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. 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.
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.
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.
Details: For additional information, refer to section 40.1 of the Medicare Claims Processing Manual (CMS Pub. 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: CMS will use the PDG to reimburse home health agencies.
• Consider a certified coder/coders on your intake/marketing team to cut down time spent running around to clarify and correct. 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. Overview 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.
Details: New Home Health Patient-Driven Groupings Model (PDG) Tool. Health Details: To help you determine the visit threshold, the Home Health Low Utilization Payment Adjustment (Luna) Threshold Calculator was developed based on the CMS CY 2020 PDG Case Mix Weights and Luna Thresholds. Simply enter the Hips code, click Search, and the therapy visit threshold will display.
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. 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. Details: CMS offers a list of them on its CY 2020 PDG GrouperTool page (Download the file and look for the ICD-10 DNS Excel spreadsheet).
PDG + COVID-19 changed the home health landscape dramatically this year! Tack on CMS' release of the 2021 Home Health Final Rule on October 29, and we recognize that agencies may be struggling to navigate reimbursement regulations, declining caseload volumes, staff anxieties/shortage & more.
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 ...
“Take to whoever is doing your coding and tell them, ‘Do not, as of today, send me one more plan of care or one more OASIS or one more claim that has a primary diagnosis that is not on this list ... 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: 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. Details: There, operators can find a list of all 43,278 primary diagnoses acceptable under PDG.
Instructions: Type part of a diagnosis code into the search box and press Enter. Included in the v02.1.21 HH PPS Grouper software update are the FY 2021 International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes, effective beginning January 1, 2021.
Implementation of New International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Diagnosis Codes, Effective April 1, 2020: 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.