CMS Holding Certain PDPM Claims

The Centers for Medicare and Medicaid Services (CMS) is notifying nursing home providers that they are holding a number of Patient-Driven Payment Model (PDPM) claims as they make refinements to their claims processing system. The claims being held are those that have:

• dates of service of Oct. 1, 2019 or later;
• inpatient (21X) and swing bed (18X) services billed under PDPM; and
• multiple, different Health Insurance Prospective Payment System (HIPPS) codes.

CMS indicates that this hold is impacting a small number of claims and anticipates that they will be released for processing in late November. Providers do not need to resubmit these claims. In addition, CMS underpaid some skilled nursing facility (SNF) inpatient services (21X) and swing bed services (18X) claims for dates of service in October 2019 with a single line item. These are being automatically reprocessed and corrected.

We have heard of few difficulties related to the transition from Resource Utilization Group (RUG)-IV to PDPM as the basis for SNF Part A payment thus far, but providers are just beginning to see their first PDPM-based payments. We urge members to compare claims and payments and to let us know if they encounter difficulties, errors, or delays.

Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841