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.
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.
CMS is aware of issues with the latest PDP DLL Package (V1.0002 FINAL). 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. 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. Stakeholders should use these revised SNF PDP files (Version 2) to inform their comments on the proposed rule.
CMS has contracted with Acumen, LLC to identify potential alternatives to the existing methodology used to pay for services under the SNF PPS. 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. 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.
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.
PT/OT CategoryAcute NeurologicMajor Joint Replacement or Spinal SurgeryNon-Orthopedic SurgeryOther Orthopedic Section Functional Abilities at Admission6.
Eating: The ability to use suitable utensils to bring food to the mouth and swallow food once the meal is presented on a table/tray. Includes modified food consistency.6.
Not Attempted C. Toileting Hygiene: The ability to maintain perineal hygiene, adjust clothes before and after using the toilet, commode, bedpan, or urinal. If managing an story, include wiping the opening but not managing equipment.6.
Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.6. Supervision or Touching Assistance3.
Not Attempted Due to Environmental Limitations88. Not Attempted C. Lying to sitting on the side of bed: The ability to safely move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support.6.
Not Attempted D. Sit to Stand: The ability to safely come to a standing position from sitting in a chair or on the side of the bed.6. Not Attempted Due to Environmental Limitations88.
Not Attempted E. Chair/Bed-To-Chair Transfer: The ability to safely transfer to and from a bed to a chair (or wheelchair).6. Not Attempted Due to Environmental Limitations88.
Not Attempted F. Toilet Transfer: The ability to safely get on and off a toilet or commode.0. No, and walking goal is NOT clinically indicated.1.
Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns.6. Not Attempted K. Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space. Clear All.