Patient-Driven Payment Model – A Decrease in Administrative Burden for MDS Coordinators

By Melissa Keiter, RN, RAC-CT, DNS-CT, DON And Melissa Sabo, OTR/L, CDP, CSRS

RUGS-IV contains intricate rules and regulations along with a significant number of assessments based on the complex scheduling system. From SOTs to COTs and the rarely used EOT-R assessments, as well as the constant potential for assessment throughout the entire skilled stay, RUGS-IV has required a significant increase in the number, type and complexity of assessments that must be completed. While RUGS-IV focuses on the volume of services the resident receives, the new payment structure, called The Patient-Driven Payment Model or PDPM, is resident-driven and will focus reimbursement on the clinical indicators for each individual resident, rather than on the volume of therapy or nursing services provided.

PDPM will drastically decrease the number of assessments MDS Coordinators must complete by utilizing the 5-day SNF PPS assessment to set reimbursement for the resident’s entire stay. The assessment window for the 5- day assessment can be set on days 1-8, removing the use of “grace days” from the assessment window in RUGS IV.

Now of course, CMS was aware that residents may experience clinical changes during the SNF stay, so PDPM includes a new assessment called an Interim Payment Assessment, or IPA. The IPA is comprised of same items as the 5-day SNF PPS MDS Item Set (Item Set NP) and while optional, should to be completed when a reassessment is indicated. Because the IPA is an optional assessment, there are no penalties for not completing one when indicated, however CMS plans to monitor errors or frequent missed IPAs closely, so providers should endeavor to schedule these when indicated/ Per CMS, providers should complete an IPA in cases where the following two criteria are met:

  1. “There is a change in the resident’s classification in at least one of the first-tier classification criteria for any of the components under the proposed PDPM such that the resident would be classified into a classification group for that component that differs from that provided by the 5-day scheduled PPS assessment, and the change in classification group results in a change in payment either in one particular payment component or in the overall payment for the resident. In other words, a change in RUG classification.
  2. The change(s) are such that the resident would not be expected to return to his or her original clinical status within a 14-day period and the change is not expected to be acute.”

Per CMS, SNFs will continue to complete the PPS Discharge Assessment, as appropriate (including a report of therapy total minutes by discipline and group/concurrent minutes by discipline), for each SNF Part A resident at the time of Part A or facility discharge.

The combination of the 5-day Scheduled PPS assessment, the IPA Assessment, and PPS Discharge Assessment gives flexibility for providers to capture and accurately report the resident’s condition, as well as correctly reflect resource utilization associated with that resident.  The decrease in assessments required under the proposed PDPM will thus minimize the administrative burden on the SNFs and MDS coordinators.

 

References

Centers for Medicare and Medicaid Services. Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities (SNF) Proposed Rule for CY 2019, SNF Value-Based Purchasing Program, SNF Quality Reporting Program. Available April 27, 2018, at https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-09015.pdf

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