Pdpm Grouper Tool Cms

David Lawrence
• Tuesday, 28 September, 2021
• 17 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.

pdpm calculator mds tools mppr
(Source: www.broadriverrehab.com)


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.

pdpm crosswalk healthpro heritage rugs iv
(Source: healthpro-heritage.com)

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. The Centers for Medicare & Medicaid Services (CMS) posted an updated PDPMGrouper DLL v1.0007 to the MDS 3.0 Technical Information webpage.

pdpm resource guide mds tools consultants
(Source: mds-consultants.com)

HCA PDP Grouper Tool User Guide1201 L Street, NW Washington, DC 20005 P | 202.842.4444 F | 202.842.3860 canal.org 2019 American Health Care Association Table of Contents Introduction & Overview 3 Data Input 4 Running the Model 5 Patient Analysis 7 Facility Analysis 8 Appendix: Data Input Glossary 9 Introduction & Overview The tool allows the user to input patient-level data and derive estimated PDP payments for non-interrupted patient stays.

The user will be able to use this tool to understand the difference between reimbursement under RUG-IV and PDP at a patient and facility level. As a reminder, HCA replies to inquiries on a biweekly basis.

Introduction: This tab provides a high-level overview of the model including a table of contents. Payment Analysis: The patient PDP calculation is run through an embedded Macro in the Excel document and patient-level results are summarized on this tab.

Certain ICD -10 codes are insufficient to be considered a Primary Diagnosis. If an entered Primary Diagnosis Code (Column “CX”) is insufficient, it will be flagged as “Return to Provider” and the user will be required to provide another primary diagnosis code.

Note: If the I8000A (Primary Diagnosis Code) is blank, the patient will receive a $0 PDP payment for the stay. Running the Model Step 1: Click the “Developer” tab at the top of the page and select Macros on the left.

(Source: www.youtube.com)

If you don't have the Developer tab, click on the File menu and then select Options. Click Developer checkbox under the list of main tabs on the right.

Step 2: Highlight the “Macro2” line from the options available and select “Edit”. Step 3: Update the “from=47” to the number of lines in the Data Input tab.

Note: Every time you wish to refresh a data set, the results of the calculation in the “Payment Analysis” tab need to be cleared by deleting Row 22 and below. For the benefit of the user, Rows 1-21 have been locked and can’t be edited or deleted accidentally.

You can then copy/paste your list into the highlighted yellow fields in order to auto populate the table. Note: There is no further manipulation required for the patient analysis tab.

Both Pfizer Inc. and the Annals of Internal Medicine have granted permission to freely use these instruments in association with the MDS 3.0. The implementation of PDP makes it ever more important to show the value and cost-effectiveness of physical therapist services within skilled nursing facilities.

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(Source: www.monterotherapyservices.com)

The PDP is a shift away from volume-driven SNF payment to a model that focuses on the unique characteristics, needs, and goals of each patient. Since we launched the PDP Calculator in May 2018, we’ve received an incredible amount of positive feedback.

This payment model is a major change from the way SNES are currently reimbursed. To ensure a smooth transition, prevent denials, and avoid resulting cash flow disruptions, your revenue cycle team needs to be prepared for PDP.

Facilities should be benchmarking their key revenue cycle indicators including, but not limited to, accounts receivable aging comparisons, days in accounts receivables, and collections as a percentage of revenues. Benchmarking can help a facility detect issues early on and resolve them before they become a bigger problem.

Most facilities are not tracking or monitoring ICD-10 diagnosis codes, as the majority of diagnoses don’t impact quality measures or reimbursement. The implementation of PDP will require the use of ICD-10 diagnosis codes, which are more detailed and call for accurate documentation.

For SNF providers, this means the old ways of documenting resident assessments on the MDS won’t work under the new model. One of the most important changes under PDP is that ICD-10 diagnoses will be the key drivers for reimbursement.

(Source: www.healthpro-heritage.com)

ICD-10 diagnosis codes will be used to place a resident into one of 10 PDP clinical categories, that will determine the payment components for physical therapy (PT), occupational therapy (OT), speech (SLP), and skilled nursing services, as well as non-therapy ancillaries (TNA). Compare the codes you most frequently use to the CMS PDP Clinical Category Mapping If codes map to “Return to Provider” you need to review the patient record to find a more specific primary diagnosis Make sure you capture the resident’s comorbidities on I8000 to ensure appropriate payment for Non-Therapy Ancillaries (TNA).

Communicate with anyone who contributes to the diagnosis documentation, including the physician, medical director, PT/OT/SLP, and other specialty care professionals such as wound specialists or dietitians to understand why the resident is there. Identifying the reason the resident is there and assigning the correct diagnosis code will help a facility to be successful with PDP.

Review the changes being made to the Minimum Data Set (MDS) The draft indicates that there are more than 80 items will be added, deleted, or changed for PDP implementation.

Facilities also have the option to perform an interim payment assessment if the patient’s clinical characteristics change. This assessment must be completed within 14 days of the change in characteristics and can affect reimbursement.

Section GG is more standardized and has more comprehensive measures of functional status. Providers need to be sure to complete Section GG in its entirety as missing responses will receive zero points for the functional score calculation.

pdgm checklist
(Source: www.healthpro-heritage.com)

Over the years, the MDS has primarily been utilized as an assessment tool to drive the plan of care with little impact to reimbursement. You may need to revise the systems you currently have in place to make sure that the information critical to reimbursement is recorded accurately on the five-day assessment.

Missing an item on the five-day MDS will impact reimbursement for the entire resident stay. Skilled Nursing Facilities will need internal processes, workflows, and staff training in place well before October 1, 2019, in order to be successful under PDP.

Without a doubt, there will be things that arise at the last minute or processes that don’t work as planned. We can help you address issues and problems or work with you to create a new workflow process.

Over the last few weeks, CMS and the President have enacted legislation and released guidance to assist the senior living industry in coping with the impact of COVID-19. Our senior living professionals have written this article to highlight new regulations impacting the industry and offer practical tips for guarding your facility's financial health through the COVID-19 outbreak.

To ensure that your facility is getting much needed financial relief and being properly reimbursed for the full impact of COVID-19, we recommend tracking your expenditures related to the coronavirus. Expenditures related to COVID-19 go beyond the cost of additional Personal Protective Equipment (PPE), they will likely include additional direct care staffing, along with housekeeping, dietary and laundry staffing, and supplies needed to maintain the heightened level of hygiene required to combat the spread of COVID-19 in your facility.

pdgm questionable encounters
(Source: www.healthpro-heritage.com)

CMS issues waiver of 3-Day Stay and Spell of Illness On March 14, Centers for Medicare and Medicaid Services (CMS) issued two waivers to aid skilled nursing facilities in addressing the national COVID-19 outbreak. The exception applies to traditional Medicare coverage only (Medicare Advantage plans may or may not follow this exception); It is in effect as of March 1, 2020, and will only be in effect while public health emergency is declared; Applies only to beneficiaries affected by the emergency or who experience dislocations; Providers have to document medical necessity and clinical reasons for not meeting 3-midnight requirement, understanding that the intent of this provision is to free up hospital beds and reduce potential risk of exposure to the patient; Providers are to use condition code “DR” on the claims.

Families First Coronavirus Response Act (FF CRA) On March 18, 2020, the President signed into law, H.R. The legislation eliminates patient cost-sharing for COVID-19 testing and related services, establishes an emergency paid leave program, and expands unemployment and nutrition assistance.

Moreover, the bill provides a temporary 6.2% increase in Federal Medical Assistance Percentages (Map) for each calendar quarter occurring during an emergency period. This would result in less funding for provider rate increases to cover COVID-19 related costs.

However, on March 21, 2020, the federal government also announced that it is considering a special enrollment period for Affordable Care Act Health Insurance Exchange coverage. A special enrollment period would offer lower cost coverage to individuals with reduced incomes and could influence how the Map increase will be used, possibly resulting in more being allocated to covering provider rates.

Facilities are encouraged to use the CDC developed COVID-19 Focused Survey for Nursing Homes. The White House has signaled that it will sign the measure as approved by the Senate.

healthpro heritage cms
(Source: www.healthpro-heritage.com)

$150 million for modifications of existing hospital, nursing home, and “domiciliary facilities” undertaken as part of COVID-19 response. $65 million for housing for the elderly and people with disabilities for rental assistance, service coordinators and support services for the more than 114,000 affordable households for the elderly, and more than 30,000 affordable households for low-income people with disabilities.

$2.8 million to provide staff treating veterans living at Armed Forces Retirement Homes with the personal protective equipment they need. The funding provides this and other necessary equipment and staffing support to help minimize the spread of the coronavirus among residents.

$200 million for the Centers for Medicare & Medicaid Services to assist nursing homes with infection control and support states’ efforts to prevent the spread of the coronavirus in nursing homes. Be sure the timing of your cash receipts will cover payroll and supplies expenditures each week.

Contact your lenders to obtain or increase available working capital lines of credit. We are here to help Please contact the Berry Dunn senior living team if you have any questions, or would like to discuss your specific situation.

In our consulting work with Skilled Nursing Facilities (SNES) we have identified some early trends in PDP implementation we would like to share. Many are reporting increases in Medicare revenues and feel PDP has also been positive for the industry.

healthpro heritage pdgm pdpm under health therapy cms patient non fact does encounters questionable released blogheader welcome groupings finale rule
(Source: www.healthpro-heritage.com)

There were predictions that SNES were not going to be prepared and smaller providers were going to go out of business because they could not adapt to PDP. Initial PDP news is positive for the industry, but to be successful providers must continue to adapt.

There still needs to be more education on the Minimum Data Set (MDS) to optimize reimbursement. There are several factors contributing to missed reimbursement opportunities, including delays in receiving information from physicians and other departments.

Facilities need to build better relationships with physicians and provider networks to improve communication that focuses on clinical conditions and co-morbidities of the resident. To be in compliance with Medicare regulations and prevent take backs on audit, diagnoses must be supported by the resident care plan.

However, it is more likely that CMS will make an adjustment to weights and rates as part of the 2020 rule making process. As we move further into 2020, you can expect to see more data on PDP claims and reimbursements, which will help you make operational and financial decisions about your facility.

In the meantime, you should keep focusing on patient care and achieving quality outcomes while thinking about what you can do now to adapt to be successful under PDP. For proper reimbursement, your staff will have to gather all relevant clinical information on the resident in a shorter period of time.

icd code comorbidity oasis calm keep adjustment return diagnoses reflected secondary drive
(Source: www.healthpro-heritage.com)

A strong admissions team and processes will help you achieve financial success under PDP. Under PDP, facilities are going to have to involve more team members in the pre-admission process to ensure proper and thorough screening of residents.

Since PDP focuses on all the resident’s clinical characteristics, you will need readmission input from many team members, including but not limited to physicians, nurses, therapy providers, and case management. You will need to assess many other elements up front you miss something in the screening, you won’t receive adequate reimbursement.

The admissions team will need to get a comprehensive background on each residentincluding all comorbidities, recent surgical history, and other clinical characteristics and services that determine a resident’s case-mix. For example, in some cases, two diagnoses, such as aftercare for major joint surgery and an infectious complication, may compete for the primary diagnosis.

Review changes to the Minimum Data Set (MDS) the entire admissions team needs to understand the changes to the MDS so that they capture all the required resident information. There are nearly 40 new MDS items that directly influence a resident’s clinical classification and payment rates.

I0020BTo report the ICD-10-CM primary diagnosis code representing the main reason for Skilled Nursing Facility (SNF) admission J2100-J5000New patient surgical history items that affect the PDP physical and occupational therapy and speech-language pathology components I8000To report comorbidities that affect non-therapy ancillaries O425A1-O0425C5To capture discharge information on therapy delivery over the course of the resident's entire Part A stay, including use of group and concurrent therapy. Effective October 1, 2019, Skilled Nursing Facilities (SNF)s will be reimbursed under a new payment system.

pdpm management healthcare calculator
(Source: www.retrocube.com)

The existing case mix classification group, Resource Utilization Group IV (RUG- IV) will be replaced with a new case mix model, the Patient Driven Payment Model (PDP). CMS has indicated factors leading to the change in the payment system include over utilization of therapy and incentives for longer lengths of stay.

The IMPACT Act requires to be standardized patient assessment data across post-acute care (PAC) settings to enable: Comparisons of quality and information exchange across post-acute settings Improvement of Medicare beneficiary outcomes through shared-decision making, care coordination, and enhanced discharge planning Non-therapy ancillaries (TNA) payment is determined by a base rate and separate CMI.

PDP will be a significant shift in how SNES are paid, and facilities need to start preparing for the change. Value Base Purchasing (VIP), SNF Quality Reporting Program and PDP are all initiatives advancing the IMPACT act and moving payment from fee for service to value.

Accurate coding of patient conditions must occur at the time of admission, and while the information coming from the hospital will be helpful, facilities cannot rely on hospital information when coding the MDS. Diagnosis and accurate coding are critical to assigning the appropriate case mix group to make certain there is adequate payment for the stay.

Facilities can perform an optional interim payment assessment within 14 days of a change in the resident’s characteristics. The MDS has been an important tool in driving resident care over that last 30 years, and is relied upon for reimbursement and quality data.

pdgm impact health tool patient driven groupings oasis under fazzi cms agency revenue simplified accuracy coding documentation important even encouraged
(Source: www.fazzi.com)

Determine your hiring and training needs Look at therapy contracts, how do they align with new payment model Talk to software vendors to be sure they will be ready for the new MDS and ICD-10 NOTE: if you’re a current Berry Dunn client, feel free to stop reading here.

All kidding aside, here’s a recipe for making an auditor change that meets your needs and advances your organization. While sooner is better, balance your needs with the former audit firm’s schedules, so they don’t charge you for rushed work and to make sure the right team members can be involved.

Through delivering the final product, constant communication is crucial to working with your new audit team. Successful transitions happen because both auditors and clients are aware of ongoing issues, challenges, and opportunities.

Scheduled update meetings and weekly notifications of engagement status are two methods used to easily communicate with all stakeholders. Daily check-ins during the audit can help remove many obstacles to an efficient transition.

c. Listings for confirmations including banking institutions and legal firms consulted throughout the year. Ideally you and your engagement manager should hold regular logistics and progress updates.

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(Source: www.facebook.com)

Your team will want to have access to the permanent files and general ledger structure/codes before auditors come onsite. Both parties are hopeful that the effort put into the transition pays off in a smooth engagement, but also in many future years of working together.

Communicating, planning, and remaining flexible are the foundation for any good business relationship. Setting expectations and being able to rely on the fact that your audit team knows your industry and can hit the ground running are essential to a successful transition.

The forms are not available at the SBA or Treasury websites, but were released through the PPP Loan Forgiveness portal to lenders. We recommend that you carefully review what information you have not flagged as confidential before submitting the form.

Instructions for submitting comments: Agency Clearance Officer Curtis Rich Small Business Administration 409 3rd Street SW 5th Floor Washington, DC 20416 Comments should include one or all of the following: (a) whether the collection of information is necessary, (b) whether the estimate of 1.6 hours to complete or review the proposed application form is accurate (42,000 applications, 67,833 annual hour burden), (c) whether there are ways to minimize this burden, and (d) whether there are ways to enhance the quality, utility, and clarity of the information.

The new functionality empowers healthcare providers with improved assessment capabilities for Patient Driven Payment Model (PDP) reimbursement, as well as physician certification compliance. The PDPMGrouperTool and Hips Calculator within Managed Care MASTER work together to better assess and predict PDP revenue at readmission.

pdpm selector management features user
(Source: www.retrocubellc.com)

With deep multi-vendor interoperability expertise, including the integration of 70+ healthcare applications and 3,500+ EDI payers, Prime Care Technologies offers the leading data warehouse and claims clearinghouse in post-acute care.

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