Patient Driven Payment Model SNF Resources Available from CMS

Patient Driven Payment Model SNF Resources Available from CMS

The Patient Driven Pay Model (PDPM) will change the Skilled Nursing Facility (SNF) Prospective Payment System’s (PPS) method of classifying SNF patients in a Medicare-covered Part A stay Oct. 1.  The Centers for Medicare & Medicaid Services (CMS) provide a number of resources on their web site.

Patient Driven Pay Model

According to the Centers for Medicare & Medicaid Services (CMS), the Patient Driven Payment Model is a new case-mix classification system for classifying SNF patients in a Medicare Part A covered stay into payment groups under the SNF Prospective Payment System.  PDPM will replace the current case-mix classification system, the Resource Utilization Group, Version IV (RUG-IV) Oct. 1.

CMS maintains the PDPM will lessen the administrative burden for SNFs. CMS explains that The PDPM classification methodology utilizes a combination of six payment components to derive payment. Five of the components are case-mix adjusted to cover utilization of SNF resources that vary according to patient characteristics. There is also an additional non-case-mix adjusted component to address utilization of SNF resources that do not vary by patient.

Different patient characteristics are used to determine a patient’s classification into a case-mix group (CMG) within each of the case-mix adjusted payment components. The payment for each component is calculated by multiplying the case-mix index (CMI) that corresponds to the patient’s CMG by the wage adjusted component base payment rate, then by the specific day in the variable per diem adjustment schedule when applicable. The payments for each component are then added together along with the non-case-mix component payment rate to create a patient’s total SNF PPS per diem rate under the PDPM.

Under the out-going RUG-IV method, Under RUG-IV, payment is derived from a combination of two case-mix adjusted payment components and two non-case mix adjusted components. The RUG-IV payment methodology assigns patients to payment classification groups, called RUGs, within the payment components, based on various patient characteristics and the type and intensity of therapy services provided to the patient. Under the PDPM, six payment components are utilized to derive payment.

Unique PDPM Codes

SNFs bill for services under PDPM using the Health Insurance Prospective Payment System (HIPPS) code that is generated from assessments with an ARD on or after October 1, 2019. The HIPPS code under PDPM is still a five character code, as under RUG-IV, CMS said. However, under RUG-IV, the first three characters represent the patient’s RUG classification and the last two characters are an assessment indicator (AI) code, to represent the assessment used to generate the patient classification. Under PDPM, the first character of the HIPPS code represents the patient’s PT component and OT component classification. The second character represents the patient’s SLP component classification. The third character represents the patient’s nursing component classification. The fourth character represents the patient’s NTA component classification. The fifth character represents the AI code.

More PDPM Information

Here are the resources CMS provides:

  • Administrative Level of Care Presumption Under the PDPM
  • PDPM Payments for SNF Patients with HIV/AIDS
  • Concurrent and Group Therapy Limit
  • PDPM Functional and Cognitive Scoring
  • Interrupted Stay Policy
  • MDS Changes
  • NTA Comorbidity Score
  • PDPM Patient Classification
  • Variable Per Diem Adjustment

 

 

 

Brad Ericson

Brad Ericson

Director of Publishing at AAPC
Brad Ericson, MPC, CPC, COSC, is a seasoned healthcare writer and editor.He directed publishing at AAPC for nearly 12 years and worked at Ingenix for 13 years and Aetna Health Plans prior to that. He has been writing and publishing about healthcare since 1979. He received his Bachelor's in Journalism from Idaho State University and his Master's of Professional Communication degree from Westminster College of Salt Lake City.
Brad Ericson

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About Has 394 Posts

Brad Ericson, MPC, CPC, COSC, is a seasoned healthcare writer and editor. He directed publishing at AAPC for nearly 12 years and worked at Ingenix for 13 years and Aetna Health Plans prior to that. He has been writing and publishing about healthcare since 1979. He received his Bachelor's in Journalism from Idaho State University and his Master's of Professional Communication degree from Westminster College of Salt Lake City.

2 Responses to “Patient Driven Payment Model SNF Resources Available from CMS”

  1. RoseV says:

    Thank you for this information. How/will this change reimbursement to the professional providers for consolidated billing?

  2. rose vega says:

    Thank you for this information. How/will this change reimbursement to the professional providers for consolidated billing?

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