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 CMS Updates PDPM Materials, Including Fresh FAQs

In its latest guidance on the ongoing transition to the Patient-Driven Payment Model (PDPM) set to occur Oct. 1, the Centers for Medicare & Medicaid Services (CMS) has released a number of materials for stakeholders to review, including updates to its PDPM-related frequently asked questions (FAQs).

Of these updates is a new version of the PDPM FAQs covering the basics, like Payment Overview and Billing and What is PDPM?, as well as more technical issues, like coding.

CMS, for instance, spells out how the new payment model for skilled nursing facility (SNF) patients in a Medicare Part A covered stay will have a new case-mix classification system come this fall, with PDPM replacing the current case-mix classification system, the Resource Utilization Group, Version IV (RUG-IV).

On the subject of how SNF patients are classified into payment groups under PDPM, the FAQ said PDPM classification methodology use a combination of six payment components to derive payment. Of these, five are case-mix adjusted to cover utilization of SNF resources that vary according to patient characteristics.

There is, however, an additional non-case-mix adjusted component to address utilization of SNF resources that do not vary by patient, CMS said. 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. 

CMS said the PDPM classification methodology differs from RUG-IV because under the current system payment is found via 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,” CMS said.

But, the new PDPM and its six payment components use clinically relevant factors, rather than volume-based service for determining Medicare payment.

“Under the PDPM, patient characteristics are used to assign patients into CMGs across the payment components to derive payment. Additionally, the PDPM adjusts per-diem payments to reflect varying costs throughout the stay,” CMS said.

Other areas the FAQs discuss include the topics of how providers bill for services under PDPM, what health insurance prospective payment system codes represent under PDPM, what the default code is under PDPM, and, how ICD-10 coding will work with the new model.

In addition to the FAQs, CMS also released additional updated resources relevant to PDPM implementation, including various coding crosswalks and classification logic.

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