With less than a month until the skilled nursing facility (SNF) Patient-Driven Payment Model (PDPM) takes effect, concerns about preparedness for this major payment change abound. Recent polls of HDG Learn webinar attendees indicate:

  • Most respondents are not prepared for PDPM.
  • Over half of respondents are not comfortable with ICD-10 coding.
  • At least two-thirds of respondents are concerned their clinical documentation would not pass an audit.

While the Centers for Medicare and Medicaid Services (CMS) provided 14 months to prepare for the new payment model, PDPM is a more complicated payment system than the RUG-IV model, and it relies on a broader array of disciplines for successful execution. Even though recommended as a best practice, it has turned out to be challenging for some SNFs to run parallel RUGs and PDPM models, slowing preparation further.

Under PDPM, clinical proficiencies will be paramount; nurses, as well as the whole interdisciplinary team (IDT), will have renewed concentration on critical thinking skills as the paradigm shifts to a more medically complex model. This will become the new normal.

Key Elements of PDPM

Here are some key elements of the new normal that SNF managers and the IDT must ensure they focus on:

  • ICD-10 Coding—Determining the primary diagnosis, fully specifying secondary conditions, and ensuring that staff are trained to select the most appropriate diagnosis code are all critical to receiving correct payment and ultimately getting credit for higher acuity patients in your quality scores.
  • Non-Therapy Ancillaries (NTAs)—Relating diagnoses and conditions through an in-depth review of the medical record, as well as having ongoing dialogue with the physician/NP team to identify new diagnoses; use the helpful CMS mapping tool.
  • MDS Section GG Functional Abilities and Goals—Collaborating by PT/OT and Nursing IDT members is required; must have weekends covered for assessment of new patient admissions.
  • Speech-Language Pathology (SLP) Comorbidities—Carefully reviewing the medical record to identify SLP comorbidities as this has been typically under-coded in the RUGs payment era; the Brief Interview for Mental Status (BIMS) places a premium on solid interviewing skills.
  • Nursing Case-Mix Groups (CMGs)—Capturing patient characteristics and services that drive the primary and secondary splits for nursing is especially vital as payment for nursing is no longer embedded within therapy payment as was the case with RUGs.

At this point in PDPM preparedness, skilled nursing providers should be able to:

  • Understand the basics of ICD-10 coding.
  • Select the correct primary diagnosis.
  • Determine how NTA components relate to diagnoses.
  • Use the CMS mapping tool for correctly coding diagnoses.
  • Identify the PPS Nursing CMGs and components.

Action Items

HDG recommends the following action items to revamp your current practices for the new normal under PDPM:

  • Initiate discussions with physicians and referral sources on how the referral process will change and what will be asked of physicians upon patient admission to the SNF.
  • Determine how your therapy minutes will be managed; and who will evaluate outcomes.
  • Assess how your preadmissions process may need to change.
  • Promote collaborative IDT discussions of section GG.
  • Review your electronic medical record (EMR) for available PDPM conversions, reports, and tools.

Don’t forget that all Medicare patients will need an Interim Payment Assessment (IPA) if they will continue on a Medicare stay past September 30, 2019. PDPM is a “hard transition” on October 1—don’t make it harder by not preparing!

How HDG Can Help

Health Dimensions Group offers comprehensive PDPM consulting solutions to assist you in preparing for this significant payment change, including on-site education, focused clinical and operational reviews, and financial benchmarking and projections, as well as live and recorded webinars. We can also help you make the pivot to medically complex care through service line development and market assessments. For more information, visit our website or contact us at 763.537.5700 or info@hdgi1.com.

Authored by: Katherine Davis, MS, CCM, CDMS, RCP, CRC, Manager, Consulting Services