposed rule, an important change that will need to be considered as SNFs transition from RUG-IV to PDPM: “Obsess about ICD-10 codes,” says Steven Littlehale, MS, GCNS-BC, Executive Vice President & Chief Clinical Officer at PointRight. “Determine how you are going to capture them, because they drive PDPM reimbursement. Traditionally SNFs haven’t needed to hire coders, however you can further educate your MDS coordinator in the technicalities of coding.”

Littlehale reassures providers that they shouldn’t put their energy into worry about lengths of stay and how reimbursement tapers down under PDPM’s reimbursement model. Instead, “just provide quality care and achieve the best outcome in the shortest time. This mantra will help in any payment program that your facility is currently engaged.”

To determine how a resident is classified for payment purposes and how per diem payment is calculated under PDPM, CMS has created a calculation worksheet. We’ve included the draft worksheet on the Billers’ Association resources page.

Click here to download the worksheet.

Members-only webcasts

Enjoy past webcast events with your AMBR Membership! Click here!

Free Resources

Access sample white papers, tools, analysis, and resources.