Harmony Healthcare Blog

Patient Driven Payment Model: Questions and Answers (Part 3 of 3)

Posted by The Harmony Team on Thu, Mar 07, 2019


Edited by Kris Mastrangelo

C.A.R.E.

Compliance • Audits/Analysis • Reimbursement/Regulatory/Rehab • Education/Efficiency


Ask An Expert sign with clouds and sky backgroundIs your Skilled Nursing Facility ready for the October 1, 2019 implementation of Patient Driven Payment Model (PDPM) as CMS proposed in the SNF PPS Final Rule FY 2019?  We encourage you to use this 3 Part Blog Series to gain an understanding of the Patient Driven Payment Model Reimbursement System.  Questions were submitted to HHI during our recent webinar:  Patient Driven Payment Model: 5 Things to Do Now!

  1. Any idea how Case Mix states will handle this new classification system for Medicaid only facilities since section GG isn't done for these residents?

    For states that rely on the RUG-IV assessment schedule for calculating Case Mix group for NF patients, CMS has created an optional assessment so that Medicaid payments are not adversely impacted when PDPM is implemented as of October 1, 2019. States will have the ability to determine the policy associated with this assessment to meet your Medicaid payment needs. The optional assessment will be in place from October 1, 2019 through September 30, 2020. 

  1. Do we know yet what will happen with patients who are evaluated prior to October first and already had MDS(s) done prior to the new system?

    Yes, the transition between RUG-IV and PDPM will be a “hard” transition, meaning that the two systems will not run concurrently at any point. All days of service on or prior to September 30, 2019 will be billed under RUG-IV, while all days of service beginning October 1, 2019 will be billed under PDPM.  To receive a PDPM HIPPS code that can be used for billing beginning October 1, 2019, all providers will be required to complete an IPA with an ARD no later than October 7, 2019 for all SNF Part A patients.

    October 1, 2019 will be considered Day 1 of the variable per diem schedule under PDPM, even if the patient began their stay prior to October 1, 2019. Any “transitional IPAs” with an ARD after October 7, 2019 will be considered late and the late assessment penalty would apply. The HIPPS code derived from the transitional IPA should be used to bill for dates of service beginning October 1, 2019. 
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  1. Has your team been able to estimate therapy minutes per Case Mix group that would be financially efficient?

    The Case Mix groups are not determined by minute or delivery of care.  Delivery of therapy services is resident centered and based on medical necessity.  The Case Mix Groups for PT, OT and SLP will be calculated for all patients regardless of therapy involvement.  
  1. Where is the mapping tool?

    CMS PDPM Resources has the Clinical Mapping Tool, Comorbidities and Grouper at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html

  2. If re-skilling a patient within the 30-day window rule, what MDS assessment is required and how is the reimbursement calculated?

    The Minimum Data Set (MDS) - Version 3.0 Resident Assessment and Care Screening Nursing Home PPS (Np) Item Set would be used for a standalone PPS Assessment. (MDS 3.0 NP PPS v1.12.0) 
  1. If you are doing a new assessment starting Oct 1st for Med A patients, would you have to do a discharge PPS for all Med A patients on Sept 30th? If so, does the billing calendar reset?

    No, a discharge PPS MDS is not done as the stay is not ending.  The patient will have an Interim Payment Assessment.  The patient will be credited for days used.  The Variable Payment Adjustment will begin on October 1, 2019. 
  1. How does this impact States with Case Mix for Medicaid payment?

    CMS has developed an Optional State Assessment (OSA) for use October 1, 2019 through September 30, 2020.  CMS will continue to report the RUG-III and RUG-IV Health Insurance Prospective Payment System (HIPPS) codes, as requested by the state, until September 30, 2020 on the 5-day PPS, OBRA comprehensive and OBRA quarterly assessment types.

    If a State requires the calculation of RUG-III or RUG-IV more frequently, the State may require its providers to submit the OSA at time points determined by the State.

Harmony Healthcare International (HHI) is available to provide assistance You can contact us by clicking here. Looking to train your staff?  Join us in person at one of our upcoming Competency/Certification Courses.  Click here to see the dates and locations. 


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Tags: Patient-Driven Payment Model

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