SNF PPS Patient-Driven Payment Model: Get Ready for Implementation on Oct. 1st

The Medicare Learning Network (MLN) included the following article in its Sept. 5, 2019 issue of MLN Connects:

On October 1, the new Patient Driven Payment Model (PDPM) is replacing the Resource Utilization Group, Version IV (RUG-IV) for the Skilled Nursing Facility (SNF) Prospective Payment System (PPS). PDPM improves the accuracy and appropriateness of payments by classifying patients into payment groups based on specific, data-driven patient characteristics, while simultaneously reducing administrative burden.

Changes to the Assessment:

Both RUG-IV and PDPM use the Minimum Data Set (MDS) 3.0 as the basis for patient assessment and classification, but the assessment schedule under PDPM is more streamlined and less burdensome on providers. See the presentation (starting on slide 52) to find out how your assessments will change.

Billing for Services:

Use the Health Insurance Prospective Payment System (HIPPS) code generated from assessments with an assessment reference date on or after October 1, 2019, to bill under the PDPM.

Changes to Payment:

Under the PDPM, clinically relevant factors and patient characteristics are used to assign patients into case-mix groups across the payment components to derive payment. Additionally, the PDPM adjusts per diem payments to reflect varying costs throughout the stay.

CMS has resources to help you prepare:

• PDPM webpage, including fact sheets, FAQs, presentation, and coding crosswalks/classification logic
• Videos: PDPM: What Is Changing (and What Is Not) and Integrated Coding & PDPM Case Study
• Materials from the Medicare Learning Network call in December
• Implementation of the SNF PDPM MLN Matters Article
• New Medicare Webpage on PDPM MLN Matters Article

Contact: Dan Heim, dheim@leadingageny.org, 518-867-8866