Welcome PDPM, RIP RUG-IV
Projecting Medicare revenue based on the new Patient-Driven Payment Model (PDPM) reimbursement methodology is difficult, but a new tool developed by LeadingAge WI provides a streamlined way to approximate total annual Part A reimbursement. By entering the estimated count of resident days by case mix group for each component that comprises the rate and entering the average length of stay, users can get an understanding of the annual revenue that such a resident profile would yield. It replaces the RUG-IV revenue estimate template available in prior years. The tool is available on the LeadingAge website here but does require member log-in.
The process of projecting individual case mix categories is no easy task. Members should be careful when using past Minimum Data Set (MDS) data to assign PDPM categories given recent changes to the MDS as well as the fact that some MDS items that may be PDPM payment drivers may not have been comprehensively captured under RUG-IV. Members may want to wait until they have data on resident distribution across case mix categories during the first months of PDPM before finalizing annual revenue projections.
Posted along with the revenue projection template is a grouper tool that can assist in determining the correct case mix group for each component based on resident characteristics. The tool also generates a PDPM Health Insurance Prospective Payment System (
Once the case mix groups are assigned, the LeadingAge NY rate calculator (available for download here) can be used to automate the rate calculation to view daily reimbursement as well as reimbursement for the full stay.
We remind members that the transition requires homes to complete a special PDPM assessment on every resident admitted prior to Oct. 1st that remains in the home into October. Because these will be treated as new admissions for PDPM reimbursement purposes, the non-therapy ancillary (NTA) component of the rate will be tripled for the first three days, making it important that the assessments capture all items accurately, especially those that determine the NTA component. Providers should be certain to carefully and completely document category assignments. We recommend that members talk to the Medicare Advantage plans with which they contract to fully understand whether and when the plan may adopt PDPM as the basis for payment.
Members should also be sure that their software vendors are using the latest Centers for Medicare and Medicaid Services (CMS) PDPM grouper. PDPM DLL Package (V1.0002 FINAL) corrected a few bugs that were identified after the V1.0000 release and is available on the CMS MDS technical information page here. It was posted late last week. CMS requests that users report any issues by contacting the PDPM Support team at PDPM@cms.hhs.gov. PDPM fact sheets, a Frequently Asked Questions (FAQ) document, and other resources are available on the dedicated CMS PDPM site here.
Please let us know if you have questions, require assistance with the tools, or encounter difficulty with the transition.
Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841