Grouper Interactive Tool For Pdpm

Elaine Sutton
• Tuesday, 10 November, 2020
• 10 min read

In July 2018, CMS finalized a new case-mix classification model, the Patient Driven Payment Model (PDP), that, effective beginning October 1, 2019, will be used under the Skilled Nursing Facility (SNF) Prospective Payment System (PPS) for classifying SNF patients in a covered Part A stay. This site includes a variety of educational and training resources to assist stakeholders in preparing for PDP implementation.

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In May 2017, CMS released an Advanced Notice of Proposed Rule making (AN PRM) which outlined a new case-mix model, the Resident Classification System, Version I (RCS-I), that would be used to replace the existing RUG-IV case-mix model, used to classify residents in a covered Part A stay into payment groups under the SNF PPS. Since the AN PRM, we continued our stakeholder engagement efforts to address the concerns and questions raised by commenters with RCS-I.

Below are several items we have posted concurrent with the FY 2019 SNF PPS Norm to assist stakeholders in reviewing and commenting on the proposed PDP. For a subset of these ICD-10-CM diagnosis codes, the clinical category will be modified if there were specific related surgical procedures performed in the hospital stay immediately preceding admission to the skilled nursing facility.

The surgical procedure code lists provided will be used as a reference by the skilled nursing facility staff to augment the resident’s clinical category classification. The staff would review the information sent by the preceding hospital stay to identify any procedures defined in these surgical clinical categories.

To assist stakeholders in understanding the process by which SNF residents would be classified into PDP payment groups, we are providing three files. The first file provides a narrative step-by-step walkthrough that would allow stakeholders to manually determine a resident’s PDP classification based on the data from an MDS assessment.

In the second phase of the project, which is now in process, the contractor is using the findings from this Base Year Final Summary Report as a guide to identify potential models suitable for further analysis. Acumen hosted a third Technical Expert Panel in June 2016 to provide an outline of basic payment structure for a revised SNF PPS, including the various new components of the revised SNF PPS and a discussion of potential pricing schedules which may be incorporated.

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Acumen hosted a fourth Technical Expert Panel in October 2016 to provide an outline of the recommended alternative payment model for a revised SNF PPS, including the various new components of the revised SNF PPS and a discussion of potential pricing schedules which may be incorporated. Based on the work conducted by Acumen during the second phase of the project, which included substantial feedback from stakeholders and four Technical Expert Panels, the contractor drafted a Technical Report (PDF), which discusses the research conducted by the contractor on developing an alternative to the existing methodology used to pay for services under the SNF PPS.

To assist stakeholders in their review of the RCS-I model, as discussed in the SNF PPS Advance Notice of Proposed Rule making (AN PRM) and Technical Report provided above, we are providing a provider-specific impact analysis file, which details the estimated impact of the RCS-I model discussed in the AN PRM on Medicare Part A payments to each SNF in the country. This file provides a step-by-step walk-through that allows stakeholders to manually determine a resident’s RCS-I classification based on the data from an MDS assessment.

This document should be used in conjunction with the discussions found in the AN PRM and accompanying Technical Report to better understand the process for resident classification under RCS-I. The contractor is continuing with further refinements and considering potential improvements to the overall SNF PPS payment structure, and we welcome your comments and feedback.

Both U07.1, COVID-19 and U07.0, Vaping-related disorder are assigned to the Medication Management, Teaching and Assessment-Respiratory (MMTA-Respiratory) clinical group for purposes of case-mix adjustment under the HH PPS. The PDG relies more heavily on clinical characteristics, and other patient information to place home health periods of care into meaningful payment categories.

One case-mix variable is the assignment of the principal diagnosis to one of 12 clinical groups to explain the primary reason for home health services. CMS is aware of issues with the latest PDP DLL Package (V1.0002 FINAL).

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We are targeting to release an updated version on Monday, October 7, 2019, which corrects the identified grouper discrepancies. Late submission payment penalties do not apply under the SNF PPS.

Taking the following steps can help nurse assessment coordinators (ACS) capture the optimal TNA comorbidity score: This video tutorial is approximately 22 minutes in length and is designed to provide targeted guidance for accurate coding using live-action patient/resident scenarios.

Read more An update to the PDP Grouper DLL has been posted, along with its source code and test cases. This version, V1.0008, corrects an issue with a dynamic array that was not consistently reinitialized when processing multiple assessments within a short time frame.

It is important to include the control item STATE_ PDP _OBRA_CD (as defined in the V3.00.5 errata for the FINAL version (v3.00.1) of the MDS 3.0 Data Specifications) for assessments with target date on or after October 1, 2020. Note that this FINAL version supports the ICD-10 codes that are defined in the data specifications as valid for item I0020B for FY2021.

Also, please note that the grouper expects valid FY2021 ICD-10 codes for I8000A-J when processing assessments with target date on or after October 1, 2020. Read more Navigating the COVID-19 public health emergency can be difficult for skilled nursing facilities (SNES).

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Read more Key information about how to submit MDS files and how to obtain and understand error messages on initial and final validation reports. While most of the information used to establish these codes is already on the Bra assessments, the additional data collection will require both time to complete and training performing correctly.

Notably, the addition of completing the admission performance column for section GG (Functional Abilities) will take the most time. However, the stress and workload can be mitigated with a strong preparation plan and ongoing support to direct care staff.

Follow these four steps to ensure your team is ready to complete successfully the documentation and data collection for section GG on Bra assessments: CMS is publishing this final rule consistent with the legal requirements to update Medicare payment policies for SNF son an annual basis.

In recognition of the significant impact of the COVID-19 public health emergency, and limited capacity of health care providers to review and provide comment on extensive proposals, CMS has limited annual SNF rule making required by statute to essential policies including Medicare payment to SNES. In response to stakeholder feedback, we are also finalizing changes to the International Classification of Diseases, Version 10 (ICD-10) code mappings, effective October 1, 2020.

Finally, this rule includes minor administrative changes related to the SNF Value-Based Purchasing (VIP) Program. The positive aspect of this is that facilities will be compensated for the non-therapy ancillary and clinical care they are providing to their residents.

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We have carefully reviewed the worksheet to ensure that it represents the resident classification logic presented in the Norm and accompanying Technical Report. As opposed to RUG-IV, in which a resident’s classification into a single group determines the case-mix indexes and paradigm rates for all case-mix adjusted components, PDP classifies residents into a separate group for each of the case-mix adjusted components, which each have their own associated case-mix indexes and per diem rates.

Additionally, PDP applies variable per diem payment adjustments to three components, PT, OT, and TNA, to account for changes in resource use over a stay. As the disclaimer states, this is a tool that will give facilities a rough idea of how residents will be classified under the new payment structure.

The American Health Care Association has compiled a list of the most frequently asked questions regarding PDP. These FAQs are generally updated bi-weekly and address common PDP questions submitted by HCA members.

The responses are developed by HCA staff based upon published Centers for Medicare and Medicaid Services (CMS) policy and guidance materials or CMS direct responses to specific questions not currently addressed in such materials. As you enter the different criteria based on the information about the resident you will be able to see how each item impacts reimbursement for the facility.

Understand, this is only intended to be used to give you an ESTIMATE on the reimbursement and it could change as the PDP structure is finalized by CMS. Details: For additional information, refer to section 40.1 of the Medicare Claims Processing Manual (CMS Pub.

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10) Use this tool to prevent your RAP for periods of care that begin on or after January 1, 2020, from being auto-cancelled by the Fiscal Intermediary Standard System (Fish). Though some experts have doubted the grouper tool ’s accuracy, at the very least, it provides agencies a place to start.

Details: The CY 2019 Home Health Payment System Rate final rule was published last week and, as expected, the Patient-Driven Groupings Model (PDG) will be implemented for 30-day periods of care starting on or after January 1, 2020. Alta has created and gathered the following resources to help prepare you for the new Medicare Home Health Prospective Payment System (PPS) payment model, the Patient-Driven Groupings Model (PDG).

Details: Details: The PDG Analysis Tool by Simone Healthcare Consultants will provide a clear view of what is coming and what to do to effectively handle the specific circumstances in your home health organization. Details: Home Health Patient-Driven Groupings Model | CMS Details: The PDG relies more heavily on clinical characteristics, and other patient information to place home health periods of care into meaningful payment categories.

Details: CGS Overview: Home Health Patient-Driven Groupings Model (PDG) Effective for claims with a “From” date on or after January 1, 2020, Change Request (CR) 11081 implements the policies of the home health Patient-Driven Groupings Model (PDG) as described in the Calendar Year (CY) 2020 home health (HH) final rule (CMS-1711-FC). The PDG changes the unit of payment from 60-day episodes of care ... Details: New Home Health Patient-Driven Groupings Model (PDG) Tool.

(always look for the most recent updated) 2) Laterality and specificity should be queried as needed (see Common Home care ... even if the condition is not the focus of any home health treatment itself. Details: A lot has been written about PDG, the new home healthcare Patient-Driven Groupings Model first proposed by the Centers for Medicare & Medicaid Services (CMS) in July 2018.

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CMS released the final rule on October 31, 2018, and PDG will become effective on or after January 1, 2020. CMS PDG Revised Manual Instructions for Claims Processing Transmittal 4452.

It uses data from the Centers for Medicare and Medicaid Services’ projections that were updated with final 2019 payment rates and reflects methodology changes incorporated into the Final Rule released October 31, 2018. A list of all ICD-10 codes and their correlating clinical groupings is available on the CMS website under the PDG GrouperTool.

If the primary code does not match this list, CMS will not be able to assign the 30-day period to one of the six PDG clinical groups, and will likely return the claim to the provider ... Details: • The PDG is a new payment model for the Home Health Prospective Payment System (HH PPS) that relies more heavily on clinical characteristics and other patient information to place home health periods of care into meaningful payment categories and eliminates the use of therapy service thresholds.

Details: CMS is now only showing the 43,287 acceptable codes in their GrouperTool under the “ICD10 DNS” excel tab. Details: On August 21, 2019, CMS had a Home Health Patient Driven Groupings Model Operational Issues Call.

Health Details: This document provides PDG transition guidance including OASIS time point, data set version and M0090 Date Assessment Completed considerations for patients where resulting assessments must provide the Health Insurance Prospective Payment System (Hips) code for a PDG payment period that begins January 1, 2020, or later ... Details: The PDG Analysis Tool by Simone Healthcare Consultants will provide a clear view of what is coming and what to do to effectively handle the specific circumstances in your home health organization.

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Based on the data CMS released in the PDG final rule, Simone brings significantly more insight for analysis, offering: Details: In designing the Patient-Driven Groupings Model (PDG), officials from the U.S. Centers for Medicare & Medicaid Services (CMS) made a handful of assumptions about how Medicare-certified home health operators would respond once the overhaul went live.

Among those assumptions, CMS believed home health agencies would automatically “opcode,” or pick the primary diagnosis code tied to Details: To assist home health providers in determining reimbursement for Medicare home health PPS/PDG claims, Palmetto GBA offers providers the ability to estimate their claims payment amount online.

The online calculator is designed to estimate the amount of reimbursement for all types of Medicare HHA claims with service episodes/periods beginning on ... Details: PDG Impact on Your Agency: A Simplified Tool Posted on November 1, 2018, July 30, 2019, by Jazz Associates Last month we encouraged you to access the information that CMS has provided to learn the potential impact of the Patient-Driven Groupings Model (PDG) on your agency.

Just scroll down to start mastering PDP diagnoses with the SimpleAnalyzer™ Diagnosis Explorer… Instructions: Type part of a diagnosis code into the search box and press Enter.

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