Harmony Healthcare Blog

PDPM: Top 3 Areas for Systems Implementation

Posted by Pam Duchene on Tue, Jul 02, 2019


Edited by Kris Mastrangelo

C.A.R.E.

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


Time for Changes on Black-Golden Watch Face with Closeup View of Watch Mechanism.The Patient Driven Payment Model incorporates a multitude of changes into the current Medicare Part A SNF payment model.  Some of the criteria that require immediate application include:

  1. Interruptions in Stay;
  2. Interim Payment Assessments; and
  3. Administrative Level of Care Presumption.

While HHI intensive PDPM training currently focuses on the understanding the 6 components that comprise PDPM and ICD-10 Codes; it is equally important that organizations comprehend and develop policies surrounding PDPM implementation. 

The Top 3 Areas that require systems implementation include: 

  1. Interruptions in Stay

    Interruptions in a patient stay requires accurate tracking of departure and arrival times for every patient.  Patients who remain at the hospital past midnight on day three will not qualify for an interrupted stay and will need a new 5-Day assessment.  Two examples follow:


    Example 1:

    Patient in a Skilled Medicare A stay for 15 days:


    Day 16:  Transfer to the hospital for evaluation.  The patient is admitted (considered Day 1)
    Day 2:    Remains at the hospital
    Day 3:    Returns before midnight = Considered an interrupted stay.  Resume on Day 16 of the Medicare stay.  No additional assessment is required.

    Example 2:

    Patient in a Skilled Medicare A stay for 15 days:


    Day 1:   Transfer to the hospital for evaluation.  The patient is admitted (considered Day #1)
    Day 2:   Remains at the hospital
    Day 3:   Remains at the hospital
    Day 4:   Returns before midnight = Considered a new stay.  A New assessment required.  No new days are added to the benefit period.

    Recommendation:  Interruptions in Stay

    Prior to October 1, 2019, SNFs need to have an accurate way of dating/timing arrivals and departures of patients in the Medicare Part A program.

    PDPM Calculator
  2. Interim Payment Assessment (IPA)

    The Interim Payment Assessment (IPA) is optional and it seems that CMS may expect a low frequency of completion.  That said, all patients on a Medicare Part A stay that spans though October 1, 2019, will require an Interim Payment Assessment.  In addition to the initial IPA for patients during that first week of October, SNFs should consider completing an IPA if one or more of the PDPM components changes to a higher level of payment.  If additional co-morbidities are identified in NTA, following the 5-Day assessment that will result in a change in payment group, the IPA will adjust the per diem rate.


    Example:  A patient who develops pneumonia following admission for skilled care associated with a hospitalization for acute on chronic congestive heart failure might merit an IPA.  If the patient requires IVs, for example, the facility can receive credit for providing the high-level skill and monitoring respiratory status, as long as the IPA results in a skilled level of care.

    The change will be reflected on the same day in the schedule

    Their new payment will not be triple the NTA rate as at the start of the stay.  A new GG section and a repeat interview with BIMS/CPS will be required.  As an example, if a patient develops pneumonia and requires IV antibiotics on day 20, an interim payment assessment could be done.  The NTA would move by 3 points for IVs; nursing could move to Special Care High.  Both of these changes might increase the rate but would not result in a second three-day initial rate.


    Recommendation: Interim Payment Assessment (IPA)

    Review changes in patient needs and requirements to determine if the rate may be positively impacted by changes in care needs.  This is most likely to occur with acuity changes or change in the complexity of care needs.  The patient’s assessment must continue to demonstrate a skilled level of care with the IPA for the change to result in a payment change. 


  3. Administrative Level of Care Presumption

    The Administrative Level of Care Presumption supports the assumption that patients whose clinical complexities place the assessment into the designated, intensive Case Mix classifiers for the 5-day assessment (completed no later than Day 8) are automatically assumed to meet a skilled level of care through the ARD.


    In other words, Patients whose assessments categorize them into the following groups will be presumed to be skilled:
    • Nursing:
      • Extensive Services, Special Care High, Special Care Low, and Clinically Complex
    • PT and OT Groups:
      • TA, TB, TC, TD, TE, TF, TG, TJ, TK, TN, and TO;
    • SLP Groups:
      • SC, SE, SF, SH, SI, SJ, SK, and SL; and
    • NTA Component’s
      • Uppermost (12+) comorbidity group

If the Interim Payment Assessment fails to place the patient into one of these groups, it is not assumed that the patient is at a skilled level of care.

Recommendation:  Administrative Level of Care Presumption
Monitor patients and related classification levels for accuracy and for significant changes. 

Key Strategies:

  1. Develop an Interim Payment Assessment Policy which spells out how the decision is communicated to complete an IPA. The IPA includes completion of Section GG and repeating the BIMS or the CPS interview.  The team must be involved in the decision to complete the IPA. 
  1. Determine how accurate recordings of entry and exit are from the facility. If “time of entry” is relying on the time of the admission or re-entry nursing note, is it accurate?  Review such practices now to assure they are accurate. 
  1. Understand and highlight the levels of care considered by CMS to be a skilled level of care.

Harmony Healthcare International (HHI) is available to assist with any questions or concerns that you may have.  You can contact us by clicking here.  Looking to train your staff?  Join us in person at one of our our upcoming Competency/Certification Courses.  Click here to see the dates and locations. 


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