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. Similarly, the Snappy Technical Report discusses the additional analyses conducted, many in response to stakeholder feedback on the AN PRM, in development of 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.
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.
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. 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. Navigating health reform Update: 8/22/2020 Our 2021 PDP rate listing and calculator is now available.
CMS also finalized a sub-regulatory process for updating ICD-10-CM codes used for PDP patient classification. Download the Calculator CLA can assist you with PDP readiness assessments, training of clinical, coding, and management staff, and therapy contract renewals.
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.
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).
Details: One mechanism guaranteed to help all home health agencies prepare for PDG is CMS ’s interactive grouper tool, which calculates agencies’ expected payments under the new model, Miller said. 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.
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.
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.
Details: There, operators can find a list of all 43,278 primary diagnoses acceptable under PDG. 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. This article outlines steps your facility can take to prepare 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. 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. In early January, CMS issued a draft version of the MDS 3.0.
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. The IPA should only be used if a patient’s clinical characteristics are not expected to change in the short term.
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.
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.
$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.
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.
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.
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.
In October 2018, SNES began receiving a payment adjustment based on hospital readmissions under the SNF Quality Reporting Program. The implementation of PDP will be one more step towards moving reimbursement for care from volume to value.
Therapy is broken out into the three disciplines (physical, speech and occupational), with each having its own base rate and case mix index: Non-therapy ancillaries (TNA) payment is determined by a base rate and separate CMI.
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.
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. Planning meetings, document requests, and learning a bit about your business and any significant issues takes time from your team’s schedules.
Permanent file documents, including: articles of incorporation, by-laws, debt agreements c. Listings for confirmations including banking institutions and legal firms consulted throughout the year.
Having a leader of the audit team onsite helps make decisions faster and the engagement more efficient. Talk in advance about meeting deadlines: both those of your staff and those of the audit team.
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. It could be very difficult to manage if it hits during a month or quarter close, or even worse at year-end.
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. 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.